*Corresponding author: Tel. + 386 41 761 288; E-mail: marjan.zaletel@kclj.si; mzaletel34@gmail.com
10.2478/sjph-2021-0007 Zdr Varst. 2021;60(1):38-45
38
ESTIMATION OF THE IMPACT OF MIGRAINE ON SELF-RATED HEALTH:  
A CROSS-SECTIONAL STUDY IN SLOVENIA
Matjaž POPIT
1
, Lijana ZALETEL-KRAGELJ
2,3
, Ivan ERŽEN
2,3
, Lorna ZADRAVEC-ZALETEL
4
, Marjan ZALETEL
5*
1
General Hospital Jesenice, Cesta maršala Tita 112, 4270 Jesenice, Slovenia
2
University of Ljubljana, Faculty of Medicine, Public Health Centre, Zaloška 4, 1000 Ljubljana, Slovenia
3
National Institute of Public Health, Trubarjeva 2, 1000 Ljubljana, Slovenia
4
Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
5
University Medical Centre Ljubljana, Vasular Neurology, Zaloška 2, 1000 Ljubljana, Slovenia 
OCENA VPLIVA MIGRENE NA SAMOOCENO ZDRAVJA: 
SLOVENSKA PRESEČNA ŠTUDIJA
Popit M, Zaletel-Kragelj L, Eržen I, Zadravec-Zaletel L, Zaletel M. Estimation of the impact of migraine on self-rated health: a cross-sectional study in 
Slovenia. Zdr Varst. 2021;60(1):38-45. doi: 10.2478/sjph-2021-0007.
Received: Jun 19, 2020
Accepted: Nov 20, 2020 
Original scientific article
ABSTRACT
Keywords: 
migraine, self-rated 
health, European 
Health Interview 
Survey, Slovenia 
IZVLEČEK
Ključne besede: 
migrena, samoocenjeno 
zdravje, evropska 
raziskava o zdravju 
EHIS, Slovenija
Aim: With the aim of providing a foundation for evidence-based public health actions, as well as the more 
individualised clinical treatment of migraine in Slovenia, the objective of our study was to assess the association 
between poor self-rated health (PSRH) and migraine, adjusted for selected comorbidity and socioeconomic factors.
Methods: The survey, conducted between August and December 2014, involved included 6,262 adults aged 15 
years and over. Binary logistic regression was used in univariate as well as multivariate analysis. Three multivariate 
models were defined: MODEL 1 (migraine and comorbidities related to the physical dimension of health); MODEL 
2 (comorbidities related to the mental dimension of health); MODEL 3 (demographic and socioeconomic factors).
Results: In univariate as well as all three multivariate models, the odds of PSRH were statistically significantly 
higher in migraine sufferers in comparison to non-sufferers (univariate model: ORmigraine=yes vs. 
migraine=no=2.22 (p<0.001); MODEL 1: ORmigraine=yes vs. migraine=no=2.27 (p<0.001); MODEL 2: ORmigraine=yes 
vs. migraine=no=1.51 (p=0.002); MODEL 3: ORmigraine=yes vs. migraine=no=1.56 (p=0.001)).
Conclusion: Migraine is an important PSRH-related factor. Comorbidities related to the physical dimension of 
health do not reduce the power of association between migraine and PRSH, while comorbidities related to the 
mental dimension reduce the power of association of migraine and other health conditions. The power of the 
association between migraine and PRSH is also independent of demographic/socioeconomic factors. We can also 
conclude that migraine seems to be a phenomenon that is in a bi-directional relationship with mental states (thus 
having an impact on PSRH) and is itself a stressor.
Namen: Z namenom, da bi priskrbeli dokaze na eni strani za z dokazi podprte ukrepe za obvladovanje migrene 
kot velikega javnozdravstvenega problema, na drugi pa bolj individualizirano zdravljenje bolnikov z migreno na 
klinični ravni, smo si zadali za cilj proučiti povezanost med migreno in samooceno zdravja kot slabega, prilagojeno 
na izbrane zdravstvene sopojave in socio-ekonomske dejavnike.
