Sexual Dysfunction in Migraine-affected Women: A prospective Cross-Sectional Controlled Study

Abstract

Introduction
Female sexual dysfunction (FSD) is a common health problem that is inadequately investigated in Arabic countries, especially Saudi Arabia.

Aim
To assess the prevalence and trace predictors of FSD in Saudi women who suffered from migraine headaches comparable to healthy women.

Patients and methods
A prospective cross-sectional, controlled study involved 400 Saudi women complaining of migraine (Case Group) and another 400 healthy-looking Saudi women (Control Group) during three months; from January 1st, to March 31st 2023, in Jeddah city, Saudi Arabia. Data was collected by using a pre-structured Female Sexual Function Index (FSFI) questionnaire, Female Sexual Distress Scale (FSDS), Migraine Screen Questionnaire (MS-Q), with an evaluation of the severity of pain by Visual Analogue Scale (VAS), and its impact on daily activity by using both; Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) Questionnaire.

Results
A total of 800 Saudi women were recruited. Their ages ranged from 18 to 45 years old. Women with abnormally low FSFI scores were 375 (93.75 %) out of 400 with migraine and 85 (21.25 %) out of 400 without migraine. The lowest FSFI scores were mainly for desire (2.75 ± 1.05) and arousal domains (3.0 ± 1.12) followed by sexual satisfaction (3.25 ± 1.30) and orgasmic domains (3.5 ± 1.15). The foremost predictive factor behind low FSFI scores and associated FSD in our study was migraine (P < 0.00001). Additional predictors of statistical significance were low educational level (P < 0.01), urban residency (P < 0.02), high parity (P < 0.02), chronic illness such as diabetes (P < 0.01), and bad habits such as smoking (P < 0.03)

Conclusion
A significant correlation exists between migraine and female sexual dysfunction (FSD). Desire and arousal dysfunctions were the most significantly affected domains followed by satisfaction and orgasmic problems.

Full text

EUROX 23 (2024) 100319
Available online 22 June 2024
2590-1613/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-
nc/4.0/).
Sexual dysfunction in migraine-affected women: A prospective
cross-sectional controlled study
Remah M. Kamel
a
,
1
,
*
, Baraatu A. Dantata
b
, Hadiza Halilu
b
, Hafsah M. Ahmed
b
,
Khadijah H. Muzaffar
b
, Nishat T. Maria
b
, Hussain R. Alsadeq
b
a
Professor of Obstetrics & Gynaecology, General Medicine Practice Program, Batterjee Medical College (BMC), Jeddah 21442, Saudi Arabia
b
Medical Interns from the General Medicine Practice Program, Batterjee Medical College (BMC), Jeddah 21442, Saudi Arabia
ARTICLE INFO
Keywords:
Female Sexual dysfunctions
Prevalence and predictors
Migraine headaches
Saudi Arabia
ABSTRACT
Introduction: Female sexual dysfunction (FSD) is a common health problem that is inadequately investigated in
Arabic countries, especially Saudi Arabia.
Aim: To assess the prevalence and trace predictors of FSD in Saudi women who suffered from migraine headaches
comparable to healthy women.
Patients and methods: A prospective cross-sectional, controlled study involved 400 Saudi women complaining of
migraine (Case Group) and another 400 healthy-looking Saudi women (Control Group) during three months; from
January 1
st,
to March 31st 2023, in Jeddah city, Saudi Arabia. Data was collected by using a pre-structured
Female Sexual Function Index (FSFI) questionnaire, Female Sexual Distress Scale (FSDS), Migraine Screen
Questionnaire (MS-Q), with an evaluation of the severity of pain by Visual Analogue Scale (VAS), and its impact
on daily activity by using both; Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS)
Questionnaire.
Results: A total of 800 Saudi women were recruited. Their ages ranged from 18 to 45 years old. Women with
abnormally low FSFI scores were 375 (93.75 %) out of 400 with migraine and 85 (21.25 %) out of 400 without
migraine. The lowest FSFI scores were mainly for desire (2.75 ±1.05) and arousal domains (3.0 ±1.12) fol-
lowed by sexual satisfaction (3.25 ±1.30) and orgasmic domains (3.5 ±1.15). The foremost predictive factor
behind low FSFI scores and associated FSD in our study was migraine (P <0.00001). Additional predictors of
statistical signicance were low educational level (P <0.01), urban residency (P <0.02), high parity (P <0.02),
chronic illness such as diabetes (P <0.01), and bad habits such as smoking (P <0.03)
Conclusion: A signicant correlation exists between migraine and female sexual dysfunction (FSD). Desire and
arousal dysfunctions were the most signicantly affected domains followed by satisfaction and orgasmic
problems.
Background
Human sexual function is an essential element of life, and its
dysfunction affects negatively both males’ and females’ well-being and
interpersonal relationships. Female Sexual Dysfunction (FSD) is a com-
mon illness that can affect women’s mental health with an impact on the
whole family and society.
FSD is an underrated problem with a high prevalence (30–78 %)
affecting women in general [1,2]. It can be classied into four major
ailments namely; desire, arousal, orgasmic, and sexual pain disorders.
Female sexual dysfunction is often multifactorial and differs among
countries. In the United States, the prevalence of sexual dysfunction is
high-up to 63 % among women. It may be associated with advanced age,
low socio-economic level, poor education status, unemployment, as well
as medical and psychological factors. It can be attributed also to past
sexual history (as early sexual experience or early marriage before 18
years old, poor sexual education, exposure to pornographic content,
and/or sexual assaults or violence) [3,4]. Sexual dysfunction also
exhibited a strong correlation with smoking [5], genitourinary in-
fections, sexually transmitted diseases, neuroses [6], multiple sclerosis,
* Correspondence to: 4 Tyndall’s Park road, Clifton, Bristol BS8 1PG, UK.
E-mail address: remah.kamel@bmc.edu.sa (R.M. Kamel).
