2.1 Participants and Study Design

A cross-sectional, questionnaire-based study was conducted among medical students at Alfaisal University. The study population included all actively enrolled medical students from Years 1 to 6 during the 2023–2024 academic year. The survey was distributed electronically to approximately 1000 medical students using the university's student email system. The survey was hosted on Google Forms, which allowed for anonymous data collection and enabled branching logic.

2.2 Inclusion and Exclusion Criteria

All actively enrolled medical students from Years 1 to 6 at Alfaisal University during the 2023–2024 academic year were eligible to participate in the study. There were no specific exclusion criteria applied. However, participants with missing data were excluded from the analysis.

This study employed a novel approach to migraine identification by combining the ID Migraine screening tool and the International Classification of Headache Disorders 3rd edition (ICHD-3) criteria. The use of both methods enhances the accuracy of the migraine prevalence estimate compared to studies using only one method.

2.3 Migraine Identification

A stepwise approach was used to identify migraine cases. Students were first asked, “In the past 3 months, have you had headaches lasting 4 to 72 hours?” Those answering affirmatively were evaluated for probable migraine based on ID Migraine (Lipton et al. 2003) and ICHD-3 criteria (Headache Classification Committee of the International Headache Society (IHS) 2018). ID Migraine criteria were assessed through the question, “During these headaches, did you experience any of the following features? (check all that apply): Nausea and/or vomiting, Bothering you (Increased sensitivity to light and sound), Limited your ability to work/study for at least one day.” Students endorsing two or more items have a sensitivity of 81% and specificity of 75% for identifying migraines in primary care settings based on the ID Migraine criteria (Lipton et al. 2003). ICHD-3 criteria were examined through the following questions: “In the past 3 months, have you had headaches lasting 4–72 hours that were not relieved by over-the-counter medication?,” “Does it have more than 5 attacks? Yes or No,” and “Did these headaches have at least 2 of the following features? (check all that apply): Throbbing, pulsating pain, Pain on one side of the head, Moderate to severe intensity, Worsened by routine activity like walking.” Students who met all the criteria up to this point were evaluated with the question “Have you ever received a medical diagnosis of migraine headaches by a doctor?” to rule out other potential causes of headaches. Students meeting ICHD-3 were also classified as having probable migraine. To comprehensively capture all potential migraine cases, migraine prevalence was assessed using both ID Migraine (Lipton et al. 2003) and ICHD-3 criteria (Headache Classification Committee of the International Headache Society (IHS) 2018). Students meeting both criteria were categorized as having a definite migraine. However, for all subsequent analyses, only students fulfilling ICHD-3 criteria (Headache Classification Committee of the International Headache Society (IHS) 2018) considered for migraine diagnosis, were included. This focused the investigation specifically on students with migraines meeting established international criteria. Restricting these analyses to only ICHD-3 migraine enabled the characterization of impacts and patterns uniquely related to clinically confirmed migraine based on the well-established diagnostic criteria (Headache Classification Committee of the International Headache Society (IHS) 2018). Migraine severity was classified based on headache frequency using established guidelines (Headache Classification Committee of the International Headache Society (IHS) 2018). Headache intensity was measured on a 0–10 visual analog scale as recommended by the International Headache Society (Tfelt-Hansen et al. 2012). Migraine frequency, severity, and duration were assessed with the following survey questions: “In the past 3 months, how many DAYS did you have a headache?,” “What is the average duration of your migraine headaches?” and “In the past 3 months, what was the average SEVERITY of your headache pain on a scale of no pain (zero) to worst pain (10)?” This methodology enabled systematic classification of migraine severity while adhering to International Headache Society standards for measurement of pain intensity and headache characteristics.

