Primary headaches among adolescents and their association with excessive computer use

BACKGROUND AND OBJECTIVES: The use of electronic devices as entertainment and recreation means has directly affected adolescents’ lives; however their excessive use may bring consequences. This study aimed at observing the prevalence of primary headaches and their possible association with excessive use of computers among adolescents. METHODS: Participated in the study 262 teenagers aged between 14 and 19 years, students of a public school, who have answered a questionnaire to evaluate socio-demographic variables, data on computer use, presence of headache symptoms and level of physical activity. Multiple models of binary and multinomial logistic regression were used to evaluate the association among variables. Significance level was 5%. RESULTS: Prevalence of headache was 87.8%. There has been no significant difference in the prevalence of headache between genders, but among classification types, tension headache was more prevalent among females (35.4%). Females aged between 12 and 15 years and excessive computer use had higher chances of reporting headache. Females have 15.61 times more chance of reporting tension headache. Adolescents reporting excessive computer use had 2.54 times more chance of reporting migraine. CONCLUSION: Results have shown high prevalence of primary headache among adolescents, being migraine the most prevalent type. Abusive computer use were considered risk factors for the development of headache.


INTRODUCTION
The inclusion of electronic devices as leisure and recreation means is considerably increasing with technological advances and such insertion is directly affecting daily life of adolescents, occupying major space in their lives 1 .Devices such as cell phones, computers, electronic games, tablets and TV have been used both for school purposes and leisure 2,3 .Due to easy access to electronic devices more time is spent with them and, as a consequence, negative impact on adolescents' health have been reported in the literature, such as sleep changes, tiredness, anxiety, depression, overweight, de-ORIGINAL ARTICLE DOI 10.5935/1806-0013.20150049creased levels of physical activities, decreased concentration, musculoskeletal pain, stress and headache [3][4][5][6][7] .Headache, pointed as an increasing problem among children and adolescents and which is possibly related to changes in lifestyle and stress-related factors 8 , has been highlighted by some studies as a major complaint among adolescents due to the excessive use of electronic devices 6,9 .Recently, Brindova et al. 1 have observed that adolescents referring watching TV for more than three hours per day have higher chances of reporting physical and psychological complaints, including headache.Similarly, those using computers for work or leisure for more than three hours have 70% more chances of presenting headache.This reality is not different in Brazil where current studies show high prevalence of headache among adolescents, with decreased quality of life 10,11 , negative impact on daily activities 12 as well as on academic performance 11 .Brazilian technological development, both in job market and social communications, requires the mastering of electronic devices, regardless of socio-economic conditions.In the attempt to keep pace with this scenario and still aiming at social inclusion and amplification of access to information by students, the State Department of Education of Pernambuco has distributed laptops to high school students of state schools in 2012.However, the question is whether such attitude could imply more time spent with those devices and even cooperate with the appearance of mentioned complaints, including headache.In this context, in light of the increasing number of adolescents referring headache, added to the scarcity of national studies on the relationship between the use of electronic devices and this complaint, this study aimed at observing the prevalence of headache and its possible association with the use of computers and electronic games among adolescents of a state school of the city of Petrolina/PE.

METHODS
Target population of this study was made up of students enrolled in the 8 th grade of basic school and in the first three years of high school of Colégio de Aplicação Professora Vande de Souza Ferreira, school of the state public network of the city of Petrolina-PE.Sample was calculated by the WinPepi program and total population of students of the Escola de Aplicação Professora Vande de Souza Ferreira (n=600), bilateral statistics with α=0.05, power of 80%, estimated proportion of 50% absolute precision around the estimate of 5% and loss of approximately 10% were taken into consideration, reaching a minimum number of 261 individuals.The study has included students duly enrolled in the mentioned school, aged between 14 and 19 years and who have signed, dated and delivered the Free and Informed Consent Term (FICT).Exclusion criteria were adolescents with filling mistakes or incomplete filling of the questionnaire.Data were collected in the school, from October 2013 to March 2014 using a developed and adapted questionnaire, aiming at evaluating socio-demographic variables (age, gender, grade, presence of paid activity, and family income in minimum wages), data about computer use, presence of headache symptoms and physical activity level.Some questions were based on the self-applicable questionnaire: Musculoskeletal syndromes and injuries in children and adolescents and their relationship with computers and videogames 13 .Aiming at assuring further understanding and coverage of the study, some questions were adapted, such as the use of the words Notebook and Tablet instead of Laptop.To indentify whether the individual had headache, criteria was headache complaint at least once in the last year, and to classify the type of headache questions based on the international classification of headache disorders were used 14 .Physical activity level was evaluated by means of the International Physical Activity Questionnaire (IPAQ) -Short Version 15 .To calculate body mass index (BMI) body mass and height were measured using a portable electronic scale with 150kg capacity (brand Camry) and a portable stadiometer (brand Welmy), respectively.Nutritional status of adolescents was classified according to criteria suggested by Cole et al. 16 .

Statistical analysis
Nine independent variables (gender, age, socio-economic level, professional activity, physical activity level, nutritional status and time using computers) and one dependent variable (presence of headache) were considered.To classify the type of headache, tension headache, migraine and other types of headache were taken into consideration.Data were entered in an electronic Microsoft Excel spreadsheet, using the double-entry process.Data were analyzed by the program SPSS (version 20).Descriptive analysis has included relative and absolute frequency of categorical variables and confidence interval (CI 95%) for proportions.Mean and standard deviation were calculated for numerical variables.Pearson Chi-square or Fisher Exact tests were used to analyze differences between female and male variables.Bivariate logistic regression models were built to check the isolated association between the dependent variable and each independent variable.These analyses have allowed the analysis of variables which would be part of a multiple regression model, as well as the identification of potential confusion factors and identification of the need to adjust the analysis.Binary logistic regression was used to express the level of association between independent and dependent variables, through odds ratio calculation (OR) and confidence interval of 95%.In the multiple final model, variables with significance p<0.20 were selected.Finally, to observe the association between independent variables and different types of headache, multinomial regression model was used.Statistical significance was considered when p<0.05 in all tests.This study was approved by the Ethics and Research Committee, Universidade de Pernambuco (CAAE: 13598313.5.0000.5207).

