Open Access

Associations between headache and stress, alcohol drinking, exercise, sleep, and comorbid health conditions in a Japanese population

  • Masako Yokoyama1Email author,
  • Tetsuji Yokoyama2,
  • Kazuo Funazu1,
  • Takeshi Yamashita1,
  • Shuji Kondo1,
  • Hiroshi Hosoai1,
  • Akira Yokoyama3 and
  • Haruo Nakamura1
The Journal of Headache and Pain200910:113

https://doi.org/10.1007/s10194-009-0113-7

Received: 27 November 2008

Accepted: 24 February 2009

Published: 27 March 2009

Abstract

We conducted a cross-sectional survey of 12,988 subjects aged 20–79 years (5,908 men and 7,090 women) receiving health checkups at a Tokyo clinic. They filled out a self-administered structured questionnaire, and 5.4% of the men and 15.4% of the women reported having headaches. Younger subjects were more prone to having headaches. The likelihood of having headaches increased with stress level and decreased ability to relieve stress in both genders. There was an inverse dose–response relationship between having headaches and alcohol consumption, and less walking/exercise and sleep problems increased the likelihood of headaches in both genders. Headache sufferers of both genders were more likely to report multiple additional poor health conditions. A multivariate stepwise logistic analysis showed that age, self-estimated degree of stress, reported number of additional poor health conditions, and less alcohol consumption were independently correlated with having headaches. In conclusion, although women were more susceptible to headache, Japanese men and women in Tokyo shared factors associated with headache, including age, stress, having other poor health conditions, alcohol consumption, sleep, and exercise.

Keywords

Alcohol Gender Headache Poor health condition Stress

Introduction

Headaches rank among the most frequent complaints in the general and working populations [1] and they can affect the quality of life and work productivity [2] Headache sufferers tend to complain of other pains in various parts of the body [3, 4] and a wide range of lifestyle choices, including drinking, smoking, and exercise, may be involved in headache occurrence. Stress and poor sleep are frequently cited on lists of headache triggers. Headache sufferers often report that drinking alcohol is related to some of their headaches. Headaches are also a frequent symptom of both alcohol-induced flushing responses and hangover in the Japanese with inactive acetaldehyde dehydrogenase-2 (ALDH2), who fail to promptly eliminate acetaldehyde, a toxic metabolite of ethanol [5, 6]. The genetic variation prevalent in the Japanese may modify the interaction between headache and alcohol consumption. In the present study, we investigated the associations between headaches and various lifestyle choices and comorbid conditions in a very large Japanese general population in Tokyo.

Subjects and methods

The reference population of this study consisted of 16,290 Japanese who came to Mitsukoshi Clinic of Tokyo for an annual health checkup between January 2004 and December 2004. They were workers or residents of Tokyo or of neighboring areas, who had been registered on the clinic lists for annual health checkups. They were routinely asked to fill out a self-administered structured questionnaire concerning their physical condition, stress, exercise, sleep, and drinking and smoking habits for clinical use, and 13,001 of them completed all items related to stress, exercise, sleep, and drinking and smoking habits. After excluding the three persons aged 80 years or more, 12,988 persons (5,908 men and 7,090 women) who were aged 20–79 years were adopted as the subjects of this study.

Each subject was asked to indicate from the following, the poor health conditions that applied to them: I have headaches; I have lost weight; I get tired easily; I have little energy; I have little appetite; I have pain in my upper abdomen; I have pain in my lower abdomen; food sticks in my throat; I have heartburn; I have a heavy feeling in my stomach; I have nausea or vomiting; I have blood in my stools; I feel tightness in my chest; I have palpitations or shortness of breath; I have a cough or cough up sputum; I have blood in my sputum; I have low back pain; my limbs feel numb; my limbs hurt; my limbs are swollen; my hands shake; I sometimes feel dizzy; I have ringing in my ears; I get up to urinate at night; I am anxious sometimes; and I cannot sleep well.

