The association between major depression and headache: results of a longitudinal epidemiologic study in youth

Higher prevalence of psychopathological symptoms in adolescents with headache. A population-based cross-sectional study

BACKGROUND

Headache is commonly voiced by adolescents and is known to be associated with reduced quality of life. Otherwise, there are only limited data regarding associations between different types of headache and psychopathological symptoms in adolescents.

OBJECTIVES

Aim of the present study in adolescents was to assess the impact of headache on psychopathological symptoms and whether these differ between types of headache.

METHODS

Data were derived from a population-based sample (n = 1047, ages 13-17 years). Type of headache (ie, migraine, tension-type headache, miscellaneous headache) was ascertained for subjects reporting headache episodes at least once per month. Psychopathological symptoms were assessed with the Strengths and Difficulties Questionnaire. The following dimensions were taken into account: emotional symptoms, conduct problems, hyperactivity/inattention, peer problems (these 4 add to the total difficulties score), and prosocial behavior. Associations were estimated with logistic regression models with adjustment for age group, sex, and family situation.

RESULTS

Headache at least once per month was reported by 47.8% of the adolescents. Subjects with any headache were found to be at higher risk for emotional symptoms (odds ratio 1.5; 95% confidence interval 1.0-2.2) and hyperactivity/inattention (1.4; 1.0-1.9), resulting in a higher total difficulties score (1.6; 1.1-2.4). While the risk for psychopathological symptoms was not significantly increased in subjects with tension-type headache compared with subjects without headache, significant associations with emotional symptoms were found in subjects with migraine (2.9; 1.3-6.2; total difficulties score: 3.1; 1.4-6.8). Miscellaneous headache was associated with a broad spectrum of psychopathological symptoms: emotional symptoms (1.8; 1.0-3.3), conduct problems (1.6; 1.0-2.6), hyperactivity/inattention (1.9; 1.2-3.1), total difficulties score (2.7; 1.6-5.6).

CONCLUSION

Previously reported associations between headache and psychopathological symptoms in adolescents could be confirmed, but might vary with type of headache. As psychopathological symptoms may be a precursor for manifest psychiatric disorders, adolescents particularly with migraine and miscellaneous headache appear to be a vulnerable population.

Is Toxoplasma gondii a causal agent in migraine?

BACKGROUND

Many different tissues may be parasitized by Toxoplasma gondii, particularly, lung, heart, lymphoid organs, and the central nervous tissues. Tissue cysts of this parasite in the brain may spontaneously rupture, releasing parasites that cause antibody titers to rise. In immunocompetent subjects with acquired toxoplasmosis, the most frequent symptoms were lymphadenopathy and headache. In the neurogenic inflammation theory of the pathogenesis of migraine, the cause of initial release of ions and inflammatory agents has not been established. In this study, we aimed to investigate if T. gondii infection is a possible cause of neurogenic inflammation of migraines.

METHODS

The anti-T. gondii antibody status of 104 patients with migraine were studied and compared with those of control groups, 50 healthy subjects and 50 subjects with headache due to rhinosinusitis, by using a micro-enzyme-linked immunosorbent assay technique.

RESULTS

Forty-six (44.2%) patients with migraine, 13 (26.0%) healthy control subjects, and 12 (24%) control subjects with rhinosinusitis were positive for anti-T. gondii IgG antibody. The rate of positivity in the migraine patient group was statistically different from those of the control groups (P < 0.05).

CONCLUSIONS

The results show the presence of chronic Toxoplasma infection in patients with migraine. Toxoplasma infection may contribute to neurogenic inflammation as the pathogenesis of migraine, as many studies in the literature have reported that Toxoplasma infection causes biochemical and immunologic changes.

Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents

The main aim of the study was to examine the relationship between headache and familial recurrence of psychiatric disorders in parents and their children. Headache history and symptomatology have been collected in a clinical sample of 200 patients and their families, using a semi-structured interview (ICHD-II criteria). Psychiatric comorbidity was assessed by DSM-IV criteria. Chi squares and a loglinear analysis were computed in order to evaluate the main effects and interactions between the following factors: frequency and headache subtypes (migraine/not-migraine) in children, headache (migraine/not-migraine-absent/present) in parents, headache (absent/present) in grandparents, and psychiatric comorbidity (absent/present) have been analyzed: 94 mothers (47%) and 51 fathers (25.5%) had at least one psychiatric disorder, mainly mood and anxiety disorders. Considering the significant prevalence of Psi-co in children (P < 0.0001), we compared it with the presence of familiarity to headache: a significant interaction has been found (P < 0.05) showing that migraineurs with high familial recurrence of headache had a higher percentage (74.65%) of psychiatric disorders, than no-migraineurs (52.17%). Absence of headache familial loading seems to be related to psi-co only in no-migraine headache (87.5 vs. 45.5%). The occurrence of psychiatric disorders is high in children with headache, but a very different pattern seems to characterize migraine (familial co-transmission of migraine and Psi-Co?) if compared with non-migraine headache.

Serotonin effects on sleep and emotional disorders in adolescent migraine

OBJECTIVE

To determine frequency of emotional disorders and sleep disturbances in adolescent migraineurs with episodic and chronic headaches. To determine the relationship of whole blood serotonin, caffeine consumption, and frequency of sleep and mood disorders.

BACKGROUND

The neurotransmitter serotonin has been implicated to play a role in the initiation and maintenance of sleep and in modulating mood. A putative role in migraine pathophysiology is also known.

METHODS

Adolescents from 13 to 17 years of age were identified from our headache clinic with episodic or chronic migraine (according to International Classification of Headache Disorders-Second Edition criteria) and healthy controls enrolled. Psychological rating scales were completed, including Adolescent Symptom Inventory (4th Edition) and Child Depression Inventory. Sleep questionnaires (Pediatric Sleep Questionnaire and Child Sleep Habit Questionnaire) were completed by the teenager's parents/guardian. Whole blood serotonin levels were drawn and analyzed and caffeine consumption obtained by history.

