The Yemeni is a hard working man. Often he is employed in Saudi or Qatar or elsewhere. He is basically a very tense, anxious, nervous, angry and a worried man and has a brooding type of personality. Almost half of his attention is focussed on his health and disease. Thus, tension headache is more common in his tribe, but is never the presenting symptom and is usually overshadowed by other numerous symptoms which dominate the picture.

Bahrainis often have a clear cut family history of "headaches". Often you ask "Did your mother ("Umm" or "Mamaa") suffer from headaches?". The answer is always 'yes' ("Naam").

Often a Bahraini woman comes with the presenting symptom of "headache", (and usually the only symptom!!). Although I would ask for all the investigations including a C.T. scan of the brain (because I do not want to take a chance and miss any pathology in a "foreign" patient—after all headache is only a "symptom"!) I have found that nearly always, the final diagnosis is "migraine" or"migrainous vascular headache".

So common is migraine in the state of Bahrain that I feel it will not be too bold a statement if I am to say that every Bahraini either suffers at present from migraine (may be in the form of an occasional headache, which he attributes to other causes) or might have suffered in the past or is likely to suffer in the future.

Bronchial Asthma is another common disease in Bahrain. Incidentally there are many "common" facts about both these diseases as applied to Arab population.

1. Both diseases are more common in the State of Bahrain.
2. Both are "paroxysmal"—in between the attacks, the patient feels absolutely normal and free of symptoms.
3. Both the groups of patients "always" ask the question, "Why am I getting these attacks?"
4. Both diseases exist in the population where symptoms of tonsillitis and allergic rhinitis are in abundance.
5. Both diseases exist in "surgical minded" population of Bahrain who "first" approach the surgical, non-conservative E.N.T. specialists rather than physicians.
6. Both the groups of patients can be satisfied easily only by an E.N.T. specialist who blames the nose or the throat for their complaints!
7. Both have a so-called psychosomatic "component". The relief, lasting for a few months after an "E.N.T." operation, can be explained by the "psycho" part of the disease. Often in case of migraine, the "associated" tension headache shows marked improvement.

Migraine ("Veeraathi") is the most common cause of "Paroxysmal headaches" in Arab population. It is to be diagnosed only by history taking. Often the diagnosis is missed because of language problem. Even if an interpreter is available, but 'headache' is not a presenting symptom, there is not enough time or energy to ask detailed questions for an incidental symptom! Though the frequency of migraine is highest in Bahrain, it reduces (in this order) in countries like U.A.E. (especially Abu Dabhi), Qatar, Saudi, Oman and is seen least in Yemen. Incidentally this graph of frequency is opposite to that of irritable bowel syndrome and psycholneurosis!

So rare are other causes of "Paroxysmal" headache like 'cluster headache' or 'trigeminal neuralgia' in the Arab population, that I could swear on the diagnosis of migraine if only I could confirm that the headaches are "Paroxysmal".

The following difficulties can arise in the diagnosis-

1. Langauge problems in history taking.
2. Symptom-free intervals, which are diagnostic of migraine, are often overshadowed by

1. Associated tension headaches which seem to be increasing in Bahrain population since I saw the first few patients 15 years back.
2. Attacks of upper respiratory tract infections with symptom of headache in addition to cold and cough.
3. Attitude of an Arab patient who will call weekly headaches as more or less daily headaches. Really speaking weekly headaches are "paroxysmal" because there is symptom free interval of one week.
4. "Panadol" (Paracetamol) is such a common allopathic drug in the 'Arab' world that there is hardly any Arab who does not know about it. The most common indication that they use this tablet for, is "headache". So I would ask "how often do you use Panadol tablets?" This would give the frequency of headaches. Very few Arab patients use "Aspirin" for the same purpose. Nowadays, some of them use "Novalgin".

The other diagnostic features of "migraine" to be elicited from the history are

• Associated nausea and occasional vomiting
• Unilateral headache.
• Visual disturbances preceding the headache.
• Headache coming for ‘no’ apparent reason.
• Early morning headaches
• Week-end-headaches
• Precipitating factors like exposure to sun
• Positive family history.

(1) Associated nausea—The nausea ("Loaa", "Gatayan") associated with headache is so characteristic of migraine that this symptom should always be enquired into. in my experience, it is elicited in more than 90% of Arab patients. Often, if you ask for more details, there will also be slight sweating ("Arakkg"). Very often nausea does not end in vomiting and subsides with the headache. However, vomiting when present, is also diagnostic of migrainous headache. At other times, the headache is relieved and the attack comes.to an end with vomiting ("Zoa", "Tarash"), which makes the patient feel that acidity was the cause of the attack of headache!