The questionnaire asked the subjects to estimate their degree of stress in comparison with others by choosing from: little or none; low; average; somewhat high; very high, and their ability to relieve stress by choosing from: good; fairly good; little; and none. The choices for the average duration of sleep were: less than 5 h; 5 h to less than 6 h; 6 h to less than 8 h; and 8 h or more. The questionnaire also asked the subjects to report alcohol intake as frequency of consumption per week and the usual amount(s) and type(s) of alcoholic beverage(s) consumed per day. Subjects were classified as non-drinkers or as current drinkers who consumed less than 1 unit/day (1 unit = 22 g ethanol, the ethanol content of one serving of sake), 1 unit to less than 2 units/day, 2 units to less than 3 units/day, and 3 units/day or more. The subjects were asked to report on smoking and weekly frequency of walking or exercise for at least 20 min at a time or at least a total of 1 h a day. The choices for frequency of walking or exercise were: seldom; 1 day/week; 2 days/week; 3–4 days/week; and 5 days/week or more. Blood pressure measurements were made in the arm, with an automated sphygmomanometer (BP-103iII, Omron Healthcare Co. Ltd., Kyoto) between 9:00 am and 11:00 am and with the subjects in the sitting position. The subjects were requested to refrain from eating and drinking for at least 12 h and from smoking for at least 30 min before the examination. The subjects were divided into four groups according to systolic pressure measured at the time of the health checkup: under 100, 100–119, 120–139, and 140 mmHg and over.

This study was conducted following the Ethical Guidelines for Epidemiological Research in Japan and reviewed and approved by the Ethics Committee of Mitsukoshi Health and Welfare Foundation.

Statistical analysis

Data are summarized as percentage values, and the chi-squared test was used for comparisons between groups. The relationships between headache and lifestyle and health conditions are expressed as odds ratio (OR) and 95% confidence interval (CI) estimated by a multiple logistic regression model with adjustment for age and other confounding factors. The stepwise procedure with P < 0.05 for entry and removal was used to select independent significant factors. All statistical analyses were performed using SAS software (version 9.1, SAS Institute, Cary, NC).

Results

Prevalence of headache

Table 1 shows the proportions of subjects who reported having headaches according to gender and age group. Of the 12,998 subjects, 1,411 (5.4% of the men and 15.4% of the women) reported having headaches. A significantly higher rate of women reported having headaches than the men in all age brackets. The younger subjects were more prone to having headaches, regardless of gender. Headache ranked 3rd in women and 11th in men among the poor physical conditions asked in the questionnaire.
Table 1

Proportion of headache sufferers based on gender

Age (year)

Men

Women

P*

N

Proportion of headache sufferers (%)

N

Proportion of headache sufferers (%)

20–29

236

12.3

707

16.8

NS

30–39

1,113

7.9

1,890

18.6

<0.0001

40–49

1,582

5.4

1,609

15.2

<0.0001

50–59

2,119

4.4

1,975

13.7

<0.0001

60–69

811

2.7

714

11.9

<0.0001

70–79

47

4.3

195

8.7

NS

Total

5,908

5.4

7,090

15.4

<0.0001

  

P < 0.0001**

 

P < 0.0001**

 

P men versus women by χ2 test

** P for homogeneity among age groups by χ2 test

Headaches and stress

The likelihood of having headaches increased in stepwise fashion with stress level and decreased ability to relieve stress, in both men and women (Table 2). The subjects whose self-estimated degree of stress was “little or none” had the lowest rate of headache (1.5% of men and 6.1% of women) among all the subcategories of lifestyles evaluated in this study, in contrast to the highest rate (18.1% of men and 30.7% of women) among the subjects whose ability to relieve stress was “none”. The age-adjusted ORs for the highest versus lowest level of stress and the lowest versus highest ability of stress release in men were approximately twofold stronger than in women (11.74 vs. 4.9 and 6.96 vs. 3.52, respectively).
Table 2

Relationship between headache and lifestyle choices

 

Men

Women

N

Proportion of headache sufferers (%)

