Introduction
According to the Global Burden of Disease (GBD) study, headache disorders are among the most
prevalent causes of disability worldwide.1 In 2021, approximately 40% of the global population is
estimated to be affected by headaches.2 Over 90% of the individuals who seek headache evaluation are diagnosed with primary headache disorders.3 According to the International Classification of Headache Disorders (ICHD), primary headache disorders include migraine, tension-type headache (TTH), trigeminal autonomic cephalalgia (TAC), and other primary headache types.3,4

Globally, 14% of the population experiences migraine, and 26% experience TTH.1,5 GBD has ranked migraine and TTH as the second and ninth leading causes of global neurological disability adjusted life years, respectively.6 Other clinically heterogeneous primary headache disorders are relatively uncommon.4,7

Migraine is considered a long-term condition, characterized by recurrent, moderate-to-severe headaches associated with nausea, vomiting, photophobia, and phonophobia.8,9 A migraine attack typically lasts 4-72 hours, and chronic migraine persists for more than 15 headache days per month for at least three months.4,5 Triggers include alcohol consumption, caffeine intake, smoking, stress, sleep deprivation, noises, sunlight, smells, and medication overuse.6,9 Migraine is associated with various comorbidities including neurological, cardiovascular, and psychiatric conditions.5,10 Migraine with aura increases the risk of ischemic stroke, while migraine without aura is linked to haemorrhagic stroke.11 TTH is the most common neurological disorder. Its clinical manifestations include mild-to-moderate, bilateral, and hatband-like distributed headaches with relatively less pronounced neurological symptoms.9 Common triggers of TTH include sleep disturbance, alcohol consumption, sunlight, and weather changes.6 TACs are a group of rare primary headache disorders characterized by unilateral headaches with ipsilateral cranial autonomic symptoms.3,12 TACs include cluster headache, short-lasting unilateral neuralgiform, paroxysmal hemicrania, and hemicrania continua.12 Common triggers include lack of sleep, mood changes, specific smells, chocolate, coffee, and alcohol consumption.6 The remaining primary headache disorders are heterogeneous and relatively uncommon. They include (i) headaches associated with physical exertion, such as coughing, exercise, or sexual activity, as well as thunderclap headache, which is linked to conditions like subarachnoid hemorrhage;4,7 (ii) headaches caused by direct physical stimuli, including cold-stimulus and external-pressure headaches;4 (iii) epicranial headaches, such as primary stabbing (localized, single or series of stabs) and nummular headaches (mild to moderate continuous pain, occasionally severe);4,7 (iv) other miscellaneous primary headache disorders, such as hypnic headaches and new daily persistent headaches, which are generally considered benign.4,7 Previous evidence indicates that in the Middle East and North Africa (MENA) region, primary headache disorders, particularly tension-type headaches (TTH), had an age-standardized point prevalence of 24,504.5 per 100,000 people in 2019.13 The prevalence of headache problems differs markedly across countries, with Saudi Arabia reporting rates between 8% and 12%.14 Notwithstanding these statistics, there exists a significant deficiency of thorough research on headache problems in most
MENA nations, which obstructs the formulation of focused healthcare policies.15 Recent studies underscore the necessity for comprehensive research to address gaps in understanding the epidemiology of headache problems in this region.13,15 The variation in prevalence rates among countries further highlights the importance of region-specific studies to guide public health policies. Accurate diagnosis and treatment play a crucial role in mitigating the adverse effects of headache disorders. However, misdiagnosis and inadequate treatment remain significant challenges.5,6,16 Early detection and treatment are crucial; yet the complex etiology and variability of symptoms make early diagnosis elusive.5,6 Identifying risk factors, including demographics and triggers, can help predict the high-risk patients and enable early intervention. Prognostic prediction further supports the optimization of therapy plans. A predictive approach, applicable at every stage of headache management, is essential for delivering tailored care.6 

Materials and Methods
This single-centre retrospective study included 1,500 patients registered in the Internal Medicine and Neurology departments of a tertiary healthcare centre located in Doha, Qatar, between August 2017 and August 2023 for headaches. Patients aged 18 years and older of both sexes were included in the study. The hospital caters to a broad demographic, reflecting the multicultural nature of Doha. Patients include local Qataris as well as expatriates from South Asia, the Middle East, and other regions. Across its facilities, Aster DM Healthcare in Qatar treats between 2,000 and 2,200 patients daily, reflecting a high volume and diverse case mix. The hospital offers specialized outpatient services, including neurology and headache clinics, which are integral to studies on primary headache disorders.