RESULTS
Information of 265 adolescents was collected.However, three volunteers were lost due to poor questionnaire filling, thus totaling a final sample of 262 adolescents (101 males and 161 females).Sample mean age was 15.36±1.56years; body mass was 56.61±11.21kgand height was 165.45±8.41cm.Most respondents were physically active (160 subjects -61.1%) and were overweighed or obese (192 subjects -73.3%).With regard to time spent with computers, adolescents had usage mean of 228.75 minutes per week, or 3.83 hours per day.Table 1 shows the analysis of the frequency of headache and its possible classification between genders.There has been no statistically significant difference in the presence of headache, but among classification types, tension headache was more frequent among females (p=0.001).Multiple regression analysis has shown that variables gender, age, and computer use were maintained in the final model.Females aged between 12 and 15 years and using computers for more than three hours per day had higher chances of reporting headache (Table 2).Multinomial regression analysis has shown, for different types of headache, that females have 15.61 times more chances of having tension headache and 72% less chances of classifying headache as "other types".Adolescents referring computer use for more than three hours per day had 2.54 more chances of reporting migraine, as shown in table 3.

DISCUSSION
There are still few Brazilian studies evaluating the association of the use of electronic devices and headache, which has justified the objective of this study.After observing the high prevalence of headache among 262 evaluated adolescents, it was clear the importance of this study about factors which could be associated to this complaint.The prevalence of headache in the studied population was 87.8%.Prevalence as high as this has been also reported by other authors 17,18 , however it is still possible to find lower figures (35.1%) 19 , and such differences may be explained by different methodological designs and by the ways to evaluate headache, since some studies classify as has having headache people presenting at least one headache episode in the last three months and other studies consider one episode in the last year.Recently, Albers et al. 19 have proposed a systematic review on the prevalence of headache among children and adolescents and have concluded that its increase is proportional to age; however this finding is different from our study which has observed higher chance of reporting headache in the age group from 12 to 15 years of age as compared to adolescents from 16 to 19 years of age.There are different headache triggering factors in different age groups, which may explain different results, and in this context Juang et al. 20 and Tietjen et al. 21have observed that factors linked to family structure, such as stress and/or divorce, may be associated to headache in younger adolescents.Such associations were not observed in our study, which was limited to evaluating possible association with computer use, what has restricted the identification of other possible associations.
As to frequency distribution of different types of primary headache, there has been a prevalence of 30.2% for migraine and 22.5% for tension headache.In a study by Xavier et al. 18 with Brazilian adolescents and similar methodology, migraine was also the most common type of headache (19.3%), followed by tension headache (17.9%).Notwithstanding the similarity of methodological designs, discrepancies among prevalence rates were found, possibly because the recruited sample could be exposed to different primary headache triggering factors.
In our study, females had higher prevalence of tension headache as compared to males.Another relevant finding was that girls had 271% more complaints and were 15.61 times more prone to reporting tension headache.Shantakumari et al. 22 have also observed that females had 78% more chance of developing headache.Albers et al. 19 have reported that from 22 studies on prevalence of primary headache between genders, 15 have reported higher values for females.This association between headache and female gender is already well documented in the literature 19,23,24 and a possible reason might be hormonal issues present during this phase 25 .Such data emphasize the importance of considering headache as a symptom associated to gender.About electronic devices use, it was observed a total usage time of 228.75 minutes per week, or 3.83 hours per day.These figures show abusive use of such devices by adolescents and call the attention as possible risk factor for the development of headache.In addition, adolescents using computers for more than three hours per day have 3.44 times more chance of referring headache.Specifically, the use of computers subjects individuals to increased migraine complaints in 154%.
Confirming such findings, a study carried out with 8042 adolescents with mean age of 13.13 years in Finland, has shown that spending more than three hours per day watching TV increases the chances of having headache 1 .Xavier et al. 18 state that adolescents abusively using electronic devices have higher chances (OR=1.52) of having headache.
The literature also states that overload of visual system and maintenance of inadequate postures for long periods are reflected in headache reports by adolescents 2,9 .
Notwithstanding our results being in agreement with most current literature and presenting statistical and social relevance, the study was limited by the fact of generalizing results for students of a public school and extending them to private school students.In addition, the use of self-applicable questionnaires could lead both to over and underestimation of values due to memory bias of evaluated subjects.However, results have their importance justified as risk indicators for headache associated to time of computer use, gender and age.So, it is clear the need for following up adolescents abusively using such devices, aiming at restricting, as much as possible, negative influences of such use in the daily life of adolescents.

CONCLUSION
Our results show a high prevalence of primary headache among evaluated adolescents, being migraine the most prevalent type, followed by tension headache.Excessive computer use was considered risk factor for the development of headache, especially among females.

Table 2 .
Association of independent variables and presence and absence of headache among adolescents MW = minimum wage.

Table 1 .
Description, in absolute frequencies, of the presence of headache and its classification in adolescents of both genders

Table 3 .
Factors associated to the presence of different types of headache in adolescents of a public school of Petrolina, PE. 2013-2014