RESULTS

A total of 18 controls (8 girls) and 15 patients each with episodic migraines (9 girls) and chronic migraine (10 girls) were studied. Patients with headache had significantly more sleep problems than controls. Patients with chronic migraines had increased daytime sleepiness and dysthymia compared with teenagers with episodic migraines. Serotonin levels were not significantly different, and no association was noted between serotonin levels and sleep abnormalities or emotional rating scales. Increased caffeine intake was related to sleep and depressive complaints.

CONCLUSIONS

Sleep and emotional disorders were common in adolescents with migraine. Sleep disorders and dysthymia were more prevalent with increased headache frequency. No correlation was noted with whole blood serotonin levels.

Parental psychopathology and migraine headaches among adolescent girls

Migraine headaches and depression often co-occur within individuals, and both syndromes run in families. However, knowledge about how these disorders relate across generations, as well as how migraine relates to other forms of psychopathology, is sparse. This study examined risk for migraine among female adolescent offspring of parents with different types of psychopathology. The sample was drawn from the Minnesota Twin Family Study, a community-based study of adolescents and their families (n = 674, 17-year-old female adolescents and their biological parents). Diagnoses of maternal, paternal and offspring major depression, antisocial behaviour, alcohol dependence and drug dependence were based on structured interviews. Migraine headaches in each family member were assessed via interviews with the mother. Parental depression, antisocial behaviour and drug dependence were associated with offspring migraine. These associations mostly remained significant even when parental migraine and the corresponding type of psychopathology in offspring were adjusted for. In contrast, there were no significant associations between parental psychopathology and offspring stomach problems, indicating that these associations did not extend to all offspring somatic symptoms. These results emphasize the need to look at antisocial behaviour and substance-related problems when examining associations between migraine and psychopathology, and indicate that more research on inter-generational links between migraine and psychopathology is needed.

Combined effects of major depression, pain and somatic disorders on general functioning in the general adult population

This study was carried out to assess the prevalence of major depressive disorder (MDD) in persons suffering from pain symptoms in various locations, both with and without comorbid somatic disorders and to analyze the single and combined effects of MDD, pain symptoms and somatic disorders on general functioning in the community. The 12-month prevalence of MDD, somatic disorders and pain symptoms, grouped according to location, were determined among 4181 participants from a community sample. Depression was assessed utilising the Composite International Diagnostic Interview. Pain symptoms were self-reported by participants whereas medical diagnoses were validated by medical examinations. General functioning was evaluated utilising the established MOS-SF-36 scale. The prevalence of MDD was significantly increased for persons with pain in any location. In the absence of a somatic disorder, MDD prevalence was highest in persons with abdominal/chest pain (9.3%) and arm or leg pain (7.9%) and lowest in persons with back pain (6.2%). Mental and physical well-being were lowest for persons with both MDD and a somatic disorder, irrespective of pain locations. Increasing numbers of pain locations impaired mental and physical well-being across all groups, but the effect on mental well-being was most marked in participants with MDD and comorbid somatic disorders. The presence of pain increases risk of associated MDD. The number of pain locations experienced, rather than the specific location of pain, has the greatest impact on general functioning. Not only chronic pain, but pain of any type may be an indicator of MDD and decreased general functioning.

Antidepressants for the treatment of chronic pain

Chronic pain represents one of the most important public health problems and, in addition to classical analgesics, antidepressants are an essential part of the therapeutic strategy. This article reviews available evidence on the efficacy and safety of antidepressants in major chronic pain conditions; namely, neuropathic pain, headaches, low back pain, fibromyalgia, irritable bowel syndrome (IBS) and cancer pain. Studies, reviews and meta-analyses published from 1991 to March 2008 were retrieved through MEDLINE, PsycINFO and the Cochrane database using numerous key words for pain and antidepressants. In summary, evidence supports the use of tricyclic antidepressants in neuropathic pain, headaches, low back pain, fibromyalgia and IBS. The efficacy of the newer serotonin and norepinephrine reuptake inhibitors is less supported by evidence, but can be recommended in neuropathic pain, migraines and fibromyalgia. To date, evidence does not support an analgesic effect of serotonin reuptake inhibitors, but beneficial effects on well-being were reported in several chronic pain conditions. These results are discussed in the light of current insights in the neurobiology of pain, the reciprocal relationship between pain and depression, and future developments in this field of research.

Canadian adolescents with migraine: impaired health-related quality of life

The objective of this study was to determine the impact of migraine headaches on health-related quality of life among Canadian adolescents. The Canadian Community Health Survey (CCHS) collects information related to health status, health care utilization, and health determinants for the Canadian population. Analysis was limited to those adolescents 12-19 years of age residing in Manitoba. Respondents reported whether they had migraine and mood/anxiety disorders. Health-related quality of life was measured using the Short Form-36 survey, which covers 8 health concepts related to functional status, well-being, and overall health. Multivariate linear regression analysis was used to model each Short Form-36 scale against age (12-14 years vs 15-19 years), gender, migraine, and the presence of a mood or anxiety disorder. The CCHS was completed by 994 respondents; 9.3% (95% confidence interval, 7.3%-11.5%) reported a diagnosis of migraine. Reported migraine predicted both statistically (P < .0001) and clinically significantly lower health-related quality of life in all Short Form-36 domains except vitality and general health perceptions. Adolescents reporting a mood disorder (2.1%) scored significantly lower in 6 of 8 health-related quality of life domains, most pronounced for emotional role, general mental health, and social functioning. Canadian adolescents with migraine report clinically and statistically significant impairment in health-related quality of life compared to their peers, independent of psychiatric comorbidities.

Does neck pain determine the outcome of adolescent headache?

The aim of the study was to examine the influence of concomitant neck pain (NP) on the outcome of headache (HA) frequency and HA type in adolescence. A population-based sample of 13-year-olds with or without HA (n = 228) was followed for 3 years. NP was evaluated at the beginning of the follow-up on the basis of recorded muscle tenderness and self-reported symptoms. During the 3 years of follow-up, changes in both HA type and frequency were common. NP interfering with daily activities at the age of 13 years predicted change from non-frequent (0-1/month) to monthly HA (>1/month), especially in boys (P = 0.03 boys, P = 0.06 girls). The use of physiotherapy predicted persistence of monthly HA in boys (P = 0.004). The changes in HA type were not predictable by NP. In conclusion, the risk of worsening HA in adolescence is more probable if the HA is associated with NP interfering with daily activities.