Key exclusion criteria comprised patients with systemic, metabolic, or traumatic conditions, along
with those presenting radiological findings, directly or indirectly associated with headache causation. Systemic and metabolic conditions were ruled out through a combination of detailed clinical evaluation and routine laboratory investigations, including complete blood count, fasting blood glucose, renal and liver function tests, thyroid function tests, and serum electrolytes. Headaches originating from or referred to the cranium due to conditions in the maxillofacial region, pharynx, paranasal sinuses, neck, or ear were excluded. Additionally, patients with incomplete clinical data, insufficient diagnostic or treatment information, or those who failed to complete the one-year follow-up were not included in the study. Clinical presentations and radiological data were collected and analyzed. This study compared, classified, and analyzed the
characteristics of primary headache disorders with reference to both national and international studies.

This study utilized a retrospective cohort approach, examining data from patients with headache
disorders, identified from pre-existing medical records during a specified timeframe. The single-center methodology guaranteed uniformity in diagnostic standards, data acquisition, and imaging
procedures. This strategy may add selection bias and restrict generalizability; however, stringent
inclusion and exclusion criteria along with standardized diagnostic techniques were employed
to alleviate these risks. Methodical data extraction further diminished information bias.

Procedure
Headache diagnoses were made according to the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria, which provide standardized and internationally accepted
definitions for primary headache disorders including migraine, tension-type headache, and trigeminal autonomic cephalalgias. All patients underwent brain MRI using institutional protocols for headache evaluation, which included multiplanar T1-weighted, T2-weighted, and FLAIR sequences to assess for structural abnormalities and exclude secondary causes. Additional sequences, such as MR venography or contrast-enhanced imaging, were performed when clinically indicated, following published neuroimaging guidelines for headache. All imaging studies were reviewed by experienced neuroradiologists to ensure diagnostic accuracy.

Statistical Analysis
All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).
Descriptive statistics were used to summarize demographic and clinical characteristics, with categorical variables presented as frequencies and percentages, and continuous variables as means ± standard deviations. Comparisons between groups (e.g., migraine, TTH, TAC, and other primary headaches) were conducted using Chi-square tests for categorical variables and independent t-tests or ANOVA for continuous variables, as appropriate. To adjust for potential confounders such as age and sex, multivariate logistic regression analyses were performed to assess the association between headache types and relevant clinical features, aggravating/relieving factors, and MRI findings. Odds ratios (ORs) with 95% confidence intervals
(CIs) were calculated. Age and sex were included as covariates in all regression models to control for their confounding effects. Statistical significance was set at P <0.05.

Results
Prevalence and Sex Distribution of Primary
Headache Disorders

Of the 1500 patients, 1,104 (male, n = 444; female, n = 660) were diagnosed with migraine, 309 (male, n = 130; female, n = 179) with TTH, 81 with TAC (male, n = 41; female, n = 40), and 6 with other types of primary headaches (male, n = 5; female, n = 1) (Table 1, Figure 1).

Characteristics of Migraine, TTH, and TAC
Migraine was most prevalent among individuals aged 20–25 years, with a prevalence of 28.1%. TTH and TAC were most common in the 36-40 age group, with prevalence rates of 29.1% and 28.2%, respectively. Of TAC patients, 87.6% had cluster headaches and 12.4% had paroxysmal hemicrania. Overall, only a small proportion of patients experienced headaches after the age of 40 across all three types of headaches. Migraine and TTH were more common in females than males, while TAC was slightly more prevalent in males. A positive family history of migraine was significantly more common in migraine (63.8%) compared to TTH (1%) or TAC (22.2%) (Table 1).