1
https://orcid.org/0000–0002-9089–5439
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and
Reproductive Biology: X
journal homepage: www.journals.elsevier.com/european-journal-of-obstetrics-and-gynecology-and-
reproductive-biology
https://doi.org/10.1016/j.eurox.2024.100319
Received 10 March 2024; Received in revised form 4 June 2024; Accepted 9 June 2024

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
2
bronchial asthma [7], diabetes type-I, Diabetes type-II [8], infertility,
and pelvic oor dysfunctions [9]. Women’s quality of life is substantially
improved by screening, diagnosing, and controlling associated illness
[10].
In Arab nations, the link of sexual dysfunctions with women has yet
to be investigated, with only a few studies available. This is due to the
Fig. 1. Recruitment Flowchart of Study Population.
Table 1
Female Sexual Distress Scale.
SN Individual Questions Answer’s Options
How often did you feel: ………. Never Rarely Occasionally Frequently Always
1 Distressed about your sex life? 0 1 2 3 4
2 Unhappy about your sexual relationship? 0 1 2 3 4
3 Guilty about sexual difculties? 0 1 2 3 4
4 Frustrated by your sexual problems? 0 1 2 3 4
5 Stressed about sex? 0 1 2 3 4
6 Inferior because of sexual problems? 0 1 2 3 4
7 Worried about sex? 0 1 2 3 4
8 Sexually inadequate? 0 1 2 3 4
9 Regrets about your sexuality? 0 1 2 3 4
10 Embarrassed about sexual problems? 0 1 2 3 4
11 Dissatised with your sex life? 0 1 2 3 4
12 Angry about your sex life? 0 1 2 3 4
13 Bothered by low sexual desire? 0 1 2 3 4
Total Score Range (0-52) 0 13 26 39 52
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European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
3
relatively sensitive nature of the problem, in addition to the religious
scholars’ preferring not to discuss similar issues (sexual conservative
beliefs, or considering sex as sin).
A recent cross-sectional study [2], done in 2019, in Saudi Arabia has
evaluated the female sexual dysfunctions among Saudi women by using
the Arabic version of FSFI (ArFSFI). The study showed 60 % of women
had a risk of sexual dysfunctions with a predictive risk in patients older
than 40 years and those with low family incomes. The most signicantly
affected domains in that study were sexual desire and arousal followed
by orgasmic problems.
On the other hand, headache is one of the most common disorders of
the nervous system and many of its types may lead to considerable levels
of disability as migraine and tension-type headaches. Globally, the
proportion of adults with headaches is 65 %; 42 % for tension-type
headache, 20 % for migraine, and 3 % for chronic headaches [11]. In
Saudi Arabia, the incidence of migraine, in general, is 26.97 %, with
women having three times the frequency of men [12].
Migraine is dened as a unilateral recurrent primary headache often
presented clinically by diverse symptoms, such as throbbing headache,
light sensitivity (photophobia), dizziness, nausea, and/or vomiting, all
of which are not related to any other illness. The risk of facing migraine
increases with age above 16 years old. One study indicated prevalence of
migraine among women is 18.2 %, and only 6.5 % among men. Some
hypothesized the role of sex hormones (mainly Oestrogen) in the path-
ophysiology of migraine which could explain its higher prevalence
among females [12].
The reasons for FSD in women with migraine are not entirely clear,
but it is believed that the pain and discomfort associated (depression and
anxiety) may contribute to sexual dysfunction. Additionally, the use of
migraine medication, such as beta-blockers and antidepressants, can
also cause low libido and vaginal dryness.
A systematic review conducted by El-Metwally A, et al., in 2020 [13],
at the College of Public Health and Health Informatics (CPHHI), Riyadh,
Table 2
Migraine Screen - Questionnaire (MS-Q).
SN Individual Questions
Answer’s
Options
No Yes
1 Do you have frequent or intense headaches? 0 1
2 Do your headaches usually last more than 4 h? 0 1
3 Do you usually suffer from nausea when you have a headache? 0 1
4 Does light or noise bother you when you have a headache? 0 1
5 Does headache limit any of your physical or intellectual
activities? 0 1
Full Scale Score Range 0 5
Table 3
Socio-demographic characteristics of the study participants.
Variables
Sociodemographic Data
Case Group
(With Migraine)
Control Group
(Without Migraine) Chi-Square X
2
P value*
N=400 (%) N =400 (%)
Age (in years)
18 - <25 55 (13.75) 60 (15.0)
1.309 0.86
25 - <30 80 (20.0) 75 (18.75)
30 - <35 160 (40.0) 170 (42.5)
35 - <40 75 (18.75) 70 (17.5)
40 - 45 30 (7.50) 25 (6.25)
Body Mass Index
<18.5 10 (2.5) 12 (3.0)
2.753 0.60
18.5 - 24.9 80 (20.0) 75 (18.75)
25 - 29.9 110 (27.5) 113 (28.25)
30 - 34.9 130 (32.5) 115 (28.75)
≥35 70 (17.5) 85 (21.25)
Education Level*
Primary (G1-6) 20 (5.0) 15 (3.75)
13.55 0.01*
Intermediate (G7-9) 80 (20.0) 75 (18.75)
High school (G10-12) 110 (27.5) 140 (35.0)
University 170 (42.5) 165 (41.25)
Postgraduate 20 (5.0) 5.0 (1.25)
Saudi Ethnicity Arabic 365 (91.25) 372 (93.0) 0.844 0.36
Mixed-Arabic 35 (8.75) 28 (7.0)
Home Residence* City (Urban) 345 (86.25) 320 (80.0) 5.570 0.02*
Village (Rural) 55 (13.75) 80 (20.0)
Marital duration (in years)
<5 55 (13.75) 60 (15.0)
1.185 0.88
5 - <10 80 (20.0) 75 (18.75)
10 - <15 155 (38.75) 165 (41.25)
15 - <20 65 (16.25) 60 (15.0)
≥20 45 (11.25) 40 (10.0)
Parity*
None 55 (13.75) 60 (15.0)
9.417 0.02*
1-2 60 (15.0) 75 (18.75)
3-4 135 (33.75) 155 (38.75)
≥5 150 (37.5) 110 (27.5)
Work status Housewife 180 (45.0) 195 (48.75) 1.129 0.29
Employed 220 (55.0) 205 (51.25)
Annual family income (in USD)
<15,000 50 (12.5) 40 (10.0)
4.177 0.38
15,000 - <20,000 100 (25.0) 120 (30.0)
20,000 - <25,000 125 (31.25) 115 (28.75)
25,000 - <30,000 110 (27.5) 105 (26.25)
≥30,000 15 (3.75) 20 (5.0)
Special habits*
None 265 (66.25) 295 (73.75)
7.163 0.03* Smoking 130 (32.5) 104 (26.0)
Drinking 5.0 (1.25) 1.0 (0.25)
Chronic illness*
None 245 (61.25) 263 (65.75)
11.825 0.01*
Hypertension 45 (11.25) 35 (8.75)
Diabetes Mellitus 95 (23.75) 70 (17.5)
Others 15 (3.75) 32 (8.0)
*
Statistical signicance (p <0.05).
