Development and Validation of Scale of Psychosocial Issues for Patients With Migraine

The current study was intended to develop and explored psychosocial issues of migraine patients in Pakistani culture context. In first phase of scale development, 16 participants were interviewed individually with inclusion criteria of diagnosed migraine history, aged 18-35 years generating an item pool of 44 psychosocial issues experienced by them. After 13 experts’ validation, 36 items were finalized and piloted on 10 participants. To determine psychometric properties of scale, PSI was presented along with demographic sheet to 160 migraine patients (41 men and 119 women). Exploratory factor analysis of PSI clustered total of 34 items into three factors named as Functional Impairment, Mental Exhaustion, and Somatic Problems. PSI was found to have high internal consistency .92, test-retest reliability .80, split-half reliability .86 and .85, and acceptable convergent validity. Moreover, results are discussed in context of factor structure of PSI, demographics and risk factors as predictors of PSI in cultural context.

Migraine is a significant health issue in both industrialized and developing countries. It is currently regarded as a significant public health burden on society, ranking as the world's 19th most serious health condition. It has had a substantial impact on daily activities, resulting in acute and temporary disability concerns (Stark et al., 2013). Globally, migraine accounted for 16.3% of the attributable disability-adjusted life-years lost worldwide in 2016 as a result of neurological illnesses, making it the second highest contributor (Feigin et al., 2019). Between 1990 and 2019, the age-standardized prevalence of migraine grew by 1.7% worldwide. According to Bonafede et al., (2018), individuals with migraine had a much higher economic burden in the United States than those without the condition. Migraine pain predominates in 47% of cases, followed by migraine in 10%, TTH in 38%, and chronic headache in 3%. The lifetime prevalence of headaches is higher, as expected: 66% of people reported having a headache, 14% migraine, 46% TTH, and 34% chronic headache (Puledda et al., 2017 ). Women had three times the frequency of migraines as males, according to previous studies (Peterlin et al., 2011). Migraine is a prevalent neuro-degenerative illness that affects up to 6% of men and 18% of women, with the maximum prevalence occurring between the ages of 25 and 55 years.
Each year, migraine headaches affect over one billion individuals globally, making it one of the most common neurological disorders, with higher frequency and morbidity, specifically in women and young adults. Co-morbidities associated with migraine include anxiety, insomnia, and suicidal ideation and actions. Many biological and social risk factors, such as hormonal irregularities, genetic and epigenetic changes, neurological, immunological, and cardiovascular disorders, have been hypothesized as causes of migraines due to the complex and mostly unknown processes behind their development (Amiri et al., 2022). A migraine is a neurovascular illness marked by recurring bouts of fair to rigorous headaches, commonly one-sided, exacerbated by corporal exertion, and frequently accompanied by an unsettled stomach, queasiness, light, and sound sensitivity (Olesen, 2018). Furthermore, it is said to be a chronic disorder with episodic manifestations, which means that while a person has the condition all of the time, attacks can happen at any time. Migraine is comprised of a constellation of symptoms and diagnosis is based on several criteria. Headache is usually the main symptom and can last from 4 to 72 hours. The headache is usually unilateral (one-sided) and pulsating, and it is made worse by movement or activity, such as walking upstairs (Puledda et al., 2017).
Migraine is caused by the commencement of meningeal perivascular pain fibers and enhanced sharpening of central pain neurons, which progress the information from intracranial structures as well as extra-cranial skin and muscles. A migraine attack can occur by a variety of inner and outer factors. Any sort of tension, changes in weather, exhaustion, specific food items, sleep disturbance, keeping oneself hungry for a long time, and menstruation are all major triggers (Jain et al., 2020). The phenomenon of migraine can be best understood by the bio-psycho-social model. In the clarification of disease/condition, the bio-psycho-social model can be characterized as considering the multiple directional interactions between genetic (physical), mental (behavioral and emotional), and societal (environmental) components. The bio-psycho-social model describes humans as having an intricate interplay of biological predispositions, psychological characteristics, and social relationships (Thomas et al., 2019).
In terms of biological components of migraine, the pathophysiology of migraine is the disorder's genetic nature. Many patients have first-degree relatives who also suffer from migraines, as evidenced by clinical practice. Migraine transmission from parents to children has been reported since the seventeenth century, and various investigations have found a favorable family history (Goadsby, 2012). According to a study the progression of migraine headaches may lead to changes in baseline neurologic function between episodes of headache which can be seen in electrophysiological and functional imaging studies, while the psychological factors of migraine include an increase in depression, anxiety, fatigue and affected quality of life (Lee et al., 2018).
