Comparison of the Migraine Disability (MIDAS Scores) in Two Genders and the Impact of BMI
and Age on It: A Cross Sectional Descriptive Study
Qamar Zaman*, Muhammad Farhan Khan and Maimoona Siddiqui
Division of Neurology, Shifa International Hospital, Pakistan
Submission: February 25, 2019; Published: May 08, 2019
*Corresponding author: Qamar Zaman, Division of Neurology, Shifa International Hospital H-8/4, Islamabad Pakistan
How to cite this article: Qamar Zaman, Muhammad Farhan Khan, Maimoona Siddiqui. Comparison of the Migraine Disability (MIDAS Scores) in Two
Genders and the Impact of BMI and Age on It: A Cross Sectional Descriptive Study. Open Access J Neurol Neurosurg. 2019; 10(5): 555798. DOI: 10.19080/OAJNN.2019.10.555798.
Background: The disability of the migraine attacks varies among the individuals. The epidemiological, genetic and hormonal factors might be the underlying reason for this variation. We compared the MIDAS Scores of two genders with respect to the age and the BMI to identify the influence of these factors on migraine disability in the two genders.
Materials and Methods: It was a cross-sectional descriptive study in which the males and the female were compared to each other regarding MIDAS scores at the various ages (15-55 years) and the BMI groups (normal, overweight and obese). Descriptive statistics were calculated, and the Chi square test was applied using (p<0.05) as a significant.
Results: There were 135 participants, with 99 (73.3 %) females and 36 (26.7 %) males. The mean MIDAS score of females was 47.44 compared to 33.97 in males. There was no significant difference between the two genders on the basis of MIDAS sores at various ages but the frequency of severe migraine (MIDAS >21) was highest at the age 36-45 years in both genders followed by perimenopausal period in the females. Effect of BMI on MIDAS scores showed increasing frequency of severe migraine with the increasing BMI.
Conclusion: Disability linked to the migraine worsens in the late adulthood and the increasing BMI also increases the migraine disability in both genders in similar pattern. Like the females, hormonal factors might have influence on the migraine in males. Further studies are required to confirm the findings.
Keywords: Body mass index; Headache; Migraine; Tension type headache
Migraine is among the one of the commonest headache disorders that usually impairs the quality of life of many young, active and the working individuals of the community. It may result in absence or impaired performance at work, home activities, and social gatherings and may also lead to the frequent emergency visits. The situation is further complicated by the frequent use of parenteral therapies in acute settings, providing only transient relief. Also repeated injudicious use of pain medications leads to the medication overuse headaches.
The Severity, frequency and disability of the migraine vary among the different individuals. Genetic and the life style factors most likely underlie these variation [1,2]. As observed in several studies in which various factors like gender, age, education level, socioeconomic status, depression and BMI were studied regarding their influence on the MIDAS scores in the migraine patients and they were found to have varying influences [3,4].
Impact of hormonal factors (estrogen and progesterone) on migraine in females is well known as obvious by the findings that some females have migraine attacks only during the perimenstrual period. Also, it has been observed that in majority of the females, migraine improves during the pregnancy and totally inactive after the menopause [5,6]. Similarly combined oral contraceptives and progestin only preparations have been found helpful in the females with migraine. Influence of the hormones on migraine in males and similarly influence of testosterone and other hormonal factors on migraine in females is less established and limited data is available. As observed in the recent studies, testosterone levels were found to be low in several cases of cluster headache and also chronic migraine not only in the male participants but also the female participants as well . Another small study on male migraine participants, found that non-obese migraneours had higher levels of estrogen compared to similar men without migraine .
Also like the female hormones, testosterone replacement
therapy was found to produce beneficial response in the
cluster headache patients, when the standard therapies were
not working . These findings implicate that the hormonal
influences in males with migraine cannot be ignored and need
to be considered as well in the future research. In this study
we compared migraine patients in two genders on the basis of
MIDAS scores, because it might help to identify the factors that
influence the migraine disability in both genders including the
role of hormonal factors. We preliminary took into account the
differences in the various age and BMI groups of two genders to
find out how they differ with respect to each other.
Objective: To identify the influence of age and BMI on the
MIDAS scores in male and female with migraine.
It was a cross sectional, descriptive study done at outdoor
setting of the Neurology clinic Shifa International Hospital
Islamabad for a period of 6 months. Approval was taken from
IRB of the hospital.
Migraine was diagnosed according to IHS criteria for the
migraine (ICHD-3)  2013. It included both episodic and
chronic migraine cases. The age and gender of the participants
was documented, and BMI was calculated according to the WHO
formula for Asian population  (Annex B). The disability was
assessed according to MIDAS scale  (Annex C). Sample Size
was calculated keeping the ± 5% as Precision levels, Confidence
Level as 95%, P=0.5, power of the test was taken as 0.5 by
Cohen’s d and Power hypothesis testing . Non-probability
sampling technique was used for data collection with the written
and informed consent taken from all the participants.
