Exploring the Association Between Type of Pain and Mental Health With Four Dimensional Symptom Questionnaire

Exploring the Association Between Type of Pain and Mental Health With Four Dimensional Symptom Questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Association Between Type of Pain and Mental Health With Four Dimensional Symptom Questionnaire Nurver Turfaner Sipahioglu, Aysen Kutan Fenercioglu, Ebru Unur Demircan, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3870788/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : A biopsychosocial approach is needed to assess the background of headache and pain disorders for their effective treatment. Method : Four dimensional symptom questionnaire (4DSQ) was used to determine the mental health status of 158 participants who were seperated into four groups as follows: 1: Control; 2: Headache, 3: Bodily pain without headache, 4: Headache with bodily pain. A demographic data form, a pain questionnaire querying the type, severity, duration of pain and other pain attitudes were both applied to the participants. The data were evaluated by SPSS 21, using Kruskal Wallis, Fischer’s exact, Chi square tests and logistic regressions. Results: Participants with headache (groups 2 and 4) had significantly higher scores on all four dimensions of 4DSQ than participants without headache (group1 and 3) (p<0.01). Headache group was significantly different from those without headache in terms of gender, age, income, occupation, psychiatric disease, exercise, alcohol use, and diabetes (p=0.001, p=0.001, p=0.001, p=0.001, p=0.031, p=0.023, p=0.005, p=0.018, respectively). Participants with headache and bodily pain (group4) had significantly higher scores on somatization and distress than other three groups (p<0. 001), and higher scores on depression than control group (p=0. 006) and higher scores on anxiety when compared to control and ‘bodily pain without headache’ groups (group 1 and 3) (p<0.001). The severity of pain was significantly correlated with anxiety (p=0.014), distress (p=0.003), and somatization (p=0.032). The severity of pain was significantly higher in the group with headache and bodily pain when compared to bodily pain group (p=0.003). In the logistic regression analysis performed to determine the factors that independently affected headache symptom: somatization (OR: 4.75;1.90-11.87) and lower or middle income levels (OR: 9.13;1.64-50.77, OR: 5.67; 2.18-14.74, respectively) were directly related while older age (OR:0.93; 0.89-0.97) and alcohol use (OR:0.20; 0.07-0.58) were inversely related with headache symptom. Discussion and conclusion: Patients with primary headache are likely to have a multifaceted etiology as well as comorbidities. Socioeconomic and several individual factors seem to influence the relationship between headache and mental symptoms . It is of paramount importance for primary health service providers not to overlook psychiatric symptoms and to interrogate pain in other regions to improve patient compliance and satisfaction. 4DSQ headache mental health pain Background Pain is defined as an unwanted sensory and emotional experience linked with a real or estimated tissue damage. Epidemiological studies imply that pain could be a risk indicator for depressive and anxiety disorders (1). Chronic pain develops as a result of organic, psychologic, and socioenvironmental factors. Headache, back problems, arhritis and cancer are major organic illnesses leading to chronic pain. Depression is the most common psychological reaction among others in many patients. Pain, on the other hand, is frequent in patients with psychiatric disorders such as depression, anxiety, and somatization (2). Relating the cause of headache to psychiatric disorders suggests a direct causal relationship between them. According to the 2nd version of the IHS classification, headache can be secondary to psychotic disorders, somatisation disorders, depressive disorders and anxiety disorders (separation anxiety disorders, generalized anxiety disorders, panic disorders, social phobia, and post traumatic stress disorder (3). Somatization describes the condition in which psychological distress presents as persistent headache, nausea, gastrointestinal discomfort, etc. Familial, genetic, biological, demographic, cognitive and psychiatric predisposing factors play an essential role in the development of the disease (4). Frequent attendees in primary care are a challenge for family physicians. Physical complaints are the most typical presentations of anxiety and depression whereas some patients experience somatization and are only preoccupied with their physical symptoms (5). Patients experiencing somatic symptoms such as headaches, constipations, weakness, or back pain are common among depressed patients, especially those seen by primary care physicians. According to certain earlier research, patients in non-Western nations are more likely than those in Western nations to experience somatic symptoms (6). Somatization sufferers may be the hardest to treat due to their wide range of recurrent complaints affecting several organ systems. They frequently describe contextual symptoms—which, despite their strangeness, may resemble real diseases—using impressionistic language. The condition is best comprehended in relation to "illness" behavior, which conceals an underlying mental illness and only shows up as somatic symptoms (7). Patients who present with chronic pain require tailored treatment based on a thorough understanding of the elements contributing to each patient's chronic pain condition (2). In this current study, we aimed to further extend our comprehension on the association of headache symptom in primary care with biopsychosocial factors, life style and mental disorders. Material And Method Study Design Our study was carried out as a multi-center, cross-sectional study between May 2022 and June 2023 involving patients from Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Family Medicine outpatient clinic, Kanuni Sultan Suleyman Research and Education Hospital Family Medicine outpatient clinic and from three different family health centers. The number of admitted patients were 158 of which 93 (58.9%) were females and 65 (41.1%) were males. Inclusion criteria were age between 18-65, primary headache and/or body pain complaint and being able to communicate verbally. Primary headache included patients with tension type headache, migraine and trigeminal autonomic cephalalgia. Exclusion criteria were history of malignancy, history of intracranial operation or serious neurologic disease (eg: intracranial aneurysm, Parkinson’s, Alzheimers’s, multiple sclerosis, myasthenia gravis), psychotic diseases, secondary headache, having a communication problem and present alcohol addiction. Three questionnaires were applied to all participants by face to face method or handing out the query following necessary instructions. The first questionnaire aimed to obtain demographic information of the participants, including their age, gender, comorbidities, habits, education, income, employment and marital status along with a detailed health history. Second questionnaire was developed by the researchers to collect information about pain experiences of the participants.This questionnaire was developed for this study and not published elsewhere previously. An English language version of this questionnaire is prepared and uploaded as a supplementary file. Questions on type, location, duration, recurrence and severity of pain, drugs used, hospital referrals, medical or non-medical methods they used for cure and influence on life quality were included in this questionnaire. The pain localizations that were questioned in the study were head, chest, abdomen, inguinal, and musculoskeletal (cervical, lomber, muscular) regions. The third questionnaire that was used for measuring anxiety-depression-distress and somatization levels of the participants was four dimensional symptom questionnaire (4DSQ). The 4DSQ was developed by a Dutch physician, Dr. Berend Terluin, in 1996, especially to be used for assessing patients in four dimensions of mental health status in the primary care setting. It includes 50 questions of which 16 are evaluating distress dimension, six are evaluating depression dimension, 12 are evaluating anxiety dimension and 16 are evaluating somatization dimension. The Turkish validation study of the 4DSQ was performed by Unalan C. P et al. in 2016 (8). Participants were seperated into four groups according to their localizations of pain: 1: Control 2: Headache 3: Bodily pain without headache 4: Headache with bodily pain Ethics Approval and Consent to Participate Ethical consent was obtained from Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, (approval date: 05.05.2022, number: 01.02-90658). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was received from all participants including controls. Statistics The Statistical Package for the Social Sciences version 21.0 for Windows (IBM Corp., Armonk, NY, USA) was used for data evaluation and analysis. Categorical variables were presented as frequencies (n) and percentages (%), and numeric variables were presented as mean±standard deviation or median (25p-75p) values. The Kolmogorov-Smirnov test was used to evaluate normality. The Chi-square test or Fisher’s exact test was used to compare the categorical variables. According to normality of the distributions: The Independent samples t test or Mann-Whitney U test were used to compare continuous variables between two independent samples, the one-way ANOVA test or Kruskall-Wallis test were used to compare continuous variables between more than two independent samples. Post hoc tests were performed with adjusted p value for identifying which groups were different. The significance level of statistical tests was set at p<0.05. Results The number of admitted patients were 158 of which 93 (58.9%) were females while 65 (41.1%) were males. The demographic features of the participants are demonstrated in Table 1.Headache plus bodily pain (group4) was significantly associated with distress and somatization scores compared with other three groups (Table 2). Headache plus bodily pain (group4) was significantly associated with anxiety scores compared with headache only and control group (Table 2). Headache plus bodily pain (group 4) was significantly associated with depression scores compared with control group (Table2). Table 2. Comparison of 4DSQ*scores between pain groups *Four dimensional sympt om questionnaire There was a significant difference between groups in terms of age (Table 3). The groups with headache and headache plus bodily pain had a significantly lower median age than the other two groups without headache (p<0.001). The median age of the control group was 57 (54-58). The median age of the headache group was 39 (27-52), the median age of the group with bodily pain without headache was 53(46-58), and the median age of the group with headache plus bodily pain was 44 (38-51). The age distribution of the pain groups are shown in Table 3. The severity of pain was significantly higher in the group with headache and bodily pain when compared with the group of bodily pain (p=0.003). The severity of pain was also significantly correlated with anxiety (p=0.014), distress (p=0.003), and somatization (p=0.032) dimensions of 4DSQ. There was no significant relation between pain duration and pain frequency or 4DSQ. Table 3. Age distribution of pain groups Headache symptom was encountered significantly more in female subjects (p=0.001), low income group <7300 TL (p=0.001), in less exercise group (p=0.023), in those with psychiatric disease (p=0.031), and in housewives and students (p=0.001both). Anxiety (p=0.003), stress (p=0.001), depression (0.005), and somatization (p=0.001) were significantly higher in participants with headache symptom (Table 4). Alcohol use (p=0.005), and diabetes (p=0.018) were two factors that were inversely related with headache complaint (Table 4). The logistic regression analysis was performed to determine the factors affecting headache symptom. Income, age, somatization, and alcohol use remained to be significant factors (Table 5). Somatization (OR: 4.75;1.90-11.87), and