R.M. Kamel et al.

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
4
Saudi Arabia, found the prevalence of migraine in the general popula-
tion ranged from 2.6–32 %. The estimated updated percentage of
migraine in Saudi Arabia is 25 % [14], which is higher than in other
parts of the Middle East region. Gender was signicantly correlated with
migraine prevalence (odds ratio =0.28) [11]. Its prevalence in females
is 61.8 % with great effects on quality of life, productivity, and rising
healthcare costs [15].
The most accepted theory for the pathogenesis of migraine is the
trigeminal-vascular theory, where the trigeminal nerve bers that sur-
round basal meninges and cerebral blood vessels are thought to be
stimulated by triggers (such as hypoglycemia, sleep disturbance, stress,
or hormonal changes) upon which different inammatory mediators
released. The mediators induce local inammatory reactions, aggravate
vasodilatation and further stimulate other nerve bers thus inducing
pain. Migraine can occur with aura (typical migraine) or without aura
(classical migraine) [11]. The most commonly reported comorbidities
with migraine includes; anxiety, hypertension, irritable bowel syn-
drome, and depression [13].
The connection between female sexual dysfunction and migraine
needs to be investigated. Previous studies disclosed that migraine as a
chronic pain can disrupt the quality of life for women and cause female
sexual dysfunction [16]. This may be caused by organic reasons, or less
likely caused by psychogenic illness [17].
Table 4
Domains of Female Sexual Function Index (FSFI) with Scoring System.
SN FSFI Domains Individual Questions Score
Range
Domain
Factor
Minimum
Score
Maximum
Score
Cutoff
Values
Case Group
(with
Migraine)
Control
Group
(without
Migraine) P value*
Mean ±SD Mean ±SD
1 Desire (Libido) 1. Frequency. 1-5 0.6 1.2 6.0 4.28 2.75 ±1.05 5.25 ±0.75 <0.0001
* 2. Level (Degree). 1-5
2 Arousal (Excitement)
3. Frequency. 0-5
0.3 0.0 6.0 5.08 3.00 ±1.12 5.50 ±0.50 <0.0001
*
4. Level (Degree). 0-5
5. Condence. 0-5
6. Satisfaction. 0-5
3 Lubrication (Feeling
wet)
7. Frequency. 0-5
0.3 0.0 6.0 5.45 3.80 ±1.25 4.75 ±0.25* <0.0001
*
8. Difculty in getting
wet. 0-5
9. Maintaining wetness. 0-5
10. Difculty in
maintaining wetness. 0-5
4 Orgasm (Climax)
11. Frequency. 0-5
0.4 0.0 6.0 5.05 3.50 ±1.15 4.20 ±0.50* <0.0001
*
12. Difculty to achieve. 0-5
13. Satisfaction. 0-5
5 Satisfaction
(Pleasure)
14. Emotional closeness
to partner. 0-5
0.4 0.8 6.0 5.04 3.25 ±1.30 5.25 ±0.75 <0.0001
* 15. Sexual relationship. 1-5
16. Overall sexual life. 1-5
6 Pain (Vaginismus,
Dyspareunia)
17. During vaginal
penetration. 0-5
0.4 0.0 6.0 5.51 3.80 ±1.25 5.70 ±0.25 <0.0001
*
18. After vaginal
penetration. 0-5
19. Level (Degree). 0-5
Full Scale Score Range 2.0 36.0 26.55 20.1 ±1.19 30.65 ±0.5 <0.0001
*
*
Statistical signicance (p <0.05).
Fig. 2. Participants’ FSFI Scores.
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European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
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Aim of the study
1. Reduces the gap between medical studies and clinical research on
male and female sexual dysfunctions, concerning its prevalence in
Arabic countries.
2. Measures the incidence of female sexual dysfunctions among Saudi
women with migraine comparable to healthy women.
3. Highlights the other possible underlying predictive factors that may
contribute to the development of sexual dysfunctions in women.
4. Traces the impact of the problem “Migraine” and its comorbidity
“Sexual dysfunction” on the affected women’s daily life and activity.
Study design and setting
This is a prospective, cross-sectional, case-controlled study con-
ducted online (through a private invitation link for females to share
“anonymously” on different platforms of social media commonly used in
Saudi Arabia like; Facebook®, Messenger®, WhatsApp®, Twitter®,
Instagram®, Telegram®, Snapchat®, and TickTok®) aiming to
approach a large number of women across different cities and villages
within Saudi Arabia, as well as, to overcome any personal embarrass-
ment, cultural barriers, and social taboos. The study extended for a
period of three months; starting from January 1st to March 31
st,
2023.