Similarly, according to the study of Lehrer and Murphy (2009) patients with more severe headaches such as Tension-Type Headaches and Migraine Headaches are found to be emotionally and autonomically vulnerable to pain and psychological stress. Chronic headaches have been associated with perceived stress, somatic anxiety, fear, and avoidance disorders, and headache frequency influences the association between pain and pain tolerance. Research findings of Sefat et al. (2019) explained that people with migraine issues reported poor wellbeing; they had also expressed dissatisfaction with their inability to regulate their emotions. They usually find it difficult to tolerate stress at that time because of the pain and according to the study, their overall living, as well as daily activities, gets affected resulting in chronic discomfort. A study done by Hassan et al. (2022) reported significant psychosocial problems in their findings that are associated with migraine resulting in considerable loss of work hours, productivity, and quality of life, culminating in a health burden and significant cost.
Psychosocial issues are psychological characteristics of people or their social circumstances that play a significant role in the beginning, course, intervention, or management of an illness. Most modern research investigate psychosocial variables using a Vulnerability-Stress Model (Demke, 2022) in which behavioral markers of personal susceptibility are investigated in the setting of intra-familial and
extra-familial environmental stresses.
Psychosocial difficulties are mental function deficits, activity restrictions, and contribution margins that affect social contacts, such as at work, in the family, and leisure activities, as well as everyday activities, such as those related to the daily routine, schoolwork, or mobility (George et al., 2021). These challenges are accountable for the personal and socioeconomic cost of migraine, it's critical to recognize and comprehend the influence of the elements that cause the start and progression of psychosocial difficulties. The psychosocial difficulties associated with migraine are implicit in the requisites of the bio-psycho-social model found in the international classification of functioning, disability, and health.
A study done by Razzak et al. (2023) highlighted the risk factors of migraine headache among Pakistani population which includes stress, extreme physical activities, and menstruation. Surprisingly, many of the migraine sufferers were not aware of the fact that stress was the major trigger factor for their migraine headache. So, this present study will also give the insight and psycho educate them regarding the trigger factor of migraine in their case and how in future they could avoid frequent migraine attacks.  According to the study by Raggi et al. (2012) migraine is a burdensome condition, and migraine patients encounter a variety of psychosocial issues, including arousing troubles, decreased energy, throbbing, and greater than before powerlessness, work-related problems, and psychological and bodily health issues. Dysfunctioning related to migraine is directly proportional to its severity, affecting areas of performance such as the transmission of messages, agility, self-preservation, social involvement, and interpersonal connections (Leonardi et al., 2010) and with family members are particularly affected. According to another study by Raggi et al. (2012) tribulations with motivation and function of driving, poignant responses, and pain awareness, difficulty with remunerative occupation; basic assessments of psychological and somatic wellbeing, interaction with people, and disability assessments on a global scale were among the psychosocial problems indicated by the participants.
A study done by Lebedeva et al. (2017) highlighted many psychosocial issues migraine patients suffer from in their study and those issues were dissatisfaction with school and family life, poor financial status, stress, overwork, insufficient or interrupted sleep, depression, anxiety, impatience, and a proclivity for conflict. In general, many of the psychosocial challenges that a migraine patient faces are also prevalent in our culture. In addition, most of the difficulties described above were commonly addressed in our culture, as evidenced by the initial interviews conducted with migraine patients. Similarly, these psychosocial problems can lead to severe interpersonal difficulties later.
The global burden of migraine study conducted by Gooch et al. (2017) stated that migraine results in considerable loss of work hours, productivity, and quality of life, diminished social activities and work capability culminating in a health burden and significant cost, resulting in interpersonal issues among migraine patients. The purpose of the current study is to investigate the psychosocial issues reported by migraine patients and secondly to develop a consistent and accurate scale for measuring different psychosocial problems/issues reported by migraine patients. Many of the migraine assessment related indigenous research done up till now were related to the triggers, prevalence, and predictors of the problem (Anwar et al., 2021), there is little to no work done to investigate/assess the psychosocial problems migraine sufferers experience. So, the aim and the purpose of the present study was also to find out all the psychological and social factors a migraine patient has to face while having a migraine attack. The study is significant because it will assist increased awareness and open the door for more research on migraine, as there aren't many research articles on the subject in Pakistan.

