Abstract
Allergic rhinitis is one of the most common and undertreated diseases in the world. In recent times, there has been increased development of non-sinus headaches among patients with allergic rhinitis. Various common endogenous molecules such as nitric oxide, calcitonin gene-related peptide, and histamine have been implicated in the development of migraines, which leads to the development of migraines among allergic rhinitis patients. The study aims to determine the prevalence of migraine among allergic rhinitis patients and to find the association between the various demographic factors and the presence of migraine. This cross-sectional study was conducted in the ENT department of a tertiary care hospital in Puducherry. All patients aged more than 18 years old with the symptoms of allergic rhinitis were included in the study. The study was conducted six months, from July 2023 to December 2023. ARIA classification is used to determine the severity of the allergic rhinitis, and, per International criteria for headache, was used to diagnose migraine. A total of 282 patients with allergic rhinitis participated in the study. The mean age of the patients was found to be 38.89 ± 11.04 years. The prevalence of migraine among allergic rhinitis patients was found to be 69.1%—Economic status (39.4%). About 16.7% of the patients with diabetes were associated with migraine. The study showed a significant association between sex (p-0.006), age (p < 0.001), and socio-economic status (p-0.034) with the presence of migraine. The study also showed a significant association between the severity of allergic rhinitis and the presence of migraine (p-0.034) and the type of migraine (p-0.004). The study concludes that a significant proportion of the patients with allergic rhinitis were associated with migraine. So, clinicians should always screen for the presence of the migraine in all patients with allergic rhinitis to improve the patient’s quality of life.
Keywords: Migraine, Allergic Rhinitis, ARIA, Allergy
Introduction
Allergic Rhinitis (AR) is one of the most common and undertreated diseases in the world and persists throughout life [1]. The prevalence ranges from 0.8 to 39.7% of the world population, and it is increasing [2]; the prevalence of AR in India was found to be 11% [3]. It affects everyone regardless of age, sex, race and socioeconomic status [4]. It causes significant disability both mentally and physically, and most of the time, it is often managed poorly [5].
AR is characterised by having two or more symptoms of anterior or posterior rhinorrhea, recurrent attacks of sneezing, nasal blockage and nasal itching for a duration of two or more days for more than one hour on most days [6]. An early and late hypersensitivity response to an allergen and IgE-mediated action of mast cells in the nasal mucosa mediates it. Based on Allergic Rhinitis and its impact on Asthma (ARIA) Guidelines, AR has been classified into mild intermittent, mild persistent, moderate-to-severe intermittent and moderate-to-severe persistent AR [7].
Migraine is a severe form of headache occurring in attacks lasting from 3 h to 3 days [8]. A migraine is characterised by the presence of a moderate to severe intensity headache and often presents unilaterally and is often associated with other systemic symptoms such as nausea, vomiting, and phonophobia with or without photophobia [9]. Various studies have revealed that endogenous molecules such as nitric oxide, calcitonin gene-related peptide and histamine have been implicated in the development of migraine. However, the exact underlying mechanism of the development of the migraine is still unclear [10, 11]. Most of the time, the disorder is often undiagnosed or underdiagnosed, which leads to one of the causes of the disability and the loss of work. Because of the high prevalence and increased morbidity of various systemic illnesses, it is considered public importance. The early identification of migraine headaches helps to seek early medical treatment [12]. Also, it helps initiate individualized therapy to decrease the development of complications in the patient and increase the patient’s quality of life. So, this study was planned to assess the prevalence of migraines among patients with allergic rhinitis and identify how the demography of the patients and the severity of allergic symptoms influence the outcome of migraine attacks in patients with allergic rhinitis.
Materials and methods
This cross-sectional study was conducted in the ENT department of a tertiary care hospital in Puducherry. All patients aged more than 18 years old with the symptoms of allergic rhinitis were included in the study. The study was conducted six months, from July 2023 to December 2023. Pregnant women, patients with known immunodeficiency, patients with a history of anti-allergic medications, patients with tumours of the nose and paranasal sinuses, and those with known immunodeficiency were excluded from the study.