Metode: V presečno raziskavo, izvedeno med avgustom in decembrom 2014, je bilo vključenih 6.262 odraslih, 
starejših od 15 let. Tako v univariatni kot tudi multivariatni analizi smo kot analitično metodo uporabili logistično 
regresijo. Opredelili smo tri multivariatne modele – v MODEL 1 smo vključili poleg migrene še izbrane zdravstvene 
sopojave, povezane s telesno dimenzijo zdravja, v MODEL 2 še zdravstvene sopojave, povezane z duševno 
dimenzijo zdravja, v MODEL 3 pa še demografske in socio-ekonomske dejavnike.
Rezultati: O b e t i z a s a m o o c e n o z d r a v j a k o t s l a b e g a s o b i l i p r i b o l n i k i h z m i g r e n o v p r i m e r j a v i z u d e l e ž e n c i 
raziskave, ki o migreni niso poročali, statistično značilno višji v vseh modelih (univariatni model: ORmigrena = 
da vs. migrena = ne = 2,22 (p < 0,001); MODEL 1: ORmigrena = da vs. migrena = ne = 2,27 (p < 0,001); MODEL 2: 
ORmigrena = da vs. migrena = ne = 1,51 (p = 0,002); MODEL 3: ORmigrena = da vs. migrena = ne = 1,56 (p = 0,001).
Zaključek: Kot kaže, je migrena pomemben dejavnik v samooceni zdravja kot slabega. Njenega pomena ne 
zmanjšujejo zdravstveni sopojavi, povezani s telesno dimenzijo zdravja, ga pa zmanjšujejo sopojavi, povezani z 
duševno dimenzijo zdravja. Prav tako njenega pomena ne zmanjšujejo demografski in socio-ekonomski dejavniki. 
Zaključimo lahko tudi, da je migrena pojav, ki je povezan z duševnimi stanji, istočasno pa ima tudi samostojen 
vpliv na samooceno zdravja.
© Nacionalni inštitut za javno zdravje, Slovenija. 

1 INTRODUCTION
Human health is a complex concept with multiple 
dimensions (1). While the physical dimension is undoubtedly 
extremely important, the mental and social dimensions 
are important as well. At any particular moment, a 
person perceives all the dimensions that are important to 
them. Consequently, self-rated health (SRH) has become 
an important indicator for obtaining a rough assessment 
of health at both individual and population levels (2). 
Despite initial scepticism, SRH is today known as a valid 
and reliable measure among patients without cognitive 
impairment. Moreover, it is a strong predictor of health-
care seeking, morbidity, mortality and frequent use of 
hospital services (3). Especially poor SRH (PSRH) showed a 
strong association with an increased risk of mortality, even 
after adjustment for covariates such as comorbidity (4).
The recent Global Burden of Disease (GBD) 2019 study 
confirmed that, among neurological disorders, migraine 
in particular is a major public health problem, especially 
in young and middle-aged women (5). It is still unclear 
whether migraine is independently related to SRH, and 
particularly to PSRH. While few studies have so far 
shown the relationship between migraine and PSRH, they 
were not systematically controlled for comorbidity and 
socioeconomic factors. For example, Kroll et al. reported 
the association of PSRH with migraine, controlled only 
for education (6), while Molarius et al. reported this 
association, controlled for symptoms of musculoskeletal 
pain and psychosomatic symptoms (7). In order to clarify 
the impact of migraine on SRH, it is therefore essential 
to consider accompanying factors such as comorbidity 
(including stroke, coronary heart disease, hypertension, 
psychiatric diseases and asthma) that affect SRH (8). 
Moreover, it is well-known that PSRH is associated with 
socioeconomic factors (9). 
Among neurological disorders, migraine accounts for 
a significant part of the overall burden of disease in 
Slovenia. As measured by the YLD (Years Lived with 
Disability) indicator in the GBD 2019 study, it was even 
ranked first, accounting for 3.95% of the total YLDs, in 
Slovenia (5). Moreover, a recent study on productivity 
losses due to migraine in Slovenia highlights the problem 
from another perspective (10). Consequently, the data 
shows that public health action is imperative. 