Method

Snowball sampling strategy was used to collect the data from the target population. The sample was selected from both general and clinic/hospital settings. Diagnosed migraine patients were reached out to conduct the present study. The scale development comprised of four steps beginning from item generation which was done after taking detailed interviews of migraine sufferers and their responses were converted in the form of items. Later those items were provided to the experts for their validation and then a tryout was done to see the reliability and validity of the scale.  

Phase I: Item Generation

To explore phenomenology of psychosocial issues of migraine patients in Pakistani culture, the experiences of migraine patients were explored through a phenomenological approach by taking 16 semi-structured in-depth interviews. Interviews were solely conducted in-person. The sample included 5 men and 11 women participants with diagnosed migraine history and their age range was 18-35 years
(M = 23.84, SD = 3.64). All participants were approached through personal acquaintances via non-probability snowball sampling technique.
The phenomenological question was asked that “What kind of problems/difficulties do you usually experience during a migraine headache?” After exploring phenomenology, 44 items were made based on participants verbatim and those vague and ambiguous, seeming somewhat colloquial or slangy, and imprecise were removed from the list of exact words even after participant explanation. Some of the repeated and overlapped items were merged to make one appropriate statement. In this manner, 44 items were finalized after first phase of scale development.

Phase II:  Subject Matter Experts

In this section, the final list of the items, generated in the item generation phase was sent to 13 experts for the rating of items on the degree of their relevance to the desired construction 0-5 Likert type rating scale where 0 means strongly disagree and 5 means strongly agree. The majority of the experts rated items on 4 or 5. Based upon rating of 13 experts including doctors, clinical psychologists, and a health psychologist, few items were molded and a final of 36 items were retained. After expert validation, the final list of scale items was transformed into 4-point rating scale (0-4) and named as Psychosocial Issues Scale.  

Phase III: Pilot Study

The scale finalized in expert validation phase, was administered on 20 migraine patients both men and women participants as trial phase to check language difficulty, statement’s understanding level, and queries. The participants reported no queries; therefore, the scale was finalized.

Phase IV: Main Study

The main study was carried out to assess psychometric properties of PSI.

Participants

The sample was comprised of 160 migraine patients (41 men and 119 women) of Lahore with age range of 18-35 years (M = 23.84,
SD = 3.64) and the participants included in the study were those with a diagnosed migraine history, having at least one migraine attack in a month. The participants were instructed to fill in the questionnaires; all participants were approached through personal acquaintances by using non-probability snowball sampling technique.   

Measures

Scale of Psychosocial Issues

A newly developed indigenous scale PSI in Urdu Language was used for measuring the psychosocial issues of migraine patients. PSI scale was comprised of 34 statements on 4-point rating scale reflecting theme of psychosocial difficulties during migraine attack. The guidelines of PSI scale were, “The following statements reflect the problems faced by migraine sufferers. Please read these statements carefully and state to which extent it applies to you”. The scoring options included (0) not at all, (1) a little, (2) to some extent, and
(3) very much. A high score represented more psychosocial issues a migraine patient experienced. The scale items reflect the dysfunctioning of daily activities due to migraine headache including unable to concentrate on work and finish tasks on time, avoid travelling and going to crowded places, repetition of disturbing thoughts in the mind, and getting irritated easily.