Recurrent headache as the main symptom of acquired cerebral toxoplasmosis in nonhuman immunodeficiency virus-infected subjects with no lymphadenopathy: the parasite may be responsible for the neurogenic inflammation postulated as a cause of different types of headaches

Headache and/or migraine, a common problem in pediatrics and internal medicine, affect about 5% to 10% children and adolescents, and nearly 30% of middle-aged women. Headache is also one of the most common clinical manifestations of acquired Toxoplasma gondii infection of the central nervous system (CNS) in immunosuppressed subjects. We present 11 apparently nonhuman immunodeficiency virus-infected children aged 7 to 17 years (8 girls, 3 boys) and 1 adult woman with recurrent severe headaches in whom latent chronic CNS T. gondii infection not manifested by enlarged peripheral lymph nodes typical for toxoplasmosis, was found. In 7 patients, the mean serum IgG Toxoplasma antibodies concentration was 189 +/- 85 (SD) IU/mL (range 89 to 300 IU/mL), and in 5 other subjects, the indirect fluorescent antibody test titer ranged from 1:40 to 1:5120 IU/mL (n= <1:10 IU/mL). Some of the patients suffered also from atopic dermatitis (AD) and were exposed to cat and/or other pet allergens, associated with an increased IL-4 and decreased IFN-gamma production. These cytokine irregularities caused limited control of cerebral toxoplasmosis probably because IL-4 down-regulated both the production of IFN-gamma and its activity, and stimulated production of a low NO-producing population of monocytes, which allowed cysts rupture, increased parasite multiplication and finally reactivation of T. gondii infection. The immune studies performed in 4 subjects showed a decreased percentage of T lymphocytes, increased total number of lymphocytes B and serum IgM concentration, and impaired phagocytosis. In addition, few of them had also urinary tract diseases known to produce IL-6 that can mediate immunosuppressive functions, involving induction of the anti-inflammatory cytokine IL-10. These disturbances probably resulted from the host protective immune reactions associated with the chronic latent CNS T. gondii infection/inflammation. This is consistent with significantly lower enzyme indoleamine 2,3-dioxygenase (IDO) activity reported in atopic than in nonatopic individuals, and an important role that IDO and tryptophan degradation pathways plays in both, the host resistance to T. gondii infection and its reactivation. Analysis of literature information on the subjects with different types of headaches caused by foods, medications, and other substances, may suggest that their clinical symptoms and changes in laboratory data result at least in part from interference of these factors with dietary tryptophan biotransformation pathways. Several of these agents caused headache attacks through enhancing NO production via the conversion of arginine to citrulline and NO by the inducible nitric oxide synthase enzyme, which results in the high-output pathway of NO synthesis. This increased production of NO is, however, quickly down-regulated by NO itself because this biomolecule can directly inactivate NOS, may inhibit Ia expression on IFN-gamma-activated macrophages, which would limit antigen-presenting capability, and block T-cell proliferation, thus decreasing the antitoxoplasmatic activity. Moreover, NO inhibits IDO activity, thereby suppressing kynurenine formation, and at least one member of the kynurenine pathway, 3-hydroxyanthranilic acid, has been shown to inhibit NOS enzyme activity, the expression of NOS mRNA, and activation of the inflammatory transcription factor, nuclear factor-kB. In addition, the anti-inflammatory cytokines IL-4 and IL-10, TGF-beta, and a cytokine known as macrophage deactivating factor, have been shown to directly modulate NO production, sometimes expressing synergistic activity. On the other hand, IL-4 and TGF-beta can suppress IDO activity in some cells, for example human monocytes and fibroblasts, which is consistent with metabolic pathways controlled by IDO being a significant contributor to the proinflammatory system. Also, it seems that idiopathic intracranial hypertension, pseudotumor cerebri, and aseptic meningitis, induced by various factors, may result from their interference with IDO and inducible nitric oxide synthase activities, endogenous NO level, and cytokine irregularities which finally affect former T. gondii status 2mo in the brain. All these biochemical disturbances caused by the CNS T. gondii infection/inflammation may also be responsible for the relationship found between neurologic symptoms, such as headache, vertigo, and syncope observed in apparently immunocompetent children and adolescents, and physical and psychiatric symptoms in adulthood. We therefore believe that tests for T. gondii should be performed obligatorily in apparently immunocompetent patients with different types of headaches, even if they have no enlarged peripheral lymph nodes. This may help to avoid overlooking this treatable cause of the CNS disease, markedly reduce costs of hospitalization, diagnosis and treatment, and eventually prevent developing serious neurologic and psychiatric disorders.

Headache and psychological functioning in children and adolescents

Headache can affect all aspects of a child's functioning, leading to negative affective states (eg, anxiety, depression, anger) and increased psychosocial problems (for instance, school absences, problematic social interactions). For children and adolescents who experience frequent headache problems, comorbid psychological issues are a well-recognized, but poorly understood, clinical phenomenon. The confusion surrounding the relationship between pediatric headache and psychopathology exists for several reasons. First, in some cases, headache has been inappropriately attributed to psychological or personality features based on anecdotal observations or interpretations that go beyond the available data. Additionally, measures of psychopathology have not always adhered to the American Psychiatric Association's diagnostic criteria, thus reducing the reliability of diagnostic judgments. Furthermore, the diagnosis of headache has not always followed standard criteria, and has been complicated by the emergence of new terms and evolving measures. Finally, methodological shortcomings, such as incomplete descriptions of the procedures and criteria used for the study, inadequate descriptions of headache severity, lack of a control group for comparison with individuals without headaches, reliance primarily on cross-sectional research designs that are often discussed with inferences to causal hypotheses, and the use of unstandardized assessment measures, have significantly limited the validity of research findings. The goal of the current review is to examine the extant literature to provide the most up-to-date picture on what the research has made available about the magnitude, specificity, and causes of psychopathology in children and adolescents with headache, in an effort to further elucidate their relationship and prompt a more methodologically rigorous study of these issues.