With the aim of providing a foundation for evidence-based 
public health actions, as well as the more individualised 
clinical treatment of migraine in Slovenia, the objective 
of our study was to assess the association between PSRH 
and migraine, adjusted for selected comorbidity and 
socioeconomic factors. We hypothesise that migraine is 
independently associated with PSRH, and that the association 
could be changed along with an adjustment to physical and 
mental comorbidities and socioeconomic factors.
10.2478/sjph-2021-0007 Zdr Varst. 2021;60(1):38-45
39
2 METHODS
2.1 Study design
The data was collected as part of the second wave of the 
European Health Interview Survey (EHIS) (11), conducted 
in Slovenia from August to December 2014 (12) by the 
Slovenian National Institute of Public Health (NIJZ). 
The cross-sectional study was carried out on a 
representative sample (two-stage random sampling) 
of inhabitants of Slovenia aged 15 and over residing in 
private households (12). The initial sample consisted of 
11,000 units, while the final sample consisted of 10,005 
units (with 995 units unsuitable) (12).
2.2 Data collection procedure and study instrument
Data was collected by means of online and personal 
surveys at the addresses of selected individuals using 
computer-assisted personal interviewing (CAPI) (12). The 
study instrument was a questionnaire harmonised at the 
European level (11), containing questions about health 
status, risk factors and healthcare, with some additions 
made in the Slovenian version (13).
2.3 Observed outcome
The outcome phenomenon of interest to the study was 
SRH, measured through a single question: “How is your 
health in general? Is it…” (1=very good, 2=good, 3=fair, 
4=bad, 5=very bad). For the needs of this study, a new 
variable (PSRH) was designed by combining participants 
who rated their health as bad/very bad into a common 
group (no, yes).
2.4 Explanatory factor and comorbidities
The main explanatory factor was migraine. Individuals 
were classified as migraine sufferers if they responded 
‘‘yes’’ to the question: “During the past 12 months, have 
you had any of the following diseases or conditions? ... 
heavy headache, migraine” (no, yes). 
Comorbidities that could be related to PSRH and were 
collected as part of the EHIS study were selected from 
two groups of questions. The first group consisted of 
medical conditions that had affected the participants 
during the last 12 months (“During the past 12 months, 
have you had any of the following diseases or conditions? 
…” (no, yes). For the purpose of the analysis, some of 
them were combined. The final selection was as follows: 
asthma (asthma and/or allergies), chronic obstructive 
pulmonary disease, ischemic heart disease (acute 
myocardial infarction and/or coronary disease/angina 
pectoris), arterial hypertension, stroke, diabetes mellitus, 
arthrosis, spinal pain (back pain and/or neck pain), liver 
cirrhosis, cancer, urinary tract diseases (urinary bladder 
problems and/or kidney problems), and mood disorders 
(depression and/or anxiety) (no, yes in all of them). The 

10.2478/sjph-2021-0007 Zdr Varst. 2021;60(1):38-45
40
second group consisted of selected problems that had 
affected participants over the last two weeks (“Over the 
last two weeks, how often have you been bothered by any 
of the following problems? …” (1=not at all, 2=several days, 
3=more than half the days, 4=nearly every day)). Poor 
sleep was selected for insertion into the analysis (more 
than half the days or nearly every day: no, yes). For the 
purpose of analysis, comorbidities were regrouped into 
the following two groups: those related to the physical 
dimension of health and those related to the mental 
dimension of health.
2.5 Confounding factors
Confounding factors consisted of demographic and 
socioeconomic factors: gender (male, female), age 
(≤65 years, >65years), marital status: married (no, yes), 
education level: low (no, yes) and employment status: 
unemployed (no, yes). 
2.6 Methods of analysis
The association between PSRH as observed outcome and 
migraine as explanatory factor was assessed univariately 
and multivariately by using logistic regression. Three 
models were defined in the multivariate analysis. MODEL 
1 (migraine and comorbidities related to the physical 
dimension of health); MODEL 2 (comorbidities related to 
the mental dimension of health); MODEL 3 (demographic 
and socioeconomic factors). In all statistical tests, a 
p-value of ≤0.05 was considered significant. IBM SPSS for 
Windows Version 21.0 (SPSS Inc., Chicago, IL., USA) was 
used for the statistical analysis.
3 RESULTS
3.1 Description of the study group
The invitation to participate in the survey was accepted 
by 6,262/10,005 persons (response rate 62.6%). Their 
characteristics are presented in Table 1.