Patients and methods
Selecting and excluding criteria
The selection criteria include Saudi married women in a stable het-
erosexual relationship (cohabitating with their husbands), aged between
18–45 years old, who are looking healthy (Control Group), and those who
previously diagnosed with migraine, with or without aura, or have had
at least one episode of migraine, and got engaged in sexual activity
during the last 4 weeks (Case Group). Our excluding criteria include; all
males, non-Saudi females, unmarried women (not yet engaged in sexual
activity) or married but having no sex within the last 4 weeks, aged less
than 18 or more than 45 years old, pregnant, breastfeeding, or with
pelvic oor disorders or neurological diseases other than migraine, on
Fig. 3. Box and Whisker Plot for FSFI Scores of the Study.
Table 5
Severity of FSD among Migraine patients according to Kamel’s modication of Sahar’s Grading System.
SN FSFI Domains Score Range Cutoff Values Kamel’s Grades for Female Sexual Dysfunction
Extremely Severe
N=25 (6.25 %)
Severe
N=75 (18.75 %)
Moderate
N=180 (45.0 %)
Mild
N=95 (23.75 %)
None
N=25 (6.25 %)
Score: 0 - 1 Score: 2 Score: 3 Score: 4 Score: 5
1 Desire (Libido) 1-5 4.28 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.75 ±0.20 1.80 ±0.95 2.20 ±1.05 3.75 ±0.55 5.25 ±0.75
2 Arousal (Excitement) 0-5 5.08 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.10 ±0.25 0.65 ±0.65 1.95 ±0.50 3.00 ±0.25 5.50 ±0.50
3 Lubrication (Feeling wet) 0-5 5.45 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.00 ±0.00 0.65 ±0.01 2.50 ±0.65 3.05 ±0.65 5.48 ±0.25
4 Orgasm (Climax) 0-5 5.05 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.03 ±0.11 1.50 ±0.23 2.40 ±0.15 3.20 ±0.85 5.15 ±0.50
5 Satisfaction (Pleasure) 0/1-5 5.04 0.8 or 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.05 ±0.10 1.85 ±0.95 2.75 ±0.30 3.65 ±0.82 5.25 ±0.75
6 Pain (Vaginismus, Dyspareunia) 0-5 5.51 1.2 2.4 3.6 4.8 6.0
Mean ±SD 0.02 ±0.50 1.05 ±0.85 2.20 ±1.20 3.00 ±0.85 5.70 ±0.25
Total Score 26.55 6.8 or 7.2 14.4 21.6 28.8 36
*The accepted cut-off value for total FSFI is 26.55 [18,24–26]
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European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
6
medications as antidepressants [18,19], and those whom never been
diagnosed with migraine or had any episode of primary headache.
Sample size calculation
The minimal sample size required for a valid study is 385 women
which was calculated in two ways; online at www.calculator.net and
conrmed by using the mathematical equation; considering the level of
condence is 95 % with an expected prevalence of 50 % and precision of
0.05.
n=z2X p (1−p)
ε
2
n=1.962X0.5(1−0.5)
0.052=384.16
Where:
n: is the sample size.
z: is the z-score of 95 % condence level (1.96).
p: is the expected population proportion (50 %).
ε
: is the margin of error (5 %).
We planned initially to recruit a total of 1000 participants (500 as a
control group and 500 as a case group) to increase the statistical validity
and reliability of our study. We received a total of 1150 answered sheets.
After the process of ltration, a number of participants were excluded
(n =325) as missing one or more of the inclusion criteria, or with one or
more of the listed exclusion criteria. Accordingly, the nal readjusted
number for each study arm became 400 women (Fig. 1).
Study tools
The study data were acquired by using a semi-structured predesigned
online Google document questionnaire sheet (written in English and
Arabic languages). For every participant fullled the study’s inclusion
criteria and agreed to participate in the current survey, the following
data were collected:
•Demographic data: as female age (in years), weight (in kilograms),
height (in centimeters), level of education (primary G1-6, interme-
diate G7-9, high-school G10-12, university, or postgraduate),
ethnicity (Arabic, or mixed Turkish, Iranian, Indonesian, Filipino,
Indian, or African as early immigrants pilgrims borne in Saudi Ara-
bia), home residence (city or village), duration of marriage (in
years), parity, occupation (housewife or working), annual family
income (measured in US Dollars), special habits of medical signi-
cance as smoking, or drinking alcohol, as well as, any current chronic
illness (as hypertension, diabetes, or others).
•The Female Sexual Function Index (FSFI) is the gold standard test for
the evaluation of FSD with high-reliability coefcients (r =0.79-
0.86) and high internal consistency scores (Cronbach’s
α
values of
0.82 or higher) [20]. It is a brief, multidimensional Likert scale,
composed of six domains; sexual desire, arousal, lubrication, orgasm,
satisfaction, and pain (Appendix-I). For scoring every single domain,
we have to add the scores of its individual questions and multiply the
sum by a specic domain’s factor. In the end, we added the scores of
the six domains together to obtain the total FSFI score. Women with
FSFI scores less than 26.55 (the clinical cutoff value with a specicity
of 0.733 and a sensitivity of 0.889) were categorized as having sexual
dysfunction [16,21–23]. The optimal cutoff value for each single
domain is a crucial prerequisite for epidemiologic surveys and for
follow-up of women with sexual dysfunctions.
•The Arabic Female Sexual Function Index (ArFSFI) was combined
with the English form for a better understanding of the meaning and
for accurate evaluation. On testing, the ArFSFI form revealed high
test-retest reliability coefcients (r =0.92-0.98) in addition to high
internal consistency (Cronbach’s
α
values of 0.85-0.94). The cut-off
value for total ArFSFI scores is 28.1 to differentiate between
women with FSD and those without (sensitivity 96.7 %, specificity
93.2 %) [24].
•To provide a clinical grading system to reect the severity of female
sexual dysfunction (FSD) we adapted the new “Sahar’s Grading
System” [25] with terms and values re-adjustment into extremely
severe, severe, moderate, mild, and none (normal) and we called it
“Kamel’s Grading System”.
•To assess the degree of female distress due to sexual dysfunction, we
used the Female Sexual Distress Scale (FSDS) – Revised 2005 [26].
The scale was composed of 13 questions related to the concerned
female comorbidities associated with FSD during the last 4 weeks.