Sample size
Considering the prevalence of migraine in allergic rhinitis as 68% [13], with a 95% confidence interval and taking alpha error as 8%, the minimum sample size was calculated to be 282. The sample size calculation was calculated using 4pq/d2 formula.
After getting informed and written consent from the patient, the patients were enquired about the demographic details, and then the patients were categorised into one of the subtypes of allergic rhinitis based on ARIA guidelines, such as mild intermittent allergic rhinitis, mild persistent allergic rhinitis, moderate to severe intermittent allergic rhinitis and moderate to severe persistent allergic rhinitis. Then, the patients were asked about the symptoms of migraine as per International criteria for headache and then categorised into one of the two types of migraine, such as migraine with aura and migraine without aura. Then, the association between the patient of allergic rhinitis and the development of migraine with or without aura will be compared, and the level of association between the various demographic details of the patients with the development of allergic rhinitis with or without migraine was compared.
Results
A total of 282 patients with allergic rhinitis participated in the study. The mean age of the patients was found to be 38.89 ± 11.04 years. Nearly 31.2% of the patients were between 30 and 40 years of age, followed by 25.5% of those between 40 and 50. 52.8% of the patients who participated in the study were found to be females, whereas males contributed to 47.2% of the total study population. More than half of the patients, 60.6%, were from urban areas. 39.4% of the patients were semiskilled workers, followed by 25.2% of the patients were unskilled workers, and only 14.2% were found to be professional workers. And more than half of the patients, 57.1%, had a monthly income of more than Rs.1059. Hypertension is the most common comorbidity among the patients with allergic rhinitis, which accounts for 27%, followed by 21.3% with asthma, 20.6% with anxiety, and 20.2% with diabetes mellitus, as in Table 1.
Table 1.
Socio-demography of the patients
| Frequency | Percentage | |
|---|---|---|
| Age (in years) | ||
| 18–30 | 68 | 24.1 |
| 30–40 | 88 | 31.2 |
| 40–50 | 72 | 25.5 |
| > 50 | 54 | 19.1 |
| Gender | ||
| Male | 133 | 47.2 |
| Female | 149 | 52.8 |
| Locality | ||
| Rural | 111 | 39.4 |
| Urban | 171 | 60.6 |
| Occupation | ||
| Unskilled | 72 | 25.5 |
| Semiskilled | 111 | 39.4 |
| Skilled | 59 | 20.9 |
| Professional | 40 | 14.2 |
| Socio-Economic Status | ||
| < 1059 | 161 | 57.1 |
| > 1059 | 121 | 42.9 |
| Co-morbidities | ||
| Asthma | 60 | 21.3 |
| Acetylsalicylic acid intolerance | 13 | 4.6 |
| Diabetes | 57 | 20.2 |
| Hypertension | 76 | 27 |
| Depression | 45 | 16 |
| Anxiety | 58 | 20.6 |
According to the ARIA classification, about 34.4% of the patients who participated in the study had Moderate to severe intermittent allergic rhinitis, followed by 25.5% had mild persistent allergic rhinitis, and moderate to severe persistent allergic rhinitis was present in 22.7% of the patient and only 17.4% had mild intermittent allergic rhinitis, as in Fig. 1.
Fig. 1.
Distribution of patients based on the ARIA classification
The study found that about 69.1% of the patients with allergic rhinitis had migraine. Nearly half of the patients, 52.1% of the patients, had migraine without aura, followed by 17% of the patients who had migraine with aura, as in Table 2.
Table 2.