3.2 Results of analysis of association between poor self-
rated health and migraine
PSRH was reported by 488 respondents (7.8%). Its 
prevalence within categories of different factors, including 
migraine, is presented in Table 1. 
The results of the univariate analysis showed that migraine 
sufferers were more likely than non-sufferers to rate their 
health as poor. However, migraine was not one of the most 
important factors for perceiving PSRH in the univariate 
analysis (Table 1). The picture changed considerably in the 
multivariate analysis, where most of comorbidities lost 
much of their power of association, while with migraine 
the power decreased the least (Table 2).
Migraine
MIGRAINE COMORBIDITIES RELATED TO PHYSICAL DIMENSION OF HEALTH
Asthma/allergy
COPD
Ischemic heart disease
Stroke
Arterial hypertension
Diabetes mellitus
Table 1. Prevalence of poor self-rated health (PSRH) within categories of selected factors, with the results of the univariate analysis 
of the relationship between PSRH and these factors in the European Health Interview Survey, Slovenia 2014.
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
350/5262 (6.7%)
139/951 (13.7%)
363/5007 (7.2%)
122/1219 (10.0%)
408/5982 (6.8%)
78/257 (30.4%)
388/5964 (6.5%)
96/256 (37.5%)
447/6145 (7.3%)
37/94 (39.4%)
209/4690 (4.5%)
275/1546 (17.8%)
376/5790 (6.5%)
110/427 (25.8%)
6,213
6,226
6,239
6,220
6,239 
6,236
6,217
1.00
2.22 (1.79–2.75)
1.00
1.41 (1.14–1.76)
1.00
5.90 (4.44–7.85)
1.00
8.57 (6.52–11.26)
1.00
8.33 (5.45–12.73)
1.00
4.63 (3.82–5.60)
1.00
4.99 (3.92–6.35)
 
<0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Risk factor Category N
det
/N
cat
(%) N
tot
OR (95% CI limits 
for OR)
p

10.2478/sjph-2021-0007 Zdr Varst. 2021;60(1):38-45
41
Arthrosis
Liver cirrhosis
Cancer
Urinary tract diseases
MIGRAINE COMORBIDITIES RELATED TO MENTAL DIMENSION OF HEALTH
Mood disorders
Poor sleep
Spinal pain
DEMOGRAPHIC AND SOCIOECONOMIC FACTORS
Gender 
Married
Low education level
Unemployed
Age 
Legend: N
tot
=total number of observations, N
det
=number of patients with PSRH; N
cat
=number of patients within the category; OR=odds 
ratio; CI=confidence interval; COPD=chronic obstructive pulmonary disease
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Male
Female
No
Yes
No
Yes
No
Yes
≤65 years
>65 years
405/5940 (6.8%)
79/278 (28.4%)
467/6185 (7.6%)
15/34 (44.1%)
444/6071 (7.3%)
39/138 (29.3%)
325/5494 (5.9%)
161/747 (21.6%)
312/5345 (5.8%)
172/864 (19.9%)
284/5487 (5.2%)
204/776 (26.3%)
104/3568 (2.9%)
383/2666 (14.4%)
207/3082 (6.7%)
280/3180 (8.8%)
249/3115 (8.0%)
239/3148 (7.6%)
147/3616 (4.1%)
338/2585 (13.1%)
93/2889 (3.2%)
394/3321 (11.9%)
5054/245 (4.8%)
243/1208 (20.1%)
6,218
6,219
6,209
6,241
6,209
6,262
6,234
6,262
6,255
6,201
6,262
6,262
1.00
5.40 (4.08–7.14)
1.00
9.40 (4.72–18.72)
1.00
4.95 (3.37–7.26)
1.00
4.36 (3.54–5.37)
1.00
4.00 (3.26–4.90)
1.00
6.54 (5.36–7.99)
1.00
5.60 (4.48–7.00)
1.00
1.34 (1.11–1.61)
1.00
0.94 (0.78–1.13)
1.00
3.54 (2.90–4.33)
1.00
4.05 (3.21–5.11)
1.00
4.94 (4.08–5.98)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.002
0.538
<0.001
<0.001
<0.001
Migraine
MIGRAINE COMORBIDITIES RELATED TO PHYSICAL DIMENSION OF HEALTH
Asthma/allergy
COPD
Ischemic heart disease
Arterial hypertension
Stroke
Diabetes mellitus
Table 2. Results of multivariate analysis of relationship between poor self-rated health (PSRH) and migraine adjusted for 
accompanying health conditions and demographic and socioeconomic factors in the European Health Interview Survey, 
Slovenia 2014 (Model 1: n=6042; Model 2: n=6015; Model 3: n=5946).