Of the 220 patients with migraine with aura, 75.5% (n = 166) experienced visual aura and 24.5% (n = 54) experienced sensory aura. The temporal region was the most common site of migraine pain, affecting 64.3% of patients. Frontal, parietal, and occipital regions were affected in 21.2%, 10.1%, and 4.4% of patients, respectively (Table 2).

Throbbing headaches were more common in patients with migraine (81.8%), while aching headaches were more prevalent in TTH and TAC patients (53.7% and 51.8%, respectively). Band-like compressive sensations were less common in patients with migraine (0.5%) and TTH (11.7%). Pricking sensation was less common in patients withTAC (12.3%). Migraine episodes most commonly lasted 1–4 hours (31%) or 5-8 hours (30.8%). TTH and TAC episodes were more often 5-8 hours in duration (32.7% and 39.5%, respectively), followed by 1-4 hours (31.4% and 23.4%). Prolonged episodes lasting more than 12 hours were less common across all three headache types (Table 3).

Various factors, such as a head bath, lack of sleep, mental or physical stress, sunlight, travel, perfume, petrol/diesel smell, chocolate, and alcohol, have been reported as aggravating factors for headaches (Figure 2). Head bath with lack of sleep was observed to be the most frequent aggravating factor of migraine (23.3%), while physical stress and sunlight exposure were identified as the key aggravating factors of TTH and TAC, with 43.7% and 37% of patients, respectively. No known factors have been identified for 1.9%, 0.6%, and 6.2% of patients with migraine, TTH, and TAC, respectively.

The medical and non-medical relieving factors include sleep, rest, analgesics, coffee, tea, and
topical application (Figure 3). The most common relieving factor for migraine was sleep (21.1%),
followed by a combination of rest and analgesics (20.4%). The most common relieving factors
for TTH were a combination of rest, analgesics, Preventive And Symptomatic Relief (PRASRE),
and sleep (26.5%), followed by rest and analgesics (25.6%). For TAC, the most common relieving
factor was the combination of rest, analgesics, and sleep (33.3%), followed by rest and sleep (30.8%).

Other Types of Primary Headaches
Table 4 presents data on patients with various primary headache types, including primary stabbing headache, primary exertional headache, and primary hypnic headache, with two patients reported for each type. The table details age distribution, headache duration, headache characteristics, family history, and both aggravating and relieving factors for these patients.

MRI Findings
MRI findings were normal in 85.6% of patients with headaches, while abnormal white matter hyperintensities (WMHs) were observed in the temporal (9.5%), frontal (3.3%), and periventricular (1.6%) regions. MRI findings of migraine with aura showed normal results in 4.1% of patients. The remaining patients exhibited WMH in temporal (63.6%), frontal (22.7%), and periventricular (9.5%) regions. MRI findings of migraine without aura were predominantly normal (99.6%), with only 0.2% of patients showing WMH in frontal and periventricular regions (Table 5).

Discussion
In our investigation, migraine had the highest prevalence, succeeded by tension-type headache (TTH) and trigeminal autonomic cephalalgias (TAC), among 1,500 individuals with primary headaches. The GBD 2019 data suggested a higher global prevalence of TTH; nevertheless, South Asia had the highest frequency of migraine, aligning with our findings.17 Conversely, data from the GBD 2016 revealed that the prevalence of tension-type headache (TTH) surpasses that of migraine across the Eastern Mediterranean region, including Saudi Arabia.18 A population-based, cross-sectional study in Saudi Arabia indicated that the 1-year prevalence of tension-type headache surpasses that of migraine.15 The majority of migraine cases (80.1%) were classified as migraine without aura, aligning with global trends. In general, approximately 15-33% of individuals with migraine experience aura.19 Corroborating our clinical findings, the hospital-based cross-sectional investigation conducted in the Middle East, Asia, and Africa revealed a
comparable prevalence of TAC (3.5%) within the study population.20 When compared to global statistics, the incidence of migraine in the Middle East is typically lower or exhibits significant variability, with reported rates ranging between 2.6% and 32%, and certain research suggesting a reduced prevalence of migraine in Saudi Arabia relative to other nations.21,22 This regional difference may be influenced by cultural variables, including societal attitudes that dissuade men from seeking treatment for headaches, potentially resulting in underreporting and underdiagnosis.22 Furthermore, environmental stimuli such as noise, potent scents, and severe weather are frequently reported by patients in the location and may influence unique
headache patterns relative to other areas globally.23

