Problematic usage of the internet among Hungarian elementary school children: a cross-sectional study.

INTRODUCTION: Problematic usage of the internet (PUI) is perhaps one of the most frequently studied phenomena of the 21st century receiving increasing attention in both scientific literature and the media. Despite intensive research there have been relatively few meaningful studies among elementary school students in Hungary and worldwide, who may be considered as a high-risk population with regard to problematic internet use. The aim of our study was to carry out a complex research focusing on the prevalence and risk factors of PUI among elementary school children aged 10-15 years (Grade 5-8). METHODS: Demographics included were gender, age, place of stay, type of residence, family type, parental education, start of internet use, used devices, daily internet use, purpose of internet use, internet accounts, ways of keeping in touch with friends and sporting activities. PUI was evaluated using the paper-based version of the Potentially Problematic Use of the Internet Questionnaire. RESULTS: Overall, 2000 paper-based questionnaires were successfully delivered and the final analysis included 1168 responses (overall response rate 58.4%). Mean age was 12.55 ± 1.24 years. Female gender (OR = 2.760, p = 0,006, CI 95% 0.065 to 0.384), younger age (11-12 years) (OR = 3.812, p < 0.001, 95% CI: 1.747-4.731), early exposure to the internet (OR = 3.466, p = 0.001, 95% CI 1.535-5.446), living in a small village (OR = 1.081, p = 0.002, 95% CI 1.041-1.186) urgency to answer online (OR = 4.677, p < 0.001, 95% CI: 2.714-6.639), decreased frequency of personal contact with friends (OR = 2.897, p = 0.004, 95% CI: 1.037-1.681), spending more than 6 h online (OR = 12.913, p < 0.001, 95% CI: 10.798-14.892), morning and nighttime internet use (OR = 3.846, p < 0.001, CI 95% 1.886-5.810) and never doing any sports (OR = 2.016, p = 0.044, 95% CI: 1.050-3.354) were independently associated with problematic internet use. CONCLUSIONS: Based on the results of our questionnaire survey more than 10% seemed to be problematic users in our study population, which is a relatively high rate. Early exposure to the internet as well as younger age were strongly related to this phenomenon. Duration of being online as well as daily time interval of internet use are important predisposing factors. Scarcely studied social factors such as being online at the expense of personal relationships and the lack of physical activity should be payed more attention to prevent the development of PUI.

The association of problematic usage of the internet with burnout, depression, insomnia, and quality of life among Hungarian high school students.

Introduction: The extensive availability of the internet has led to the recognition of problematic usage of the internet (PUI) or so called internet addiction (IA), probably mostly involving adolescents. Aim: Here we present a study focusing on the incidence and consequences (including burnout, which is relatively rarely studied) of internet addiction among high school students using a questionnaire-based non-random sampling cross-sectional survey. Included questionnaires were the Problematic Internet Use Questionnaire, the Maslach Burnout Inventory General Survey for Students MBI-GS (S), the 9-item short version of Beck Depression Inventory (BDI-SF), the Athens Insomnia Questionnaire and the EQ-5D (quality of life) questionnaire. Data were evaluated the exertion of Student's t-test, chi square test and Pearson's rank-order correlation. Logistic regression analysis was used to determine the significance of the different parameters as independently associated with PUI. Results: Overall 3,000 paper-based questionnaires were successfully delivered and 2,540 responses received (response rate of 84.6%). 1,309 males (mean age 17.6 ± 1.43 years) (51.5%) and 1,231 females (mean age 17.5 ± 1.4 years) (48.5%) took part in our study. Problematic usage of the internet was detected in 486 (19.1%) students (232 males, mean age 17.6 ± 1.35 years and 254 females, mean age 17.34 ± 1.37 years). In a logistic regression analysis sleep disturbance (OR: 1.84, 95% CI: 1.83-2.03), depression (OR: 1.97, 95% CI: 1.77-2.02) and burnout (OR: 1.8, 95% CI: 1.16-1.94) were significantly associated with PUI. Conclusion: Nearly one fifth of our study population suffered from PUI, which was strongly associated with school burnout, insomnia and depression, which underlines the importance of this phenomenon.