0.001
0.431
<0.001
<0.001
<0.001
0.003
<0.001
0.002
0.273
<0.001
<0.001
<0.001
0.001
<0.001
<0.001
0.792
<0.001
<0.001
<0.001
0.002
<0.001
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
1.00
1.56 (1.18–2.05)
1.00
0.89 (0.68–1.17)
1.00
3.41 (2.40–4.86)
1.00
2.77 (1.97–3.92)
1.00
1.63 (1.28–2.08)
1.00
2.31 (1.34–4.01)
1.00
2.37 (1.74–3.22)
1.00
1.51 (1.16–1.96)
1.00
0.86 (0.65–1.12)
1.00
3.57 (2.52–5.05)
1.00
3.32 (2.37–4.64)
1.00
2.08 (1.65–2.61)
1.00
2.60 (1.50–4.50)
1.00
2.60 (1.92–3.53)
1.00
2.27 (1.77–2.91)
1.00
1.03 (0.80–1.33)
1.00
4.24 (3.03–5.9)
1.00
3.89 (2.82–5.38)
1.00
2.55 (2.04–3.18)
1.00
2.30 (1.35–3.91)
1.00
2.66 (1.98–3.57)
Risk factor
p p p
Category Model 1 Model 2 Model 3
OR (95% CI limits 
for OR)
OR (95% CI limits 
for OR)
OR (95% CI limits 
for OR)
Risk factor Category N
det
/N
cat
(%) N
tot
OR (95% CI limits 
for OR)
p

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42
Legend: N
tot
=total number of observations, N
det
=number of patients with PSRH; N
cat
=number of patients within the category; OR=odds 
ratio; CI=confidence interval; COPD=chronic obstructive pulmonary disease
Arthrosis
Liver cirrhosis
Cancer
Urinary tract diseases
MIGRAINE COMORBIDITIES RELATED TO MENTAL DIMENSION OF HEALTH
Spinal pain
Mood disorders
Poor sleep
DEMOGRAPHIC AND SOCIOECONOMIC FACTORS
Gender 
Age 
Married
Low education level
Unemployed
0.130
0.001
<0.001
0.045
<0.001
0.008
<0.001
0.711
<0.001
0.029
<0.001
0.037
0.039
<0.001
<0.001
<0.001
<0.001
0.011
<0.001
<0.001
<0.001
<0.001
<0.001
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Male
Female
≤65 years
>65 years
No
Yes
No
Yes
No
Yes
1.00
1.32 (0.92–1.91)
1.00
4.04 (1.81–9.01)
1.00
2.75 (1.71–4.43)
1.00
1.31 (1.00–1.72)
1.00
3.02 (2.32–3.91)
1.00
1.43 (1.09–1.84)
1.00
3.63 (2.84–4.63)
1.00
0.95 (0.75–1.21)
1.00
1.64 (1.25–2.51)
1.00
0.77 (0.61–0.97)
1.00
1.84 (1.45–2.35)
1.00
1.36 (1.01–1.84)
1.00
1.46 (1.02–2.09)
1.00
4.63 (2.08–10.30)
1.00
2.78 (1.72–4.49)
1.00
1.60 (1.23–2.08)
1.00
3.18 (2.46–4.11)
1.00
1.39 (1.07–1.80)
1.00
3.77 (2.97–4.80)
1.00
2.11 (1.49–2.99)
1.00
6.78 (3.00–15.31)
1.00
2.57 (1.60–4.11)
1.00
2.15 (1.67–2.76)
Risk factor
p p p
Category Model 1 Model 2 Model 3
OR (95% CI limits 
for OR)
OR (95% CI limits 
for OR)
OR (95% CI limits 
for OR)
4 DISCUSSION
The results indicate that migraine is an important PSRH-
related factor and that the comorbidities related to 
the physical dimension of health do not reduce the 
power of migraine association with PRSH. On the other 
hand, comorbidities related to the mental dimension 
of health reduce the power of both migraine and other 
health conditions. The power of the association between 
migraine and PRSH is also independent of demographic 
and socioeconomic factors. This is a relatively new finding 
since, up to now, we have not had extensive data available 
on this issue. 