We rate the answers according to the points listed in each column.
The total score ranges from 0 to 52, where higher scores more than or
equal to 11 effectively discriminates between women with sexual
distress and those without (Table 1).
•Migraine Screen Questionnaire (MS-Q): It was included in the
main participants’ questionnaire sheet and used to evaluate migraine
headaches as their frequency, duration, associated symptoms such as
nausea, factors trigger it as light and noise, as well as, its inuence on
Fig. 4. Severity of Pain according to VAS (Cases versus Control groups).
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European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
7
daily activities (Table 2). A score of 0 is assigned for each “NO”
response and of 1 for each “YES” response. The total score is 0-5,
where a clinical cut-off point of more than or equal to 4 was used
to indicate a potential case of migraine [27].
•The severity of the participants’ headache attacks was assessed by
the attached 100-mm Visual Analog Scale (VAS) with Wong-Baker
facial ideographic scale for scoring over the preceding 4 weeks.
•The impact of headaches on the participants’ daily activity and
quality of life was evaluated with Headache Impact Test (HIT) 6-
score questionnaire, as well as, by the Migraine Disability Assess-
ment (MIDAS) questionnaire. Though both appear to measure
headache-related disability, HIT-6 evaluates headache intensity and
MIDAS evaluates its frequency. Using both tools together may give a
more accurate assessment of headache-related disability. To score
Headache Impact Test (HIT-6), we asked each participant to
answer 6 questions and then we rated her answers according to the
points listed in each column. The total score ranges from 36 to 78,
where higher scores more than or equal to 50 indicate greater impact
on daily activity and quality of life. To score Migraine Disability
Assessment (MIDAS), we invited each participant to answer 5
questions on how many days (within the last 3 months) was affected
by the headaches and then we graded her answers from I to IV ac-
cording to the total number of days.
Ethical considerations
Approval was obtained before the start of the study from the insti-
tutional research board (IRB) of the Batterjee Medical College, Jeddah,
Saudi Arabia. All procedures were consistent with ethical and scientic
research committee standards and with the Helsinki Declaration of 1964
and its later modifications. Informed consent has been taken from all
women who agreed to participate “freely” in our study. Data were
collected anonymously and the condentiality of participants’ data were
guaranteed.
Data analysis
The collected data were statistically analyzed using Microsoft Ofce;
Excel® version 2016 (64-bit edition), and the Statistical Package for
Social Studies (SPSS®) version 26.0 (64-bit edition) created by IBM,
Chicago, IL, USA.
Prior to conducting analysis of different data sets, we removed all
identifying information for the participants (if present) and provided
each woman with a unique research code number to be used for analysis
and interpretation to assure a blind study without bias.
The impact of the different demographics and clinical characteristics
on female sexual function was assessed using the Pearson Chi-square
test; Fisher’s exact test for categorical variables and Student’s t-test for
continuous data variables. The level of signicance was adopted at a P-
value <0.05. Our ndings are presented in the form of numbers, per-
centages, mean values, medians, and standard deviation ( ±SD). Box
and Whisker plot was used to show data distribution with its limits. The
correlation between the severity of migraine (assessed by VAS) and the
conforming severity of FSD (assessed by Kamel’s Grading Score) was
done by linear regression analysis.
Results
The current study’s participants were 800 Saudi married, non-
pregnant women, divided into two groups; 400 women with migraine
(Case Group) and 400 women without migraine (Control Group). Their
ages ranged between 18 to 45 years old with almost a bell-shaped dis-
tribution and a mean of 33 ±1.5 years (Table 3) without a signicant
difference between the two groups (P=0.86).
From the collected data concerning women’s height and weight,
body mass index (BMI) was calculated for each participant. The range of
BMI was from less than 18.5 up to more than 35 with a mean of 31 ±2
without a signicant difference between the two groups (P=0.60).
The number of women with higher education levels (university and
postgraduate) was more in the case group (shift to right) comparable to
the low education levels (up to high school) in the control group with a
signicant difference between the two groups (P=0.01). No signicant
difference found between the two groups concerning the ethnicity of
recruited Saudi women; Arabic or mixed-Arabic (P=0.36).
Most patients with migraine reported their residency in cities while
Table 6
Headache Impact Test (HIT-6) and its interpretation.
SN Individual
Questions
Answer’s Options
Never Rarely Sometimes Very
often Always
1
When you have
headaches, how
often is the pain
severe?
6 8 10 11 13
2
How often do
headaches limit
your ability to do
usual daily
activities
including
household work,
work, school, or
social activities?
6 8 10 11 13
3
When you have a
headache, how
often do you wish
you could lie
down?
6 8 10 11 13
4
In the past 4
weeks, how often
have you felt too
tired to do work or
daily activities
because of your
headaches?
6 8 10 11 13
5
In the past 4
weeks, how often
have you felt fed
up or irritated
because of your
headaches?
6 8 10 11 13
6
In the past 4
weeks, how often
did headaches
limit your ability
to concentrate on
work or daily
activities?
6 8 10 11 13
Full Scale Score Range
(36-78) 36 48 60 66 78
Interpretation Guide
≤49
Little or No impact on life
activities.
•Case Group 25 (6.25)
•Control Group 375 (93.75)
•P value* <0.00001*
50 - 55
Some impact on life activities.
•Case Group 95 (23.75)
•Control Group 20 (5.0)
•P value* <0.00001*
56 - 59
Substantial impact on life
activities.
•Case Group 180 (45.0)
•Control Group 5 (1.25)
•P value* <0.00001*
60 - 78
Severe impact on life activities.
•Case Group 100 (25.0)
•Control Group 0.0 (0.0)
•P value* <0.00001*
*
Statistical signicance (p <0.05).
R.M. Kamel et al.

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
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the majority of women in the control group resided in villages, thus a
signicant difference between the two groups was recorded (P=0.02).