lower or middle income (OR: 9.13;1.64-50.77. OR: 5.67;2.18-14.74, respectively) were directly related with headache. On the contrary, older age (OR:0.93;0.89-0.97), and alcohol use (OR:0.20; 0.07-0.58) were inversely related with headache symptom. Table 5: Factors significantly affecting headache Backward: LR method was used. Model included gender, occupation, income, age, alcohol, exercise, distress, depression, somatization, anxiety Discussion The presence of psychopathological symptoms such as anxiety, and depression in chronic daily headache is common (3,9).The aim of this study was to assess the relationship of headache symptom in primary care with sociodemographic factors, and mental disorders. In order to differentiate between headache and other types of pain, a control group and two other pain groups were included. It was determined in our study that participants with headache symptom were significantly more somatized, depressed, anxious and distressed than the control group and group with bodily pain without headache. In addition, the group with headache plus bodily pain was significantly more stressed, anxious, and somatized but not depressed than the other three groups. Several researchers have studied the connection between pain and mental symptoms. A number of them examined the physical manifestations of mental illnesses. In psychiatric disorders such as major depression and somatization, headache was a prominent complaint (7,10,11). Five hundred individuals with major depressive disorder were referred for one of these investigations, which took place in Iran. The presenting symptoms were categorized into three primary groups through psychiatric interviews: mental symptoms, pain, and physical symptoms without pain via a mental health interview. Patients occasionally reported headache (15.2%), irritability (10.6%), and pain in various body regions (10.4%) as their main complaints. Patients with rural cultural backgrounds, lower levels of education, women, and married individuals were more likely to experience pain and physical symptoms (10). In a different cross-sectional study, 60 somatizing patients who visited the family medicine clinic were examined in Nigeria. Ninety-three percent of the patients, with female predominance and a mean age of 35 at onset, had at least five somatization symptoms, and 90% had recurrences that lasted at least ten years. The symptoms included headache, insomnia, a lump in the throat, a pounding heart, an unexplained limb ache, and a crawling sensation (7). Another study conducted in Japan found that the presence of multiple symptoms (odds ratio [OR] = 4.98 for palpitation, OR = 4.36 for dyspnea, OR = 3.46 for tiredness, and OR = 2.99 for headache) was associated with the presence of a psychiatric disorder diagnosed with ICPC-2 among 150 patients who attended primary care clinics (11). In some other studies, in similarity with ours, patients with headache and/or bodily pain were investigated for psychiatric symptoms with various questionnaires (9,5,12,13,14). Researchers compared patients with chronic headache (CH) and those with headache plus fibromyalgia (CHFM) in a Spanish study. They discovered that patients with CHFM had significantly higher scores on the MMPI-2 for hypochondriasis, depression, hysteria, paranoia, and schizophrenia, as well as more somatization. Obsession, and anxiety on SCL-90-R (12). Israeli researchers used a mental health screening questionnaire to randomly evaluate 40 patients who were seen in the family practice unit. The average age of the study-referred patients was 52 years old, and most of them were female. Fatigue was the second most common symptom, after headache. The three main mental health issues found were somatization, depression, and anxiety (5). A Dutch study found that during a 2- and 4-year follow-up, 15.5% of patients from a cohort of 614 participants with various chronic pain localizations had an anxiety or depression disorder. The development of mental symptoms was directly correlated with increasing pain localizations and pain intensity. The results of this study agree with ours on these parameters (1). According to a recent meta-analysis on medical students investigating the somatization of mental illness, somatic symptoms were found to be significantly correlated with mental illness in the majority of cases, with a prevalence ranging from 5.7 to 80.1%. Back pain, neck pain. Hheadaches, sleep disturbances, and functional gastrointestinal disorders were examples of somatic symptoms (13). The results of a different meta-analysis stated that the most frequent psychiatric comorbidities in subjects with primary headaches were anxiety and depression, followed by post-traumatic stress disorder; these comorbidities were found, respectively, in 25 % (95 % CI: 22–28 %). 23 % (95 % CI: 20–26 %) and 15 % (95 % CI: 6–28 %) of the subjects (14). In an international study. it was observed that a somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio. 1.8; 95 percent confidence interval, 1.2 to 2.7) (6). The predominance of female gender in headache patients, which has been yielded in many studies including ours, can be due to gender specific illness behaviour as well as to estrogen-induced changes in pain sensitivity (15). Another argument on psychosocial aspect may be that the female gender who take on housekeeping and sometimes professional responsibilities are deprived of an equal income with their opposite sex even when they work with the same input and dedication. The results of our study revealed that housewives, students, and participants with lower income were significantly more prone to headache. This kind of social inequality could aggrevate distress, somatization, anxiety, and sometimes depression presenting with headache and/or bodily pain. In some cultures, especially eastern, direct explanation of inner psychic world is inhibited and stigmatized, therefore finding alternative modes of expression (10). There are other studies focusing on the female predominance and low socioeconomic level observed in primary headache patients as well as the assumably protective role of aging pointed out by the decrease in prevalence in older age (16,17). An epidemiological study conducted in USA stated that migraine and severe headaches were a serious public health issue in the United States, with the highest impact in women of childbearing age and those of lower socioeconomic status. Socioeconomic disadvantages also were highly prevalent among those with daily headaches. The economic consequences of the coronavirus pandemic were likely to exacerbate all of these inequities (16). An unexpected finding in our study is the decrease in headache incidence in older age, in other words the favorable effect of aging. As primary care physicians, we can attribute this to the fact that as people get older, they may normalize pain as a symptom and consider it as a physiologic part of aging. An alternative explanation may be that with aging, patients improve their skills in coping with stressors and pain. Financial freedom increasing with aging may also play a role considering the fact that less income causes more headache. A metaanalysis by Italian researchers revealed that the comorbidities observed with primary headache, fibromyalgia, restless leg syndrome, and depressive disorders were at higher rates in younger and female population. In this study, primary headache was most prevalent between ages 14-47 (14). The findings of a different recent metaanalysis suggested that exercise may be a useful treatment for primary headaches, with moderate to low quality evidence regarding the beneficial effects on headache frequency, intensity, and duration (18). This finding may help to explain our study's finding that increase in headache complaints were associated with less exercise. Exercise was found to be negatively correlated with headache syndromes besides different anxiety and pain disorders, dysthymia, and other depressive symptoms (19). A metaanalysis by Polish researchers describing the fact alcohol consumption and migraine were inversely related arrived at a conclusion that the exact mechanism behind this observation may indicate migraine led to alcohol-avoidance, rather than alcohol having any protective role against migraine. In this review, there was no relationship between headache and drinking (20). Another explanation of our finding may be the relationship of headache and female gender as well as headache and lower income. In our country, like the rest of the World, alcohol consumption is significantly higher among those with higher socioeconomical status and among men compared with women and these two factors may cause an incline towards lower headache incidence in alcohol consumers in our study (21,22,23). Regarding the coexistence of headache and diabetes. there are contradictory findings. A recent review found that the prevalence of diabetes among people who had headache was 6% (95 %CI: 5–7%). According to another study, between patients with diabetes mellitus and healthy controls, there were no appreciable differences in the prevalence of migraines (14). The 4DSQ is frequently used in pain research studies (24,25). In a research from Netherlands, an intervention study was designed for treatment-resistant chronic pain patients with stressors, relational problems with support partner, and distress, anxiety or depression. Before and 1, 3, and 6 months after the intervention, patients completed the 4DSQ along with four other questionnaires. Lasting improvements in depression and distress but not in somatization and anxiety were observed (24). A different study was designed for orthopedic shoulder patients using 4DSQ to measure their mental health symptoms (25). There may be a bias in our study originating from the pandemic conditions that were still current at the time of participant admittance (26). The results of a Polish study demonstrated increased levels of anxiety, depression, headache and parafunctional oral behaviors during the COVID-19 pandemic in both North American and European residents (27). A study in our country reported that anxiety levels were higher in those with low life satisfaction scores during COVID 19 pandemic; a finding that indicates the increased likelihood of accompanying anxiety in any comorbidity like chronical pain (28). Conclusion Patients with primary headache are likely to have a multifaceted etiology as well as comorbidities. Psychological distress with varying severity might be associated with or exacerbating headache. Socioeconomic factors and several individual characteristics influence the relationship between headache and mental symptoms. Among them, alcohol use and exercise may need further study. A strong partnership between the patient and the family physician is essential in order to gain insight to the problem and a biopsychosocial approach along with a person-centered attitude should be adopted. Thus, it is of paramount importance for primary health service providers not to overlook psychiatric symptoms and to interrogate pain in other regions to improve patient compliance and satisfaction. Declarations Funding: There is no funding in this study. The authors have no competing interests . Publication consent is not applicable for this study. The data of this study is available at request. Author contributions: N.T.E: Design, Conception, Draft, Revision, Data interpretation E.U.D: Data acquisition, Conception A.K.F: Design, Revision G.A: Data acquisition. S.K: Data interpretatio S.C.D: Data acquisition U.S.: Data analysis, interpretation V.S.E.: Conception, data acquisition, revision U.U.: Conception, revision References Marloes M.J.G. Gerrits, Patricia van Oppen, Harm WJ van Marwijk, Brenda W.J.H. Penninx. Henriette E, Van der Horst. Pain and the onset of depressive and anxiety disorders. Pain.2014;55:53-59. France RD. Psychiatric aspects of pain. Clin J Pain. 1989;5 Suppl 2: S35-41; discussion S41-2. doi: 10.1097/00002508-198906002-00006. Radat F. Headaches associated with psychiatric disorders. Rev Neurol (Paris). 2005 Jul;161(6-7):723-4. doi: 10.1016/s0035-3787(05)85129-x. Wankhade D., Anjankar AP. Management of Somatization in COVID-19: A Narrative Review.Cureus. 