The lack of studies with a similar approach to analysis 
makes it almost impossible to compare our results. The 
greatest similarities are with the studies produced by Kroll 
et al. (6) and Molarius et al. (7). However, both studies were 
significantly less detailed. In the former study, there was a 
significant association between PSRH and the coexistence 
of migraine, tension-type headaches and neck pain, but 
it was controlled for education attainment only. In the 
latter study, where migraine in multivariate models was 
controlled for age, gender, spinal pain and psychological 
symptoms, there was a significant association between 
PSRH, recurrent headaches and migraine. Comparison 
is also difficult because, in our study, we tried to 
place the relationship between PSRH and migraine 
within a new health concept, taking into account the 
multidimensionality of health. This multidimensionality is 
also reflected in the counter-concept of health, which can 
be characterised as an illness, disease or sickness (14). 
This concept was followed by the design of multivariate 
models in our study. It was interesting to note from the 
neurological perspective that, in MODEL 1, migraine 
retained all its power of its relationship to PSRH in 
comparison with the univariate model, while the other 
disease phenomena appeared to be mutually competitive 
and could also lose a considerable portion of their power, 
because nowadays migraine is recognised as a physical, 
biological state, related to calcitonin gene-related peptide 
(CGRP) aetiology (15). However, patients’ perception of 
the impact of migraine on health, which is the focus of 

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43
our study, offers a completely different perspective on 
the issue. Peters et al. showed that headache sufferers 
perceived headaches as less serious than other illnesses, 
and gave low priority to headaches as a health problem (16). 
In the same study, participants rated the importance of 
other diseases related to the physical dimension of health 
more highly, but with different priorities. On the other 
hand, in MODEL 2 the power of migraine’s relationship to 
PSRH dropped substantially in comparison to the previous 
model, although it was still statistically significant, thereby 
indicating an important interaction between migraine and 
comorbidities related to the mental dimension of health. 
This is not surprising, since it is well-known that mental 
conditions, including mood disorders, poor sleep and 
widespread pain, are comorbidities, especially in frequent 
episodic and chronic migraine (17). This suggests that 
sensitisation phenomena may be an issue of both migraine 
and mental disorders, and may be a connection mechanism 
between them. However, there is another point common 
to migraine and mental disorders: stress (18–20). Frequent 
or chronic distress can lead to permanent sensitisation of 
the nervous system, which lowers the migraine threshold 
and increases the frequency of migraine episodes. 
Migraine can be regarded as a phenomenon that is in a 
bidirectional relationship with mental states (thus having 
an impact on PSRH) and is itself a stressor. Finally, in 
MODEL 3, migraine retained its power of relationship to 
PSRH in comparison with the previous model, and was 
not influenced by socioeconomic or demographic factors, 
which may indicate that, in our society, migraine appears 
to be quite well-accepted illness. 
This study has some limitations. First, the validity of the 
questions included in the survey for classifying individuals 
as migraine sufferers has not been evaluated, and migraine 
diagnosis was not confirmed by a neurologist. Expert 
opinions on this issue are controversial. While the use of 
a single question to determine the presence of migraine 
is supported (21), some experts recommend that in 
order to estimate migraine prevalence, confirmation of 
the migraine diagnosis by a neurologist is required (22). 
While headache-specific questionnaires do exist (e.g. the 
HARDSHIP questionnaire (23)), their length makes them 
less feasible for use in a survey such as ours. It is certainly 
important to be aware that in the case of migraine, both 
under- and over-reporting by subjects should be expected 
when interpreting patient-reported outcome measures. 