Rarely, I find a few young Bahraini women coming only for the symptom of "paroxysmal vomiting". I would make the diagnosis of migraine by eliciting the history of slight headache preceding the attack. These women are obsessed by the symptom of vomiting and do not mention the headache, probably because they feel that it is not an important or a serious symptom.

(2) Unilateral headache—Unilateral ("Nous") headache is not very common in the Arab population, but when seen, it is usually in the Bahrainis and is diagnostic of migraine. More often the headache is occipital, frontal or generalised. Also the site changes in subsequent attacks.

(3) Visual disturbances preceding headache—Such symptoms which are present in "classical" migraine are more often absent. But if present, you would always find that the patient is a young Bahraini woman!

(4) Headache coming for no apparent reason—Although migraine attacks can follow a number of known precipitating factors, many of the attacks would come for "no" reason. It is this factor which is diagnostic of migraine. Now-a-days much research has been done and many platelet and biochemical abnormalities have been shown in the blood during the attack. Unfortunately this explanation becomes the cause of confusion in the Arab patient. He does not comprehend the biochemical reasons but wants to hear of understandable causes (like E.N.T.).

(5) Early morning headache—is often diagnostic of migraine. Often the patient would admit that he had a good night's rest and sleep, yet he woke up with the headache.

(6) Week-end headache—on detailed inquiry it is found that headache is more on Thursday and Friday ("Jummah"), which correspond to a week-end of Saturday and Sunday.

(7) Precipitating factors—The most common precipitating factor is "exposure to sun" ("Tahaat Shamz"). Since these countries are very hot, it is possibly one of the main reasons for the very high frequency of migraine.
In Bahrain, consumption of alcohol is sometimes one of the factors. The young Bahraini men and women consume so much of chocolates, cheese and citrous fruits ("Borchugaal"). These are wellknown precipitating factors. "Empty stomach" as a precipitating factor, as seen in the Indian population is rare in Arabs.

(8) Positive family history—if elicited with "patience", this nearly always confirms the diagnosis. Basically, Arabs are very impatient persons. (Even in the clinic, they are restless if they are made to wait for a long time.) Only with perseverence and persistent questioning you will be able to get the correct history
"Status migrainous"—is a common presentation in Bahrainis. Often the patient is a young or a middle aged female. Unlike the text book description, migraine does not reduce in frequency with growing age. In fact this disease is more common in middle-aged Bahraini females. They would say that for the last twenty years, they suffered from attacks of headache only once in a while. But now, they are bothered once every few days, if not weekly.Also a combination of tension headache and migraine is very common in middle-aged Bahraini ladies. Thus they end up having headaches daily.
These patients look miserable. They have been having severe migrainous headaches associated with persistent nausea, vomiting, exhaustion and are dehydrated because of less intake of fluids. Often they have not slept for a couple of nights. Off and on such patients may need hospitalization because they need intravenous fluids, and heavy sedation. Unless they are investigated (to remove the fear of space-occupying lesion of the brain), they do not respond. Their super-added 'tension headache' should also be treated. Sometimes, if they have been prescribed "Cafergot" tablets I find that they have consumed excessive number and now have developed "Ergot headache" along with numbness of fingers, toes and limbs.

Finally it is interesting to note that in most of the Arab patients, migraine responds to "Panadol" (Paracetamol) tablets and the patients do not need ergot preparations. In Bahrainis, allergic bronchial asthma is also common and betablockers if prescribed for migraine, can increase bronchial asthma or precipitate bronchial spasm.

Other Headaches

Sinus headache—is again more often seen in Bahrainis. I label this headache as "nasal" headache. As mentioned elsewhere, the frequency of Allergic Rhinitis ("Hassasia"), tonsillitis ("Liwaaz") and upper respiratory tract infection in these patients is very high. Symptoms of nasal block ("Khushaam Siqid"), purulent nasal discharge ("Usfaar Moyee") and tenderness of the sinuses are all in favour of the diagnosis.

So often patients having "migraine" also complain of "Sinus" symptoms, both being very common in the same population. A surgeon has no patience of going into the detailed history, because he has not had that training. It is only the physician who can "sort out" symptoms due to migraine and those due to E. N. T. problems. These should then be handled separately. In case E. N. T. problem needs surgical interference, I always explain to the patient, that even after the operation, his "migrainous" headaches will persist.