2022 Oct 13;14(10):e30262. doi: 10.7759/cureus.30262. Matalon A., Nahmani T., Rabin S., Maoz B..Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources. Fam Pract. 2002 Jun;19(3):251-6. doi: 10.1093/fampra/19.3.251. Simon GE., VonKorff M., Piccinelli M., Fullerton C., Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999 Oct 28; 341(18): 1329-35. doi: 10.1056/NEJM199910283411801. Obimakinde A.M., Ladipo M.M., Irabor A.E., Ann I.B. Symtomatology and Comorbidity of Somatization Disorder Amongst General Outpatients Attending a Family Medicine Clinic in South West Nigeria.. Postgrad Med. 2014 Dec;12(2):96-102. Terluin. B., Unalan. P.C., Turfaner Sipahioğlu. N. et al. Cross-cultural validation of the Turkish Four-Dimensional Symptom Questionnaire (4DSQ) using differential item and test functioning (DIFandDTF) analysis. BMC FamPract. 2016;17:53.https://doi.org/10.1186/s12875-016-0449-4. Abbass A., Lovas D., Purdy A. Direct diagnosis and management of emotional factors in chronic headache patients. Cephalalgia. 2008 Dec;28(12):1305-14. doi: 10.1111/j.1468-2982.2008.01680.x. Epub 2008 Sep 2. Seifsafari S., Firoozabadi A., Ghanizadeh A., Salehi A. A symptom profile analysis of depression in a sample of Iranian patients. Iran J Med Sci. 2013 Mar;38(1):22-9. Ishikawa Y., Takeshima T., Mise J., Ishikawa S., Matsumura M. Physical symptoms in outpatients with psychiatric disorders consulting the general internal medicine division at a Japanese university hospital. Int J Gen Med. 2015 Aug 13; 8:261-6. doi:10.2147/IJGM.S82006. Sala I., Roig C., Amador-Campos J.A., García-Sánchez C., Rodríguez A., Díaz C.et.al Psychopathological symptoms in patients suffering from chronic cephalea with or without fibromyalgia. Rev Neurol. 2009 Sep 16-30;49(6):281-7. Sperling E.L., Hulett J.M., Sherwin L.B., Thompson S., Bettencourt B.A. Prevalence, characteristics and measurement of somatic symptoms related to mental health in medical students: a Scoping Review. Ann Med. 2023;55(2):2242781.doi:10.1080/07853890.2023.2242781. PMID: 37552776; PMCID: PMC10411307. Valeria Caponnetto, Manuela Deodato, Micaela Robotti, Maria Koutsokera, Valeria Pozzilli, Cristina Galati, et.al. Comorbidities of primary headache disorders: a literature review with meta-analysis. J Headache Pain. 2021 Jul 14;22(1):71. doi: 10.1186/s10194-021-01281-z. Henningsen P., Derra C., Türp J.C., Häuser W. Functional somatic pain syndromes: summary of hypotheses of their overlap and etiology. Schmerz. 2004 Apr;18(2):136-40. doi: 10.1007/s00482-003-0299-6. Burch R., Rizzoli P., Loder E. The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys. Headache. 2021 Jan;61(1):60-68. doi: 10.1111/head.14024. Ziegler D.K., Burch R., Rizzoli P., Loder E. Headache, public health problem .Neurol Clin. 1990 Nov;8(4):781-91. Varangot-Reille C., Suso-Martí L., Dubuis V., Cuenca-Martínez F., Blanco-Díaz M.. Salar-Andreu C., et.al. Exercise and Manual Therapy for the Treatment of Primary Headache: An Umbrella and Mapping Review. Phys Ther. 2022 Mar 1;102(3): pzab308. doi: 10.1093/ptj/pzab308. Henkel K., Reimers C.D., Knapp G., Schneider F. Physical training for neurological and mental diseases. Nervenarzt. 2014 Dec;85(12):1521-8. doi: 10.1007/s00115-013-3978-2. Błaszczyk B., Straburzyński M., Więckiewicz M., Budrewicz S., Niemiec P., Staszkiewicz M., et al. Relationship between alcohol and primary headaches: a systematic review and meta-analysis. J Headache Pain. 2023 Aug 23;24(1):116. doi: 10.1186/s10194-023-01653-7.PMID: 3761259 Buzrul S. “Türkiye’de Alkollü İçki Tüketimi” (Alcoholic Beverage Consumption in Turkey). Journal of Food and Health Science. 2016; 2(3): 112-122. doi: 10.3153/JFHS16012. World Health Organization. Global Status Report on Alcohol and Health 2014 accessed at: 01-12-2023 from:https://iris.who.int/bitstream/handle/10665/112736/9789240692763_eng.pdf?sequence=1 Emeç H., Gülay E. Alkol Tüketimi ve Sosyo-Demografik Değişkenlerin Alkol Tüketimi Üzerine Etkisi (Alcohol Consumption and the Effect of Sociodemographic Variables on Alcohol Consumption). Ekonomik Yaklaşım (Economical Approach). 2008; 19(68): 115-134. Jongen P.J., Ruimschotel R.P., Museler-Kreijns Y.M., Dragstra T., Duyverman L., Valkenburg-Vissers J., et al. Improved health-related quality of life, participation, and autonomy in patients with treatment-resistant chronic pain after an intensive social cognitive intervention with the participation of support partners. Pain Res. 2017 Dec 1; 10: 2725-2738. doi: 10.2147/JPR.S137609. Koorevaar R.C., Terluin B., Van't Riet E., Madden K., Bulstra S.K. Validation of the four-dimensional symptom questionnaire (4DSQ) and prevalence of psychological symptoms in orthopedic shoulder patients. J Orthop Res. 2016 Apr;34(4):683-91. doi: 10.1002/jor.23051. Wankhade D., Anjankar A.P. Management of Somatization in COVID-19: A Narrative Review. Cureus. 2022 Oct 13;14(10): e30262. doi: 10.7759/cureus.30262. Wieckiewicz M., Danel D., Pondel M., Smardz J., Martynowicz H., Wieczorek T., et al. Identification of risk groups for mental disorders, headache and oral behaviors in adults during the COVID-19 pandemic. Sci Rep. 2021 May 26;11(1):10964. doi: 10.1038/s41598-021-90566-z. Özsat K., Serdal Işıktaş S., Lesinger FY. Covid-19 panemi Sürecinde Bireylerin Anksiyete ve Yaşam Doyumu Düzeylerinin İncelenmesi (Evaluation of anxiety and life satisfaction levels of individuals during Covid-19 pandemic period). Uluslararası Türk Kültür Coğrafyasında Sosyal Bilimler Dergisi) International Journal of Social Sciences in Turkish Cultural Geography) (TURKSOSBİLDER) 2022; 7(1): 65-75. Tables Table 1 Demographic distribution of the participants n % Groups control 32 20.1% headache only 39 24.5% pain without headache 30 18.9% headache plus other pain 58 36.5% Gender female 93 58.9% male 65 41.1% Civil status married 109 69.0% bachelor 30 19.0% widowed/divorced 17 10.8% other 2 1.3% Income 15.000 73 47.1% Occupation clerk/worker 62 39.2% freelance/private 38 24.1% housewife/student/retired 58 36.7% Chronic Diseases 75 46.5% diabetes 23 14.6% hypertension 20 12.6% COPD 8 5.0% rheumatologic disease 11 6.9% psychiatric disease 7 4.4% heart disease 6 3.8% Smoking no 127 79.9% yes 32 20.1% Alcohol no 128 80.5% yes 31 19.5% Exercise no 109 68.6% sometimes 45 28.3% regularly 5 3.1% Table 2 Comparison of 4DSQ*scores between pain groups Control Headache Pain without headache Headache plus other N % N % N % N % P value** distress .00 27 87.10% 28 71.79% 22 73.33% 18 31.03% 1.00 4 12.90% 11 28.21% 8 26.67% 40 68.97% < 0.001 depression .00 24 77.42% 24 61.54% 20 66.67% 24 41.38% 1.00 7 22.58% 15 38.46% 10 33.33% 34 58.62% 0.006 somatization .00 25 80.65% 22 56.41% 21 70.00% 16 27.59% 1.00 6 19.35% 17 43.59% 9 30.00% 42 72.41% < 0.001 anxiety .00 26 83.87% 26 66.67% 19 63.33% 22 37.93% 1.00 5 16.13% 13 33.33% 11 36.67% 36 62.07% < 0.001 **The Chi-square test was applied. Table 3 Age distribution of pain groups age P value groups control 57(54–58)a < 0.001 headache 39 (27–52)c Pain without headache 53(46–58)a,b Headache with bodily pain 44 (38–51)c,b Somatization yes 46(35–55) 0.036 no 52(39–57) Depression yes 46(36–55) 0.126 no 51(40–57) Anxiety yes 45(36–54) 0.042 no 52(40–57) Distress yes 45(35–53) 0.005 no 52(39–57) Table 4 Relationship of demographic and clinical factors with headache symptom No headache(group1.3) With headache(group2.4) N % N % P value Gender female 26 42.6% 67 69.1% 0.001 male 35 57.4% 30 30.9% Income(TL) 15.000 46 76.7% 27 28.4% Chronic disease no 30 50.0% 54 55.7% 0.489 yes 30 50.0% 43 44.3% diabetes No 47 77.0% 88 90.7% 0.018 yes 14 23.0% 9 9.3% hypertension no 56 90.3% 83 85.6% 0.378 yes 6 9.7% 14 14.4% COPD no 60 96.8% 91 93.8% 0.405 yes 2 3.2% 6 6.2% rheumatic dis. no 57 91.9% 91 93.8% 0.649 yes 5 8.1% 6 6.2% psychiatric dis. no 62 100.0% 90 92.8% yes 0 0.0% 7 7.2% 0.031 cardiac problems no 58 93.5% 95 97.9% yes 4 6.5% 2 2.1% 0.157 BMI mean median mean median 27.59 ± 4.38 27.68(25.11–30.10) 27.07 ± 5.09 26.32(22.96–30.86) 0.516 Smoking no 49 79.0% 78 80.4% yes 13 21.0% 19 19.6% 0.832 Alcohol no 43 69.4% 85 87.6% yes 19 30.6% 12 12.4% 0.005 Exercise no 36 58.1% 73 75.3% sometimes 25 40.3% 20 20.6% 0.023 regular 1 1.6% 4 4.1% Distress no 49 80.3% 46 47.4% 0.001 yes 12 19.7% 51 52.6% Depression no 44 72.1% 48 49.5% 0.005 yes 17 27.9% 49 50.5% Somatization no 46 75.4% 38 39.2% yes 15 24.6% 59 60.8% 0.001 Anxiety no 45 73.8% 48 49.5% yes 16 26.2% 49 50.5% 0.003 Occupation Clerk,worker 30 48.4% 32 33.0% freelance 20 32.3% 18 18.6% 0.001 Student, housewife 12 19.4% 47 48.5% Table 5 Factors significantly affecting headache OR %95 Confidence interval P value Somatization 4.748 1.899 11.869 0.001 Income(Ref: >15.000) < 0.001 < 7300 9.130 1.642 50.770 0.012 7300-15.000 5.665 2.177 14.739 < 0.001 age 0.927 0.888 0.968 0.001 Alcohol use 0.197 0.067 0.578 0.003 Additional Declarations No competing interests reported. Supplementary Files questionnaire.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3870788","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267569781,"identity":"dc16895f-73bb-4468-8f6c-27e07a2ebdc2","order_by":0,"name":"Nurver Turfaner Sipahioglu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtElEQVRIiWNgGAWjYPACGx4wxUOCljS4FglitRxmIF6LuUTuM4mPe87LGBw/wPjgbRtDnXkDAS2WM9LNJGc8u81jcCaB2XBuG4OEzAECWgxupDEb8xwAarnBwCbNC9RC0GVgLX8OnANpYf9NrBbGxwwHDoBtYSZOy5lnjA97DiTzSJ5JbJacc05CcgZBLcfTGA78OGBnz3f88MEPb8ps+ImOGCBgbGAgISZHwSgYBaNgFOADAHRfN4DPJGynAAAAAElFTkSuQmCC","orcid":"","institution":"Istanbul University Cerrahpaşa, Cerrahpasa Medical Faculty, Department of Family Medicine","correspondingAuthor":true,"prefix":"","firstName":"Nurver","middleName":"Turfaner","lastName":"Sipahioglu","suffix":""},{"id":267569782,"identity":"2855a222-c329-4bec-b383-258017909452","order_by":1,"name":"Aysen Kutan Fenercioglu","email":"","orcid":"","institution":"Istanbul University Cerrahpaşa, Cerrahpasa Medical Faculty, Department of Family Medicine","correspondingAuthor":false,"prefix":"","firstName":"Aysen","middleName":"Kutan","lastName":"Fenercioglu","suffix":""},{"id":267569783,"identity":"31108f87-a96d-4e9b-927c-777044acc425","order_by":2,"name":"Ebru Unur Demircan","email":"","orcid":"","institution":"Besiktas No:6 Family Health Center","correspondingAuthor":false,"prefix":"","firstName":"Ebru","middleName":"Unur","lastName":"Demircan","suffix":""},{"id":267569784,"identity":"beee4df2-8b19-4331-9036-17fa5a8cd08c","order_by":3,"name":"Sevda Karabacak","email":"","orcid":"","institution":"Istanbul University Cerrahpaşa, Cerrahpasa Medical Faculty, Department of Family Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sevda","middleName":"","lastName":"Karabacak","suffix":""},{"id":267569785,"identity":"837393fa-023a-4c90-815c-26c4cd800c8e","order_by":4,"name":"Merve Hazal Ser","email":"","orcid":"","institution":"Istanbul Education and Research Hospital, Neurology Clinic","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"Hazal","lastName":"Ser","suffix":""},{"id":267569786,"identity":"7781a18f-90a1-47bf-8eb8-609d3351af5c","order_by":5,"name":"Didem Kafadar","email":"","orcid":"","institution":"Istanbul University Cerrahpaşa, Cerrahpasa Medical Faculty, Department of Family Medicine","correspondingAuthor":false,"prefix":"","firstName":"Didem","middleName":"","lastName":"Kafadar","suffix":""},{"id":267569787,"identity":"79e3732d-06c2-41b0-8078-eea09db19b58","order_by":6,"name":"Ugurcan Sayılı","email":"","orcid":"","institution":"Istanbul University Cerrahpaşa, Cerrahpasa Medical Faculty, Department of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Ugurcan","middleName":"","lastName":"Sayılı","suffix":""},{"id":267569788,"identity":"33e0b750-bb6f-4630-bea6-462687e9bf90","order_by":7,"name":"V. Selçuk Engin","email":"","orcid":"","institution":"Department of Family Medicine, Health Sciences University, Kanuni SUAM","correspondingAuthor":false,"prefix":"","firstName":"V.","middleName":"Selçuk","lastName":"Engin","suffix":""}],"badges":[],"createdAt":"2024-01-16 19:32:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3870788/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3870788/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51008484,"identity":"0a7691ab-f29a-48dd-a9c7-ba9d361be768","added_by":"auto","created_at":"2024-02-12 15:53:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":345588,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3870788/v1/a71d112d-7d70-4016-b472-2c13655b34fd.pdf"},{"id":49808853,"identity":"2d71b2e8-5f5d-45f9-bff0-9fb38f9b184a","added_by":"auto","created_at":"2024-01-18 11:23:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27503,"visible":true,"origin":"","legend":"","description":"","filename":"questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-3870788/v1/99a4c8c7e00ec4fa0bc31e31.