Age-adjusted OR

95%CI

N

Proportion of headache sufferers (%)

Age-adjusted OR

95%CI

Stress

 Very high

305

16.7

11.74

4.16–33.15

484

25.4

4.90

2.75–8.75

 Somewhat high

1,364

8.4

5.37

1.96–14.76

1,706

22.2

4.10

2.36–7.13

 Average

3,307

3.9

2.56

0.94–6.99

4,001

12.8

2.15

1.24–3.72

 Low

662

3.5

2.37

0.81–6.94

666

8.9

1.48

0.81–2.71

 Little or none

270

1.5

1.00

Referent

231

6.1

1.00

Referent

   

P < 0.0001

  

P < 0.0001

Ability to relieve stress

 Good

2,489

3.0

1.00

Referent

2,728

10.9

1.00

Referent

 Fairly good

2,272

6.3

2.11

1.58–2.81

2,824

15.0

1.41

1.21–1.66

 Little

1,074

8.3

2.76

2.00–3.80

1,416

22.9

2.39

2.01–2.84

 None

72

18.1

6.96

3.63–13.34

114

30.7

3.52

2.32–5.34

   

P < 0.0001

  

P < 0.0001

Drinking

 Non-drinker

1,410

7.5

1.00

Referent

4,366

16.5

1.00

Referent

 Less than 1 unit/day

1,688

6.2

0.76

0.57–1.01

1,883

14.0

0.77

0.66–0.90

 1 to less than 2 units/day

1,287

4.2

0.56

0.40–0.79

585

13.0

0.72

0.56–0.93

 2 to less than 3 units/day

789

3.9

0.55

0.36–0.83

154

7.8

0.39

0.22–0.71

 3 units/day or more

734

3.5

0.51

0.32–0.79

99

11.1

0.59

0.31–1.11

   

P = 0.0009

  

P < 0.0001

Walking or exercise

 5 days/week or more

2,042

4.9

0.68

0.50–0.92

2,297

14.7

0.85

0.72–1.01

 3–4 days/week

1,069

5.2

0.77

0.54–1.10

1,658

15.4

0.93

0.77–1.13

 2 days/week

859

3.7

0.53

0.35–0.81

889

12.5

0.71

0.56–0.90

 1 day/week

745

6.3

0.88

0.61–1.28

665

15.5

0.88

0.68–1.12

 Seldom

1,193

7.2

1.00

Referent

1,579

17.7

1.00

Referent

   

P = 0.020

  

P = 0.063

Sleep

 Less than 5 h

305

9.2

2.04

1.33–3.14

510

17.1

1.33

1.03–1.70

 5 to less than 6 h

2,127

7.0

1.63

1.28–2.08

2,957

17.2

1.31

1.15–1.50

 6 to less than 8 h

3,279

4.0

1.00

Referent

3,476

13.7

1.00

Referent

 8 h or more

196

6.1

1.89

1.02–3.51

142

10.6

0.76

0.44–1.32

   

P < 0.0001

  

P = 0.0003

Smoking

 Never smoker

2,370

5.4

1.00

Referent

5,559

15.0

1.00

Referent

 1–19 cigarettes/day

1,016

6.3

1.07

0.78–1.46

884

16.9

1.05

0.87–1.28

 20–29 cigarettes/day

1,304

5.4

0.98

0.73–1.33

216

14.8

0.92

0.63–1.35

 ≥30 cigarettes/day

493

5.7

1.09

0.71–1.67

30

20.0

1.42

0.58–3.49

 Ex-smoker

725

4.1

0.75

0.50–1.14

400

17.0

1.07

0.82–1.41

   

P = 0.60

  

P = 0.87

Blood pressure, systolic

 <100 mm Hg

525

5.9

1.00

0.67–1.50

2,374

15.7

0.98

0.85–1.14

 100–119 mm Hg

2,304

6.0

1.00

Referent

3,008

15.4

1.00

Referent

 120–139 mm Hg

2,254

5.1

0.92

0.71–1.19

1,343

15.3

1.13

0.94–1.36

 ≥140 mm Hg

825

4.6

1.03

0.70–1.50

365

12.9

1.04

0.75–1.45

   