Headache due to cervical spondylosis is hardly ever seen m Arab population, not even in elderly people.

Headaches due to hypertension are rare in this population. A few Bahrainis especially more educated ones may develop tension headaches due to the anxiety of high blood pressure. Similarly a few Yemenis will give a history like this—"Last month when I had headache at the B. P. Ievel of 144!"—All these are muscle contraction headaches due to fear, or anxiety of having hypertension.

Headache is very common in young, educated, Bahraini women who are consuming oral contraceptives. After taking the detailed history, I always come to the conclusion that these are either migraine or tension headaches because of fear and anxiety of the "side-effects" of oral contraceptives of which they have been reading in the magazines or listening to in social gatherings.

Refractory errors are once in a way found to be the cause of headache, often in Bahrainis.

Tension headache is extremely common in Arab countries. A common man thinks that an Arab is a rich man, does not have to work hard or pay income tax and does not have "tension". I find that Bahrainis have tension ("Taab", "Tafkeer") of their "work" or business. More than men, women have tension of the domestic problems! Next in order, or often more than Bahrainis, Yemenis have severe tension of their "jobs". Most of them have superadded tension of a disease or an imaginary illness. This added element makes their tension more than that of Bahrainis. Thus tension or muscle contraction headche is verv common in Yemenis and is seen m decreasing order of frequency in patients coming from, Bahrain, U. A. E. Qatar, Oman and Saudi Arabia. The only difference in the presentation is that in a Yemeni, this symptom is "drowned" in the midst of multiple other complaints, while in other Arab patients, it stands out and they expect extensive investigations of their heads!

Finally I have observed certain Arabs as having "Caffeine headache". This is because of their habit of consuming "Qahwah" as many as 10 to 20 or 30 times a day or more! Whatever stimulant it contains is in a concentrated form and when taken excessively, can produce a headache. Diagnosis is easy when there is no other cause of headache and the patient complains of weakness and insomnia. On examination presence of tahycardia and fine tremors favour the diagnosis.

Giddiness: if asked, as a leading question, giddiness ("Doraa" or "Dohaa") is found to be very common in the Arab population and every patient's answer will always be 'yes'—he may only add—"sometimes" ("Saa-Aad" or"Aao Kaat").

If you ask them, "is it vertigo—with a sense of rotation", many would say "no". in Arabs, severe vertigo is very uncommon. Labyrinthitis or Meniere's syndrome are rare as the causes of chronic "giddiness".

On majority of the occasions "giddiness" is a symptom of anxiety in connection with their health. For some reason, Arabs "associate" headache with giddiness. Amongst Yemeni men and women, this symptom would be heard of in more than 95% cases. In other countries, females complain of this symptom more often than men. At other times, some doctor may have told them that their symptom is due to high or low blood pressure. This increases their anxiety. As discussed elsewhere, hypertension is less common in Arabs especially in Yemenis. I do also see a few Arabs (especially Yemeni men and women and Bahraini women) who have become neurotic over their so called "low blood pressure (a popular diagnosis in private practice!) as the cause of giddiness.

Surprisingly on a re-check up visit, I did not come across many patients who are not happy with their improvement in giddiness!! Therefore, it is a symptom heard often before the prescription is given. Arabs are more concerned about a "pain" rather than giddiness. It is also rare to see an Arab complaining of giddiness as a presenting symptom! If ever seen, it turns out to be "vertigo" (that is with a sense of rotation also).

Weakness Fatigue: Weakness ("Daeet" or "Guaa Maafi") or fatigue ("Taihabaan") are symptoms which in practice have more or less the same etiology. The least common cause of weakness in an Arab is presence of an organic illness.

The most common cause of weakness is "sex weakness" (as also discussed elsewhere). The patient (especially a Saudi, Qatari or an U.A.E. merchant) goes "round about" to complain of weakness. And he would like to have a detailed physical examination and investigations done, because in his mind he has concluded that there is some organic illness in the body, which has caused sexual weakness.

The next common cause of weakness is "psychogenic weakness". Thus "anxiety and depression" or psychoneurosis is the most common cause of weakness specially in Yemenis. The facial and body gestures made while complaining of weakness and tiredness are to be seen to be believed. I have never heard of such symptoms even from a patient of severe iatrogenic hypokalemia or Myasthenia Gravis. An average physician will easily be fooled. Looking at the general health he would think of diabetes, Kochs, malignancy or electrolyte imbalance etc.!

