chronic illness   and chronic pain   can have profound negative effects on relationship and sexual satisfaction of both patients and partners .
the effects of chronic illness on sexuality are multifactorial and have an impact on all phases of sexual response . sexual desire ,
arousal and activity may be altered by illness through interference with the hormonal , vascular and neural integrity of the mind and the genitalia , as well as the effects and side effects of medications .
anxiety , fear , loss of self - esteem , grief and depression are strongly associated with chronic illness and may also impair sexual function .
studies examining   the prevalence of sexual dysfunction , and the role of psychological variables , including quality of life , on sexual activity in patients with non - cancer pain found that sexual dysfunction was common , and more frequently reported by those with greater disability and depression , shorter pain duration , and infrequent use of coping self - statements .
although sexual dysfunction was commonly reported , subjects perceived it had less importance in quality of life than did other factors possibly because of adaptation to the impact of chronic illness on sexual function .
migraine is an extremely prevalent disease : the lifetime prevalence of migraine in women is 33% and the 1-year prevalence of migraine in women is 25% . in men ,
it is a chronic  episodic disease , most common in men and women between the ages of 1555  years that can impair many aspects of life .
the aim of the present study was to compare the prevalence of sexual dysfunctions between the migraine sufferers and non - sufferers participants .
in the present cross - sectional study , we evaluated female students from the ben - gurion university of the negev who agreed to participate in the study .
all the participants were included after having received a detailed explanation on the purpose and design of the study .
previously published data or the researchers assumptions regarding pain and sexual function were not presented to the participants .
female students were recruited from classrooms , in which a brief presentation of the study was given .
subjects who were pregnant , were not sexually active during the year prior to questionnaire administration , and subjects who suffered from any neurological disorder ( other than headache ) or sustained a head trauma during the last year , were excluded from the study . the participants were requested to fill a questionnaire .
questionnaires were filled without the presence of an interviewer , and did not include any recognizable data to assure full anonymity of the collected data .
all subjects completed the following questionnaires : demographics and background : participants were asked to answer questions regarding their personal background ( e.g. , age , marital status , religion , extent of religious observance , height , weight etc.).headache history : the participants were asked to report whether they suffered from troubling headache and if so , to report headache characteristics and accompanying features , using a list of items ( frequency , number of headache days / month , severity , aura symptoms , localization , quality , exacerbating factors , nausea , vomiting , sensitivity to light and sound , triggers etc . ) .
migraine diagnosis was based on the 2004 ihs criteria for migraine with and without aura .migraine disability assessment scale ( midas ) : the migraine disability assessment ( midas ) scale was used to quantify headache - related disability .
midas is a brief and reliable headache - specific tool , which captures headache - related disability .
it consists of five questions relating to the influence of headache on everyday activities over the preceding 3  months.the israeli sexual behavior inventory ( isbi ) : the isbi is a 33 items questionnaire which was primarily designed to assess the impact of sexual problems , chronic illness and disability on sexual functioning and experience .the questionnaire was designed to evaluate several dimensions (  domains  ) of female sexuality  sexual desire , orgasm , sexual avoidance , interpersonal sexual relationship , health influence , satisfaction and pain , during the previous year .
the participants rated their answers in a scale of 15 according to the rate of agreement with certain phrases or according to the incidence of experiencing phenomenon asked in the questionnaire .
demographics and background : participants were asked to answer questions regarding their personal background ( e.g. , age , marital status , religion , extent of religious observance , height , weight etc . ) .
headache history : the participants were asked to report whether they suffered from troubling headache and if so , to report headache characteristics and accompanying features , using a list of items ( frequency , number of headache days / month , severity , aura symptoms , localization , quality , exacerbating factors , nausea , vomiting , sensitivity to light and sound , triggers etc . ) .
migraine diagnosis was based on the 2004 ihs criteria for migraine with and without aura .
migraine disability assessment scale ( midas ) : the migraine disability assessment ( midas ) scale was used to quantify headache - related disability .
midas is a brief and reliable headache - specific tool , which captures headache - related disability .
it consists of five questions relating to the influence of headache on everyday activities over the preceding 3  months . the israeli sexual behavior inventory ( isbi ) : the isbi is a 33 items questionnaire which was primarily designed to assess the impact of sexual problems , chronic illness and disability on sexual functioning and experience .
this instrument was proved to be a reliable and valid self - report measure of sexual behavior .
the socio demographic and health related characteristics were presented as proportion for categorical variables and mean with standard deviation for continuous variables .
the isbi questions were mapped on the scale from 1 to 5 as the higher grade signed the lower dysfunction .