[Rumination and schizotypal personality traits]. / A rumináció és a szkizotip személyiségvonások összefüggései pszichotikus zavarral élok és sine morbo személyek körében.

Background and purpose:

Although ru­mination and schizotypal traits can be considered transdiagnostic phenomena and can occur within non-clinical population as well, a relatively small number of research has been carried out on the topic involving both patient and non clinical participants. The aim of this study is to examine the rela­tionship between schizotypal traits and rumination using a transdiagnostic approach, involving participants living with psychotic disorders and sine morbo individuals.

We recruited participants living with psychotic disorders (paranoid schizophrenia, hebephrenia, schizoaffective disorder, etc.) (n = 30) and controls who had not been diagnosed with any mental illnesses (n = 67). The connection between rumination and schizotypal traits was examined by self-report questionnaire method in a cross-sectional arrangement. The Oxford-Liverpool Inventory was used to measure schizotypal traits, and the Ruminative Thought Style Questionnaire was used to determine the level of rumination. 

Schizotypal symptoms (β = 0.575; p < 0.001), especially cognitive disorganization (β = 0.459; p < 0.001) and unusual experiences (β = 0.221; p = 0.029) significantly explained the degree of rumination. 

Our results support the hypothesis that the association between rumination and schizotypic traits is due to decreased cognitive inhibitory functions.

Prevalence and Risk Factors of Problematic Internet Use among Hungarian Adult Recreational Esports Players.

Background: Esports are highly prevalent in modern culture, particularly among young people, and are a healthy hobby for the majority of users. However, there is a possible link between video gaming (including esports) and problematic internet use (so-called internet addiction, IA), mostly involving adolescents. Methods: Here we present an online survey focusing on the prevalence and risk factors of internet addiction among adult esports players. Demographics included age, gender, family type, type of work, working years and daily internet use. Medical conditions associated with IA such as smoking, alcohol and drug intake, hypertension, diabetes, ischemic heart disease, musculoskeletal pain and history of depression were also recorded. Results: Overall, 2313 players including 176 females (7.6%) and 2137 males (92.4%) participated in our online survey. Age distribution was the following: 18−25 years 90.3% (2088/2313), 26−35 years 7.95% (184/2313), 36−45 years 0.86% (20/2313), 46−55 years 0.82% (19/2313), 56−62 years 0.04% (1/2313) and 62 years or older 0.04% (1/2313). Internet addiction was detected in 19.9% of players (461/2313) based on the Problematic Internet Use Questionnaire. In a multivariate analysis internet addiction was significantly associated with age between 18 and 25 (OR: 1.675, p = 0.002), being single (OR = 1.505, p = 0.014), internet use > 6 h daily (OR = 4.338, p < 0.001), having < 3 children (OR: 2.037, p = 0.023) and having secondary employment (OR = 1.789, p = 0.037). Regular alcohol intake (OR = 18.357, p < 0.001) and history of depression (OR= 5.361, p = 0.032) were also strongly correlated with IA. Conclusion: This is the first study from Hungary investigating the prevalence and risk factors of internet addiction among adult esports players. One out of five adult gamers suffered from IA. Our study also draws attention to increased risk within this group and risk factors such as younger age, family status and type of employment.

Ischemic stroke mimics: A comprehensive review.

BACKGROUND: Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed. METHODS: The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations. RESULTS: Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation. CONCLUSION: Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

[The examination of burnout among healthcare workers]. / A kiégés vizsgálata egészségügyi dolgozók között.