2.4 Academic Impacts

The effects of migraines on academic performance were evaluated in multiple ways. First, students were asked, “Do exams trigger your migraine headaches?” with a yes/no response to determine if exams acted as a trigger. Specific migraine symptoms and characteristics during exams were then assessed categorically for students meeting ICHD-3 migraine criteria. Questions included: 1. “DURING exams, did you experience an increase in migraine headache frequency compared to other times?” (Yes/No) 2. “DURING exams, did you experience an increase in migraine headache intensity/severity compared to other times?” (Yes/No) 3. “What is the average duration of your migraine headaches DURING exams?” (<4, 4–12, 12–24, 24+ h). Finally, the impacts of migraine symptoms on academics were examined with questions on exam absences, lost productivity, and GPA changes: (1) “DURING exams, how many EXAMS did you miss due to migraine headaches?” (2) “DURING exams, how many DAYS did migraine headaches SIGNIFICANTLY LIMIT your productivity/concentration?” (3) “Did your GPA decrease from migraine headaches?” (Yes/No). Chi-squared tests compared academic impacts across academic years. This multifaceted approach evaluated migraine triggers, symptom exacerbation, and disruption of academic performance during exam periods.

2.5 Statistical Analysis

The collected questionnaire data were analyzed using Statistical Package for the Social Sciences (SPSS) for Windows version 27 to assess migraine prevalence, clinical migraine characteristics, academic impacts, and coping strategies. Descriptive statistics summarized the sample. Chi-squared tests compared categorical migraine variables like symptoms and academic impacts across demographic groups. One-way ANOVA tested differences in numerical migraine characteristics like frequency, severity, and duration across gender, age, and academic year. Associations between academic impacts and demographics were evaluated using chi-squared tests. p values below 0.05 were considered statistically significant. SPSS enabled thorough analysis of associations and group differences.

3.1 Study Population

Out of 1000 students who received the invitation, 352 provided consent and completed surveys after excluding 13 with missing data, representing a 35.2% response rate. Across the questionnaire items, missing data were minimal, affecting less than 4% of the total sample, so we excluded them all. Table 1 presents a complete breakdown of the study's demographic composition, detailing both sample sizes and corresponding percentages. The majority were female (68.5%) and in early academic years, with first years most represented (44.5%). Age skewed young, with most participants 18–20 years old (61.1%). There were significant differences across gender, age groups, and academic years (all p < 0.001), indicating disproportionate representation. The sample reflects a convenience approach rather than probability sampling.

3.2 Migraine Prevalence

The analysis identified three estimates of migraine prevalence based on different criteria. ICHD-3 diagnosis, ID Migraine screening, and a definite migraine subgroup meeting both criteria. Figure 1 shows the overall prevalence percentages for each approach. Using the ICHD-3 criteria, the migraine prevalence was 36.8%. The ID Migraine screening tool identified a prevalence of 38.8%. Further analysis identified a definite migraine prevalence subgroup meeting both ICHD-3 and ID Migraine criteria, which provides a more conservative estimate requiring agreement across measures. This subgroup had a prevalence of 18.5%. There were no statistically significant differences in definite migraine prevalence based on gender (19.5% female vs. 16.2% male, p = 0.555), age (ranging from 17.7% to 20%, p = 0.972), or academic year (ranging from 12.7% to 25.0%, p = 0.638). Full details on the three migraine prevalence estimates and demographic comparisons are presented in Table 2.

3.3 Migraine Characteristics

Among the 130 students meeting ICHD-3 migraine criteria, frequency analysis found a mean of 3.5 migraine days per month (SD 1.6), with no significant differences by gender (p = 0.055), age (p = 0.118), or academic year (p = 0.476) (Table 3). For migraine severity, the mean rating was 6.4 (SD 2.1) on a 10-point scale. No significant differences were detected by gender (p = 0.093), age (p = 0.061), or academic year (p = 0.825). The mean migraine duration was 9.3 h (SD 7.6), with significant differences across age groups (p = 0.029) but not gender (p = 0.892) or academic year (p = 0.372). Chi-square analysis evaluated associations between specific migraine symptoms and demographic factors among the 130 respondents (Table 3). The symptom of moderate-to-severe headache intensity showed a significant association with the academic year (χ² = 17.84, p = 0.0032). No other symptoms demonstrated significant associations. Nausea and sensitivity to light/sound were common, reported by 67% and 76%, respectively. The throbbing pain was experienced by 77%. Prevalence was similar across groups. The symptom “limited ability to work/study” was not significantly associated with gender (χ² = 0.0010, p = 0.9742), age (χ² = 3.20, p = 0.3613), or academic year (χ² = 3.85, p = 0.5712). Figure 2 shows the prevalence of key migraine symptoms. Full details of migraine symptoms in the study population are presented in Appendix A1.