the isbi questions were combined into domains and the score for each domain was calculated as the sum of related questions grades .
the socio demographic and health related characteristics were compared between the migraine sufferers and non - sufferers participants using chi square test , fisher s exact test and student s t test .
whitney non - parametric test due to the small sample size in subgroups and discrete nature of the isbi scores .
the multivariable analysis for sexual behavior based on linear regression . a p values of < 0.05 ( two tail ) were defined as significant .
in the present cross - sectional study , we evaluated female students from the ben - gurion university of the negev who agreed to participate in the study .
all the participants were included after having received a detailed explanation on the purpose and design of the study .
previously published data or the researchers assumptions regarding pain and sexual function were not presented to the participants .
female students were recruited from classrooms , in which a brief presentation of the study was given .
subjects who were pregnant , were not sexually active during the year prior to questionnaire administration , and subjects who suffered from any neurological disorder ( other than headache ) or sustained a head trauma during the last year , were excluded from the study . the participants were requested to fill a questionnaire .
questionnaires were filled without the presence of an interviewer , and did not include any recognizable data to assure full anonymity of the collected data .
all subjects completed the following questionnaires : demographics and background : participants were asked to answer questions regarding their personal background ( e.g. , age , marital status , religion , extent of religious observance , height , weight etc.).headache history : the participants were asked to report whether they suffered from troubling headache and if so , to report headache characteristics and accompanying features , using a list of items ( frequency , number of headache days / month , severity , aura symptoms , localization , quality , exacerbating factors , nausea , vomiting , sensitivity to light and sound , triggers etc . ) .
migraine diagnosis was based on the 2004 ihs criteria for migraine with and without aura .migraine disability assessment scale ( midas ) : the migraine disability assessment ( midas ) scale was used to quantify headache - related disability .
midas is a brief and reliable headache - specific tool , which captures headache - related disability .
it consists of five questions relating to the influence of headache on everyday activities over the preceding 3  months.the israeli sexual behavior inventory ( isbi ) : the isbi is a 33 items questionnaire which was primarily designed to assess the impact of sexual problems , chronic illness and disability on sexual functioning and experience .the questionnaire was designed to evaluate several dimensions (  domains  ) of female sexuality  sexual desire , orgasm , sexual avoidance , interpersonal sexual relationship , health influence , satisfaction and pain , during the previous year .
the participants rated their answers in a scale of 15 according to the rate of agreement with certain phrases or according to the incidence of experiencing phenomenon asked in the questionnaire .
demographics and background : participants were asked to answer questions regarding their personal background ( e.g. , age , marital status , religion , extent of religious observance , height , weight etc . ) .
headache history : the participants were asked to report whether they suffered from troubling headache and if so , to report headache characteristics and accompanying features , using a list of items ( frequency , number of headache days / month , severity , aura symptoms , localization , quality , exacerbating factors , nausea , vomiting , sensitivity to light and sound , triggers etc . ) .
migraine diagnosis was based on the 2004 ihs criteria for migraine with and without aura .
migraine disability assessment scale ( midas ) : the migraine disability assessment ( midas ) scale was used to quantify headache - related disability .
midas is a brief and reliable headache - specific tool , which captures headache - related disability .
it consists of five questions relating to the influence of headache on everyday activities over the preceding 3  months . the israeli sexual behavior inventory ( isbi ) : the isbi is a 33 items questionnaire which was primarily designed to assess the impact of sexual problems , chronic illness and disability on sexual functioning and experience .
this instrument was proved to be a reliable and valid self - report measure of sexual behavior .
the socio demographic and health related characteristics were presented as proportion for categorical variables and mean with standard deviation for continuous variables .
the isbi questions were mapped on the scale from 1 to 5 as the higher grade signed the lower dysfunction .
the isbi questions were combined into domains and the score for each domain was calculated as the sum of related questions grades .
the socio demographic and health related characteristics were compared between the migraine sufferers and non - sufferers participants using chi square test , fisher s exact test and student s t test .
whitney non - parametric test due to the small sample size in subgroups and discrete nature of the isbi scores .
the multivariable analysis for sexual behavior based on linear regression . a p values of < 0.05 ( two tail ) were defined as significant .
out of 172 candidates , 138 ( about 80% ) agreed to participate in the study .
eleven subjects ( 7.9% ) met the exclusion criteria due to sexual inactivity during the last year .
the rest , 127 participants were included into the study . the median age of the subjects was 25  years .
thirty - two ( 25.2% ) of the participants met the ihs criteria for episodic migraine with or without aura .
the characteristics of the study population with and without migraine are presented in table  1 .
migraine sufferers did not differ significantly from non - sufferers in any of the demographic measures , such as age , marital status , regular partner , and sexual orientation , nor by number of children , bmi , religion , religiousness and contraceptive use . 