The age distribution indicated that migraines are more prevalent among young adults, particularly
those aged 20-40 years, aligning with international research findings. A telephone-based interview in the US revealed the highest occurrence of migraines in the 30-39 age demographic.24 TTH and TACs were more common in the older age demographics. In accordance with our findings, the GBD 2016 report indicated a significant prevalence of TTH among individuals aged 35-44 in the Eastern Mediterranean region.18 The GBD 2019 survey indicated that the regional point prevalence of TTH in the MENA was highest among men aged 35-39 and women aged 70-74.13 Cluster headaches exhibited a comparable age distribution, predominantly affecting individuals aged 20-40, consistent with an Asian study indicating that the mean age of onset for cluster headaches varied from 26.7 to 37.9 years.25

Women are primarily impacted by primary headache disorders, especially migraines, which exhibit the greatest gender gap. TTH demonstrates a marginally greater prevalence in women, whereas cluster headaches are somewhat more common in men. Our results correspond with the GBD 2019 data, which indicated a greater prevalence of migraine and TTH among females.1
A study examining sex hormones in primary headaches indicates that women exhibit greater susceptibility to migraines and tension-type headaches, primarily attributable to hormonal fluctuations throughout their lives, notably during pregnancy and menstrual cycle.9,26 Narrative literature regarding cluster headaches in Asian countries exhibited a pronounced male predominance, aligning with our findings.25 

A favourable familial history is a prevalent risk factor for migraines, signifying a genetic susceptibility. Genome-wide investigations revealed 178 linkage disequilibrium-independent single nucleotide polymorphisms (SNPs) correlated with migraine. A total of 181 independent SNPs were linked to migraine, with three specifically connected with females.27 Research demonstrates that hereditary variables substantially influence the risk of cluster headaches. First-degree relatives of individuals with cluster headaches demonstrate a 5–18-fold elevated risk, and second-degree relatives show a 1–3-fold increased risk, relative to the general population.6 Head showers, sleep deprivation, physical strain, and exposure to sunlight were the predominant triggers for all three headache categories. A previously published Indian study revealed hair washing and bathing as a prevalent trigger for migraines.28 A thorough assessment of migraines in Arab nations revealed stress, exhaustion, sleep difficulties, extended exposure to intense sunlight or heat, and hunger as the predominant factors.29 A meta-analysis of primary headache disorders indicates that stress and sleep are the most often identified triggers of primary headaches.30 The most prevalent technique for alleviating all three types of headaches was the combination of rest, sleep, and analgesics. The systematic analysis in Arab countries also indicated drugs, pigmentation, massage, rest, and adequate sleep as alleviating variables for migraines, corroborating our findings.29

The MRI results were predominantly normal in individuals with headaches and those with migraine without aura. Migraine with aura is mostly linked to WMH in the temporal, frontal, and periventricular areas, especially inside the temporal lobe. In individuals suffering with migraine, lesions typically present as silent infarct-like abnormalities, characterized by T2 hyperintensities in the white matter on MRI.31 White matter lesions (WMLs) are more prominent in individuals with aura and can adversely affect physical and cognitive abilities.32 Cerebral blood flow patterns during migraine attacks may differ between individuals with and without aura.33 A study reported that white matter hyperintensities (WMHs) are most frequently located in the frontal lobes, followed by the parietal lobes. Migraine patients exhibiting WMHs are considerably older and possess greater WMHs in the lobar (frontal, temporal, parietal, and occipital) and periventricular regions in comparison to their younger counterparts.34 A retrospective cross-sectional study in Saudi Arabia found that patients over 40 with migraines were more likely to exhibit aberrant imaging findings.35 