On the one hand, the self-reporting of health conditions 
generally generates higher values of prevalence than 
reporting by physicians (20); on the other, migraine could 
even be under-reported, as it is a health phenomenon that 
may still be perceived by some patients as stigmatising (24), 
especially in relation to the workplace (25). In our study, 
we understand this problem as minor, as it was designed to 
be a study for the rough estimation of possible interactions 
between the phenomena observed. In addition, data from 
the GBD study shows that there is no significant difference 
in the estimate of prevalence between our study and the 
GBD study (5). Second, information obtained from the 
interviews is subjective and may contain recall errors, or 
a tendency by subjects to give socially desirable responses 
in the interviews, particularly those regarding their 
lifestyle habits. Furthermore, while one could argue that 
the response rate is relatively low, there is no agreed-upon 
standard for acceptable response rates (26). According to 
Babbie, cited by Draugalis et al., 50% is regarded as an 
acceptable response rate in social research surveys (26). 
Consequently, we assumed that the response rate achieved 
in our study still was high enough for reliable conclusions. 
One could also argue that the data underlying this study is 
relatively old. Unfortunately, consolidated data from the 
third wave of the EHIS survey in Slovenia in 2019 was not 
yet available at the time of this study. This meant that 
we could not use the very latest data. However, nothing 
happened in Slovenia between the second and the third 
wave of the EHIS survey that would have substantially 
affected the field of migraine-related research. Finally, 
one can argue that only binary logistic regression with a 
dichotomised observed outcome (PSRH yes vs. no) was 
applied, rather than multinomial logistic regression with 
trichotomised SHR (poor/very poor, fair and good/very 
good). However , our starting point was that it was necessary 
above all to find new approaches to help migraine sufferers 
who assess their health as poor or very poor, as they do not 
have appropriate mechanisms for managing and accepting 
their disease. Therefore, in the initial phase of the 
research, we only dichotomised the observed outcome. 
Nevertheless, this survey is important because it provides 
valuable information related to migraine and not available 
from other sources of information. The EHIS survey has 
also been used by other authors in different countries, 
which makes the data internationally comparable, and 
the present study’s findings provide additional insights 
into the demographic aspects of migraine in the Slovenian 
population (there is little information on this at the level 
of the general population). The strength of this study 
in comparison with previous similar studies also lies in 
the fact that the results have been adjusted for various 
factors, including several diseases, functional symptoms 
and socio-economic factors.
The study is important from several different perspectives. 
On the one hand, it is important for the public health 
profession because it clearly indicates a relationship 
between migraine and PSRH. The group of headaches 
that fall under the rubric of neurological disorders is 
therefore receiving evidence-based confirmation of its 
public health significance in Slovenia and elsewhere, and 
the study is also important for neurology as a clinical 
discipline. Knowing that comorbidities from the mental 
health dimension group are in interaction with migraine 
in perceiving one’s own health can make it easier to 

plan a more individualised approach to the treatment of 
migraine sufferers.
Further research should first be extended to multinomial 
logistic regression with trichotomised SRH. This would be 
important for assessing the consistency of the present 
study’s findings. As it continues, the research should focus 
on exploring the relationship between migraine and the 
use of healthcare services. As part of such a study, it 
would be interesting to explore in depth the healthcare 
utilisation behaviour of those migraine sufferers who 
assess their own health as poor. It would be even more 
interesting to use the knowledge gained from this study to 
design an intervention similar to e-healthcare for diabetes 
mellitus type 2 patients in Slovenia, which would be 
evaluated through an intervention study (27).
5 CONCLUSION
While migraine is undeniably an important factor in 
perceiving one’s own health as poor, we could have 
expected it to be even more important than the results 
of our study suggest. The reason for this certainly lies 
in the fact that, on average, migraine sufferers possess 
good coping mechanisms and can manage their disease 
relatively well. One result of the study is that comorbidities 
related to the physical dimension of health do not reduce 
the power of migraine association with PSRH, while those 
related to the mental dimension of health do reduce the 
power of migraine and other health conditions. 
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
FUNDING
The study was performed in the frame of regular tasks of 
NIPH.
ETHICAL CONSIDERATIONS
European Union Regulations (EC) No 1338/2008 and (EU) No 
141/2013 provide the legal basis for EHIS data collection. 
These documents also encompass ethical considerations.
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