table  1study population characteristicscharacteristictotal population ( n  =  127)migraine ( n  =  32)non - migraine ( n  =  95)page , mean ( sd)25.2 ( 3.4)26.0 ( 4.3)24.9 ( 3.1)0.146married , % 2525251presence of children , % 86.58.51presence of regular sexual partner , % 76.467.779.30.188bmi , mean ( sd)21.8 ( 3.0)21.3 ( 2.4)22.0 ( 3.2)0.323sexual orientation  homosexual , % 2.503.40.596  bisexual , % 3.43.33.4religiousness  traditional , % 5.76.55.40.587  orthodox , % 2.403.3contraception  oral , % 72.979.370.80.495  condom , % 18.617.219.1comparison between migraine and non - migraine subject study population characteristics comparison between migraine and non - migraine subject migraine features among migraine participants are summarized in table  2 .
only eight ( 24.2% ) of them had a previous physician diagnosis of migraine , and only two ( 6% ) were using prophylactic anti migraine medications . 

table  2headache characteristics among migraine suffering subjectscharacteristicmigraine subjects ( n  =  32)aura , % 39.4headache features  unilateral , % 78.8  throbbing , % 87.9  moderate to severe intensity , % 90.9  exacerbated by activity , % 90.9accompanying features  vomiting / nausea , % 51.5  phonophobia / photophobia , % 90.9midas  mean ( sd)12.5(14.5 )  minimal ( 05 ) , % 39.4  mild ( 610 ) , % 21.2  moderate ( 1120 ) , % 15.2  severe ( > 20 ) , % 15.2 headache characteristics among migraine suffering subjects levels of sexual activity , sexual desire , ability to experience orgasm and general satisfaction from sexual life did not differ significantly between migraine and non - migraine subjects . nevertheless , migraine patients reported a greater degree of pain during intercourse and a higher frequency of fear of sexual intercourse and penetration and lower levels of satisfaction ( fig .  1 ) .
the total isbi score among migraine sufferers was significantly lower than in non - sufferers ( mean rank 49.5 vs. 68.9 ; p  =  0.01 ) .
multivariable analysis showed that migraine , absence of regular sexual partner , and self - reported religiousness ( traditional or orthodox ) was independently associated with lower isbi scores . among these predictors , migraine had the strongest relationship with the dependent variable ( table  3 ) .
* sexual desire , p  =  0.138 ; * * satisfaction , p  =  0.032 ;  orgasm , p  =  0.250 ;  pain , p  =  0.022 ;  interpersonal sexual relationships , p  =  0.661 ;   health influence , p  <  0.001table  3predictors of isbi total score 
errorbetapmigraine ( yes vs. no)2.270.570.34<0.001regular partner ( no vs. yes)1.260.590.180.034religiousness ( traditional or orthodox vs. secular)1.980.890.190.028 comparison of isbi domain scores ( mean ranks ) between migraine sufferers and non - sufferers . * sexual desire , p  =  0.138 ; * * satisfaction , p  =  0.032 ;  orgasm , p  =  0.250 ;  pain , p  =  0.022 ;  interpersonal sexual relationships , p  =  0.661 ;   health influence , p  <  0.001 predictors of isbi total score  multivariable analysis the severity of migraine , as reflected by the midas score , was found to be correlated to lower scores in the health domain ( rs  =  0.404 ; p  =  0.024 ) .
it was not associated with other domains of the score or with the total isbi score .
female sexual dysfunction   is a general term used for various disorders of the sexual process in women affecting the various segments of the sexual response cycle : desire , arousal , orgasm and resolution .
inability or difficulty to enjoy any of these stages can interfere with sexual satisfaction and cause some degree of dysfunction .
female sexual dysfunctions can be accordingly subdivided in the dsm iv into desire , arousal , orgasmic and sexual pain disorders . in the presented study
, we attempted to evaluate sexual function and dysfunction among young women suffering from migraine compared to non - migraine sufferers , using the isbi .
sexual desire , orgasm and sexual interpersonal relations were similar among migraineurs compared to non - migraineurs , and where comparable to previous reports regarding israeli women in this age group . unlike a recent study , we did not find migraine patients to have higher degrees of sexual desire .
three domains were significantly impaired among migraine sufferers : health influence , sexual pain and satisfaction .