Sleep, sleepiness, and behavior problems in children with headache

The purpose of this study was to assess sleep, daytime sleepiness, and behavior problems in children suffering from headaches and in controls, with a special focus on the role of gender. A clinical group of 28 children with persistent headache complaints and a control group of 108 healthy children were included. Sleep was assessed by actigraphy and diaries. Behavior problems were assessed by parental reports. In comparison with the control group, the sleep quality of the clinical group was poorer and they complained more about excessive daytime sleepiness. Children suffering from headache showed higher levels of internalizing behavior problems. Gender was found to be a moderating factor for the relationships between headache and sleep. Compared with control girls, girls suffering from headaches had poorer sleep quality, whereas the opposite was true for the boys. The results highlight the importance of assessing sleep, daytime sleepiness, and psychologic adjustment in children complaining about headaches as an integral part of their routine assessment.

The associations among childhood headaches, emotional and behavioral difficulties, and health care use

BACKGROUND

Headaches are common among children and adolescents, particularly migraine and tension-type headaches. They contribute to missed school days, affect children's peer and family relationships, and significantly impact children's quality of life, often times into adulthood.

OBJECTIVES

This study, based on responses to the Strengths and Difficulties Questionnaire, was designed to examine difficulties and impairments related to emotions, concentration, behavior, and social functioning among children with frequent or severe headaches (FSH).

METHODS

We used a cross-sectional study of 9264 children aged 4-17 years from the 2003 National Health Interview Survey, an ongoing, computer-assisted personal interview survey of the noninstitutionalized US population.

RESULTS

Approximately 6.7% of children experienced FSH during the previous 12 months. Overall, children with FSH were 3.2 times more likely than children without FSH to have a high level of difficulties and 2.7 times more likely to have a high level of impairment, suggesting potential mental health issues. More specifically, analyses revealed that children with FSH were significantly more likely than those without FSH to exhibit high levels of emotional, conduct, inattention-hyperactivity, and peer problems and were significantly more likely than children without FSH to be upset or distressed by their difficulties and to have their difficulties interfere with home life, friendships, classroom learning, and leisure activities.

CONCLUSION

Because children with FSH experience notable pain, mental health issues, and functional limitations, integrated care using a biopsychosocial approach is warranted.

Patterns of physical symptoms and relationships with psychosocial factors in adolescents

OBJECTIVES

Physical symptoms are common in otherwise healthy adolescents. This study sought to identify meaningful patterns of multiple physical symptoms and to examine relationships between the patterns and psychosocial factors. One-year stability of symptom patterns and factors contributing to stability were also examined.

METHODS

This secondary data analysis used longitudinal data from a nationally representative sample of adolescents in grades 7 through 12 (n = 9,141) who participated in the National Longitudinal Study of Adolescent Health during 1994 to 1996. Ten selected physical symptoms (i.e., headache, stomachaches, fatigue) were used to construct clusters. Each cluster was compared in regard to demographic factors, psychological adjustment and interpersonal relationships.

RESULTS

K-means in combination with Ward method clustered the sample into 4 groups according to the overall patterns of the 10 symptoms: nonsymptom (41%), moderate symptom (38%), high symptom (19%) and extreme symptom (2%). Adolescents in higher symptom clusters were more likely to be girls, nonwhites, or from families on welfare and reported high depressive symptoms, low self-esteem, and poor perceptions of parental affection and friendship quality. About 16% in clusters with lower symptom patterns develop somatizing patterns in Wave II; new onset was predicted by gender, younger age, and depressive symptoms.

CONCLUSION

Symptom patterns characterized by overall high frequencies of multiple symptoms may indicate somatization. This study also suggests that adolescents with a somatizing tendency are more likely to experience psychological and interpersonal difficulties, and girls and younger adolescents are more vulnerable. Targeted prevention programs are needed for these vulnerable individuals by addressing their psychosocial functioning.

Management of migraine in children and adolescents in the emergency department and inpatient setting

Migraine is a chronic disorder that can be debilitating, especially when the attacks are severe and frequent. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted due to more recognition of the disease in this population throughout the past century. Severe chronic migraine can cause failure in academic work and may lead to depression. Multiple medications are used to break an acute attack. Most approaches are based on outpatient treatments and include the use of over-the-counter medications and triptans and narcotics. This manuscript reviews most of the available therapies for acute treatment of primary headache that did not respond to outpatient management.

Disability is the major determinant of the severity of depressive symptoms in primary headaches but not in low back pain

Pain syndromes are often associated with depression. In a prospective study we analysed if determinants of depression differ among patients with different primary headaches and between headaches and non-headache pain. During a 2-year period between 1 February 2002 and 31 January 2004, 635 subjects (migraine n = 231; tension-type headache n = 176; cluster headache n = 11; patients with low back pain n = 103; and healthy subjects n = 114) seen by two neurologists filled in a questionnaire on pain characteristics, the MIDAS questionnaire and the Beck Depression Inventory. A multivariate general regression model was used to identify independent predictors of the severity of depressive symptoms. Pain was most frequent in chronic tension-type headache and most intense in the cluster subgroup (P < 0.001, Kruskal-Wallis ANOVA). In univariate tests gender, age, pain frequency, pain intensity and disability were all significantly associated with the severity of depressive symptoms. In the multivariate model disability was the most important independent determinant of the severity of depressive symptoms in the pooled headache group as well as in the migraine and tension-type headache subgroups. In contrast to patients with headache, pain frequency and pain intensity were the significant independent predictors of the severity of depressive symptoms in patients with low back pain. In a multivariate model, after controlling for other factors, determinants of the severity of depressive symptoms were different in headache and non-headache pain subjects, suggesting a different mechanism for developing depression in primary headaches and in other pain syndromes.