Subscales of Interpersonal Difficulties Scale

Saleem et al. (2014) developed Interpersonal Difficulties Scale. In the present study it was used to establish convergent validity. It is a 61-item scale with 6 factors, which included dominant by others, low self-confidence, mistrust, lack of assertiveness, lack of boundaries, and unstable relationships to be rated on 5-point rating scale. For the present study, two factors of Interpersonal Difficulties Scale that is lack of assertiveness and unstable relationships by taking 14 items were used.  The Cronbach’s Alpha ranges from .71 to .93 showing that the scale is found to have high internal consistency.

Procedure

Initially institutional approval was obtained from the director to carry out the study. After that data was collected through snowball sampling technique. Furthermore, Google Form was also prepared. Data was gathered both online and through one-to-one administration with participants in university settings, private clinics, from government and private hospitals, family, friends, and their recommended participants through chain of references. The participants were inducted to fill out the questionnaires after reading each statement thoroughly. The participants were briefed regarding the purpose of the study. Confidentiality and privacy were guaranteed both during and after the study. The questionnaire booklet was given to the participants who consented to participate, and they were advised that they might withdraw from the study at any moment. Researchers read statements to participants if they were having trouble understanding the questions. Following data collection, SPSS 25 version was used to analyze all the data.

Results

Exploratory Factor Analysis

Exploratory factor analysis (EFA) of PSI was done for refining, identifying, and meaningfully finding underlying factors of PSI. Scree Plot was used to explore the factor structure of PSI. Principal component analysis with Promax rotation and scree plot were used to explore the factor structure of the scale. Criteria that Eigen value should be more than one and every factor must include a minimum of 5 items were used for determining factors.

Factor Analysis of Psychosocial Issues

Factor Analysis of indigenous developed PSI was done for identifying the findings of underlying factors of data so that an explicit and significant explanation of data can fall out. Furthermore, factor analysis also identifies correlations between variables to bind them into underlying factors driving their values and highlight important factors of scale. Initially, Varimax factor rotation was used with both four and three factors on 0.35 and 0.40 factor loading but because of items being interrelated with each other as the items were in the same direction and unclear picture, Promax rotation was done.
From the scree plot, it was analyzed on different factors patterns and loading that tells a graphical representation of Eigen Value of scale factors. From the scree plot factors numbers were assessed that were coming under the elbow of the scree plot of factor loading of 0.35. In addition, from the output of factor analysis, KMO and Bartlett's test were also found to be acceptable as the KMO value was seen as 0.860, and Bartlett's test (.000) was found highly significant.
Figure 1 of the scree plot was used as a graphical tool in the selection of no. of the relevant component of factors in principal axis factoring. The factors were determined with the help of inflection of the scree plot and the number of factors under the elbow was considered to be the total factors. From the scree plot initially exploratory factor analysis on Varimax rotation was carried out on 4 factors firstly with 0.40 factor loading but because of the unclear picture the analysis was again carried out with 0.30 factor loading, but due to dubious values it was not considered, and 3 factors rotation was done with 0.35 factor loading. Again, the picture was not very good and the number of items in 1 factor falls below 5. Therefore, afterwards Promax Rotation was carried out.

Figure 1
Scree Plot Showing the Extraction of Factors of Psychosocial Issues of Migraine Patients

Firstly, it was carried out on four factors with 0.30 factor loading; the picture was good as compared to Varimax Rotation. Just to confirm further, the same analysis was carried out on four factors with 0.35 factor loading but due to the massive number of discarded items and blurred picture it was not considered, and the analysis was repeated on 3 factors with 0.35 factor loading. Hence 3 factor solution with 0.35 factor loading was finalized where only items 1 and 21 were not loaded but a very fine picture of items was seen with only one dubious item (item 12) and a clear reflection of different themes could be comprehended. Therefore, three factors were finalized on 0.35 factor loading.
Table 1 indicated factors patterns and items categories while loading on 0.35. The bold factors highlighted that they were equal and more than 0.35. The indigenous Scale of Psychosocial Issues had 36 items that were loaded on 3 factors whereas two items i.e., 1 and 21 were not loaded as they were discarded.