positive answers regarding fear of sex and avoidance of sexual intercourse were more prevalent among migraine patients . as in other chronic pain conditions ,
indeed its influence , reflected by higher scores in this domain , was found to be correlated with higher midas scores .
it seems reasonable , that avoidance , fear of penetration and consequently lower satisfaction are associated with higher levels of sexually associated pain .
sexual pain disorders [ 8 , 10 ] fall into one of two categories : dyspareunia and vaginismus .
vaginismus is the recurrent or persistent involuntary or subconscious voluntary spasm ( or contraction ) of the genital perineal muscles that surround the outer third of the vagina when the insertion of any object is attempted .
dyspareunia is estimated to affect 515% of women annually , according to the national health and social life survey , and vaginismus affects 1517% of women presenting to a sex therapy clinic [ 8 , 10 , 11 ] .
our study questionnaire was not designed to evaluate the various aspects of sexual pain disorder , and this subject should be addressed in future studies .
a possible explanation for the high prevalence of sexual pain disorder among migraine females is sensitization of pain pathways [ 10 , 12 ] often found in migraine patients ( either as a cause or consequence ) .
clinical and experimental observations   on migraine suggest that a general hyper excitability could develop along nociceptive trigeminal neurons allowing the activation of descending pathways that facilitate pain processing or the suppression of pathways that slow down pain transmission .
slowly progressive dysfunction of central pain systems secondary to the repetition of attacks of the originating headache has been implicated in transforming the process from an episodic to a chronic condition .
this concept of an irritable focus in the central nervous system is currently known as  central sensitization  and is a characteristic feature of visceral pain .
dyspareunia was found to be a co - morbid phenomenon with other pain syndromes [ 10 , 11 ] ( e.g. fibromyalgia ) , and to involve increased sensitivity to pain and touch .
it is also possible that migraineurs tend to be more attentive to somatic and pain symptoms .
recurrent pain is often characterized by elevated pain - related fear and avoidance of behaviors which the headache sufferer believe will initiate or perpetuate the headache pain , a maladaptive process which serves to promote pain related disability .
this process might be the underlying reason for the increased fear of sexual intercourse and penetration among migraine patients in this study .
the present study was designed as a pilot study , exploring different aspects of female sexuality in migraine sufferers and non - sufferers . to avoid bias ,
the evaluated population is not representative of the general population , but rather a homogenous population of young , educated , secular women belonging to a relatively high socioeconomic status .
one has to take into account that only in such a population asking intimate sexual questions , and getting honest answers ; is feasible .
compared to israeli women in similar age group [ 6 , 7 ] , our study population reported higher sexual desire , tended more to initiate sexual intercourse with their partner , and lower fear of intercourse and penetration .
the interpretation of the findings should therefore be limited to this group of women only . as the respondents were asked to report about only troubling headaches , only a small number of subjects reported headaches corresponding to ihs criteria of tension type headache .
no information regarding tension headache can be concluded from this study and further investigation is required .
therefore , no conclusions can be drawn from the current study regarding patients with this type of headache . despite these limitations , our findings suggest that migraine affects the sexual life of women suffering from it .
this effect is both severity dependent ( as represented by the health influence domain ) and independent ( intercourse associated pain ) .
future studies should be directed in exploring the incidence of sexual dysfunction in general and specifically sexual pain disorders in other migraine suffering populations , and in evaluating the exact nature of the sexual pain disorders .
 chronic illness and chronic pain can have profound negative effects on relationship and sexual satisfaction , yet the influence of migraine on sexuality has not been previously evaluated . to assess sexual functions in subjects with migraine compared to those with no migraine . 
 we evaluated female university students using the israeli sexual behavior inventory ( isbi ) . 
 migraine was diagnosed according to self - reported symptoms according to the ihs criteria . 
 several dimensions of female sexuality  desire , orgasm , sexual avoidance , interpersonal sexual relationship , health influence , satisfaction and pain were evaluated using a structured questionnaire . 
 thirty - three ( 23.9% ) of the participants met the ihs criteria for episodic migraine with and without aura . 
 sexual activity , desire , orgasm and satisfaction from sexual life did not differ significantly between migraine sufferers and non - sufferers . 
 migraine patients reported lower isbi scores , higher health influence on sexual life , higher levels of sexual pain and lower sexual satisfaction . 
 migraine negatively affected the sexual life of sufferers . 
 sexual pain disorder is more common among migraine sufferers compared to non - migraineurs . 
Introduction
Methods
Participants
Data analysis
Results
Discussion