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring the Association Between Type of Pain and Mental Health With Four Dimensional Symptom Questionnaire\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePain is defined as an unwanted sensory and emotional experience linked with a real or estimated tissue damage.\u0026nbsp;Epidemiological studies imply that pain could be a risk indicator for depressive and anxiety disorders (1).\u003c/p\u003e\n\u003cp\u003eChronic pain develops as a result of organic, psychologic, and socioenvironmental factors. Headache, back problems, arhritis and cancer are major organic illnesses leading to chronic pain. Depression is the most common psychological reaction among others in many patients. \u0026nbsp; Pain, on the other hand, is frequent in patients with psychiatric disorders such as depression, anxiety, and somatization (2).\u003c/p\u003e\n\u003cp\u003eRelating the cause of headache to psychiatric disorders suggests a direct causal relationship between them. According to the 2nd version of the IHS classification, headache can be secondary to psychotic disorders, somatisation disorders, depressive disorders and anxiety disorders (separation anxiety disorders, generalized anxiety disorders, panic disorders, social phobia, and post traumatic stress disorder (3).\u003c/p\u003e\n\u003cp\u003eSomatization describes the condition in which psychological distress presents as persistent headache, nausea, gastrointestinal discomfort, etc. \u0026nbsp;Familial, genetic, biological, demographic, cognitive and psychiatric predisposing factors play an essential role in the development of the disease (4).\u003c/p\u003e\n\u003cp\u003eFrequent attendees in primary care are a challenge for family physicians. \u0026nbsp;Physical complaints are the most typical presentations of anxiety and depression whereas some patients experience somatization and are only preoccupied with their physical symptoms (5).\u003c/p\u003e\n\u003cp\u003ePatients experiencing somatic symptoms such as headaches, constipations, weakness, or back pain are common among depressed patients, especially those seen by primary care physicians. According to certain earlier research, patients in non-Western nations are more likely than those in Western nations to experience somatic symptoms (6).\u003c/p\u003e\n\u003cp\u003eSomatization sufferers may be the hardest to treat due to their wide range of recurrent complaints affecting several organ systems. They frequently describe contextual symptoms\u0026mdash;which, despite their strangeness, may resemble real diseases\u0026mdash;using impressionistic language. The condition is best comprehended in relation to \u0026quot;illness\u0026quot; behavior, which conceals an underlying mental illness and only shows up as somatic symptoms (7).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patients who present with chronic pain require tailored treatment based on a thorough understanding of the elements contributing to each patient\u0026apos;s chronic pain condition (2). In this current study, we aimed to further extend our comprehension on the association of headache symptom in primary care with biopsychosocial factors, life style and mental disorders.\u003c/p\u003e"},{"header":"Material And Method","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study was carried out as a multi-center,\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;cross-sectional study between May 2022 and June 2023 involving patients from Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Family Medicine outpatient clinic, Kanuni Sultan Suleyman Research and Education Hospital Family Medicine outpatient clinic and from three different family health centers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number of admitted patients were 158 of which 93 (58.9%) were females and 65 (41.1%) were males.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were age between 18-65, primary headache and/or body pain complaint and being able to communicate verbally. Primary headache included patients with tension type headache, migraine and trigeminal autonomic cephalalgia.\u003c/p\u003e\n\u003cp\u003eExclusion criteria were history of malignancy, history of intracranial operation or serious neurologic disease (eg: intracranial aneurysm, Parkinson\u0026rsquo;s, Alzheimers\u0026rsquo;s, multiple sclerosis, myasthenia gravis), psychotic diseases, secondary headache, having a communication problem and present alcohol addiction.\u003c/p\u003e\n\u003cp\u003eThree questionnaires were applied to all participants by face to face method or handing out the query\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;following\u0026nbsp;necessary instructions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The first questionnaire aimed to obtain demographic information of the participants, including their age, gender, comorbidities, habits, education, income, employment and marital status along with a detailed health history.\u003c/p\u003e\n\u003cp\u003eSecond questionnaire was developed by the researchers to collect information about pain experiences of the participants.This questionnaire was developed for this study and not published elsewhere previously. An English language version of this questionnaire is prepared and uploaded as a supplementary file. Questions on type, location, duration, recurrence and severity of pain, drugs used, hospital referrals, medical or non-medical methods they used for cure and influence on life quality were included in this questionnaire. The pain localizations that were questioned in the study were head, chest, abdomen, inguinal, and musculoskeletal (cervical, lomber, muscular) regions.\u003c/p\u003e\n\u003cp\u003eThe third questionnaire that was used for measuring anxiety-depression-distress and somatization levels of the participants was four dimensional symptom questionnaire (4DSQ). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 4DSQ was developed by a Dutch physician, Dr. Berend Terluin, in 1996, especially to be used for assessing patients in four dimensions of mental health status in the primary care setting. It includes 50 questions of which 16 are evaluating distress dimension, six are evaluating depression dimension, 12 are evaluating anxiety dimension and 16 are evaluating somatization dimension. \u0026nbsp; \u0026nbsp; The Turkish validation study of the 4DSQ was performed by Unalan C. P\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;et al. in 2016 (8).\u003c/p\u003e\n\u003cp\u003eParticipants were seperated into four groups according to their localizations of pain:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1: Control 2: Headache 3: Bodily pain without headache 4: Headache with bodily pain\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical consent was obtained from Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, (approval date:\u0026nbsp;05.05.2022, number:\u0026nbsp;01.02-90658). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was received from all participants including controls.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Statistical Package for the Social Sciences version 21.0 for Windows (IBM Corp., Armonk, NY, USA) was used for data evaluation and analysis. Categorical variables were presented as frequencies (n) and percentages (%), and numeric variables were presented as mean\u0026plusmn;standard deviation or median (25p-75p) values. The Kolmogorov-Smirnov test was used to evaluate normality. The Chi-square test or Fisher\u0026rsquo;s exact test was used to compare the categorical variables. According to normality of the distributions: The Independent samples t test or Mann-Whitney U test were used to compare continuous variables between two independent samples, the one-way ANOVA test or Kruskall-Wallis test were used to compare continuous variables between more than two independent samples. Post hoc tests were performed with adjusted p value for identifying which groups were different. The significance level of statistical tests was set at p\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe number of admitted patients were 158 of which 93 (58.9%) were females while 65 (41.1%) were males. The demographic features of the participants are demonstrated in Table 1.Headache plus bodily pain (group4)\u0026nbsp;was significantly associated with distress and somatization scores compared with other three groups (Table 2).\u003c/p\u003e\n\u003cp\u003eHeadache plus bodily pain (group4) was significantly associated with \u0026nbsp;anxiety scores compared with headache only and control group (Table 2).\u003c/p\u003e\n\u003cp\u003eHeadache plus bodily pain (group 4) was significantly associated with depression scores compared with control group (Table2). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2. Comparison of 4DSQ*scores between pain groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Four dimensional sympt\u003c/strong\u003e\u003cstrong\u003eom\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003equestionnaire \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a significant difference between groups in terms of age (Table 3). \u0026nbsp;The groups with headache and headache plus bodily pain had a significantly lower median age than the other two groups without headache (p\u0026lt;0.001). The median age of the control group was 57 (54-58). The median age of the headache group was 39 (27-52), the median age of the group with bodily pain without headache was 53(46-58), and the median age of the group with headache plus bodily pain was 44 (38-51).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe age distribution of the pain groups\u0026nbsp;are shown in Table 3.\u003c/p\u003e\n\u003cp\u003eThe severity of pain was significantly higher in the group with headache and bodily pain when compared with the group of \u0026nbsp; \u0026nbsp; \u0026nbsp;bodily pain (p=0.003). The severity of pain was also significantly correlated with anxiety (p=0.014), distress (p=0.003), and somatization (p=0.032) dimensions of 4DSQ.\u003c/p\u003e\n\u003cp\u003eThere was no significant relation between pain duration and pain frequency or 4DSQ. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Age distribution of pain groups\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHeadache symptom was encountered significantly more in female subjects (p=0.001),\u0026nbsp;low income group\u0026nbsp;\u0026lt;7300 TL (p=0.001),\u0026nbsp;in less exercise group (p=0.023),\u0026nbsp;in those with psychiatric disease (p=0.031),\u0026nbsp;and in housewives and students (p=0.001both). Anxiety (p=0.003),\u0026nbsp;stress (p=0.001),\u0026nbsp;depression (0.005),\u0026nbsp;and somatization (p=0.001) were significantly higher in participants with headache symptom (Table 4).\u003c/p\u003e\n\u003cp\u003eAlcohol use (p=0.005),\u0026nbsp;and diabetes (p=0.018) were two factors that were inversely related with headache complaint (Table 4).\u003c/p\u003e\n\u003cp\u003eThe logistic regression analysis was performed to determine the factors affecting headache symptom. Income, age, somatization, and alcohol use remained to be significant factors (Table 5). Somatization (OR: 4.75;1.90-11.87), and lower or middle income (OR: 9.13;1.64-50.77. OR: 5.67;2.18-14.74, respectively) were directly related with \u0026nbsp; \u0026nbsp; \u0026nbsp;headache. On the contrary, older age (OR:0.93;0.89-0.97), and alcohol use (OR:0.20; 0.07-0.58) were inversely related with headache symptom.