A cross-sectional hospital-based study

Objective To determine the association of smartphone use with occurrence of new-onset headache and/or increased severity of headaches in patients with primary headache. Methods In a cross-sectional study between June 2017 and December 2018, patients with primary headache were divided into 2 groups: smartphone users (SUs) and non-smartphone users (NSUs). A questionnaire was administered for headache characteristics and treatment taken. The primary objective was to determine the association of smartphone use with new-onset headache or increase severity. The secondary objective was to determine any differences in the requirement of acute medication and prophylaxis. Results Four hundred patients were included in the study, of which 194 were NSUs and 206 were SUs. The NSUs were older with lower education and socioeconomic status. The headache characteristics were similar in both the groups, except for higher occurrence of aura (NSUs: 15 [7.7%] vs SUs: 36 [17.5%]; p = 0.003) in the SU group. There was, however, higher proportion of patients taking analgesics (NSUs: 157 [80.9%] vs SUs: 197 [95.6%]; p < 0.001), with less relief in headache with medication in the SU group. This was driven by increased pill count (low SUs: 5.0 [3.0; 10.0] vs high SUs: 10.0 [5.0; 15.0]; p = 0.007) and poor response to medication in the high SU group. Conclusions The use of smartphone was associated with increase in requirement of acute medication and less relief with acute medication. Longitudinal studies may be required to confirm these findings. Department of Neurology (PU, DV, KP, AKS, AKP) and Department of Biostatistics (SND), All India Institute of Medical Sciences, New Delhi, India. Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp. RELATED ARTICLE Editorial Smartphone use and headaches: Are we ready to accept a link? Page 467 Copyright © 2020 American Academy of Neurology 473 Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Smartphone technology is advancing at a rapid rate. Although this is opening avenues for interesting applications for health education and management, the excessive engagement with these devices is also raising health concerns. As of December 2017, there were total 1.2 billion mobile phone users in India and account for 20–25% of total mobile phone users worldwide. The smartphone ownership base is expected to increase from 239 million in 2015 to 445 million by 2020. Studies have shown that the use of mobile phone may lead to number of symptoms such as headache, impaired concentration and memory, fatigue, irritability, anxiety, insomnia, backache, neck pain, eye strain, and digital thumb. Headache was the commonest reported complain due to mobile phone use. Various causative mechanisms have been proposed, including electromagnetic field, strain over eyes and ear, neck posture, decreased sleep, mental strain, and local thermal effect. In a double-blind, sham-controlled provocation study, there was no evidence that radio frequency fields from mobile phone may cause head pain or discomfort or influence physiologic variables. However, there could be other possible explanation for headache in mobile and internet users. Lee et al. reported that long and continuous smartphone use causes posture change in the cervical and lumbar vertebrae, in addition to proprioception deficits in the cervical vertebrae. There is paucity of evidence on the association of primary headache and smartphone use. This study was aimed at determining the association between smartphone use and worsening of primary headache via a cross-sectional study. Methods The study was conducted between June 2017 and December 2018 at a tertiary care center in North India. The study design was a cross-sectional observational study. We included patients aged ≥14 years with primary headache (according to the ICHD3 β classification). Patients with secondary headache or those who denied consent were excluded. Standard protocol approvals, registrations, and patient consents Approval for this study was obtained from the institutional ethics committee. Written informed consent was obtained from eligible and consenting patients. A research tool was formulated to record the demographic details, headache characteristics, phone use, and medication history. The revised Kuppuswamy scale was used to assess the socioeconomic status. All patients underwent detailed neurologic examination and relevant investigations. Information about the headache pattern, severity, frequency, duration of episodes, character, location, and associated complaints was noted. Information was noted about newonset headache of at least 3-month duration or worsening of primary headache. Disability due to headache was assessed with the Headache Impact Test 6 (HIT-6) questionnaire. Each