Factor Description of PSI

The Scale of Psychosocial Issues was based on 3 points Likert scale with rating options as 0 = not at all, 1 = a little, 2 = to some extent and 3 = very much. Factor analysis is a method of refining data and extracting factors of scale.

Table 1
The Factor Analysis of PSI  With Promax Rotation

Note. Factor Loading > 0.35 have been bold faced.

After running factor analysis (Table 1), it was seen that PSI 34 items were loaded in three different factors whereas two items as items 1 and 21 were not loaded on any factor and were discarded. After Factor Analysis, three factors of PSI of migraine patients were comprised of 3 different themes reflecting factors of functional impairment, mental exhaustion, and somatic problems. The details of all the factors are as follows for all the factors:

Table 2
Total Score Range, Categories and Frequencies of Total PSI

The above Table 2 highlights the total score ranges, frequencies, and the categories of the total Scale of Psychosocial Issues for the current study’s participants. The total score ranges have been categorized on three levels with 1 standard deviation above and below method and the table shows that 96 participants fall at the range of severe category out of the total of 160 migraine patients.

Factor 1: Functional Impairment. This factor consisted of 20 items that refer to the limitations brought on by the sickness, since individuals suffering from the disease may not be able to perform certain daily tasks. All the 20 items falling in this factor underlined the key features of isolating oneself, being sensitive to lights, becoming angry, having no energy for doing anything (work), unable to concentrate on work, waste of time being in pain, unable to finish tasks/work on time, getting/feeling irritated by what people say, feeling tired, worsening of pain because of noise, having difficulty opening eyes, acute pain when speaking, daily activities being affected and unable to tolerate pain.  

Factor 2: Mental Exhaustion. This factor consisted of 6 items that refer to the extreme exhaustion accompanied by other emotions including indifference, cynicism, and impatience. If someone has lately experienced prolonged stress, finds it difficult to concentrate, or seems uninterested in activities they typically find enjoyable, they may be mentally weary. All the 6 items falling in this factor underlined the key features of becoming sensitive regarding things and whatever people say, avoiding usage of all types of technology (mobile/ laptop) at that time or while in pain, repetition of disturbing thoughts in the mind, feeling of tingling sensations in the head, the hassle of postponing work and

Factor 3: Somatic Problems. This factor consisted of 8 items that refer to the excessive attention paid to bodily indicators like pain or exhaustion, which results in severe emotional suffering and functional difficulties. All the 6 items falling in this factor underlined the key features of not being able to eat properly, avoiding traveling, feeling nauseous, hunger being affected, crying out in pain, feeling that one eye gets smaller in pain/ blurred vision, can’t stand out with strong smells and feelings of dizziness.

Psychometrics of PSI

To assess the reliability of the PSI, Cronbach’s alpha was used. Table 2 shows Cronbach’s alpha of PSI and subscales that reflect satisfactory internal consistency.

Table 3
Cronbach’s Alpha of Total Score and 34 Items of PSI   

Table 3 reveals that PSI is found to have a high internal consistency. Cronbach’s alpha of the scale has high internal consistency. All the values show high internal consistency of the items within factors in the scale.
To determine the split-half reliability of the Scale of Psychosocial Issues, the odd-even approach was applied. The scale was divided into two halves, the first half (Form A) was comprised of 17 items while the second half (Form B) was also comprised of 17 items. The results indicated that the split-half reliability of the Scale of Psychosocial Issues was also very high. The internal consistency of form A was .86 and of form, B was .85. These significant values of both forms of the psychosocial issues scale suggested that these could be used individually to measure the psychosocial issues of migraine patients.
To test re-test reliability of PSI, the data on this was collected from the participants after a one-week gap. Ten participants were asked to refill the form. Data were then entered in SPSS. After analysis, the results showed that the test re-test reliability of the scale of the Psychosocial issues was .80** (p < 0.01). The value is showing a highly significant test re-test reliability of the PSI.

Convergent Validity of PSI

To establish the convergent validity of the scale of the psychosocial issues of migraine, it was compared with the already established Interpersonal Difficulties Scale (IDS) developed by Ihsan et al. (2014).   