Although all recruited participants were married women, the duration of
their marital life differs from less than 5 years up to more than 20 years
without any statistical signicance (P=0.88). On the other hand, the
parity of shared women in this study shows a signicant difference be-
tween the two groups with the shift to the right (P=0.02).
Other demographic data showed that both work status and nancial
family income have no difference of statistical signicance between the
two groups (P-value =0.29 and 0.38 respectively), while bad habits
such as smoking and the presence of chronic illness like diabetes mellitus
and hypertension have statistical signicance (P-value =0.03 and 0.01
respectively).
Analysis of the Female Sexual Function Index (FSFI) questionnaire
revealed that 375 women (93.75 %) of the case group and 85 women
(21.25 %) of the control group have low scores (considering a total score
of 26.55 is the cut-off value). Signicant statistical differences
(P<0.0001) were noticed over all six domains of FSFI between the two
groups (Table 4). The mean of FSFI scores was 20.1 ±1.19 for the case
group while it was 30.65 ±0.5 for the control group. Women with
migraine recorded abnormally low FSFI throughout the six domains
while women without migraine recorded abnormality in only two do-
mains; lubrication and orgasm (Fig. 2). Box and Whisker plot formatted
for the two study groups. Women with migraine exhibited a large box
and two equal whiskers denoted symmetric distribution of data with a
wide dispersion area, while women without migraine displayed a small
box with unequal whiskers and a short upper one (negatively or left
skewed) signied asymmetric distribution of data with a limited
dispersion area. No outliers were seen. The mean and interquartile range
(IQR) for the case group were 3.35 and 1.73 respectively, while that for
the control group were 5.11 and 1.26 (Fig. 3).
According to the calculated FSFI scores for all participants, 375
women (93.75 %) in the case group and 85 women (21.25 %) in the
control group have female sexual dysfunction (FSD). For grading the
severity of FSD we used the new “Kamel’s Grading System” (Table 5).
The number of women with migraine who have extremely severe dys-
functions were 25 (6.25 %), severe dysfunctions were 75 (18.75 %),
moderate dysfunctions were 180 (45.0 %), mild dysfunctions were 95
(23.75 %), and those with normal or no dysfunctions were 25 (6.25 %).
Comparatively, the number of women without migraine whom have
severe dysfunction were 5 (1.25 %), moderate dysfunction were 20
(5.0 %), mild dysfunction were 60 (15.0 %), and those with normal or
no FSD were 315 (78.75 %).
To evaluate the degree of female sexual distress as a comorbidity
with sexual dysfunction, we used the Female Sexual Distress Scale
(FSDS). The scale was more than or equal to 11 (the clinical cut-off
value) in 280 (70 %) women in the case group, while it was so in 25
(6.25 %) women in the control group. Accordingly, 95 (23.75 %)
women in the case group and 60 (15.0 %) women in the control group
have no or mild degree of FSD without associated sexual distress.
To screen the invited participants for migraine headaches, we used
Migraine-Screen Questionnaire (MS-Q). The score was more than or
equal to 4 (the clinical cut-off value) in 400 (100 %) women in the case
group, while it was so for 60 (15 %) women in the control group. Upon
application of the Visual Analogue Scale, we found the severity of pain
was more than or equal to 3.5 (the clinical cut-off value) in 280 (70 %)
women in the case group while it was so in 25 (6.25 %) women in the
control group (Fig. 4).
The impact of headaches on the participants’ daily activity and
quality of life was evaluated by Headache Impact Test with a clinical cut-
off value of more than or equal to 50, as well as, by the Migraine
Disability Assessment with a clinical cut-off value more than or equal to
6 (Table 6).
Though not all Saudi women suffering from migraine experienced
sexual dysfunction (25 women) the majority have FSD (375 women),
and those associated with distress were (280 women) relative to those
who are looking healthy (Fig. 5). However, not all Saudi women
suffering from migraine have a life disability (120 women) but the
majority have (280 women) relative to those who are looking healthy
(Table 7). All differences between the two study groups were of statis-
tical signicance (P<0.00001).
On the linear regression analysis, there was a negative sloping (as
FSFI scores are inversely related to the FSD) with a strong correlation
between the degree of severity of migraine pain and the degree of FSD
Fig. 5. Score of FSD, FSDS, MS-Q, VAS, HIT-6, and MIDAS (Case versus Control groups).
R.M. Kamel et al.

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
9
(Fig. 6).
Discussion
Normal sexual function and satisfaction are crucial parts of human
life, along with sleeping and eating, and all have a signicant role in
determining the quality of life. On the other hand, female sexual
dysfunction (FSD) is a common health problem that affects women
worldwide with subsequent low self-esteem, social isolation, divorce,
and serious decrease in quality of life for the patient and her partner
[28]. In the current study, we investigated the risk predictors for FSD,
mainly migraine headaches, among Saudi women.
There is a large variation in the prevalence of FSD between countries
due to different socio-demographic factors and health-linked risk pre-
dictors such as chronic headaches [29,30]. Martha and her colleagues
[31], reported a prevalence of 30 % in 410 sexually active women in
Colombia, while Song and his co-workers [32], reported a prevalence of
43.1 % in 504 Korean women below the age of 40 years. Mercer et al.,
[33] reported a prevalence of 53.8 % in a study of British women.
However, Singh et al., [34] reported a high incidence of 73.2 % among
149 women in south India. The high prevalence of FSD was not shocking
as it is consistent with the prevalence of 68.9 % previously reported by
Elnashar et al., [35] during a study of 1000 women from lower Egypt, as
well as, the prevalence of 76.9 % reported by Hassanin et al., [36] in a
study of 601 women from upper Egypt. This high incidence of FSD in
Egypt can be explained by the high prevalence of female genital cutting
among rural women.
In Saudi Arabia, a cross-sectional study conducted at King Abdulaziz
University Hospital, with two groups of women under 40 years of age
and above 40, Abduljabbar HS, et al., [37] reported women above 40
years old had sexual dysfunction than younger women.
