Relationship between stress and fatigue in university students with headache

Introduction: Considered one of the most common neurovascular disorders among university students, headache has an impact on quality of life. In addition, stress and fatigue can trigger and/or intensify headaches. Objective: To investigate the relationship between fatigue and stress in university students with headache. Methods: One hundred and forty-seven students aged between 18 and 44 years, regardless of gender, and regularly enrolled at the Universidade de Fortaleza participated in the study. Data were collected through a questionnaire developed by the researchers and through validated instruments for the diagnosis of headache, the impact being measured by the HIT-6 (Headache Impact Test), the assessment of fatigue using the Fatigue Severity Scale (FGS), and quality of life through the SF-36. Data were analyzed using the SPSS 20.0 program, using the chi-square test to analyze the association between the variables. A significance level of 5% was adopted. Results: Headache complaints were present in 70.7% of the sample (n = 104), with secondary headache being more predominant (63.5%, n = 66), in females (79.8%, n = 83), with a mean age of 21.7 ± 4.0 years. The moderate intensity of the headache was reported by 60.6% (n = 63), highlighting the impact of this pain as very severe in 68.3% (n = 71) of the participants. Students with headache had more symptoms of stress (30.5 ± 7.6; p < 0.004) and fatigue (4.0 ± 1.4; p < 0.040). Conclusion: An expressive number of headache cases was found, mainly in females, related to symptoms of stress and fatigue, impacting the quality of life of these university students.


Introduction
Headache is one of the most common neurovascular disorders and despite being disabling, it is still underestimated. Indicated as a disease with a high prevalence rate, headache impairs the individual's functionality and living in society, in addition to affecting productivity, individual concentration and interactions with the environment. In this way, it is considered a public health problem, due to its debilitating properties. 1 Considering its etiology, the headache can be classified as primary or secondary, where the primary has no known cause, with migraine and tension-type headache being the most prevalent of this kind. 2 Secondary headache occurs when the headache is a consequence of some type of disease or clinical situation that occurs in the individual, such as a cranial lesion, infections of different types or orofacial pain. 3 Migraine is a type of headache that is characterized by unilateral pain, with moderate to severe intensity and can be pulsating. This type of headache can be triggered by several causes, such as sensory stimuli and the ones originated from the environment, and the symptoms are commonly associated with nausea, vomiting and sensitivity to light and sounds. 4 Therefore, tension-type headache can be triggered by situations of stress, emotional tension and muscle pain. It can be located bilaterally or in specific regions of the skull, with mild to moderate intensity. Its duration can vary according to each person and does not present associated symptoms as apparent as migraine. 5 Several surveys are carried out to verify the prevalence of headache in the population. Among these, the high prevalence in university students stands out, whose academic activities require significant effort.
A study carried out in a teaching institution in the state of Paraná, Brazil, showed a prevalence of headache in 75% of students. 6 Another study carried out with medical students in São Paulo in 2015 revealed that 99% of these students had headache, also highlighting that stress was the main cause related to the onset of headache in the population studied. 7 The Regarding lifestyle, the habit of smoking, consuming alcohol and practicing physical activity was not associated with headache, with no significant difference between participants with and without headache. When investigating the study time, however, we observed that headache was more prevalent in those who studied between six and ten hours or more ( Table 1).
The prevalence of headache in the study population was 70.7% (n = 104), with the secondary type being the most prevalent, representing 63.5% (n = 66) ( Table   2). Regarding secondary headache, 45.2% (n = 47) attributed it to problems with the face (eyes, ears and nose), temporomandibular disorders and problems in the sinuses and neck, and 15.4% (n = 16) mentioned that headache was related to the abuse of analgesics.
Regarding the duration of pain, 36.5% (n = 38) of the participants reported approximately two hours of pain even with the use of medication, and 55.8% (n = 58) reported that pain predominates in the afternoon, as shown in Table 3.
In investigating the impact caused by headache in the lives of these students, we found that 68.3% (n = 71) reported very severe impact, 17.3% (n =18) reported severe impact and 14.4% (n = 15), moderate impact (Table 4).
As for the levels of stress and fatigue, a higher score was observed in the group with headache (p < 0.004) ( Table 4). This difference was also observed in the SF-36 domains, which were more compromised in the headache group: functional capacity, physical aspects and pain (p < 0.001), social aspects and mental health (p < 0.001), and emotional aspects (p < 0.04). In the domains of general health and vitality, the p-value was not significant when the groups were compared (Table 4).

Results
The sample consisted of 147 participants, with a    In the present study, the mean age of participants with headache was 21.7 years, ranging from 18 to 44 years, which is in agreement with the findings in the literature. 3,10,15 Lifestyle, including factors such as smoking, use of alcoholic beverages, lack of regular physical activity, excessive use of electronic devices and sleep disorders are usually associated with the onset of headache. 10 In the present study, however, there were no associations of these variables with headache.
Anxiety and depression often cause headaches because of the emotional reasons these conditions entail. Emotional conflicts and psychosocial stress are factors manifested by those who suffer from any of these psychological disorders. 16 Although the current study has not shown a significant association of these conditions with headache, we observed that students with headache had a higher percentage of this condition (Table 1).
Stress is also a risk factor for the onset of headache, in view of the neurophysiological changes that occur due to annoyances during routine, mood swings and unpleasant events, 17 a fact that can be complemented