Table 4
Inter Correlations of PSI and Interpersonal Difficulties Scale

Note. PSI = Scale of  Psychosocial Issues, IDS = Interpersonal Difficulties Scale.
*p < 0.05, **p < 0.01, ***p < 0.001.

Table 4 indicated significantly high correlation with all three factors of the Scale of Psychosocial Issues which is Functional Impairment, Mental Exhaustion, and Somatic Problems with the total scores of Psychosocial Issues also with the total of Interpersonal Difficulties as all the three factors are interlinked with each other and are in the same direction.
Women as compared to men experience more frequent migraine attacks and simultaneously is more likely to face functional impairment, complains about somatic problems and is more vulnerable to be mentally exhausted as compared to men. There was a significant result for gender on all the three factors that is functional impairment, (t = -1.92, p < .05), mental exhaustion, (t = -2.90, p < .00), and somatic problems, (t = -5.11, p < .00), and total of Scale of Psychosocial Issues, (t = -3.56, p < .000); while the value of equal variance assumed (df) was 158.

Discussion

Psychosocial issues have achieved a lot of importance in clinical and counseling psychology, particularly, when dealing with migraine patients, covering a wide range of ailments that aren't simply medical or somatic. They have an impact on a patient's everyday functioning, his or her surroundings as well as life experiences. According to one perspective, it refers to a wide range of psychological issues which includes anxiety, edginess, uneasiness, (posttraumatic or severe) tension, despair and having a bad mood, burnout, bad temper, disturbed sleep, finding difficulty in recalling, behavioral issues, having difficulty in learning, challenges related to one's life stage, apprehension of psychiatric illness, and relationship issues (with friends, ancestry, and/or spouse). Hence, on the other hand, it is concerned with a variety of social issues such as scarcity/economic troubles, accommodation issues, inadequate nutrition, societal and environmental issues, workplace issues, health-care issues, and academic achievement issues (Joosten et al., 2008).
Migraine is a significant health issue in both industrialized and developing countries. It is a long-term neurological condition that is characterized by headaches and nausea. Women had three times the frequency of migraines as males, according to previous studies
(Allais et al., 2020). Migraine is a common neurological illness that affects up to 6% of men and 18% of women, with the maximum prevalence occurring between the ages of 25 and 55 years. It is currently regarded as a significant public health burden on society, ranking as the world's 19th most serious health condition. Similarly, women experience more psychological and social problems which ultimately lead to frequent migraine attacks.  
According to a multi-country cross-sectional survey research of patients with migraine, the disability and functional impairment associated with the condition interfere with day-to-day living. A strain on interpersonal relationships, challenges in raising children, and missed work or social event days are a few instances of this (Vo et al., 2018). Interestingly, even a mild episode can cause problems with day-to-day activities and frequently necessitate bed rest. Patients with migraines have a lower health-related quality of life than people in general and face several challenges in their daily lives. This is a very common and crippling illness that significantly limits daily activities and has an impact on relational, emotional, and behavioral aspects of life (Corallo et al., 2015) and similar responses were observed by the research participants while exploring the phenomenology in the present study. The said population had mentioned that their daily functioning gets affected due to migraine attacks. They find difficulty performing any task they and not being able to do work, get irritated and angry with others easily, isolate themselves and become sensitive to lights, worsen pain because of noise, and avoid going to crowded places. Students claimed that their academic performance gets affected badly.
In short, the participants responded with a long list of issues they had to face while in a migraine headache. The results of our study are also like the previous literature, as the study found that migraine headache is responsible for the poor quality of life in migraines/ migraine sufferers. It is needed that practitioners must be equipped to manage and treat it effectively and educating sufferers to cope with migraine-triggering factors is very important as they affect their psychosocial life (Lateef et al., 2016; Smitherman et al., 2011). Migraine-related impairment is proportionate to the severity of the headache, affecting areas of productivity such as communication, mobility, self-care, social activity, and interpersonal connections (Leonardi et al., 2010) and with relatives is predominantly high-flown.
In the present study, the most common and frequent psychosocial issues experienced by migraine patients were collected, collated, and transformed into a 5-point self-report PSI for validation. Factor analysis of 36 items revealed three factors namely, Functional Impairment, Mental Exhaustion, and Somatic Problems. The presence of triggers is quite common in migraine patients. The different types of migraine could be due to the same trigger, tension and menstruation were the most common triggers observed in the literature of Zahid et al. (2014) among other triggers like napping, oversleeping, bright light, and menstruation were also common in our study population. The results were well supported by the study done by Kelman (2007) that recorded stress or tension as a common trigger for migraine.
Meanwhile, Rothrock et al. (2009) also reported worry and anxiety to be more common triggers and 59% of the study's participants reported that tension was a frequent migraine attack trigger. Moreover, the work of Neut et al. (2012) showed stress/tension and lack of sleep as the most prevalent triggers for migraine. Contrarily, the findings of Al-Shimmery (2010) reported that the two main causes of migraine in Iraqi Kurdish patients were stress and increasing physical activity. Geographical differences could be the cause of the disparity. Additionally, it was well-known that people with migraine attacks restrict daily activity more than headache sufferers. Regarding the features of the headache, there are several migraine treatment options, such as resting, napping, staying in a dark room, and avoiding light. All the earlier research demonstrates conclusions that are like those of our study. All the above-mentioned issues reported by migraine patients around the globe are like our research findings that psychological and social issues become the trigger for frequent headaches in migraine patients. Unattended and unmanaged psychosocial problems cause increase in interpersonal difficulties and more often migraine attacks.
Most individuals in developing nations like Pakistan are not aware of the right way to manage common headaches, especially migraine. They typically don't seek medical attention when they get headaches, instead prefer to treat them with readily available medications. Frequently, people consult quakes and just buy medications to get rid of their headaches. Once the condition has gotten bad enough and self-medication has failed to relieve the headache, a professional doctor is consulted. Only when a headache limits the patient's daily activities and lasts for an extended period does the patient visit a neurologist (Zahid et al., 2014).
Because of this, the current study's objectives are to develop an insight to the participants/said population regarding the triggers of migraine, as it is very evident from the previous literature too and the findings could be seen in the current study also that many of the participants get migraine attack due to the amount of stress they take. As claimed by the participants during the phenomenology stage that the frequency of migraine attacks is associated with the amount of stress. The study aimed to psycho-educate migraine patients to seek management and treatment regarding stress initially instead of taking painkillers and trying to get rid of the pain temporarily. This behavior results in less frequent attacks of migraine. Prior studies revealed that people who are in the productive stage of their aging process have migraines. A study done by Murtaza et al. (2009) revealed that people between the ages of 21 and 30 years of experience migraines quite frequently and the study findings are very similar to our research results.

