Ramadan fasting in smokers with primary headache disorders: Impact of nicotine dependence on headache frequency and severity

Background Nicotine withdrawal has not been studied before as a contributing factor for headache exacerbations during Ramadan. Therefore, we aimed to explore the impact of smoking status and nicotine dependence on the frequency and severity of primary headache disorders during fasting. Methods This prospective cohort study with pre–post comparisons was conducted on male smokers and nonsmokers with primary headache disorders. The patients were recruited from four headache clinics in three Egyptian governorates: Cairo, Beni‐Suef, and Fayoum at the beginning of Shaaban. The patients were hand‐delivered a questionnaire containing questions targeting the last week of Shaaban and another one targeting the first week of Ramadan. Participants were instructed to resubmit their completed questionnaires electronically at the end of the first week of Ramadan. The number of headache days (NHDs), Visual Analog Scale (VAS), and Headache Impact Test‐6 (HIT‐6) scores, as well as the Depression, Anxiety, and Stress Scale‐12 items (DASS‐12) scores, were compared during the first week of Ramadan to those during the last week of Shaaban. Intensity of nicotine dependence was assessed by the Fagerstrom Test for Cigarette Dependence (FTCD). Results This study included 1023 males with primary headache disorders (400 smokers and 623 never‐smokers). During the last week in Shaaban, smokers were found to have significantly higher NHDs, HIT‐6 total, and DASS‐12 scores than the never‐smoked group (2 [1–3] vs. 1 [0–3], p = 0.001; 58 [50–63] vs. 56 [46–63], p = 0.021; and 16 [7.25–22] vs. 10 [2–18], p < 0.001, respectively). The changes in NHDs, VAS, HIT‐6, and DASS‐12 scores during the first week of Ramadan were significantly higher in smokers than in the never‐smoked group (0 [0–2] vs. 0 [0–1], p = 0.003; 0 [0–2] vs. 0 [0–1], p = 0.001; 1 [−1 to 5] vs. 0 [−2 to 4], p = 0.008; and 0 [−1 to 2.75] vs. 0 [−2 to 0], p < 0.001, respectively). Moreover, FTCD scores were positively correlated with changes in the NHDs ( r = 0.26, p < 0.001), VAS ( r = 0.28, p < 0.001), HIT‐6 ( r = 0.27, p < 0.001), and DASS‐12 ( r = 0.38, p < 0.001) scores during the first week of Ramadan. Smoking increased the odds of clinically significant worsening in HIT‐6 by 1.44 (95% confidence interval [CI], 1.04–2.01) times. Among smokers, higher FTCD scores and greater change in DASS‐12 increased the odds of worsening by 1.17 (95% CI, 1.05–1.30) and 1.13 (95% CI, 1.07–1.19) times, respectively. Conclusion Current smoking could adversely impact the frequency and severity of primary headaches during the first week of Ramadan, in particular in those with greater nicotine dependence and who experienced higher stress and negative emotions on nicotine withdrawal.