P = 0.89

  

P = 0.54

P values are for homogeneity among the subcategories of each factor by the age-adjusted logistic regression model

Headaches and alcohol

Current drinkers, both men and women, had a lower likelihood of headaches than non-drinkers, regardless of the amount consumed (ORs = 0.51–0.76 for men and 0.39–0.77 for women). There was an inverse dose–response relationship in both the men and the women.

Headaches and exercise

There was an inverse association between having headaches and walking/exercise that was significant among the men and marginally significant among the women. When “seldom” was used as the referent, the lowest significant risk for headache for both men and women was in the “2 days/week” category (OR = 0.53 for men and 0.71 for women).

Headaches and sleep

When 6 h to less than 8 h sleep was used as the referent, both less sleep (ORs = 1.63–2.04) and excessive sleep (OR = 1.89) in men, and less sleep (ORs = 1.31–1.33) in women were positively associated with having headaches.

Headaches and smoking

There was no association between having headaches and smoking.

Headaches and blood pressure

There was no association between having headaches and systolic blood pressure.

Headaches and poor health condition

Headache sufferers of both genders were more likely to report multiple other poor health conditions (Tables 3, 4). The multivariate stepwise logistic regression model showed that the physical conditions that were significantly and independently associated with headaches were fatigability, upper abdominal pain, lower abdominal pain, heavy feeling in the stomach, lower back pain, palpitations or shortness of breath, dizziness, ringing in the ears, and anxiety in both men and women, and heartburn, nausea, chest tightness, swollen limbs, getting up to urinate at night, and sleep disturbance in women alone. The likelihood of having headaches increased greatly with the number of poor health conditions reported.
Table 3

Relationship between having headaches and other poor health conditions in men

 

Men

Other poor health conditions

Age-adjusted model

Multivariate model*

Absent

Present

N

Proportion of headache sufferers (%)

N

Proportion of headache sufferers (%)

OR

95%CI

P

OR

95%CI

P

Other poor health conditions

 Poor appetite

5,849

5.3

58

19.0

3.76

1.91–7.41

0.0001

   

 Weight loss

5,654

5.4

253

5.9

1.10

0.64–1.88

0.7360

   

 Feeling of food sticking in the throat

5,813

5.3

94

14.9

3.71

2.07–6.67

<0.0001

   

 Upper abdominal pain

5,799

5.1

108

20.4

4.77

2.93–7.77

<0.0001

1.81

1.02–3.21

0.0435

 Lower abdominal pain

5,819

5.2

88

20.5

4.99

2.91–8.56

<0.0001

2.48

1.32–4.67

0.0047

 Easy fatigability

5,038

3.9

869

14.2

3.65

2.87–4.65

<0.0001

2.20

1.68–2.88

<0.0001

 Heartburn

5,648

5.0

259

13.9

3.52

2.41–5.13

<0.0001

   

 Heavy feeling in the stomach

5,556

4.8

351

14.3

3.27

2.36–4.53

<0.0001

1.80

1.25–2.59

0.0017

 Chest tightness

5,757

5.1

150

16.0

3.65

2.31–5.76

<0.0001

   

 Lower back pain

4,621

4.2

1,286

9.6

2.68

2.11–3.40

<0.0001

1.86

1.44–2.41

<0.0001

 Numbness

5,513

5.2

394

7.6

1.81

1.22–2.69

0.0035

   

 Palpitations/shortness of breath

5,626

4.9

281

16.0

4.35

3.07–6.16

<0.0001

1.84

1.23–2.76

0.0033

 Edema

5,710

5.1

197

14.7

3.44

2.27–5.22

<0.0001

   

 Tremor

5,847

5.3

60

16.7

3.78

1.88–7.59

0.0002

   