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Factors significantly affecting headache\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBackward: LR method was used. Model included gender, occupation, income, age, alcohol, exercise, distress, depression, somatization, anxiety\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe presence of psychopathological symptoms such as anxiety, and depression in chronic daily headache is common (3,9).The aim of this study was to assess the relationship of headache symptom in primary care with sociodemographic factors,\u0026nbsp;and mental disorders. In order to differentiate between headache and other types of pain,\u0026nbsp;a control group and two other pain groups were included.\u003c/p\u003e\n\u003cp\u003eIt was determined in our study that participants with headache symptom were significantly more somatized,\u0026nbsp;depressed,\u0026nbsp;anxious and distressed than the control group and group with bodily pain without headache.\u003c/p\u003e\n\u003cp\u003eIn addition,\u0026nbsp;the group with headache plus bodily pain was significantly more stressed,\u0026nbsp;anxious,\u0026nbsp;and somatized but not depressed than the other three groups.\u0026nbsp;Several researchers have studied the connection between pain and mental symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA number of them examined the physical manifestations of mental illnesses. In psychiatric disorders such as major depression and somatization,\u0026nbsp;headache was a prominent complaint (7,10,11).\u003c/p\u003e\n\u003cp\u003eFive hundred individuals with major depressive disorder were referred for one of these investigations,\u0026nbsp;which took place in Iran. The presenting symptoms were categorized into three primary groups through psychiatric interviews: mental symptoms,\u0026nbsp;pain,\u0026nbsp;and physical symptoms without pain via a mental health interview. Patients occasionally reported headache (15.2%),\u0026nbsp;irritability (10.6%),\u0026nbsp;and pain in various body regions (10.4%) as their main complaints. Patients with rural cultural backgrounds,\u0026nbsp;lower levels of education,\u0026nbsp;women,\u0026nbsp;and married individuals were more likely to experience pain and physical symptoms (10).\u003c/p\u003e\n\u003cp\u003eIn a different cross-sectional study,\u0026nbsp;60 somatizing patients who visited the family medicine clinic were examined in Nigeria. Ninety-three percent of the patients,\u0026nbsp;with female predominance and a mean age of 35 at onset,\u0026nbsp;had at least five somatization symptoms,\u0026nbsp;and 90% had recurrences that lasted at least ten years. \u0026nbsp;The symptoms included headache,\u0026nbsp;insomnia,\u0026nbsp;a lump in the throat,\u0026nbsp;a pounding heart,\u0026nbsp;an unexplained limb ache,\u0026nbsp;and a crawling sensation (7).\u003c/p\u003e\n\u003cp\u003eAnother study conducted in Japan found that the presence of multiple symptoms (odds ratio [OR] = 4.98 for palpitation,\u0026nbsp;OR = 4.36 for dyspnea,\u0026nbsp;OR = 3.46 for tiredness,\u0026nbsp;and OR = 2.99 for headache) was associated with the presence of a psychiatric disorder diagnosed with ICPC-2 among 150 patients who attended primary care clinics (11).\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In some other studies,\u0026nbsp;in similarity with ours,\u0026nbsp;patients with headache and/or bodily pain were investigated for psychiatric symptoms with various questionnaires (9,5,12,13,14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearchers compared patients with chronic headache (CH) and those with headache plus fibromyalgia (CHFM) in a Spanish study. They discovered that patients with CHFM had significantly higher scores on the MMPI-2 for hypochondriasis,\u0026nbsp;depression,\u0026nbsp;hysteria,\u0026nbsp;paranoia,\u0026nbsp;and schizophrenia,\u0026nbsp;as well as more somatization.\u0026nbsp;Obsession,\u0026nbsp;and anxiety on SCL-90-R (12).\u003c/p\u003e\n\u003cp\u003eIsraeli researchers used a mental health screening questionnaire to randomly evaluate 40 patients who were seen in the family practice unit. The average age of the study-referred patients was 52 years old,\u0026nbsp;and most of them were female. Fatigue was the second most common symptom,\u0026nbsp;after headache. The three main\u0026nbsp;mental health issues found were somatization,\u0026nbsp;depression,\u0026nbsp;and anxiety (5).\u003c/p\u003e\n\u003cp\u003eA Dutch study found that during a 2- and 4-year follow-up,\u0026nbsp;15.5% of patients from a cohort of 614 participants with various chronic pain localizations had an anxiety or depression disorder. The development of mental symptoms was directly correlated with increasing pain localizations and pain intensity. The results of this study agree with ours on these parameters (1).\u003c/p\u003e\n\u003cp\u003eAccording to a recent meta-analysis on medical students investigating the somatization of mental illness,\u0026nbsp;somatic symptoms were found to be significantly correlated with mental illness in the majority of cases,\u0026nbsp;with a prevalence ranging from 5.7 to 80.1%. Back pain,\u0026nbsp;neck pain.\u0026nbsp;Hheadaches,\u0026nbsp;sleep disturbances,\u0026nbsp;and functional gastrointestinal disorders were examples of somatic symptoms (13).\u003c/p\u003e\n\u003cp\u003eThe results of a different meta-analysis stated that the most frequent psychiatric comorbidities in subjects with primary headaches were anxiety and depression,\u0026nbsp;followed by post-traumatic stress disorder; these comorbidities were found,\u0026nbsp;respectively,\u0026nbsp;in 25\u0026thinsp;% (95 %\u0026nbsp;CI: 22\u0026ndash;28\u0026thinsp;%).\u0026nbsp;23\u0026thinsp;% (95 %\u0026nbsp;CI: 20\u0026ndash;26\u0026thinsp;%) and 15\u0026thinsp;% (95 %\u0026nbsp;CI: 6\u0026ndash;28\u0026thinsp;%) of the subjects (14).\u003c/p\u003e\n\u003cp\u003eIn an international study.\u0026nbsp;it was observed that a somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio.\u0026nbsp;1.8; 95 percent confidence interval,\u0026nbsp;1.2 to 2.7) (6).\u003c/p\u003e\n\u003cp\u003eThe predominance of female gender in headache patients,\u0026nbsp;which has been yielded in many studies including ours,\u0026nbsp;can be due to gender specific illness behaviour as well as to estrogen-induced changes in pain sensitivity (15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother argument on psychosocial aspect may be that the female gender who take on housekeeping and sometimes professional responsibilities are deprived of an equal income with their opposite sex even when they work with the same input and dedication. The results of our study revealed that housewives,\u0026nbsp;students,\u0026nbsp;and participants with lower income were significantly more prone to headache.\u0026nbsp;This kind of social inequality could aggrevate distress,\u0026nbsp;somatization,\u0026nbsp;anxiety,\u0026nbsp;and sometimes depression presenting with headache and/or bodily pain. In some cultures,\u0026nbsp;especially eastern,\u0026nbsp;direct explanation of inner psychic world is inhibited and stigmatized,\u0026nbsp;therefore finding alternative modes of expression (10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are other studies focusing on the female predominance and low socioeconomic level observed in primary headache patients as well as the assumably protective role of aging pointed out by the decrease in prevalence in older age (16,17). An epidemiological study conducted in USA stated that migraine and severe headaches were a serious public health issue in the United States,\u0026nbsp;with the highest impact in women of childbearing age and those of lower socioeconomic status. Socioeconomic disadvantages also were highly prevalent among those with daily headaches. The economic consequences of the coronavirus pandemic were likely to exacerbate all of these inequities (16). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn unexpected finding in our study is the decrease in headache incidence in older age,\u0026nbsp;in other words the favorable effect of aging. \u0026nbsp;As primary care physicians,\u0026nbsp;we can attribute this to the fact that as people get older,\u0026nbsp;they may normalize pain as a symptom and consider it as a physiologic part of aging. \u0026nbsp; An alternative explanation may be that with aging,\u0026nbsp;patients improve their skills in coping with stressors and pain. \u0026nbsp;Financial freedom increasing with aging may also play a role considering the fact that less income causes more headache.\u003c/p\u003e\n\u003cp\u003eA metaanalysis by Italian researchers revealed that the comorbidities observed with primary headache,\u0026nbsp;fibromyalgia,\u0026nbsp;restless leg syndrome,\u0026nbsp;and depressive disorders were at higher rates in younger and female population. In this study,\u0026nbsp;primary headache was most prevalent between ages 14-47 (14).\u003c/p\u003e\n\u003cp\u003eThe findings of a different recent metaanalysis suggested that exercise may be a useful treatment for primary headaches,\u0026nbsp;with moderate to low quality evidence regarding the beneficial effects on headache frequency,\u0026nbsp;intensity,\u0026nbsp;and duration (18). This finding may help to explain our study\u0026apos;s finding that increase in headache complaints were associated with less exercise. Exercise was found to be negatively correlated with headache syndromes besides different anxiety and pain disorders,\u0026nbsp;dysthymia,\u0026nbsp;and other depressive symptoms (19).\u0026nbsp; A metaanalysis by Polish researchers describing the fact alcohol consumption and migraine were inversely related arrived at a conclusion that the exact mechanism behind this observation may indicate migraine led to alcohol-avoidance,\u0026nbsp;rather than alcohol having any protective role against migraine. In this review,\u0026nbsp;there was no relationship between headache and drinking (20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother explanation of our finding may be the relationship of headache and female gender as well as headache and lower income. In our country,\u0026nbsp;like the rest of the World,\u0026nbsp;alcohol consumption is significantly higher among those with higher socioeconomical status and among men compared with women and these two factors may cause an incline towards lower headache incidence in alcohol consumers in our study (21,22,23).\u003c/p\u003e\n\u003cp\u003eRegarding the coexistence of headache and diabetes.\u0026nbsp;there are contradictory findings. \u0026nbsp;A recent review found that the prevalence of diabetes among people who had headache was 6% (95 %CI: 5\u0026ndash;7%). According to another study,\u0026nbsp;between patients with diabetes mellitus and healthy controls,\u0026nbsp;there were no appreciable differences in the prevalence of migraines (14).\u003c/p\u003e\n\u003cp\u003eThe 4DSQ is frequently used in pain research studies (24,25).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In a research from Netherlands,\u0026nbsp;an intervention study was designed for treatment-resistant chronic pain patients with stressors,\u0026nbsp;relational problems with support partner,\u0026nbsp;and distress,\u0026nbsp;anxiety or depression. Before and 1,\u0026nbsp;3,\u0026nbsp;and 6 months after the intervention,\u0026nbsp;patients completed the 4DSQ along with four other questionnaires. Lasting improvements in depression and distress but not in somatization and anxiety were observed (24).\u003c/p\u003e\n\u003cp\u003eA different study was designed for orthopedic shoulder patients using 4DSQ to measure their mental health symptoms (25).\u003c/p\u003e\n\u003cp\u003eThere may be a bias in our study originating from the pandemic conditions that were still current at the time of participant admittance (26). The results of a Polish study demonstrated increased levels of anxiety, depression, headache and parafunctional oral behaviors during the COVID-19 pandemic in both North American and European residents (27). A study in our country reported that anxiety levels were higher in those with low life satisfaction scores during COVID 19 pandemic; a finding that indicates the increased likelihood of accompanying anxiety in any comorbidity like chronical pain (28). \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients with primary headache are likely to have a multifaceted etiology as well as comorbidities. Psychological distress with varying severity might be associated with or exacerbating headache.