Weakness being "psychogenic" in origin is suspected when the patient says that the symptoms are more in the morning after a sexual intercourse the previous night! After all the investigations are done, no organic disease can be detected to account for this symptom. I am not very sure whether a past illness like Bilharziasis (in Yemenis) can account for symptoms of psychoneurosis as has been described in "chronic Brucellosis" in our country.

Anaemia—(especially sickle cell Anaemia or Thalassaemia) and obesity are common causes of physical weakness" seen in Arabs. Diabetes is the next common organic cause. Often even when detected, it is not the cause of weakness and other causes like sexual weakness and psychogenic weakness should be excluded. At other times (especially amongst Yemenis), when associated loss of weight is present, pulmonary-Kochs should be excluded. In short, after a thorough physical examination of the patient if you have reports of an X-ray chest, a routine urine and blood count, SMA 12/60 or SMA 16/60 (all these include electrolytes, blood sugar, calcium levels and a few kidney and liver function tests), the causes of "physical weakness" can be easily diagnosed.

Iatrogenic weakness of short duration is seen in a few of them who have been drugged. But this is rare.

Tingling and numbness of limbs—arms and legs—("Naum", "Yad", "Rijley")—is a very common symptom mainly in male Yemeni population though it is seen off and on in patients (mainly females) from other Arab countries. In most of these patients there is no evidence of tetany, anaemia or peripheral neuropathy. The full blood chemistry reports done in every single case, normal nerve conduction studies (which I must have asked for in dozens of such cases), and evoked potential studies done in some of them—were all normal.

Burning feet—("Haraara" or "Haar Rijley")—is a very common symptom, specially in Yemenis. These patients have no physical signs of neuropathy. Their nerve conduction studies, haematological and blood chemistry profile are all normal. Usually they have already received plenty of injections of calcium and pantothenate.and vitamins, with no success. Very often the burning is also felt in the arms and legs. No organic cause can be found for this complaint.

Insomnia—("Naum-Maafi")—is a very common symptom in all Arab population. It is worst in Yemenis. So often dreams ("Halaam") disturb the sleep. The dreams may not be frightening, but are irrelevant. With the result, the patient gets up tired and exhausted.

Nervousness—("Assabiya")—Bahraini women so often would say 'yes' especially if you ask a leading question. Majority of Yemenis would agree to experience nervousness for "no" reason. Formerly I used to wonder whether use of "Qat" had any role to play in the above symptom in Yemenis! But then why should this symptom be heard of in Bahraini women!

Fear—("Khauff") and Anger ("Zalaan") are common "complaints" of Arabs especially Yemenis. I am not sure whether it is due to insecure feeling of Yemenis while serving in Saudi or Qatar. But why in the rest of the Arab population? Ayurvedic pandits of India whould blame their "diet" for this!

Loss of memory—is a common symptom complained of by Yemeni population. There are no positive findings in 'C.N.S. examination'. This symptom can be attributed mainly to severe tension, anxiety and psychoneurois. Loss of memory is mainly of recent events. A Yemeni gets convinced in his mind that his symptom is due to a serious disease. This in turn leads to more tension, more loss of memory and a vicious cycle develops.

Sweating of palms and soles—Although most of the Arabs sweat a lot because of the hot climate in their countries, the symptom of sweating ("Arag") of palms and soles is often complained of by a few young Bahraini female patients and sometimes by male Yemeni patients. Often there are other symptoms of autonomic nervous disturbance like cold ("Baraad") hands and feet ("Yad" or "Ad" and "Rijley")

In case of young Bahrainis, they also complain of tremors ("Asaabia"). And if the patients have big prominent eyes, a wrong diagnosis of thyrotoxicosis may be made. The points which would help to exclude this disease are:—

Absence of

1. symptoms of excessive sweating of the whole body (which cannot be missed in their hot country).
2. "complaint" of feeling very "hot". in fact most of the Arabs, although they move about in air-conditioned cars etc., they do not like a cold ("Baraad") air-conditioned room!
3. loss of weight.
4. Tachycardia
5. eye signs—when detailed examination is done.
6. warm and moist palms—which are in fact more often cold and moist especially if your clinic is air-conditioned.
7. a goitre. Although I must hasten to add that a non-toxic goitre is off and on seen mainly in Bahraini population.