BACKGROUND AND PURPOSE: Health reforms in recent decades have been largely based on economic considerations and have led to a significant problem in the sector today, with the issue of human resources being pushed back, which is exacerbated by burnout syndrome. The aim of this questionnaire-based study was to examine the complex background of burnout among health care workers in the cities of Komló, Pécs and Kecskemét. METHODS: Baseline demographic data were recorded. Burnout was assessed by the Maslach Burnout Inventory (MBI), and the intensity of dysfunctional attitudes were also studied. Depression was detected by the Beck Scale and social supports, and effort-reward dysbalance were also examined. RESULTS: Overall 411 employees participated in our study. Age group distribution was middle aged access, vast majority of the workers was between 36 and 55 years. Mean burnout scale was 58.6 (SD = 16.3), 63 workers had mild (14.2%), 356 had moderate (80.7%) and 22 had severe (5.1%) burnout. In a multivariate analysis the type of work (OR = 1.018), age (OR = 2.514), marital status (OR = 1.148), job type (OR = 1.246) the lack of social support (OR = 1.189) and allowance (OR = 9.719) were independently associated with burnout (p < 0.05 in all cases). There was a significant association among burnout, depression and dysfunctional attitudes. CONCLUSION: The vast majority of our social workers suffered from moderate and a small, but significant proportion suffered from severe burnout. Our work draws attention to the modifiable and unmodifiable risk factors of burnout in this population, which may help in the development of preventive strategies.

Prevalence and Risk Factors of Internet Addiction among Hungarian High School Students.

INTRODUCTION: The extensive availability of the internet has led to the recognition of problematic internet use (so-called internet addiction-IA) mostly concerning adolescents. AIM: Here, we present a study focusing on the prevalence and risk factors of internet addiction in Hungarian high school students, using a questionnaire-based survey. RESULTS: Overall, 3000 paper-based questionnaires were successfully delivered and 2540 responses were received (response rate of 84.6%). A total of 1309 males (mean age 17.6 ± 1.43 years) (51.5%) and 1231 females (mean age 17.5 ± 1.4 years) (48.5%) took part in our study. Internet addiction was detected in 486 (19.1%) students (232 males, mean age 17.6 ± 1.35 years, and 254 females, mean age 17.34 ± 1.37 years) based on the Problematic Internet Use Questionnaire. In a multivariate analysis, age (age of 17, OR = 3.688, p < 0.001), family status (living without parents) (OR = 2.091, p = 0.034), the size of the household (more than five people per household) (OR = 2.546, p = 0.026), spending more than 6 h online (OR = 5.457, p < 0.001), and daily time interval (OR = 84.316, p < 0.001) were significantly associated with internet addiction. Alcohol use (OR = 10.341, p = 0.001), drug intake (OR = 6.689, p = 0.001) and musculoskeletal disorders (OR = 3.966, p = 0.047) were also strongly associated with IA. CONCLUSION: A significant proportion of our students suffered from IA, which is associated with substance intake (possible abuse) and musculoskeletal pain in the multivariate analysis. Our study also draws attention to the preventable risk factors of IA, such as working hours or nighttime internet use, number of hours spent online and family surroundings.

Prevalence and Risk Factors of Internet Addiction among Hungarian High School Teachers.

The extensive availability of internet has led to the the recognition of problematic internet use (so called internet addiction, IA) mostly involving adolescents. There is limited data about the prevalence of IA in adults. Here we present a study focusing on the prevalence and risk factors of internet addiction among high school teachers. Overall 2500 paper-based questionnaires were successfully delivered and 1817 responses received (response rate of 72.7%). In our study 1194 females (65.7%) and 623 males (34.3%) participated. In a multivariate analysis including of all factors (demographic data, internet habits, comorbidity etc.) age <35 years (OR: 6.098, CI: 5.09-7.08, p < 0.001), male gender (OR = 5.413, CI: 4.39-6.18, p = 0.002), surfing on the internet > 5 h daily (OR 2.568, CI: 2.03-3.39, p < 0.001), having no children (OR: 1.353, CI: 1.13-1.99, p = 0.0248), and having secondary employment (OR = 11.377, CI: 8.67-13.07, p = 0.001) were significantly associated with internet addiction. This is the first study from Hungary showing the prevalence and risk factors of internet addiction among high school teachers. A small, but significant proportion suffered from IA. Our study also draws attention to the risk factors of IA such as younger age, family status and working type.