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocioeconomic factors and several individual\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;characteristics influence the relationship between headache and mental symptoms. Among them,\u0026nbsp;alcohol use and exercise may need further study. A strong partnership between the patient and the family physician is essential in order to gain insight to the problem and a biopsychosocial approach along with a person-centered attitude should be adopted.\u003c/p\u003e\n\u003cp\u003eThus, it is of paramount importance for primary health service providers not to overlook psychiatric symptoms and to interrogate pain in other regions to improve patient compliance and satisfaction. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e There is\u0026nbsp;\u003cstrong\u003eno funding\u003c/strong\u003e in this study.\u003c/p\u003e\n\u003cp\u003eThe authors have\u0026nbsp;\u003cstrong\u003eno competing interests\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003ePublication consent is\u0026nbsp;\u003cstrong\u003enot applicable\u003c/strong\u003e for this study.\u003c/p\u003e\n\u003cp\u003eThe data of this study is available at request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.T.E: Design,\u0026nbsp;Conception,\u0026nbsp;Draft,\u0026nbsp;Revision,\u0026nbsp;Data interpretation\u003c/p\u003e\n\u003cp\u003eE.U.D: Data acquisition,\u0026nbsp;Conception\u003c/p\u003e\n\u003cp\u003eA.K.F: Design,\u0026nbsp;Revision\u003c/p\u003e\n\u003cp\u003eG.A: Data acquisition.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.K: \u0026nbsp;Data interpretatio\u003c/p\u003e\n\u003cp\u003eS.C.D: Data acquisition\u003c/p\u003e\n\u003cp\u003eU.S.: Data analysis,\u0026nbsp;interpretation\u003c/p\u003e\n\u003cp\u003eV.S.E.: Conception,\u0026nbsp;data acquisition,\u0026nbsp;revision\u003c/p\u003e\n\u003cp\u003eU.U.: Conception, revision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMarloes M.J.G. Gerrits,\u0026nbsp;Patricia van Oppen,\u0026nbsp;Harm WJ van Marwijk,\u0026nbsp;Brenda W.J.H. Penninx. Henriette E,\u0026nbsp;Van der Horst. Pain and the onset of depressive and anxiety disorders. Pain.2014;55:53-59.\u003c/li\u003e\n \u003cli\u003eFrance RD. Psychiatric aspects of pain. Clin J Pain. 1989;5 Suppl 2: S35-41; discussion S41-2. doi: 10.1097/00002508-198906002-00006.\u003c/li\u003e\n \u003cli\u003eRadat F. Headaches associated with psychiatric disorders. Rev Neurol (Paris). 2005 Jul;161(6-7):723-4. doi: 10.1016/s0035-3787(05)85129-x.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWankhade D.,\u0026nbsp;Anjankar AP. Management of Somatization in COVID-19: A Narrative Review.Cureus. 2022 Oct 13;14(10):e30262. doi: 10.7759/cureus.30262.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMatalon A.,\u0026nbsp;Nahmani T.,\u0026nbsp;Rabin S.,\u0026nbsp;Maoz B..Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model,\u0026nbsp;patient characteristics and their use of medical resources. Fam Pract. 2002 Jun;19(3):251-6. doi: 10.1093/fampra/19.3.251.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSimon GE.,\u0026nbsp;VonKorff M.,\u0026nbsp;Piccinelli M.,\u0026nbsp;Fullerton C.,\u0026nbsp;Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999 Oct 28; 341(18): 1329-35. doi: 10.1056/NEJM199910283411801.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eObimakinde A.M.,\u0026nbsp;Ladipo M.M.,\u0026nbsp;Irabor A.E.,\u0026nbsp;Ann I.B. Symtomatology and Comorbidity of Somatization Disorder Amongst General Outpatients Attending a Family Medicine Clinic in South West Nigeria.. Postgrad Med. 2014 Dec;12(2):96-102.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTerluin.\u0026nbsp;B.,\u0026nbsp;Unalan.\u0026nbsp;P.C.,\u0026nbsp;Turfaner Sipahioğlu.\u0026nbsp;N. et al. Cross-cultural validation of the Turkish Four-Dimensional Symptom Questionnaire (4DSQ) using differential item and test\u0026nbsp;functioning\u0026nbsp;(DIFandDTF)\u0026nbsp;analysis.\u0026nbsp;BMC\u0026nbsp;FamPract.\u0026nbsp;2016;17:53.https://doi.org/10.1186/s12875-016-0449-4.\u003c/li\u003e\n \u003cli\u003eAbbass A.,\u0026nbsp;Lovas D.,\u0026nbsp;Purdy A. Direct diagnosis and management of emotional factors in chronic headache patients. Cephalalgia. 2008 Dec;28(12):1305-14. doi: 10.1111/j.1468-2982.2008.01680.x. Epub 2008 Sep 2.\u003c/li\u003e\n \u003cli\u003eSeifsafari S.,\u0026nbsp;Firoozabadi A.,\u0026nbsp;Ghanizadeh A.,\u0026nbsp;Salehi A. A symptom profile analysis of depression in a sample of Iranian patients. Iran J Med Sci. 2013 Mar;38(1):22-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIshikawa Y.,\u0026nbsp;Takeshima T.,\u0026nbsp;Mise J.,\u0026nbsp;Ishikawa S.,\u0026nbsp;Matsumura M. Physical symptoms in outpatients with psychiatric disorders consulting the general internal medicine division at a Japanese university hospital. Int J Gen Med. 2015 Aug 13; 8:261-6. doi:10.2147/IJGM.S82006. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSala I.,\u0026nbsp;Roig C.,\u0026nbsp;Amador-Campos J.A.,\u0026nbsp;Garc\u0026iacute;a-S\u0026aacute;nchez C.,\u0026nbsp;Rodr\u0026iacute;guez A.,\u0026nbsp;D\u0026iacute;az C.et.al Psychopathological symptoms in patients suffering from chronic cephalea with or without fibromyalgia. Rev Neurol. 2009 Sep 16-30;49(6):281-7. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSperling E.L.,\u0026nbsp;Hulett J.M.,\u0026nbsp;Sherwin L.B.,\u0026nbsp;Thompson S.,\u0026nbsp;Bettencourt B.A.\u0026nbsp;Prevalence,\u0026nbsp;characteristics and measurement of somatic symptoms related to mental health in medical students:\u0026nbsp;a\u0026nbsp;Scoping\u0026nbsp;Review.\u0026nbsp;Ann\u0026nbsp;Med.\u0026nbsp;2023;55(2):2242781.doi:10.1080/07853890.2023.2242781. PMID: 37552776; PMCID: PMC10411307.\u003c/li\u003e\n \u003cli\u003eValeria Caponnetto,\u0026nbsp;Manuela Deodato,\u0026nbsp;Micaela Robotti,\u0026nbsp;Maria Koutsokera,\u0026nbsp;Valeria Pozzilli,\u0026nbsp;Cristina Galati,\u0026nbsp;et.al. Comorbidities of primary headache disorders: a literature review with meta-analysis. J Headache Pain. 2021 Jul 14;22(1):71. doi: 10.1186/s10194-021-01281-z.\u003c/li\u003e\n \u003cli\u003eHenningsen P.,\u0026nbsp;Derra C.,\u0026nbsp;T\u0026uuml;rp J.C.,\u0026nbsp;H\u0026auml;user W. Functional somatic pain syndromes: summary of hypotheses of their overlap and etiology. Schmerz. 2004 Apr;18(2):136-40. doi: 10.1007/s00482-003-0299-6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBurch R.,\u0026nbsp;Rizzoli P.,\u0026nbsp;Loder E. The prevalence and impact of migraine and severe headache in the United States: Updated age,\u0026nbsp;sex,\u0026nbsp;and socioeconomic-specific estimates from government health surveys. Headache. 2021 Jan;61(1):60-68. doi: 10.1111/head.14024.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZiegler D.K.,\u0026nbsp;Burch R.,\u0026nbsp;Rizzoli P.,\u0026nbsp;Loder E. Headache, public health problem .Neurol Clin. 1990 Nov;8(4):781-91.\u003c/li\u003e\n \u003cli\u003eVarangot-Reille C.,\u0026nbsp;Suso-Mart\u0026iacute; L.,\u0026nbsp;Dubuis V.,\u0026nbsp;Cuenca-Mart\u0026iacute;nez F.,\u0026nbsp;Blanco-D\u0026iacute;az M..\u0026nbsp;Salar-Andreu C.,\u0026nbsp;et.al. Exercise and Manual Therapy for the Treatment of Primary Headache: An Umbrella and Mapping Review. Phys Ther. 2022 Mar 1;102(3): pzab308. doi: 10.1093/ptj/pzab308.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHenkel K.,\u0026nbsp;Reimers C.D.,\u0026nbsp;Knapp G.,\u0026nbsp;Schneider F. Physical training for neurological and mental diseases. Nervenarzt. 2014 Dec;85(12):1521-8. doi: 10.1007/s00115-013-3978-2.\u003c/li\u003e\n \u003cli\u003eBłaszczyk B.,\u0026nbsp;Straburzyński M.,\u0026nbsp;Więckiewicz M.,\u0026nbsp;Budrewicz S.,\u0026nbsp;Niemiec P.,\u0026nbsp;Staszkiewicz M.,\u0026nbsp;et al. Relationship between alcohol and primary headaches: a systematic review and meta-analysis. J Headache Pain. 2023 Aug 23;24(1):116. doi: 10.1186/s10194-023-01653-7.PMID: 3761259\u003c/li\u003e\n \u003cli\u003eBuzrul S. \u0026ldquo;T\u0026uuml;rkiye\u0026rsquo;de Alkoll\u0026uuml; İ\u0026ccedil;ki T\u0026uuml;ketimi\u0026rdquo; (Alcoholic Beverage Consumption in Turkey).\u0026nbsp;Journal of Food and Health Science. 2016; 2(3): 112-122. doi: 10.3153/JFHS16012.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWorld Health Organization.\u0026nbsp;Global Status Report on Alcohol and Health 2014 accessed at: 01-12-2023 from:https://iris.who.int/bitstream/handle/10665/112736/9789240692763_eng.pdf?sequence=1\u003c/li\u003e\n \u003cli\u003eEme\u0026ccedil; H.,\u0026nbsp;G\u0026uuml;lay E. Alkol T\u0026uuml;ketimi ve Sosyo-Demografik Değişkenlerin Alkol T\u0026uuml;ketimi \u0026Uuml;zerine Etkisi (Alcohol Consumption and the Effect of Sociodemographic Variables on Alcohol Consumption). Ekonomik\u0026nbsp;Yaklaşım (Economical Approach). 2008; 19(68): 115-134.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJongen P.J.,\u0026nbsp;Ruimschotel R.P.,\u0026nbsp;Museler-Kreijns Y.M.,\u0026nbsp;Dragstra T.,\u0026nbsp;Duyverman L.,\u0026nbsp;Valkenburg-Vissers J.,\u0026nbsp;et al. Improved health-related quality of life,\u0026nbsp;participation,\u0026nbsp;and autonomy in patients with treatment-resistant chronic pain after an intensive social cognitive intervention with the participation of support partners. \u0026nbsp;Pain Res. 2017 Dec 1; 10: 2725-2738. doi: 10.2147/JPR.S137609.\u003c/li\u003e\n \u003cli\u003eKoorevaar R.C.,\u0026nbsp;Terluin B., Van\u0026apos;t Riet E.,\u0026nbsp;Madden K.,\u0026nbsp;Bulstra S.K. Validation of the four-dimensional symptom questionnaire (4DSQ) and prevalence of psychological symptoms in orthopedic shoulder patients. J Orthop Res. 2016 Apr;34(4):683-91. doi: 10.1002/jor.23051.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWankhade D.,\u0026nbsp;Anjankar A.P. Management of Somatization in COVID-19: A Narrative Review. Cureus. 2022 Oct 13;14(10): e30262. doi: 10.7759/cureus.30262.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWieckiewicz M.,\u0026nbsp;Danel D.,\u0026nbsp;Pondel M.,\u0026nbsp;Smardz J.,\u0026nbsp;Martynowicz H.,\u0026nbsp;Wieczorek T.,\u0026nbsp;et al. Identification of risk groups for mental disorders,\u0026nbsp;headache and oral behaviors in adults during the COVID-19 pandemic.\u0026nbsp;Sci Rep. 2021 May 26;11(1):10964. doi: 10.1038/s41598-021-90566-z.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zsat K., Serdal Işıktaş S., Lesinger FY. Covid-19 panemi S\u0026uuml;recinde Bireylerin Anksiyete ve Yaşam Doyumu D\u0026uuml;zeylerinin İncelenmesi (Evaluation of anxiety and life satisfaction levels of individuals during Covid-19 pandemic period). Uluslararası T\u0026uuml;rk K\u0026uuml;lt\u0026uuml;r Coğrafyasında Sosyal Bilimler Dergisi) International Journal of Social Sciences in Turkish Cultural Geography) (TURKSOSBİLDER) 2022; 7(1): 65-75.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cdiv\u003eDemographic distribution of the participants\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv\u003en\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv\u003e%\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv\u003eGroups\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003econtrol\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e32\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eheadache only\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e39\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e24.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003epain without headache\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e18.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eheadache plus other pain\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e58\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e36.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eGender\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003efemale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e93\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e58.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e65\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e41.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eCivil status\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emarried\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e109\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e69.