A total of 275 Saudi women with type-II diabetes took part in a cross-
sectional study done by Almogbel TA, et al., [1] at primary care clinics in
King Khalid University Hospital, Riyadh, Saudi Arabia. FSD was re-
ported in 88.7 % of Saudi women with type-II diabetes with a signicant
association with age above 50 years (92 %). A clinic-based cross-sec-
tional study, done in 2019 [2], has evaluated the FSD among Saudi
women as 60 % with a predictive risk in patients older than 40 years
with low family income. As lubrication dysfunctions are commonly
encountered in older participants [38], we limit the age of recruited
women in our study to range between 18 and 45 years to avoid meno-
pausal changes’ effect on female sexual functions. This can explain the
relatively low prevalence of FSD in our study (21.25 %) among 400
healthy-looking Saudi women (control group).
In a cross-sectional survey conducted by Satake JT, et al., [23] in
2018 in Brazil, and by Erdos C, et. [3], in 2023 in Hungary, FSD was
28.8 %, and 20.3 % respectively. Both studies’ ndings were parallel to
our ndings (21.25 %).
In a study carried out in Jeddah, Saudi Arabia, Rouzi AA, et al., [39]
assessed sexual function among Saudi and non-Saudi healthcare women.
The overall scores were low (23.40 ±4.50 compared with 26.18 ±5.97
respectively). Bond DS et al., [40] found the rate of FSD did not affect by
the body weight of women with and without migraine which is consis-
tent with our ndings (P=0.60). Otherwise, Shah EF, et al., in 2021
[41] stated that obesity is positively correlated with FSD as it leads to an
imbalance in sexual hormones causing a lack of desire, arousal, and
orgasm, in addition to associated depression.
According to the study of Ifergane G, et al., in 2008 [42], FSD was
23.9 % of the participants with migraine, while their sexual functions
did not differ significantly comparable to healthy-looking women. These
ndings are far away from our recorded results; as the prevalence of FSD
among migraine Saudi women was about two-thirds of patients (70 %)
and there was a signicant difference between case and control groups
(P<0.00001). Similar to our ndings were noticed in the studies car-
ried out by Abdollahi M, et al., on 2015 [43], Ghajarzadeh M, et al., on
2015 [44], and Askari F, et al., on 2016 [45], where the FSD was
68–68.4 % among migraine patients.
In the study of Bestepe E, et al., [46] patients with either migraine or
tension-type headaches do experience problems in their sexuality
compared with healthy women. Eraslan D, et al., [47] found the mean of
FSFI score was 20.9 ±5.9 % and 90 % of patients had FSD that was not
related to the MIDAS score. These ndings correlate partially to our
Table 7
Migraine Disability Assessment Test (MIDAS) and its interpretation.
SN Individual Questions Answers
Number of Days
1 On how many days in the last 3 months did you miss work
or school because of your headaches? —————
2
How many days in the last 3 months was your
productivity at work or school reduced by half or more
because of your headaches? (Please do not include days
you counted in question 1 where you missed work or
school).
—————
3
On how many days in the last 3 months did you not do
household work (such as housework, home repairs and
maintenance, shopping, caring for children and relatives)
because of your headaches?
—————
4
How many days in the last 3 months was your
productivity in household work reduced by half or more
because of your headaches? (Please do not include days
you counted in question 3 where you did not do
household work).
—————
5
On how many days in the last 3 months did you miss
family, social or leisure activities because of your
headaches?
—————
Total MIDAS Score Range 0-90
Interpretation
Guide
MIDAS Grade-I 0 – 5 days
Little or No disability.
•Case Group 25 (6.25)
•Control Group 375
(93.75)
•P value* <0.00001*
MIDAS Grade-II 6 – 10 days
Mild disability.
•Case Group 95
(23.75)
•Control Group 20
(5.0)
•P value* <0.00001*
MIDAS Grade-III 11 – 20 days
Moderate disability.
•Case Group 180
(45.0)
•Control Group 5
(1.25)
•P value* <0.00001
MIDAS Grade-IV ≥21 days
Severe disability.
•Case Group 100
(25.0)
•Control Group 0.0
(0.0)
•P value* <0.00001*
*
Statistical signicance (p <0.05)
Fig. 6. Linear Regression Correlation between severity of Migraine and FSD.
R.M. Kamel et al.

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
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study as the mean of FSFI was 20.1 ±1.19 in Saudi women with
migraine and the rate of FSD was 70 %. On the other hand, we found
that the score of both HIT-6 and MIDAS were so closely related to degree
of FSD.
In comparing the study performed by Kucukdurmaz F, et al., in
Turkey [48], and our study done in Saudi Arabia; about 79.7 % of
middle-aged women have low FSFI scores (in our study it was 93.75 %).
The mean total FSFI score was 19.25 ±8.18 (in our study it was 20.1
±1.19). The mean domain scores were as follows: desire 2.99 ±0.96,
arousal 3.35 ±1.06, lubrication 3.95 ±0.89, orgasm 3.85 ±1.11,
satisfaction 4.04 ±1.01 and pain 3.87 ±1.39 (our ndings were 2.75
±1.05, 3.0 ±1.12, 3.8 ±1.25, 3.5 ±1.15, 3.25 ±1.3, and 3.8 ±1.25
respectively). The incidence of sexual distress was 67.2 % (in our study
it was 70 %), which means that about two-thirds of women with FSD
have sexual distress. Singh JC, et al., [49] also found low FSFI scores
among screened women suggesting 73.2 % with FSD.
Similar ndings were also reported in the study conducted by Pra-
deep R, et al., in 2019 [,21] where FSD was 78.3 % among migraine
women. The mean FSFI score was 23.1 ±4.76, where FSFI scores in all
domains were lower in migraine patients. Similar ndings were noticed
in women with either migraine or tension-type headaches as reported by
Nagpal M, et al., on 2018 [50].
Ozer G, in 2018 [51], reported the mean age of females participated
in his study was 30.9 ±5.7 years, and their mean FSFI score was 27.5
±7.5. The ndings were closely similar to our study; 33 ±1.5 years and
25.38 ±0.85 respectively. He also reported that the FSFI scores were
signicantly linked with employment status and body mass index
(P<0.05) while it was not in our study (P=0.29 and 0.60
respectively).