Major depressive episode and physical health in adolescents and young adults: results from a population-based interview survey

BACKGROUND

This paper aimed to investigate associations between major depressive episode (MDE) and chronic illness, disability, self-perceived health and number of sick-days among adolescents and young adults in the general population.

METHODS

The Finnish Health Care Survey 1996 was a cross-sectional nationwide epidemiological study. A random sample of 509 adolescents and 433 young adults was interviewed in 1996. DSM-III-R MDE during the past 12 months was defined using The University of Michigan Composite International Diagnostic Interview Short-Form algorithm. Data on physical health were gathered in the interview.

RESULTS

In multivariable logistic regression, chronic illness [odds ratio (OR) 1.78; 95% confidence interval (CI) 1.03, 3.05], poor self-rated health (OR 2.26; 95% CI 1.01, 5.07), more than three sick-days in the past 6 months (OR 1.72; 95% CI 1.02, 2.92) and respiratory allergies (OR 2.40; 95% CI 1.00, 5.75) were associated with MDE. Among 15- to 19-year-olds, disabling chronic illness was related to MDE (OR 2.59; 95% CI 1.06, 6.36), and thoughts of death were more prevalent in the presence of chronic illness among those with MDE [35.2% versus 65.7%; F(1,67) P = 0.024]. Migraine was associated with MDE among young adults (OR 6.18; 95% CI 1.14, 30.8).

CONCLUSIONS

Symptoms of depression should be investigated among adolescents with chronic illness or frequent sick-days. The degree of reported disability should be noted. Young people with both chronic illness and depressive symptoms should be assessed for thoughts of death and possible suicidality.

Acute treatment of pediatric headache in the emergency department and inpatient settings

Migraine headache can be debilitating. If initiated early, aggressive management may prevent severe disability and failure at school. It must be noted that treatments available for use for acute migraine headache in children and adolescents are off-label. Their use is widespread, but double-blind, placebo-controlled studies are still unavailable for this age group.

Have there been changes in children's psychosomatic symptoms? A 10-year comparison from Finland

OBJECTIVES

The aims of the study were to determine whether the prevalence of children's somatic symptoms, such as headache, abdominal pain, other pain, and nausea and vomiting, changed from 1989 to 1999 and to study the similarity of parents' and children's reports of the child's symptoms. Furthermore, the aims were to explore possible comorbidity in somatic symptoms and to investigate the associations between somatic and psychiatric symptoms.

METHODS

Two cross-sectional, representative samples were compared. All children born in 1981 (1989 sample, n = 985) and 1991 (1999 sample, n = 962) and living in selected school districts in southwest Finland served as study samples. The response rate for the 1989 sample was 95% and that for the 1999 sample was 86%. Both children and parents were asked about the children's somatic symptoms, whereas parents, children, and teachers were asked about psychiatric symptoms. To study psychiatric symptoms, the Children's Depression Inventory and Rutter's parent and teacher scales were used.

RESULTS

The prevalence of frequent headaches and abdominal pain increased somewhat from 1989 to 1999. Parents often failed to recognize their children's psychosomatic problems. Child-reported somatic symptoms were associated with conduct and hyperactivity symptoms, in addition to a previously well-documented association with depression. In associations between somatic symptoms and psychiatric symptoms, there were some differences between the 1989 and 1999 samples.

CONCLUSIONS

In clinical work, questions about somatic and psychiatric symptoms should also be addressed to children themselves, because parents and teachers do not always recognize children's symptoms. When somatic problems are being evaluated, psychiatric symptoms should be asked about, and vice versa. More research is needed to explore the reasons for the increased prevalence of somatic symptoms and their associations with psychiatric symptoms.

Depression increases onset of tension-type headache following laboratory stress

The aim of this study is to examine the influence of depression on headache onset following laboratory stress and on psychophysiological variables associated with tension-type headaches (TTHs). Diagnostic interviews identified three groups: headache prone and depressed (HP/D, N = 13); headache prone not depressed (HP/ND, N = 22); and healthy controls (HC, N = 13). Ss completed a laboratory stress task. Blind evaluations of pericranial muscle tenderness (PMT) and pressure pain thresholds (PPT) were obtained immediately before, immediately after and 24 h post-task. Ss also recorded headaches (HA) before, during, immediately post-task and for 24 h post-task. HP/D Ss were more likely than HP/ND Ss or HC Ss to report a headache during and immediately following the stress task (P < 0.05). HP/D Ss exhibited higher PMT than HP/ND Ss or HC Ss before and following the stress task (P < 0.05). HP/D Ss exhibited lower finger PPT at all assessments and lower temporalis PPT at two of three assessments than HC Ss (P < 0.05) but did not significantly differ from HP/ND Ss at most assessments. Depression increased vulnerability to TTH following laboratory stress and was associated with elevated PMT. In individuals with frequent headaches, depression may aggravate existing central sensitization increasing vulnerability to TTHs.

Externalizing problem behaviors and headache: a follow-up study of adolescent Finnish twins

OBJECTIVE

To examine the association of teacher- and parent-rated behavior with headache in a prospective follow-up study of adolescent Finnish twins.

METHODS

Questionnaire data were collected during 1995-2001 from a nationwide sample of Finnish families of 11-year-old twins who were born 1983-1987 (n = 5393) and again at age of 14. Psychological factors were measured by using parents' and teachers' ratings of a 37-item multidimensional rating instrument at the ages of 11 and 14.

RESULTS

At age 11, headache frequency (5 categories) was associated with total scales of externalizing and internalizing problem behaviors and adaptive behaviors, assessed by parents, but only with externalizing problem behaviors assessed by teachers. Results were similar at age 14. The incidence of at least monthly headache between the ages of 11 and 14 years was predicted by externalizing problem behaviors and 2 subscales of adaptive behaviors: constructiveness and poor compliance. In twin pairs discordant for headache, externalizing and internalizing problem behaviors were more common among headache sufferers than among headache-nonsufferers. Headache-discordant monozygotic co-twins confirmed the association of externalizing problem behaviors with headache.