 Loss of energy

5,394

5.3

513

6.8

1.76

1.21–2.56

0.0032

   

 Limb pain

5,703

5.1

204

12.8

3.24

2.10–5.01

<0.0001

   

 Dizziness

5,681

4.7

226

23.5

6.83

4.87–9.58

<0.0001

3.25

2.21–4.78

<0.0001

 Cough/sputum

5,225

5.1

682

7.9

1.75

1.29–2.38

0.0004

   

 Bloody sputum

5,892

5.4

15

20.0

4.81

1.33–17.38

0.0165

   

 Nausea/vomiting

5,844

5.2

63

20.6

4.18

2.23–7.84

<0.0001

   

 Ringing in the ears

5,509

4.9

398

11.8

3.41

2.43–4.79

<0.0001

1.82

1.24–2.68

0.0023

 Bloody stools

5,821

5.3

86

12.8

2.73

1.43–5.23

0.0024

   

 Urination during the night

5,569

5.4

338

6.2

1.84

1.14–2.98

0.0131

   

 Anxiety

5,452

4.8

456

12.5

2.67

1.97–3.63

<0.0001

1.43

1.01–2.02

0.0449

 Sleep disturbance

5,458

5.0

449

10.9

2.28

1.65–3.15

<0.0001

   

Number of other poor health conditions

 0

  

2,448

1.8

1.00

Referent

    

 1

  

1,453

5.5

3.49

2.39–5.10

    

 2

  

929

7.4

4.96

3.35–7.34

    

 3

  

501

6.8

4.67

2.93–7.43

    

 4–5

  

405

12.6

10.01

6.52–15.36

    

 6 or more

  

171

24.6

24.28

15.10–39.02

    
     

P < 0.0001 for trend

    

* Variables were selected by a stepwise procedure with P < 0.05 for entry and removal; age was forced to enter into the model (OR for age was not shown)

Table 4

Relationship between headaches and other poor health conditions in women

 

Women

Other poor health conditions

Age-adjusted model

Multivariate model*

Absent

Present

N

Proportion of headache sufferers (%)

N

Proportion of headache sufferers (%)

OR

95%CI

P

OR

95%CI

P

Other poor health conditions

 Poor appetite

7,004

15.1

72

25.0

1.75

1.02–3.00

0.0416

   

 Weight loss

6,870

15.1

206

17.0

1.20

0.83–1.74

0.3370

   

 Feeling of food sticking in the throat

6,926

14.9

150

29.3

2.47

1.72–3.54

<0.0001

   

 Upper abdominal pain

6,920

14.7

157

36.3

3.37

2.41–4.70

<0.0001

1.66

1.13–2.43

0.0097

 Lower abdominal pain

6,801

14.5

276

32.3

2.68

2.06–3.48

<0.0001

1.35

1.00–1.83

0.0470

 Easy fatigability

5,643

11.7

1,441

29.4

3.05

2.65–3.52

<0.0001

1.73

1.47–2.04

<0.0001

 Heartburn

6,784

14.6

292

29.8

2.85

2.18–3.71

<0.0001

1.38

1.01–1.89

0.0437

 Heavy feeling in the stomach

6,454

13.8

628

30.6

2.80

2.33–3.37

<0.0001

1.54

1.24–1.92

<0.0001

 Chest tightness

6,836

14.5

240

35.4

3.41

2.59–4.49

<0.0001

1.56

1.14–2.15

0.0062

 Lower back pain

5,344

12.1

1,740

25.1

2.52

2.20–2.89

<0.0001

1.70

1.47–1.98

<0.0001

 Numbness

6,542

14.4

541

25.7

2.29

1.86–2.82

<0.0001

   

 Palpitations/shortness of breath

6,607

14.0

472

32.8

3.30

2.68–4.06

<0.0001

1.48

1.16–1.88

0.0014

 Edema

6,273

13.8

808

26.5

2.19

1.84–2.60

<0.0001

1.31

1.08–1.59

0.0061

 Tremor

7,007

15.0

69

34.8

3.03

1.83–5.01

<0.0001

   