The American Headache Society systematic review and evidence-based guideline advocates for neuroimaging in migraine patients exhibiting atypical or persistent aura symptoms, heightened frequency or intensity of migraines, alterations in clinical presentations, inaugural or exceptionally
severe migraine episodes, migraine accompanied by brainstem aura, confusional or hemiplegic
migraine, onset of migraine in later life, aura without accompanying headache, side-locked migraine, and posttraumatic migraine.36

WMH are more frequently detected on MRI in individuals with migraine with aura than in those
without aura. Their clinical significance is rooted in the documented correlation between migraine
with aura and an elevated risk of ischemic stroke, especially among younger women and individuals with supplementary vascular risk factors like smoking or the use of oral contraceptives.37-39 The occurrence of WMH in migraine with aura is believed to indicate underlying small vessel alterations or temporary hypoperfusion associated with cortical spreading depression, the physiological mechanism of aura, which may lead to microvascular damage and heightened vulnerability to cerebrovascular incidents.37,38,40 In contrast, migraine without aura rarely exhibits such MRI abnormalities. The disparity is probably because of the lack of cortical spreading depression and the related hemodynamic variations in migraine without aura, leading to reduced microvascular stress and fewer structural alterations identifiable by MRI.40,41 Moreover, migraine is primarily a dysfunction of aberrant brain activity rather than structural anomalies, resulting in most individuals, particularly those without aura, exhibiting normal MRI scans. Thus, WMH findings in migraine with aura may serve as a marker for elevated vascular risk, underlining the necessity of monitoring and controlling modifiable risk factors in this population.

One advantage of the present study is the enrolment of patients from both the Internal Medicine department at Aster Hospital and the neurology specialists in peripheral clinics, reflecting the real-world structure of the Aster Healthcare network in Doha. This approach ensured that both general and specialized headache cases were accurately captured and assessed using standardized diagnostic protocols. By involving neurologists from peripheral centers, we enhanced diagnostic accuracy and provided a more comprehensive representation of primary headache disorders in the study population.

Limitations
The current study offers significant insights into the prevalence, demography, and characteristics of numerous headache syndromes; nevertheless, its single-centre design may introduce bias and restrict generalizability throughout the diverse Middle Eastern region. The study notably lacks longitudinal data on MRI findings, particularly regarding the growth of white matter hyperintensities (WMHs), hence limiting comprehension of their clinical importance over time. The lack of treatment outcome analysis and follow-up data constrains the evaluation of the efficacy of personalized management methods derived from clinical and radiological characteristics, underscoring a potential avenue for further investigation.

Recommendations
The discrepancies in incidence rates among various studies underscore the necessity for focused genetic and environmental studies in the Middle East. Large-scale genome-wide association studies (GWAS) and whole-exome sequencing in Middle Eastern populations should be prioritized to uncover distinct genetic risk variants for migraine and related headache diseases, as evidenced by recent studies of Arab and East Asian cohorts. Moreover, multicentre collaborations throughout the region leveraging successful frameworks such as the Mediterranean Neurosciences Network can enhance standardized data collection, facilitate environmental exposure evaluations, and promote longitudinal studies to elucidate gene environment interactions and inform the formulation of population-specific therapeutic strategies.

Conclusion
This study indicates that migraine is the most prevalent headache disorder, followed by TTH and
TAC. Individuals with migraine exhibited diverse auras, ages, sexes, familial histories, headache
patterns, and triggers, emphasizing the need for precise diagnosis and therapy. While the majority of MRI findings were unremarkable, patients with migraine with aura exhibited T2 hyperintensities, highlighting the role of neuroimaging in evaluation and treatment planning. The study also underscores the importance of understanding primary headache trends and demographic shifts, while variations in prevalence across comparative studies suggest racial and ethnic influences.

Acknowledgements
None to declare

Source(s) of support
The study was funded by Aster Ltd, Mumbai.

Conflicting Interest (If present, give more details):
The authors declare no conflicts of interest.