CONCLUSIONS

The frequency of adolescents' headache is predicted by psychological factors, especially by externalizing problem behaviors. This seems to be independent of genetic or familial influences on behavior and headache. Behavioral problems may be a sign of worsening of headache or vice versa.

The epidemiology of pain in depression

Over 75% of depressed patients in primary care complain of painful physical symptoms such as headache, stomach pain, neck and back pain as well as non-specific generalized pain. The presence of such symptoms predicts a greater severity and a less favourable outcome of depression with a poorer health-related quality of life. World Health Organization data obtained in primary care centres worldwide show that 22% of all primary care patients suffer from persistent debilitating pain and that these patients are four times more likely to have co-morbid anxiety or depressive disorder than pain-free primary care patients. Not unexpectedly, the risk of depression is greater when the pain is more diffuse, as indicated by the number of painful sites, and has a greater effect on the quality of life. Certain depressive symptoms, such as low energy and sleep disturbances, are commonly found in patients with co-morbid pain, whereas the opposite is true for symptoms such as guilt and loneliness. Increasingly, major depression is seen as being composed of psychological, somatic and painful physical symptoms. In order to achieve full sustained remission it is necessary to treat symptoms in all three of these areas. The area of painful physical symptoms is unfortunately still poorly understood and clearly merits greater attention.

Do pain problems in young school children persist into early adulthood? A 13-year follow-up

DESIGN

In a longitudinal study, 335 children ages 8, 11 and 14, first studied in 1989 were followed-up on two occasions in 1991 and 2002. The subjects filled in questionnaires on pain, the first two times in school, the last as a postal survey.

PURPOSES

To determine if headache and back pain during the school years were transitory or if they grew into pain problems in adulthood; to determine predictors of pain.

RESULTS

In the 2002 study, 59% of the women and 39% of the men reported pain at 21, 24 and 27 years. A total of 68 (52 women, 16 men) or 20% of the subjects reported pain symptoms in all three studies. The cumulative incidence rate for the presence of pain in the cohort studied was 31% for 1989-2002 and 43% for 1991-2002. Four of the 10 individuals with pain also reported signs of stress. Three predictors were found: reported back pain in 8-14-year-olds (p < 0.0001); reported headaches once a week or more in the same age group (p < 0.0001); and a positive response in the ages 10-16 to the question: "Do you often feel nervous?" (OR=2.1, 95% CI 1.3-3.4). When adjusted for age, sex and all psychosocial risk determinants studied in multiple logistic regression, a positive answer to this question was a significant predictor of pain in young adulthood. A positive response by the 10-16-year-olds to "Do you find it difficult to describe your feelings?" was a predictor of pathological anxiety in early adulthood, but stress perceived in childhood/adolescence did not predict future pain or stress.

CONCLUSIONS

Since pain reports in childhood and early adolescence seem to be associated with the report of pain in early adulthood, more attention should be given to the way ill-health is managed in adolescence in this vulnerable group.

Assessment of child neurology outpatients with headache, dizziness, and fainting

Neurologic symptoms such as headache, vertigo, dizziness, and fainting can create a diagnostic problem in pediatric neurology practice because they are also the most common presenting symptoms of psychiatric disorders. Children, especially adolescents, who are often admitted with such autonomic symptoms, are frequently misdiagnosed. In this study, we aimed to investigate the psychiatric morbidity and comorbidity rate in children and adolescents presenting with neurologic symptoms such as headache, vertigo, and syncope. We investigated 31 children who presented with these symptoms. All children were evaluated for their medical history and had a physical and neurologic examination. We attempted to rule out a possible organic etiology. All patients received a complete laboratory examination (blood count, electroencephalography), pediatric cardiology and otorhinolaryngology consultations, and a caloric test. All patients were assessed according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria. The majority of the patients (93.5%) received a psychiatric diagnosis according to the DSM-IV criteria. Most of these patients were adolescents and female. Psychosocial stressors such as academic problems, familial dysfunction, parental psychopathology, and child sexual abuse were associated with somatic symptoms. The results of this study demonstrated the importance of differential diagnosis and psychiatric comorbidity in a pediatric neurologic outpatient population. Treatment should be directed at biopsychosocial integrity, and a multidisciplinary treatment approach should be applied.

Psychiatric symptoms in children with primary headache

OBJECTIVE

To examine the association of psychiatric symptoms with migraine and tension-type headache in children.

METHOD

A questionnaire completed by 1,135 Finnish children in the sixth grade identified 154 children with migraine, 138 with tension-type headache, and 407 children who were headache-free. Seventy children were randomly selected from each group and evaluated by a structured interview to confirm headache type, resulting in a sample of 59 children with migraine, 65 with tension-type headache, and 59 without headache. The children completed the Children's Depression Inventory, and the parents completed the Child Behavior Checklist and General Functioning scale of the McMaster Family Assessment Device.

RESULTS

Children with migraine had significantly higher levels of total, internalizing, and somatic symptoms, as well as social and family problems, than those without headache and had higher levels of somatic symptoms than children with tension-type headache. Children with tension-type headache had significantly higher levels of somatic symptoms and family problems than those without headache.

CONCLUSIONS

The association between psychiatric symptoms and headaches shows differences between different headache types. However, a minority of children with migraine or tension-type headache have high levels of psychiatric symptoms.

Emotional and behavioural problems in children and adolescents with primary headache

Psychiatric co-morbidity is an important risk factor for chronification of primary headache into adulthood. The aim of this study was to investigate the extent and clinical relevance of emotional and behavioural problems in children and adolescents with primary headache. Children and adolescents (n = 128) with primary headache (International Headache Society, codes 1.1, 1.2, 2.1) and 83 matched controls aged 6-18 years were examined by standardized dimensional psychometric tests (Child Behaviour Checklist, Depression Inventory for Children and Adolescents, Anxiety Questionnaire for Pupils). Children and adolescents with primary headache suffer more often from internalizing problems (depression, anxiety, somatization) than healthy controls. The detected emotional and behavioural problems are clinically relevant and require particular therapy in every third child suffering from headache. Two out of three children and adolescents with primary headache do not show clinically relevant psychopathology and may benefit from minimal therapeutic intervention. One of three examined headache patients needs additional psychiatric therapy.

Effectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial

OBJECTIVE

To test the effectiveness of a multidisciplinary management program for migraine treatment in a group, low cost, nonclinical setting.

DESIGN

A prospective, randomized, clinical trial.

BACKGROUND

Although numerous studies document the efficacy of pharmacological migraine management, it is unclear whether an effective long-term management approach exists.

METHODS

Eighty men and women were randomly assigned to 1 of 2 groups. The intervention group consisted of a neurologist and physical therapist intake and discharge, 18 group-supervised exercise therapy sessions, 2 group stress management and relaxation therapy lectures, 1 group dietary lecture, and 2 massage therapy sessions. The control group consisted of standard care with the patient's family physician. Outcome measures included self-perceived pain intensity, frequency, and duration; functional status; quality of life; health status; depression; prescription and nonprescription medication use; and work status. Outcomes were measured at the end of the 6-week intervention and at a 3-month follow-up. Results.-Forty-one of 44 patients from the intervention group and all 36 patients from the control group completed the study. There were no statistically significant differences between the 2 groups before intervention. Intention to treat analysis revealed that the intervention group experienced statistically significant changes in self-perceived pain frequency (P =.000), pain intensity (P =.001), pain duration (P =.000), functional status (P =.000), quality of life (P =.000), health status (P =.000), pain related disability (P =.000), and depression (P =.000); these differences retained their significance at the 3-month follow-up. There were no statistically significant changes in medication use or work status.

CONCLUSIONS

Positive health related outcomes in migraine can be obtained with a low cost, group, multidisciplinary intervention in a community based nonclinical setting.

Determinants of tension-type headache in children

The objective of this study was to study the prevalence, characteristics and predisposing factors of tension-type headache in children. An unselected population-based questionnaire study was carried out in 1409 Finnish schoolchildren aged 12 years. Of them, 1135 (81%) returned an acceptably completed questionnaire. The prevalence of episodic tension-type headache in children was 12% (138 of 1135). Children with episodic tension-type headache also often reported characteristics of pain typical for migraine. Children with frequent and persistent episodic tension-type headache reported stabbing and severe occipital pain, phonophobia and abdominal pain significantly more often than children with infrequent episodic tension-type headache. Neck-shoulder symptoms, symptoms of depression and oromandibular dysfunction were each independently associated with episodic tension-type headache. The father's occupation of a lower-level white-collar worker put the child at a four-fold risk for episodic tension-type headache. We conclude that episodic tension-type headache is as common as migraine in children. It can be associated with depression, oromandibular dysfunction and muscular stress. Especially children with frequent and persistent episodic tension-type headache report characteristics of pain typical for migraine.

The confluence of mental, physical, social, and academic difficulties in middle childhood. II: developing the Macarthur health and Behavior Questionnaire

OBJECTIVES

(1) To evaluate the psychometric properties of the MacArthur Health and Behavior Questionnaire (HBQ) in two studies of 4- to 8-year-old children and (2) to explore the empirical and theoretical implications of HBQ-based study findings.

METHOD

Samples of children were recruited from (1) mental health clinics (n = 53) and community schools (n = 67) for a case-control study in three research sites and (2) a Wisconsin-based community cohort study of families and work, comprising children with high levels of internalizing and/or externalizing behavior problems and asymptomatic children (N = 122). Combinations of mothers, fathers, and teachers completed the HBQ at one or two time points in four geographically and culturally distinctive settings.

RESULTS

Assessment of HBQ reliability showed high test-retest stability and cross-informant agreement. The instrument discriminated strongly and significantly among symptom groups (i.e., high internalizing, high externalizing, high both, and low both) and showed moderate to large effect sizes for between-group differences. Substantial covariance was also found among the HBQ mental, physical, social, and academic problem subscales.

CONCLUSIONS

The HBQ is a reliable and valid parent- and teacher-report instrument for assessing multiple dimensions of health and dysfunction in middle childhood and for identifying children on whom more intensive diagnostic procedures may be warranted. Confluences among the four health dimensions suggest phenomenological and perhaps etiological commonalities among traditionally partitioned childhood difficulties and suggest possible artificiality in the conventional distinction between pediatric and child psychiatric morbidities.

Risk factors for and sequelae of headaches in schoolchildren with clinical implications from a psychosocial perspective

Functional headache, by definition, is a headache not associated with organic diseases. It is a common symptom in school children and can cause potentially serious health problems, affecting their growth and development. Therefore, this report synthesizes the literature about functional headaches in schoolchildren from a psychosocial perspective. This report examines the research on risk factors and sequelae of headaches in children, presents a framework to guide the conceptualization of this phenomenon, and suggests an application of this framework for clinical practice.

Mood disorders in children and adolescents: an epidemiologic perspective

Epidemiologic studies show that major depression is comparatively rare among children, but common among adolescents, with up to a 25% lifetime prevalence by the end of adolescence. Mania is much less common, with no more than a 2% lifetime prevalence by the end of adolescence. Developmental studies that include assessments of both hormonal changes and social changes through the pubertal transition are needed to investigate joint biological and environmental influences on the emergence of the gender difference in depression in puberty. Although subthreshold mood disorder symptoms are common, controversy exists about their clinical significance. This controversy is made more complex by methodologic uncertainties regarding inconsistent symptom reports obtained from parents, teachers, and children and by the pervasive existence of comorbidity. Retrospective reports about age of onset in adult studies suggest that at least 50% of youngsters with major depression and 90% of those with mania continue to have adult recurrences. These recurrences are mediated by adverse role transitions, such as truncated educational attainment and teenage childbearing, that typically occur before the time of initial treatment. Aggressive outreach and early treatment aimed at preventing the occurrence of adverse role effects might help decrease the persistence of child and adolescent mood disorders. Long-term follow-up studies are needed to resolve current uncertainties regarding nosology, methodology, and long-term treatment effects. Innovative epidemiologic research designs aimed at more quickly providing provisional information are also needed to advance understanding of long-term developmental processes.