 Loss of energy

7,015

15.0

61

32.8

3.01

1.75–5.17

<0.0001

   

 Limb pain

6,698

14.7

380

24.7

2.23

1.74–2.86

<0.0001

   

 Dizziness

6,365

12.9

713

36.2

3.89

3.28–4.61

<0.0001

2.08

1.71–2.52

<0.0001

 Cough/sputum

6,598

15.0

479

18.2

1.34

1.05–1.70

0.0197

   

 Bloody sputum

7,067

15.2

9

22.2

1.79

0.37–8.68

0.4713

   

 Nausea/vomiting

6,964

14.7

113

47.8

5.11

3.51–7.45

<0.0001

2.16

1.41–3.30

0.0004

 Ringing in the ears

6,446

13.7

632

30.4

3.05

2.53–3.68

<0.0001

1.66

1.34–2.05

<0.0001

 Bloody stools

7,028

15.1

49

26.5

2.06

1.08–3.91

0.0273

   

 Urination during the night

6,868

14.8

209

29.2

2.88

2.10–3.94

<0.0001

1.76

1.25–2.49

0.0014

 Anxiety

6,083

13.6

997

25.4

2.15

1.83–2.53

<0.0001

1.21

1.01–1.46

0.0411

 Sleep disturbance

6,350

14.0

730

25.6

2.25

1.87–2.70

<0.0001

1.29

1.05–1.58

0.0165

Number of other poor health conditions

 0

  

2,494

5.3

1.00

Referent

    

 1

  

1,813

13.5

2.87

2.29–3.58

    

 2

  

1,085

18.1

4.10

3.24–5.18

    

 3

  

709

20.7

4.83

3.75–6.23

    

 4–5

  

637

30.9

8.72

6.82–11.15

    

 6 or more

  

338

47.0

17.71

13.37–23.45

    
     

P < 0.0001 for trend

    

* Variables were selected by a stepwise procedure with P < 0.05 for entry and removal; age was forced to enter into the model (OR for age was not shown)

Analysis in a multivariate logistic regression model, of which independent variables were selected from all the factors by a stepwise procedure showed that age, self-estimated degree of stress, reported number of additional poor health conditions, and less alcohol consumption were independently related to headaches in both men and women and that the effects of the remaining factors no longer reached significance (Table 5).
Table 5

Multivariate analysis of risk factors for headache

 

Men

Women

Multivariate OR*

95%CI

Multivariate OR*

95%CI

Age (year)

 20–29

1.00

Referent

1.00

Referent

 30–39

0.63

0.39–1.01

0.63

0.39–1.01

 40–49

0.42

0.26–0.67

0.42

0.26–0.67

 50–59

0.31

0.19–0.49

0.31

0.19–0.49

 60–69

0.19

0.10–0.35

0.19

0.10–0.35

 70–79

0.36

0.08–1.60

0.36

0.08–1.60

 

P < 0.0001

 

P < 0.0001

 

Stress

 Very high

3.71

1.28–10.77

1.75

0.94–3.25

 Somewhat high

2.41

0.86–6.72

2.23

1.24–4.03

 Average

1.70

0.62–4.68

1.66

0.93–2.97

 Low

1.81

0.62–5.34

1.42

0.75–2.69

 Little or none

1.00

Referent

1.00

Referent

 

P = 0.0010

 

P = 0.0003

 

Number of other poor health conditions

 0

1.00

Referent

1.00

Referent

 1

3.32

2.27–4.86

2.74

2.19–3.43

 2

4.23

2.83–6.32

3.85

3.03–4.88

 3

4.07

2.53–6.54

4.50

3.47–5.82

 4–5

7.82

5.00–12.24

7.87

6.11–10.14

 6 or more

17.68

10.66–29.34

15.78

11.75–21.18

 

P < 0.0001

 

P < 0.0001

 