Neuropathic Low Back Pain and Burnout among Hungarian Workers.

Burnout is an increasingly prevalent syndrome mainly involving those working in human services. Although it is categorized as an occupational phenomenon and not as a medical condition, it seems to be strongly associated with several diseases such as pain syndromes. However, no studies examined the association between neuropathic low back pain and burnout. This questionnaire-based study was carried out between April 2019 and March 2020 in three main sites among teachers, social workers and healthcare workers. Demographic criteria included age, gender, marital status, number of children, type of work, years spent with work, work schedule, legal relation, secondary employment. Included diseases were diabetes, hypertension, ischemic heart disease, generalized pain (pain involving more than one area of the body) and depression. Low back pain was assessed by the painDETECT questionnaire, burnout was measured with the Maslach Burnout Inventory (MBI) and depression was measured by the Beck Depression Inventory. Dysfunctional attitudes were also recorded. Overall, 1500 questionnaires were successfully delivered and 1141 responses received (response rate of 76%). Three hundred social workers, 399 teachers, 339 paramedics, 35 doctors and 68 medical attendants have completed our survey. In a multivariate analysis including of all factors (demographic criteria, burnout, depression, dysfunctional attitudes, comorbidity etc.) neuropathic low back pain was associated with age > 62 (OR = 3.981, p = 0.01), number of children ≥ 2 (OR = 2.638, p = 0.003), job type (being a social worker) (OR = 6.654, p < 0.001), burnout (OR = 2.577, p < 0.001), current depression (OR = 2.397, p < 0.001), and suffering from generalized pain (OR= 4.076, p < 0.001). This is the first study showing the association of burnout and neuropathic low back pain, which is the most common cause of disability. Based on our results neuropathic low back pain and burnout have similar risk factors and consequences which raises the possibility of similar pathophysiology.

Internet Addiction and Burnout in A Single Hospital: Is There Any Association?

The extensive availability of the internet has led to the recognition of problematic internet use, the so-called Internet Addiction (IA), mostly involving adolescents. Burnout can lead to substance abuse or addictive behaviour (such as internet addiction) as a coping method. There are insufficient data about internet addiction and its possible association with burnout in adults, especially among healthcare workers. The aim of our present study was to focus on prevalence and the risk factors of internet addiction and its possible association with burnout among healthcare workers in a single hospital applying a questionnaire-based survey. In total, 49 doctors (10.1%), 198 nurses (40.9%), 123 medical assistant (25.4%), 73 other healthcare workers (15.1%), and 42 (1.7%) healthcare associated workers (cleaning, laundry, etc.) have completed our survey. In a multivariate analysis, IA was associated with age between 18 and 25 (OR: 2.6, p = 0.024), surfing on the internet >5 h daily (OR 25.583, p < 0.001), being single (OR: 4.275, p = 0.006), being childless (OR: 3.81, p = 0.011), working less than five years (OR 2.135, p = 0.048) and job type (being healthcare associated worker, OR: 2.907, p = 0.009). Illicit drug intake (OR 52.494, p < 0.001), and diabetes (OR: 4.122, p = 0.043) were also significantly associated with internet addiction. No association of burnout and IA could be found. A small but significant proportion of our healthcare workers suffered from IA, which was associated with substance abuse and diabetes in multivariate analysis. Our study also draws attention to the risk factors of IA such as younger age, family status, working type and working hours internet use. The possible association of burnout and IA merits further investigation.

The Association of Internet Addiction with Burnout, Depression, Insomnia, and Quality of Life among Hungarian High School Teachers.