Distribution of the patient based on the type of migraine
| MIGRAINE type | Frequency | Percentage |
|---|---|---|
| Without aura | 147 | 52.1 |
| With aura | 48 | 17 |
| No migraine | 87 | 30.9 |
One evaluating the association between the various demographic factors with the presence of migraine, about 42.6% of the female allergic rhinitis patients were associated with migraine. The study showed that people in the age group of 30 to 40 years (25.5%) and 40 to 50 years (19.5%) were found to be associated with migraine. About 46.8% of the patients residing in urban areas had migraines. About 27.3% of the semiskilled workers, 10.1% of the unskilled and 15.6% of the skilled workers were associated with migraine. And the migraine was more commonly seen among the people with high socio-economic status (39.4%). About 16.7% of the patients with diabetes were associated with migraine. The study showed a significant association between sex (p-0.006), age (p < 0.001), and socio-economic status (p-0.034) with the presence of migraine. However, the study didn’t find any association with the locality (p-0.104), occupation (p-0.430), and other comorbidities such as asthma (p-0.63), Acetylsalicylic acid intolerance (p-0.995), depression (p-0.694), anxiety (p-0.119), as in Table 3
Table 3.
Association of socio-demographic details with the presence of migraine
| Parameters | Migraine Present | Migraine Absent | P value | ||
|---|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | ||
| Sex | |||||
| Male | 88 | 31.2 | 45 | 16 | 0.006 |
| Female | 120 | 42.6 | 29 | 10.3 | |
| Age | |||||
| 18–30 | 36 | 12.8 | 32 | 11.3 | < 0.001 |
| 30–40 | 72 | 25.5 | 16 | 5.7 | |
| 40–50 | 55 | 19.5 | 17 | 6 | |
| > 51 | 45 | 16 | 9 | 3.2 | |
| Locality | |||||
| Rural | 76 | 27 | 35 | 12.4 | 0.104 |
| Urban | 132 | 46.8 | 39 | 13.8 | |
| Occupation | |||||
| Unskilled | 54 | 19.1 | 18 | 6.4 | 0.430 |
| Semiskilled | 77 | 27.3 | 34 | 12.1 | |
| Skilled | 44 | 15.6 | 15 | 5.3 | |
| Professional | 33 | 11.7 | 7 | 2.5 | |
| SES | |||||
| < 1059 | 111 | 39.4 | 50 | 17.7 | 0.034 |
| > 1059 | 97 | 34.4 | 24 | 8.5 | |
| Comorbidities | |||||
| Asthma | 40 | 14.2 | 20 | 7.1 | 0.639 |
| Acetyl | 9 | 3.2 | 4 | 1.4 | 0.995 |
| Diabetes | 47 | 16.7 | 10 | 3.5 | 0.020 |
| Depression | 30 | 10.6 | 15 | 5.3 | 0.694 |
| Anxiety | 45 | 16 | 13 | 4.6 | 0.119 |
On evaluating the association between the severity of allergic rhinitis and the presence of migraine, there is a significant association between the severity of allergic rhinitis and the presence of migraine (p-0.034). The study showed that patients with moderate to severe intensity of allergic rhinitis had a higher prevalence of migraine than the patients in the mild category of allergic rhinitis, as in Table 4
Table 4.
Association of classification of AR with the presence of migraine
| Presence of migraine AR classification |
Migraine Present | Migraine Absent | P value | ||
|---|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | ||
| Mild intermittent AR | 35 | 12.4 | 14 | 5 | 0.034 |
| Mild persistent AR | 47 | 16.7 | 25 | 8.9 | |
| Moderate to severe intermittent AR | 60 | 21.3 | 37 | 13.1 | |
| Moderate to severe persistent AR | 53 | 18.8 | 11 | 3.9 | |
In finding the association between the classification of allergic rhinitis and the classification of migraine, the study found that about 14.9% of patients with mild persistent allergic rhinitis had migraine without aura, followed by 13.8% with moderate to severe persistent allergic rhinitis had migraine without aura. Whereas migraine with aura was more commonly seen among patients with moderate to severe intermittent allergic rhinitis and moderate to severe persistent allergic rhinitis. The study showed a significant association between the two (p-0.004), as in Table 5.
Table 5.
