Primary headache disorders susceptibility is associated with fasting-related headache: Evidence from a multinational study across 14 countries

Abstract

Background: Fasting-related headache has traditionally been attributed to dehydration, caffeine withdrawal, and sleep disruption, but pre-existing primary headache disorders may also play an important role in determining susceptibility. Objectives: To determine the prevalence, clinical characteristics, and predictors of headache during Ramadan fasting and to explore the relative contribution of pre-existing primary headache disorders and the lifestyle-related factors assessed in this study to headache occurrence during fasting. Methods: In this multinational cross-sectional survey across 14 countries, adults (18–65 years) observing Ramadan fasting completed a 17-item questionnaire. Headache during Ramadan was the primary outcome. Classification and regression tree (CRT) modelling were used to identify predictors and characterize fasting related headache. Results: Headache attacks occurred mainly in the afternoon/pre-iftar period and improved after iftar in 54.6% of cases. Pre-existing primary headache disorders, particularly migraine, were more strongly associated with headache occurrence within the exploratory CRT model than the lifestyle variables assessed in this study. Conclusion: Fasting-related headache is highly prevalent and is influenced by both lifestyle-related factors and underlying headache susceptibility. A history of primary headache disorders was strongly associated with headache occurrence during Ramadan fasting, highlighting the importance of considering individual headache history alongside fasting- related exposures when assessing vulnerability.