In a prospective study done on sexually-active females by Aydin M,
et al., in 2018 [16], there was no signicant difference between age and
body mass index between migraine and control groups but with a sig-
nicant difference in the FSFI scores of both groups (16.77 ±4.27,
26.81 ±3.19) with P<0.001. Our ndings were consistent with that
study (mean FSFI scores were 20.1 ±1.19, 30.65 ±0.5, and P-value
<0.0001).
Aggarwal R, et al., in 2013 [52], noticed the most common dys-
functions observed were in the desire and orgasm domains, while Arafa
A and Senosy S, in 2018 [24], reported the most affected domains were
in lubrication, arousal and pain. In an observational study carried out in
2021 in Egypt, Ismail S, et al., [25] reported the most affected domains
were in arousal, orgasm, and satisfaction domains. In our nal report,
we noticed low FSFI scores of all six domains in the case group while it
was low in two domains only; lubrication and orgasm in the control
group.
Participants with FSD reported by Madbouly K, et al., in 2021 [2],
had the lowest scores for arousal and desire domains (3.03 ±1.3 and
3.12 ±1.1, respectively) followed by the orgasm domain (3.48 ±1.4),
while the predictive factors for risk of FSD were age more than 40 years,
unemployment, low family income, dissatisfaction with the spouse’s
sexual ability, and higher body weight.
Ghorbani A, et al., in 2011 [53], noted that Iranian participants’
reply to the HIT questionnaire was easier than MIDAS. Conversely, Saudi
women in our survey were able to memorize days of non-attendance at
work more easily than choosing the proper answer option in HIT-6
questionnaire. However, we recommend using both of them for clin-
ical assessment of migraine.
In a systematic review and meta-analysis conducted by Salari N,
et al., in 2022 [5], investigated the effect of smoking and FSD, the odds
ratio (OR) representing the effects of smoking on FSD was found to be
1.48 (95 %CI: 1.2–1.83), indicating that female smokers were more
susceptible to FSD than non-smokers. In our study, the OR was 35.0
(95 %CI: 22.14–55.32 with P-value <0.0001).
Strengths of the study
•The current study addresses a significant female health problem
(Female Sexual Dysfunction) that has not been adequately studied
previously in Arabic populations and in need of more clinical
research and community-based studies.
•It is considered the first study to measure female sexual dysfunction
according to the FSFI and FSDS, which is a requisite (according to
ICD-11) [54] for the diagnosis of any sexual complaints, done on a
relatively large female sample in Saudi Arabia.
•Introduction of the new “Kamel’s Grading System” for female sexual
dysfunction (FSD) based on FSFI scores.
•It is a blinded case-controlled study, where the scores for the used
tests (FSFI, FSDS, MS-Q, VAS, HIT-6, and MIDAS) were interpreted
by a doctor who was blinded to the personal and clinical data of
participants.
•The questionnaire used was published online (to cross social, cul-
tural, and provincial boundaries) and written in English and Arabic
languages (to overcome any language barriers or possible
misunderstandings).
•The recruited female sample is well represented the whole Saudi
female population (83.13 % of the participants were of urban origin,
while 16.87 % were of rural origin).
Limitations of the study
•The participants may not be a representative sample of all Saudi
women with regards to literacy. Although the rate of illiteracy
among women in Saudi Arabia is low (about 2.41 % in 2021), all the
women who responded to the questionnaire were literate, as reading
and answering it requires the ability to read and write. This could
potentially introduce bias.
•A clinical interview with women experiencing sexual distress is
necessary to obtain a detailed sexual history, past medical and drug
history, and conduct clinical examination of pelvic oor muscles that
may impact their sexual function.
Evidence-based recommendations
•The existence of FSD is considered as a warning sign of an underlying
hidden, undiagnosed problem that should be investigated and
managed properly to minimize its impact on life activity and public
income.
•All patients with chronic pain or illness, like migraine, should be
screened routinely for female sexual function (by FSFI) and possible
associated sexual distress (by FSDS).
•To diagnose clinical migraine, the affected patient should be
screened for its impact on physical activity and quality of life (using
both HIT-6 and MIDAS questionnaires).
•For future studies:
o Carry out appraisals concerning physicians’ awareness about FSD as
there is no formal clinical training regarding this critical issue during
study at medical schools.
o Use the current study nding (the link between FSD and migraine) as
a basis for public screening and planning future interventional
healthcare programs.
Conclusion
Female sexual dysfunction (FSD) is a common health problem that
affects many Saudi women, particularly those with migraine. Our study
found a signicant link between female sexual dysfunction, sexual
distress, and migraine, all of which can affect the quality of life nega-
tively and warrants its recognition as a signicant public health concern.
R.M. Kamel et al.

European Journal of Obstetrics & Gynecology and Reproductive Biology: X 23 (2024) 100319
11
Financial Disclosure
The authors declared that no nancial funding or grants were
involved in supporting this work.
Institutional Review Board Statement
The study protocol was approved by the Ethical Committee of the
Batterjee Medical College (BMC) Research Unit (Registration number for
ethical permission: RES/013/2023). All data were collected and
analyzed in accordance with the Declaration of Helsinki. Participation
was voluntary and unpaid, and informed, signed consent was provided
by all participants.
CRediT authorship contribution statement
Remah Moustafa Kamel: Writing – review & editing, Writing –
original draft, Supervision, Project administration, Methodology,
Formal analysis, Conceptualization. Baraatu Ahmed Rufai Dantata:
Data curation. Hadiza Halilu: Data curation. Hussain Raeid Alsadeq:
Data curation. Hafsah Musa Ahmed: Data curation. Khadijah Hassan
A. Muzaffar: Data curation. Nishat Tasnim Maria: Data curation.
Declaration of Competing Interest
The authors have no conict of interest.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.eurox.2024.100319.
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