Limitations and Suggestions

As the participants who were approached in the current study were mostly from one city and the data was not gathered from different cities of Punjab, as a result the researcher could not approach a large sample that might influence generalizability and stability of factor structure. It is suggested for future research to take a large sample size from different cities of Pakistan so that trigger factors of migraine headache should be studied in detail. 

Implications

The implication of the current study is significant for development of indigenous scale of psychosocial issues of migraine in our culture to explore the participants subjective experiences related to migraine attacks/headaches in our culture. It highlights the root causes/ reasons/trigger factors of migraine attacks among patients in our culture as manifested and reported by participants and how they are different from western regions. This tool may help the participants to figure out the root causes/triggers of migraine headache specifically in their case. The results of the current study would be valuable for the practitioners, doctors, counselors, and therapists to raise awareness and promote psycho-education through workshops and seminars, and investigate the psychosocial aspects of migraines in our society as a preventative measure.

Conclusion  

Present research has played a vital role by developing an indigenous scale on psychosocial issues of migraine in context of Pakistani culture to help the patients understand the subjective nature of the headache, risks, and predictors of psychosocial issues of migraine organized in 3-factors like functional impairment, mental exhaustion, and somatic problems and all these factors had strong correlation with interpersonal difficulties that emphasized future studies to work on as primary prevention step. Furthermore, PSI can be used in clinical setup while dealing with migraine patients for assessing their problems.   

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Received 16 March 2023
Revision received 17 January 2024