The extensive availability of Internet has led to the recognition of problematic Internet use (so called Internet addiction, IA) mostly involving adolescents. There are limited data about the prevalence and consequences of IA in adults especially among high school teachers. Here, we present a cross-sectional prospective study focusing on the association of Internet addiction with burnout, depression, insomnia, and lower quality of life among high school teachers taking many co-variates into account. Overall, 623 males (34.3%) and 1194 females (65.7%) participated in our study. Internet addiction was detected in 5.2% (95/1817) based on the Problematic Internet Use Questionnaire. Internet addiction was associated with severe burnout (10.5 vs. 2.7%, p < 0.001), moderate (36.8 vs. 1.7%, p < 0.001), and severe (6.3 vs. 0.1%, p < 0.001) depression, insomnia (23.1 vs. 11.4%, p < 0.001), and severe sleep disturbance (severe insomnia, 27.4 vs. 3.8%, p < 0.001) and lower quality of life in all domains (p < 0.001). There was also a significant correlation of the severity of the above-mentioned parameters and the severity of IA (overall scores, p < 0.001 in all cases). In a multivariate analysis including demographic criteria, risk factors medical conditions and the above-mentioned parameters as co-variates internet addiction was significantly associated with depression (OR = 3.836, CI: 2.92-5.44, p = 0.03), and insomnia (OR: 3.932, CI: 3.6-5.69, p = 0.002). This is the first study from Hungary and is one of the first studies showing the association of IA with mental issues, burnout, and lower quality of life among adults. It underlines the clinical importance of problematic Internet use among adults.

Burnout among social workers / A kiégés elofordulása szociális munkások körében.

Összefoglaló. Bevezetés: Napjaink egyik legszélesebb körben emlegetett jelensége a kiégés (burnout), mely a leggyakrabban a segíto szakmákban dolgozókat érinti. Célkituzés: Munkánk célja a kiégés jelenségének komplex vizsgálata szociális munkások körében. Módszerek: A demográfiai adatok felvétele mellett a kiégés vizsgálatához a Maslach Burnout Inventory (MBI) kérdoívet használtuk, a kognitív/viselkedésbeli hibákat, diszfunkcionális elvárásokat pedig a Diszfunkcionális Attitud Skála (DAS) segítségével térképeztük fel. A hangulatzavar kimutatásához a Beck Depresszió Kérdoív rövidített változatát alkalmaztuk, továbbá az Erofeszítés-Jutalom Egyensúlytalanság Kérdoív és a Társas Támogatás Kérdoív is kitöltésre került. Eredmények: Összesen 300 fo töltötte ki a kérdoívet: 106 férfi, 194 no. A munkavállalók döntoen a fiatal/középkorú korcsoporthoz tartoznak, a 26-45 év közöttiek aránya 52,2%. Az átlagos kiégési pontszám 53,9 (SD = 18,7) volt, melybol 105 fo (35,1%) alacsony, 182 fo közepes (60,6%) és 13 fo (4,3%) súlyos kiégéssel érintett. A multivariációs analízis során a noi nem (OR: 5,857), az életkor (OR: 4,126), a munkában eltöltött évek (OR: 2,721), a sokgyermekes család (OR: 2,861) és a társas támogatás hiánya (OR: 2,81) bizonyultak a kiégés független rizikótényezoinek (p<0,05 minden esetben). A depresszió és a kiégés (p<0,001), valamint a diszfunkcionális attitudök és a kiégés között pozitív kapcsolat igazolódott (korrelációs együttható = 0,316; p<0,001). Következtetés: Eredményeink alapján a szociális munkások jelentos része közepes fokú kiégésben, 5%-uk pedig súlyos fokú kiégésben szenved. A kiégésnek vannak befolyásolható (munkahelyi attitudök, társas támogatás) és nem befolyásolható (életkor, nem, család) tényezoi, melyeket az esetleges prevenciós, illetve intervenciós beavatkozások során figyelembe kell venni. Orv Hetil. 2020; 161(44): 1884-1890. INTRODUCTION: Burnout is increasingly prevalent mainly involving employees working in the social sphere. OBJECTIVE: The aim of our study was to examine the complexity of burnout among social workers. METHODS: Baseline demographic data were recorded. Burnout was assessed by the Maslach Burnout Inventory (MBI), and the intensities of dysfunctional attitudes were also studied. Depression was detected by the abbreviated version of the Beck Depression Questionnaire, furthermore social supports and effort-reward imbalance were also examined. RESULTS: Overall 300 employees participated in our study. Age group distribution was young/middle-aged access, the vast majority of the workers was between 25 and 45 years. The mean burnout scale was 53.9 (SD = 18.7), 105 workers had mild (35.1%), 182 moderate (60.6%) and 13 severe (4.3%) burnout. In a multivariate analysis, the female gender (OR: 5.857), the age (OR: 4.126), the years spent with working (OR: 2.721), the number of children (>3) (OR: 2.861) and the lack of social support (OR: 2.81) were independently associated with burnout (p<0.05 in all cases). There was a significant association among burnout, depression and dysfunctional attitudes. CONCLUSION: The vast majority of our social workers suffered from moderate and a small, but a significant proportion from severe burnout. Our work draws attention to the modifiable and unmodifiable risk factors of burnout in this population, which may help in the development of preventive strategies. Orv Hetil. 2020; 161(44): 1884-1890.