Alcohol drinking

 Non-drinker

1.00

Referent

1.00

Referent

 Less than 1 unit/day

0.80

0.60–1.08

0.79

0.67–0.93

 1 to less than 2 units/day

0.61

0.43–0.87

0.69

0.53–0.91

 2 to less than 3 units/day

0.59

0.39–0.91

0.37

0.20–0.68

 3 units/day or more

0.40

0.25–0.63

0.50

0.26–0.96

 

P = 0.0004

 

P < 0.0001

 

* Variables except age were selected by a stepwise procedure with P < 0.05 for entry and removal

P values are for homogeneity among the subcategories of each factor

Discussion

This cross-sectional large survey of headaches in a Tokyo population showed that men and women shared several factors associated with headache, but that women were much more susceptible to headaches. A multivariate analysis demonstrated that age, self-estimated degree of stress, reported number of comorbid poor health conditions, and less alcohol consumption were independently related to having headaches in both men and women. Since we used a simple questionnaire to ask subjects to indicate if the item “I have headaches” applied to them, it is impossible to classify the types of headaches in this study. One of the authors (M.Y.), a board-certified neurologist, informed the workers of a Tokyo company about the results of the health checkup and interviewed all 99 workers (29 men and 70 women aged 20–59 years; 7.0% of the present headache sufferers) who had replied that the questionnaire item “I have headaches” applied to them during the health checkup. Based on the information obtained during the interview, the author classified their headaches according to the International Classification of Headache Disorders, 2nd edn (ICHD-II) [7]. Migraine was diagnosed in 67% of them, tension-type headache in 20%, migraine with tension-type headache in 11%, and unspecified in 3%. The proportion of the subjects of this study who reported headaches was 5.4% of men and 15.4% of women. Large Japanese population-based studies have reported migraine headaches in 2.3–3.6% of men and 9.1–12.9% of women [8, 9], and the distribution of the subjects with headaches according to age in the present study was similar to that of the subjects who had migraine in these studies. Although we did not ask the time frame of the headache, these findings suggest that chronic headache sufferers tended to report that the item “I have headaches” applied to them and that a high proportion of the headache sufferers in our study had migraine. The subjects in this study consisted of workers or residents of Tokyo or neighboring areas, who had received an annual health checkup and who were more likely to be middle-aged women, probably in the middle-to-high socioeconomic bracket. These background factors at least partially explain the somewhat high headache prevalence in the subject population.

We confirmed that stress is a major precipitating factor of headaches, a finding consistent with the results of previous cross-sectional studies [10, 11] and a recent prospective study [12]. The present study also demonstrated a stepwise inverse relationship with ability to relieve stress as well as a positive association with stress level in both men and women. The two self-estimated aspects of stress had the greatest impact of all of the factors associated with having headaches in this study. Although in contrast to other quantifiable variables, self-estimated classification of stress may differ between men and women, the association between stress and headache was stronger in men than in women.

Previous studies have shown an association between the occurrence of headaches and the presence of pain elsewhere in the body [3, 4]. The present study demonstrated that headache sufferers not only tended to complain of other pain, but to report a variety of poor health conditions, and that having headaches was clearly associated with the number of poor health conditions in a stepwise fashion in both men and women. Increasing numbers of other painful areas [4] and combinations of chronic musculoskeletal complaints, gastrointestinal complaints, and psychiatric symptoms [13] have been reported to have a greater impact on the likelihood of headache occurrence. Whether the association is causal or the poor health conditions and headache share common background factors are topics for future research. However, since the comorbid conditions were all self-reported in a questionnaire, some of the strong associations between headache and poor health conditions may have been partly influenced by a tendency to answer all questions regarding complaints in a similar way (“reporting bias”) [13]. Further study is needed to clarify the associations by assessing the comorbid conditions in a more objective way.