Association of classification of AR with the classification of migraine
| Classification of migraine AR classification |
With aura | Percentage | Without aura | Percentage | P value |
|---|---|---|---|---|---|
| Mild intermittent AR | 6 | 2.1 | 29 | 10.3 | 0.004 |
| Mild persistent AR | 5 | 1.8 | 42 | 14.9 | |
| Moderate to severe intermittent AR | 24 | 8.5 | 37 | 13.1 | |
| Moderate to severe persistent AR | 13 | 4.6 | 39 | 13.8 |
Discussion
Allergic rhinitis is a systemic disease. Most of the time, allergic rhinitis is associated with a migraine, which was misdiagnosed as sinusitis, which leads to the affection of the quality of life of the patient without proper treatment [14]. Previous studies revealed that various endogenous molecules, such as calcitonin gene-related peptides, nitric oxide, and histamine, play a vital role in the pathophysiology of migraines. Among the patients with allergic rhinitis, histamine contributes to the development of the migraine headache by increasing the release of nitric oxide [15]. It also facilitates the evolution of the local neurogenic inflammation by causing vasodilatation and increasing the vascular permeability through the H1 and H2 receptors. Thus, the histamine and the nitric oxide mediate the immune-mediated inflammatory reaction and are considered a fundamental factor for the pathogenesis of allergic rhinitis with migraine [16].
In our study, about 69.1% of the patients with allergic rhinitis were diagnosed with migraine. Similar results were also noted in the study by Pai S et al. [13], Which showed that allergic rhinitis prevalence was 68%. The study by Kulkarni GB et al. [9] also showed similar results. However, the study by Dhungel et al. showed that only 18.84% of the patients with allergic rhinitis had migraine, which was lower than our study results. The study showed a significant association between sex (p-0.006), age (p < 0.001), and socio-economic status (p-0.034) with the presence of migraine. The study by Ozturk A et al. [17] Showed that there is an increased frequency of migraine among women than in men with allergic rhinitis. And the study by Jeyagurunathan A et al. [18] showed that various socio-demographic factors such as Age, gender, ethnicity, education level, and employment status were significantly associated with migraine headaches. Various other studies also showed an association between socio-demographic factors and migraine headaches [19, 20].
There are several reports which reveal the relationship between migraine and allergic rhinitis, but the number of studies which evaluate the association of migraine with allergic rhinitis is limited [10, 21]. However, the study by Lv H et al. [22] He found no causal association between allergic rhinitis and migraine in his study. Davey et al. found an association between migraine and bronchial asthma. In contrast, Mortier et al. [6] reported the presence of a higher prevalence of migraine among children with atopy than those without atopy.
Another study by Martin VT et al. [11] Explored the prevalence of migraine headaches among patients with allergic rhinitis. Also, it evaluated the relationship between the severity of the allergy with the severity and the frequency of the migraine. The patients in the study were grouped into high and low-atopic groups based on the number of allergy tests. The study showed that the association of the allergy with migraine headache depended upon age, degree of allergic sensitisation, administration of immunotherapy, and type of headache. Our study also showed that the severity of allergic rhinitis was found to be associated with headaches. Our study showed a significant association between the severity of allergic rhinitis and the type of migraine that is migraine with or without aura. And the study by Ozturk A et al. [17] Showed a significant association with the migraine with or without aura with the presence of allergic rhinitis.
Conclusion
The study explored the fact that allergic rhinitis is a risk factor for the development of migraines. The prevalence of migraine among patients with allergic rhinitis was found to be high. Various socio-demographic factors such as age, sex and socio-economic status were associated with the migraine. So, proper screening of all patients with allergic rhinitis for migraine is necessary to prevent complications from arising due to the disease and improve the quality of life of the people.
Acknowledgements
Nil.
Funding
No funding was received for conducting this study.
Declarations
Ethics approval and consent to participate
This study was approved by Institutional Ethics Committee (Human Studies) at Sri Venkateswaraa Medical College & Hospital, Puducherry with No: 134/SVMCH/IEC-Cert/Nov21.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Financial or non-financial interests
Financial or non-financial interests
Conflicts of interests
: The authors have no competing interests to declare that are relevant to the content of this article.
Footnotes
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