Framingham Risk Stratification of Middle-Aged Migraineurs.

Introduction. Migraine is a common primary headache disorder involving about 10-15% of the whole population. Several epidemiological and prospective studies showed a link between migraine (especially migraine with aura) and cardio- and cerebrovascular events. OBJECTIVES: We prospectively analyzed the data of vascular event-free middle-aged patients with migraine who were referred to our Headache Clinic between 01/2014 and 01/2018. Framingham 10-year risk were calculated; covariates included in the analysis were age, total cholesterol, HDL cholesterol, systolic blood pressure, antihypertensive medication use, current smoking, and diabetes status. RESULTS: Total of 1037 patients were screened and 221 were selected, 161 were women (mean age 55.5 ± 5.2 years) and 60 were men (mean age 56 ± 6 years). 25 patients (11.3%) were labelled as having low risk, 162 patients (73.3%) had moderate risk, and 34 patients (15.4%) had high or very high risk. Blood pressure and lipid targets were reached in 73% and in 49% in the moderate risk and in 53% and 12% in the high risk/very high risk groups, respectively. Migraine with aura (MA) was associated significantly higher cardiovascular risk profile compared with migraine without aura (MO). About one-third of our nondiabetic patients had fasting blood glucose above the normal levels. 24 patients (mean age 60 ± 4.9 years) were diabetic. Mean blood pressure was 149/85 Hgmm, mean choleterol was 5.11 mmol/l, and mean LDL was 2.93 mmol/l in this subgroup, respectively, which do not fall within the recommended targets. CONCLUSION: Our article draws attention to the higher cardiovascular risk profile of middle-aged migraineurs and highlights the deficiency of primary prevention. Pain physicians must be aware of the cardiovascular aspects of migraine and holistic approach is required instead of focusing only on pain and pain relief.

Characteristics of Patients Referred To A Specialized Headache Clinic.

Headache is a common problem with great effect both on the individual and on the society. Recent studies raised the possibility of increasing rate of specialty referrals, inappropiate treatment and advanced imaging for simple headache. The aim of our study was to analyze the characteritics of patients (including duration of symptoms, headache type, brain imaging, treatment) referred to our specialized headache clinic between 01/01/2014 and 01/01/2015 by their general practitioners and primary care neurologists due to chronic/treatment-resistant headache syndromes. 202 patients (mean age 53.6 ± 17.6 years) were evaluated in our clinic (102 females, mean age 50.14 ± 16.11 years and 100 males, mean age 57 ± 18.1 years). Migraine (84/202) and tension-type (76/202) were the most common syndromes. 202 plain brain CT, 60 contrast-enhanced CT and 128 MRI were carried out by their general practitioners or other healthcare professioners including neurologists before referral to our headache centre. Despite of extensive brain imaging appropiate treatment was started less than 1/3 of all patients and significant proportion received benzodiazepines or opioid therapy. Furthermore, more than 10% of referred patients presented with secondary headache including one meningitis. The management of headache is still a challenge for primary care physicians leading to medical overuse. Vast majority of our patients should not be referred to our specialized headache clinic as they had uncomplicated headache or other underlying conditions than pain.