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003ebachelor\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003ewidowed/divorced\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e10.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eother\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e1.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eIncome\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u0026lt;\u0026thinsp;7300\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e23\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e14.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e7300-15.000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e59\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e38.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u0026gt;\u0026thinsp;15.000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e73\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e47.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eOccupation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eclerk/worker\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e62\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e39.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003efreelance/private\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e38\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e24.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003ehousewife/student/retired\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e58\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e36.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eChronic Diseases\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e75\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e46.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003ediabetes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e23\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e14.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003ehypertension\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eCOPD\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e5.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003erheumatologic disease\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003epsychiatric disease\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e4.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eheart disease\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e3.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eSmoking\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e127\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e79.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e32\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eAlcohol\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e128\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e80.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e31\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eExercise\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e109\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e68.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003esometimes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e45\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e28.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eregularly\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e3.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\u003cbr\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComparison of 4DSQ*scores between pain groups\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHeadache\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePain without headache\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHeadache plus other\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e%\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e%\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e%\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e%\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP value**\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003edistress\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e27\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e87.10%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e71.79%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e73.33%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e18\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e31.03%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12.90%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28.21%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26.67%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e40\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e68.97%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003edepression\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e77.42%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e61.54%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e66.67%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e41.38%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22.58%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e38.46%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e33.33%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e34\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e58.62%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.006\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003esomatization\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e25\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e80.65%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e56.41%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e70.00%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e27.59%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19.35%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e43.59%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30.00%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e42\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e72.41%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eanxiety\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e83.87%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e66.67%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e63.33%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e37.93%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16.13%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e33.33%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36.67%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e62.07%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e**The Chi-square test was applied.\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAge distribution of pain groups\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\" style=\"margin-right: calc(0%); width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eage\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP value\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003egroups\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003econtrol\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e57(54\u0026ndash;58)a\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eheadache\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e39 (27\u0026ndash;52)c\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePain without headache\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e53(46\u0026ndash;58)a,b\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHeadache with bodily pain\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e44 (38\u0026ndash;51)c,b\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSomatization\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46(35\u0026ndash;55)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.036\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e52(39\u0026ndash;57)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eDepression\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46(36\u0026ndash;55)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.126\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e51(40\u0026ndash;57)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAnxiety\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e45(36\u0026ndash;54)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.042\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e52(40\u0026ndash;57)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eDistress\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.8033%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e45(35\u0026ndash;53)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"width: 16.8033%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.005\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 57.2707%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.5983%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e52(39\u0026ndash;57)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003eRelationship of demographic and clinical factors with headache symptom\u003c/span\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv\u003eNo headache(group1.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv\u003eWith headache(group2.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eN\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eN\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eP value\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eGender\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003efemale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e42.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e67\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e69.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e35\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e57.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv\u003eIncome(TL)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u0026lt;\u0026thinsp;7300\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e3.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e22.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e7300-15.000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e47\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u0026gt;\u0026thinsp;15.000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e76.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e27\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e28.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eChronic disease\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e50.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e54\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e55.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.489\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e50.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e43\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e44.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003ediabetes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eNo\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e47\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e77.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e88\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e90.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.018\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e23.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e9.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003ehypertension\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e56\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e90.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e83\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e85.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.378\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e9.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e14.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eCOPD\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e60\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e96.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e91\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e93.