patient was also enquired about the mobile phone usage with respect to type of cell phone, daily usage duration, and type of usage. A questionnaire (Smartphone Addiction Questionnaire [SAQ ]) containing 11 points based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) V criteria for substance use disorders was formulated to score the mobile phone and internet addiction (table 1). The questionnaire was also translated in the local language (Hindi). Each question was scored as 0 for “No” and 1 for “Yes”, with the highest score for questionnaire as 11. Patients were diagnosed as migraine or tension-type headache as per International Classification of Headache Disorders (ICHD) 3 β classification. The questionnaire was administered by a single investigator (P.U.). Patients were divided into 2 groups; non-smartphone users (NSUs) and smartphone users (SUs). Patients who were using feature phone were grouped into the non-smartphone group, as their mobile phone usage was limited to calling only. SUs with 0–1 score on the SAQ were further grouped into low SUs, and patients with score ≥1 were grouped into high SUs. Headache characteristics and medication history were compared between 2 groups: smartphone vs NSUs and low smartphone vs high SUs. The primary objective was to determine the association of mobile phone usage with new-onset headache or increase severity of primary headache. New-onset headache due to mobile phone and internet usage was defined as primary headache becoming chronic or getting significantly worse. Chronic headache was defined as headache occurring for This study was aimed at determining the association between smartphone use and worsening of primary headache via a cross-sectional study. Headache characteristics and medication history were compared between 2 groups; smartphone vs non-smartphone users and low smartphone vs high smartphone users. 474 Neurology: Clinical Practice | Volume 10, Number 6 | December 2020 Neurology.org/CP Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. more than 15 days in a month for more than 3 months, and worsening was defined as 2-fold increase in severity and/or intensity. Assessment of severity of headache due to mobile phone use was performed by comparison of frequency and duration of headache episodes, clustering of attacks, Visual Analogue Scale (VAS) score, and HIT-6 score. The secondary objectives were to study the association of smartphone use in patients with primary headache with requirement of medication and dosage, the type of analgesic intake, pill count of acute medication per month, number of prophylactic drugs, duration of prophylactic drug, and dosage. This was done by asking the patients, headache diaries, and verification of the same by medical records. The proportion of headache in a study by Demicri in NSUs and SUs (0.32 vs 0.51) was considered, and the sample size of 300 was calculated to achieve power of 90% with 5% level of significance. The analysis was conducted in Stata version 13 (StataCorp LP, College station, TX, USA). Statistical analysis was performed using the χ test for categorical variables and the t-test and Wilcoxon rank-sum test for continuous variables. Continuous variables not following standard distribution were analyzed with the Mann-Whitney test. Values in absolute numbers and in percentages were compared between 2 groups. Results were considered to be statistically significant if the p value was <0.05. Data availability The principal investigator (D.V.) and the first author (P.U.) as well as coinvestigator (S.N.D.) had access to all the data and checked for data accuracy. All the data acquired from the study have been mentioned in the tables, and anonymized data will be shared by request from any qualified investigator. Results Four hundred patients were included in the study period, of which 194 were NSUs and 206 were SUs. Of 194 NSUs, 76 were not using any phone and 130 were using feature phone. Ten patients were excluded during the screening (idiopathic intracranial hypertension in 4 patients and refusal in 6 patients). Demographic characteristics Demographic characteristics in both the groups are detailed in table 2. Non-SUs were older (mean [SD]: 35.2 [10.8] years) compared with SUs (30.7 [10.2] years). Overall, the majority of patients with headache were females (269/400 [67%]). However, there was higher proportion of male patients in the SU group compared with the NSU group (NSUs: 50 [25.8%] vs SUs: 81 [39.3%]; p = 0.004). The non-smartphone group is of lower socioeconomic and had lower educational attainment compared with the SU group. Clinical characteristics The clinical characteristics have been described in table 3. Age at headache onset was higher in the non-smartphone Table 1 Smartphone addiction questionnaire