The present study demonstrated an inverse dose–response relationship between headaches and alcohol consumption in both men and women. Previous data for the association have been less clear [4, 911, 14, 15], but a large population-based cross-sectional study in Norway showed a tendency for the prevalence of headache to decrease with increasing alcohol consumption [16], and another large population-based cross-sectional study in the Netherlands showed that migraine sufferers were less likely to consume alcohol [17]. A recent prospective analysis of migraine sufferers in Austria showed that consumption of beer reduced the risk of headache and migraine, as well as the risk of headache persistence [12]. Our findings are consistent with the results of these studies. In the Norwegian study only 3% of the subjects reported drinking >14 standard units of alcohol per 2 weeks, whereas in our study 48% of the men and 12% of the women reported drinking ≥22 g ethanol per day. The drinking behavior of the Japanese is strongly governed by the Asian genetic polymorphism of ALDH2. ALDH2 genotyping among a subgroup of the present study population showed a much higher frequency of ALDH2-deficient individuals among the non/rare drinkers than the drinkers (75 vs. 33% of the men and 57 vs. 20% of the women). ALDH2-deficient individuals are more sensitive to alcohol flushing responses [18] and hangover [5, 6], in both of which headache is a major symptom. Intake of alcoholic beverages has been reported to be an aggravating factor of headache [4], especially migraine [19] and cluster headache [20]. Individuals with migraine have a higher risk of delayed alcohol-induced headache than those without it [21]. Possible mechanisms by which alcohol induces headache [22, 23] include a vasodilatory effect on the intracranial vasculature, altered cytokine pathways [24], endocrine and immune system disturbance, toxic effects of congeners, and acetaldehyde-mediated changes [5, 6, 18]. Japanese headache sufferers with inactive ALDH2 may be more vulnerable to severe alcohol-induced or hangover headache, than those without inactive ALDH2, and must avoid alcohol drinking. Another possible explanation of the inverse association between headache and alcohol drinking is related to the development of tolerance for headache in drinkers. Habitual drinking leads to the development of tolerance for alcohol-induced headache [6], which may affect the mechanisms by which common headaches occur. Third, non-drinking may influence other lifestyle factors associated with headache, since alcoholic beverages serve as a stress reliever or sleep aid in some persons. Further in-depth study of the association between headache classification and drinking habit is needed.

Furthermore, possible interactions between the ALDH2 genotype, alcohol consumption, and headache prevalence in Japanese subjects may differ according to the headache classification. We have developed a screening test for inactive ALDH2 that consists of the following two questions about current and past facial flushing: (1) Do you have a tendency to flush in the face immediately after drinking a glass (approximately 180 ml) of beer? (2) Did you have a tendency to flush in the face immediately after drinking a glass of beer during the 1st to 2nd year after you started drinking? When current or former flushing individuals were assumed to have inactive ALDH2, both the sensitivity and specificity of the test were approximately 90% among both Japanese men and women 40 years of age or more [25]. We are now conducting a large cross-sectional study in Tokyo workers by using the simple flushing questionnaire, a drinking questionnaire, and a headache questionnaire designed to diagnose headache type according to the ICHD-II criteria.

An inverse association between headaches and walking/exercise was observed in the present study, and the strength of association was somewhat greater in men than in women and was most prominent among the subjects who reported a walking/exercise frequency of “2 days/week”. A study conducted in Denmark reported a significant association between low physical activity and tension-type headache in men, but not in women or in subjects with migraine [10]. Physical activity influences several factors, including stress, stress release, muscle strength, and prostaglandin and hormone levels [26], and further epidemiological and mechanistic studies are required. In our study, both less sleep and excessive sleep in men and less sleep in women were positively associated with having headaches, findings consistent with those of previous studies [27, 28].

In conclusion, although women were more susceptible to headache, Japanese men and women in Tokyo shared factors associated with headache, including age, stress, having other poor health conditions, alcohol consumption, sleep, and exercise.

Declarations

Conflict of interest

None.

Authors’ Affiliations

(1)
Mitsukoshi Health and Welfare Foundation
(2)
Department of Human Resources Development, National Institute of Public Health
(3)
National Hospital Organization Kurihama Alcoholism Center

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