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.405\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e3.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003erheumatic dis.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e57\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e91.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e91\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e93.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.649\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e8.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003epsychiatric dis.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e62\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e100.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e90\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e92.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e7.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.031\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003ecardiac problems\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e58\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e93.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e95\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e97.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e6.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e2.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.157\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eBMI\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emean\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emedian\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emean\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003emedian\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e27.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e27.68(25.11\u0026ndash;30.10)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e27.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e26.32(22.96\u0026ndash;30.86)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.516\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eSmoking\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e79.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e78\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e80.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e13\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e21.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e0.832\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eAlcohol\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e43\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e69.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e85\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e87.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.005\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv\u003eExercise\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e36\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e58.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e73\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e75.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003esometimes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e25\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e40.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.023\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eregular\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e1.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e4.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eDistress\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e80.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e47.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e51\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e52.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eDepression\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e44\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e72.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e48\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.005\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e27.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e50.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eSomatization\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e75.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e38\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e39.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e15\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e24.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e59\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e60.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv\u003eAnxiety\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eno\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e45\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e73.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e48\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eyes\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e16\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e26.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e49\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e50.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.003\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv\u003eOccupation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eClerk,worker\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e48.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e32\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e33.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003efreelance\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e32.3%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e18\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e18.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u003cspan type=\"Bold\" name=\"Emphasis\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003eStudent, housewife\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e12\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e19.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e47\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e48.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFactors significantly affecting headache\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOR\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e%95 Confidence interval\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP value\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSomatization\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.748\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.899\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11.869\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncome(Ref: \u0026gt;15.000)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;7300\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9.130\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.642\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e50.770\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.012\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7300-15.000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.665\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.177\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14.739\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eage\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.927\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.888\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.968\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.001\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAlcohol use\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.197\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.067\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.578\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.003\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"4DSQ, headache, mental health, pain","lastPublishedDoi":"10.21203/rs.3.rs-3870788/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3870788/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eA biopsychosocial approach is needed to assess the background of headache and pain disorders for their effective treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eFour dimensional symptom questionnaire (4DSQ) was used to determine the mental health status of 158 participants who were seperated into four groups as follows: 1: Control; 2: Headache, 3: Bodily pain without headache, 4: Headache with bodily pain.\u003c/p\u003e\n\u003cp\u003eA demographic data form, a pain questionnaire querying the type, severity, duration of pain and other pain attitudes were both applied to the participants. The data were evaluated by SPSS 21, using Kruskal Wallis, Fischer’s exact, Chi square tests \u0026nbsp;and logistic regressions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants with headache (groups \u0026nbsp;2 and 4) had significantly higher scores on all four dimensions of 4DSQ than \u0026nbsp;participants without headache (group1 and 3) (p\u0026lt;0.01). Headache group was significantly \u0026nbsp;\u0026nbsp;different from those without headache in terms of gender, age, income, \u0026nbsp;\u0026nbsp;occupation, psychiatric disease, exercise, alcohol use, and diabetes (p=0.001, p=0.001, p=0.001, p=0.001, \u0026nbsp;\u0026nbsp;p=0.031, p=0.023, \u0026nbsp;\u0026nbsp;p=0.005, p=0.018, \u0026nbsp;\u0026nbsp;respectively).\u003c/p\u003e\n\u003cp\u003eParticipants with headache and bodily pain (group4) had \u0026nbsp;\u0026nbsp;significantly higher scores on somatization and distress than other three \u0026nbsp;\u0026nbsp;groups (p\u0026lt;0. 001), and higher scores on \u0026nbsp;\u0026nbsp;depression than control group (p=0. 006) and higher scores on anxiety when compared to control and \u0026nbsp;\u0026nbsp;‘bodily pain without headache’ groups (group 1 and 3) (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eThe \u0026nbsp;\u0026nbsp;severity of pain was significantly correlated with anxiety (p=0.014), \u0026nbsp;\u0026nbsp;distress (p=0.003), and somatization (p=0.032).\u003c/p\u003e\n\u003cp\u003eThe \u0026nbsp;\u0026nbsp;severity of pain was significantly higher in the group with headache and \u0026nbsp;\u0026nbsp;bodily pain when compared to bodily pain group (p=0.003).\u003c/p\u003e\n\u003cp\u003eIn the \u0026nbsp;\u0026nbsp;logistic regression analysis performed to determine the factors that \u0026nbsp;\u0026nbsp;independently affected headache symptom: somatization (OR: 4.75;1.90-11.87) \u0026nbsp;\u0026nbsp;and lower or middle income levels (OR: 9.13;1.64-50.77, OR: 5.67; 2.18-14.74, respectively) were \u0026nbsp;\u0026nbsp;directly related while older age (OR:0.93; 0.89-0.97) and alcohol use \u0026nbsp;\u0026nbsp;(OR:0.20; 0.07-0.58) were inversely related with headache symptom.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and conclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients \u0026nbsp;\u0026nbsp;with primary headache are likely to have a multifaceted etiology as well as \u0026nbsp;\u0026nbsp;comorbidities.\u003c/p\u003e\n\u003cp\u003eSocioeconomic \u0026nbsp;\u0026nbsp;and several individual factors seem to influence the relationship between \u0026nbsp;\u0026nbsp;headache and mental symptoms .\u003c/p\u003e\n\u003cp\u003eIt is of \u0026nbsp;paramount importance for primary health service providers not to overlook \u0026nbsp;psychiatric symptoms and to interrogate pain in other regions to improve \u0026nbsp;patient compliance and satisfaction.\u003c/p\u003e","manuscriptTitle":"Exploring the Association Between Type of Pain and Mental Health With Four Dimensional Symptom Questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-18 11:22:57","doi":"10.21203/rs.3.rs-3870788/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5ce6af9e-ec83-40cb-89a2-1980a28bc0bb","owner":[],"postedDate":"January 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-12T15:45:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-18 11:22:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3870788","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3870788","identity":"rs-3870788","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}