Data was entered and analyzed using SPSS version. Two
genders were compared with respect to age, BMI and MIDAS
Scores. The descriptive statistics were calculated for these
variables. To decrease the effect of the confounding factors the
Participants were stratified into four age groups ranging from
15-55 years(16-25, 26-35, 36-45, 46-55) and three BMI groups
(Normal <23, overweight 23-27.4 and obese >27.4) according to
WHO formula10 and two MIDAS11 scores groups (No disabilitymoderate
MIDAS, 0-20, severe MIDAS 21 and above). Two
genders were compared with respect to the frequency of the
MIDAS scores (severe/mild-moderate) at various ages (15-55
years) and three BMI classes. Chi square test was applied using
(P<0.05) as level of significance for any differences between
two genders. Also, various age groups and BMI classes of the
individual gender were compared among themselves on the basis
of MIDAS scores to find any differences between the categories.
To compensate for the difference in the number of participants
in various comparison groups weighting method was applied.
During the study period of 6 months, 455 patients presented
with the complaint of headache in the neurology outdoor, out of
them 135 were recruited for the study. Flow chart showing the
recruitment of the participants is given in Figure 1. The majority
of the participants were females about 73% compared to 27 %
male participants. Mean age of the participants was 33.32 ± 9.21
with mean BMI of 26.6 ± 6.02 and mean MIDAS score of 43.83
± 33.75. When the two genders were compared on the bases of
MIDAS scores, the mean MIDAS score in female group was 47.44
± 36.26 and mean MIDAS score of male group was 33.97±23.14.
Females had significantly high mean MIDAS compared to the
males with p<0.05 (p=0.04). comparison of the descriptive
statistics between two genders is shown in Table 1. Due to the
difference in the number of the participants in various age and
BMI groups, weighting technique was used to adjust the effect
of the variation in each variable group. Table 2 below shows the
method used. Considering the equal proportion of female and
male in Pakistan, value of 0.5 was taken for both genders.
Suppose there were 40 participants with 30 females and
10 males, so proportion of each genders will be (Females=0.75,
Male=0.25). Weighting factor for each gender was multiplied
with actual number of the participants for respective gender
during the comparison and adjusted values were used for
further analysis. Both male and female participants showed high
frequency of MIDAS in severe range at all age groups but the age
36-45 in both genders showed the highest no. of the participants
with MIDAS in severe range. Females in the age 46-55 years
of age had the high frequency of the participants with severe
MIDAS compared to those with MIDAS in mild-moderate range.
Male tend to have no significant difference in the frequency
of participants with MIDAS scores in both severe and mildmoderate
range at this age.
Frequency of the male and female participants with MIDAS
scores in both ranges with respect to the age is shown in Figure
2 & 3. When the two genders were compared regarding the
frequency of the participants with MIDAS scores in both ranges
in relation to the body mass index, the participants with severe
MIDAS sores increased with the increasing the BMI. The effect
of BMI was comparable in both genders. The effect of the BMI
on MIDAS scores was more prominent in the obese group while
the normal BMI and overweight group showed minor difference
in the frequency of the participants with respect to the MIDS
scores. The line diagram Figure 4 shows the trend of MIDAS
scores with the increasing BMI in both genders.
Chi square test was applied for comparing two genders in
all age groups. Difference between the two genders in different
age groups on the basis of MIDAS scores was not significant
(p>0.05). Similarly difference between the various age groups
when male were compared with each other and also the females
from various age groups were compared with each other on the
basis of MIDAS scores were found to be non-significant(p>0.05).
When the two genders are compared with respect to MIDAS
Scores in three BMI classes, there was no significant difference
between the two genders in any of the BMI classes (p>0.05)
When females were compared with one another according to
MIDAS scores in various BMI classes, it showed a linear pattern
i.e. with increasing BMI from normal to overweight and obese,
the percentage of participants with severe migraine increased
and a significant difference was found in BMI classes with
p=0.011, (p<0.05). Also, in male when compared on the basis of
MIDAS scores in various BMI groups, a significant difference was
Disability of the Migraine is assessed using MIDAS scores
and it differs among the individuals. Results of our study showed
mean MIDAS to be 43± 33.75 and most of the patients (71.1%)
had MIDAS score in severe disability range, while (28.9 %) had
MIDAS in mild-moderate range that is higher compared to the
other regional studies from India and Taiwan. A study from the
USA showed the frequency of disabling migraine to be 72 % .
It was observed in an Indian study where means MIDAS score
was 33.72 and a study from Taiwan showed mean MIDAS score
of 34.2+45.90. Another study from Korea showed mean MIDAS
score of 37.2 [14,15].