3.4 Academic Impacts

Among the 130 respondents with a lifetime migraine diagnosis, the impacts of migraine headaches on academic performance and exams were analyzed. Exams were reported to trigger migraine headaches for 86/130 (66%) students. Chi-square analysis showed migraine triggered by exams had a significant association with the academic year (χ² = 11.256, p = 0.047). An increase in migraine headache frequency during exam periods compared to other times was reported by 82/130 (63%) respondents, which was not significantly associated with demographics. Increased migraine intensity/severity during exams was reported by 77/130 (59%) and showed a significant association with the academic year (χ² = 12.564, p = 0.028). The average duration of migraine headaches during exams was 4–12 h for 37/130 (29%), <4 h for 36/130 (28%), 12–24 h for 35/130 (27%), and 24+ h for 22/130 (17%). Duration was not significantly associated with gender, age, or academic year. Changes in migraine frequency or severity during exams compared to previous years were highly associated with age (χ² = 37.762, p = 0.000019) and academic year (χ² = 85.193, p < 0.00001). Regarding academic disruption due to migraine, a productivity limit of ≥1 day was reported by 112/130 (86%), with 2–4 days being the most common (51/130; 39%). The number of exams missed due to migraine differed significantly by academic year (χ² = 47.792, p = 0.00045), with more exams missed in later years. Decreases in GPA showed highly significant associations with gender (χ² = 11.120, p = 0.0111), age (χ² = 42.803, p = 0.00000234), and academic year (χ² = 98.647, p < 0.00001). Figure 3 shows the prevalence of exams triggering migraines differed significantly across academic years (p = 0.047). Figure 4 illustrates the impact of migraines on GPA decrease, which varied by academic year. Figure 5 displays changes in migraine severity and frequency during exams across academic years. Further details are presented in Appendices A2 and A3.

3.5 Coping Strategies

Among 130 medical students with migraine, the most commonly used coping strategies were rest/sleep (77.7%), avoiding light/noise (57.7%), and over-the-counter (OTC) medication (56.9%). Figure 6 shows the prevalence of coping strategies among migraine-diagnosed medical students. ANOVA found no significant differences in the use of rest/sleep across academic years (p = 0.376). However, OTC medication use increased significantly with the academic year (p = 0.0028), from 42.4% in the first year to 100% in the sixth year. No significant differences were seen in avoidance of light/noise by academic year (p = 0.435).

4.1 Limitations and Recommendations

This study has several limitations that should be considered when interpreting the results. First, the cross-sectional design precludes causal inferences about the relationship between migraine and academic performance. Second, the convenience sampling method and the study's focus on a single university may limit the generalizability of the findings to other medical student populations. Third, the reliance on self-reported data may introduce recall bias and underestimate the true prevalence and impact of migraine. Despite these limitations, our study provides valuable insights into the prevalence, characteristics, and academic impacts of migraine among medical students. We recommend that future research efforts should employ longitudinal designs and probability sampling methods to better understand the causal relationships between migraine and academic performance and to improve the generalizability of the findings. Additionally, we recommend the development and evaluation of targeted interventions, such as migraine education programs, stress management workshops, and preventive treatment strategies, to mitigate the impact of migraine on medical students’ academic performance and overall well-being. Finally, we recommend that medical schools and universities provide support services and accommodations for students with migraines to help them manage their symptoms and minimize the negative impact on their academic success.