Genetic, hormonal, psychological and other life style factors
might underlie these differences . Migraine is a genetic
disorder so genetic factors might be playing a role in variation
in MIDAS score among the different families and the individuals
in the same family. The difference in MIDAS scores due to the
genetic influences is shown by the various studies done in
different parts of the world . However epidemiological factor
also play a significant role, MIDAS scores have been observed
to be affected by the education and socioeconomic status 
likely due to more awareness resulting in avoiding the triggers
and appropriate and timely treatment in the educated class.
Also, low socioeconomic status likely through more stress,
difficult living and working factors triggering the migraine might
be involved. Psychological factors also play an important role in
migraine disability as observed in a study showing MIDAS scores
to be worse in depressed patients .
The mean MIDAS score was found to be higher in females
compared to male with a significant difference (p<0.05). It has
also been observed in various studies that mean MIDAS score was
higher in females compared to males . High MIDAS scores in
females are postulated to be due to fluctuating hormonal levels
and also increase sensitivity to pain triggers, and psychological
factors . Also, high prevalence of obesity and metabolic
syndrome and sedentary life style in females might be resulting
in this gender difference in MIDAS scores .
Although the male and female had comparable MIDAS scores
at all age groups with no significant difference, the participants
from both genders showed high frequency of the MIDAS scores
in severe range at the age 36-45 and 15-25 years. The age group
where the female differed from the male participants on the basis
of the frequency of the participants with mild-moderate versus
severe MIDAS was 46-55 years. At this age the females had the
high frequency of the participants with severe MIDAS compared
to those with MIDAS in mild-moderate range. It is commonly
believed that migraine usually affect the younger females and it
prevalence and disability declines after the mid age . However
recently it has been observed that in many female’s disability
linked to migraine worsens during the perimenopausal period
that are supposed to be due to fluctuating hormonal levels at
this age period . Compared to the western countries, females
in south Asia have early menopause. It could be the reason for
worsening migraine at this age.
Reason behind the Worsening MIDAS scores in the late adult
hood observed in males in or study could also be due to influence
of hormones. Hormonal influence in male migraine patients is
less studied phenomena and might be likely due to the decline of
the male sex hormones with increasing age . In male levels of
testosterone increases at puberty and start declining in the late
adulthood, while estrogen gradually increases leading to female
features like increasing weight, osteoporosis and cardiovascular
In our study the effect of BMI on MIDAS score also did not
vary much between the two genders. Both male and female
participants had the increasing trend in severe MIDAS scores
with the increasing BMI. There was a significant difference in
frequency of disabling migraine of the obese group compared to
overweight and normal BMI group (p<0.05). Increasing estrogen
levels might be linked to prominent effect of BMI in females and
also the males after the late adulthood period, which was not
obvious below 35 years.
BMI had been one of the factors largely studied recently with
its influence on migraine in different ways. Several studies have
shown more or less association between BMI and prevalence,
clinical features, frequency and severity/disability of a migraine
although results have been inconsistent [23,24]. It is postulated
that various obesity proteins Orexin and Adipokines are involved
in this link. Our study is conforming the recent finding of high
MIDAS scores in the females around the perimenopausal period.
We also observed that the migraine disability in the males
might worsen in the late adulthood compared to the young.
Although the exact mechanism underlying these observations is
not known but hormonal factors might be responsible as some
recent studies,  showed that the low testosterone level was
associated with cluster headache and also chronic migraine not
only in the male but also in females as well. The use of hormonal
therapies in females and recently the finding that the testosterone
replacement therapy was associated with beneficial response in
the cluster headache  patients, where the standard therapies
were not working. Further studies are required to confirm these
finding and the mechanism underlying it. These observations
give a food for thought that there may be a possibility that in
males with severe migraine, checking the testosterone, estrogen
levels and Sex Hormone Binding Globulin (SHBG) be done and
if found low, testosterone replacement in the form of patches or
other routes might be a possibility. It might help the disability
related to the migraine in these selected individuals.
Important observations of our study were high MIDAS or
disability scores in the male participants after the late adulthood.
Females also showed the perimenopausal worsening of the
migraine disability besides the high MIDAS scores in forties
like male participants. The influence of BMI on the migraine
disability was similar in both genders. There was significantly
high disability in obese participants compared to the normal and
overweight counterparts. Reason behind this variation is yet to
be established but the hormonal changes might be contributing
to it. Further studies might help to confirm these findings and
also clarify the role of hormonal therapies in male with high
It was a hospital based; cross-sectional study so may not
be the actual representative of the society. Data was collected
by simple non probability sampling technique, so it may be
confounded as only patients with severe headache may be
visiting hospital which may result in high proportion of the
participants with the severe migraine.
It was the first study from Pakistan on Migraine and
epidemiological factors affecting it, done in tertiary care hospital
of the capital city with patients from a large captive area and in
statistical analysis parametric test were used so the results are
more likely to be of significance and powerful.