Prevalence and predictors of headaches in US adolescents

OBJECTIVES

To examine the prevalence of headaches among US adolescents; to explore the differences in prevalence by sex, race, and age; and to test the nature of the association between headaches and depression, self-esteem, and insomnia.

METHODS

This longitudinal study used a nationally representative sample of adolescents (n = 6072) who were interviewed in 1995 (wave 1) and then interviewed a year later in 1996 (wave 2). Path analyses were used to test for the relationships among headaches, insomnia, depression, and self-esteem.

RESULTS

More than 90% of subjects had experienced one or more headaches during the past 12 months. Of that 90%, about 30% reported recurrent headaches occurring weekly or more frequently. Girls tended to report more recurrent headaches (37.6%) than boys (21.3%). American Indians experienced the highest rate (35. 6%) of recurrent headaches followed by white adolescents (32.1%). Depression and low self-esteem in wave 1 were found to precede the headaches in wave 2 in girls, but not in boys. No causal relationship was found between insomnia and headaches.

CONCLUSIONS

Headaches are prevalent among US adolescents, especially in girls and American Indians. This study suggests the existence of different paths involving different factors in headache-presenting behavior for boys and girls. Further studies are needed to illustrate the different mechanisms of headache in the two sexes.

Recurrent headache, coping, and quality of life in children: a review

OBJECTIVES

To clarify the concepts of coping with pain and quality of life (QoL) and to present a literature review of the strategies that children with recurrent headaches use to cope with their pain, the impact of recurrent headaches on children's QoL, and the influence of personal and situational variables on headache, coping, and QoL in children.

METHODS

The literature search encompassed published articles that were found by means of a CD-ROM search of MEDLINE (1966 to December 1998) and PsycLIT (1974 to December 1998) and the snowball method.

RESULTS

In pediatric headache research, only three studies have been found in which children report the use of various coping strategies, and only two studies considered QoL. Demographic factors and psychological variables such as depression, anger, and anxiety influence headache prevalence. The impact of headache-related variables such as headache type, severity, perceived cause, and prior experience on QoL has only been studied in adults.

CONCLUSIONS

More research on coping and QoL is needed in pediatric headache. The conceptual model that is presented in this article may serve as a guide.

Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches

OBJECTIVE

To examine the associations of somatic complaints with DSM-III-R-defined depression, anxiety disorders, conduct disorder, oppositional defiant disorder, and attention-deficit hyperactivity disorder in a population-based sample of children and adolescents.

METHODS

Data from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky Mountains Study were analyzed.

RESULTS

Overall, somatic complaints were strongly associated with emotional disorders in girls and with disruptive behavior disorders in boys. For girls, stomach aches and headaches together and musculoskeletal pains alone were associated with anxiety disorders. For boys, stomach aches were associated with oppositional defiant disorder and attention-deficit hyperactivity disorder. Musculoskeletal pains were associated with depression in both girls and boys.

CONCLUSIONS

There were gender-, illness- and complaint-specific associations between somatic complaints and psychopathology. It appears likely that there are differences in the psychobiological processes underlying these associations in boys and girls. Clinical recommendations include screening children and adolescents with persistent complaints of headaches, stomach aches, or musculoskeletal pains for psychiatric disorders with an awareness that gender may affect the type of psychopathology associated with the somatic complaints.

Headaches and psychopathology in children and adolescents

OBJECTIVE

To examine the association between chronic headaches and DSM-III-R-defined psychiatric disorders, including depression, anxiety disorders, conduct disorder, oppositional defiant disorder and attention-deficit hyperactivity disorder, in a population-based sample of children and adolescents.

METHOD

1,013 children aged 9 to 15 years in the Great Smoky Mountains Study were evaluated annually over a 3-year period using the Child and Adolescent Psychiatric Assessment, a child and parent diagnostic psychiatric interview. Headaches that lasted at least 1 hour and occurred at least once a week during the 3 months prior to the interview were studied.

RESULTS

Girls with depression and anxiety disorders had a significantly greater prevalence of headaches than girls without an internalizing disorder. This association was not found for boys. Conduct disorder was significantly associated with headaches in boys. Each of these associations was constant with age.

CONCLUSIONS

This study suggests that a distinct gender difference exists between boys and girls in the associations between headaches and psychopathology. Carroll's theory of dysfunction in central pain regulation as an underlying cause of depression is discussed in relation to the proposed serotonergic dysregulation common to headaches, depression, anxiety, aggression, and pain.

Adolescent depression. Epidemiology, nosology, life stress and social network. Minireview based on a doctoral thesis

The study engaged a total population of 16-17-year-old urban high-school students and 2300 (93%) were screened for depression and previous suicide attempts. Adolescents with high depression scores in self-evaluation (12.3%) or reporting previous suicide attempts (2.4%) were diagnostically interviewed together with one control for each, matched for gender and educational program. After the interview self-ratings were completed regarding social network, family climate, and life events. Major depression was prevalent during the last year in 5.8% and during life time in 11.4%, 4 girls for every boy. A depression with remaining symptoms for a year or more was the most common type. Dysthymia without major depressive episodes was diagnosed in 1.1%, two girls for every boy. Short hypomanic episodes had been experienced by 13.2% of those with major depressive disorder. Anxiety disorder was comorbid to depression in one half and conduct disorder in one forth of the depressed adolescents. Alcohol was abused by 6.5% and used regularly by another 12%. Other drugs were used by 6.5% of depressed adolescents and not at all by controls. The depressed used tobacco twice as frequently as non-depressed. Social network and family climate were compared within the originally matched pairs. Adolescents with long-lasting depressions had a smaller and unsatisfying social network. They also had experienced many stressful life events related to family adversities, while those with shorter depressive episodes had stress related to the peer group. Depressed adolescents with comorbid conduct disorder reported insufficient support from the close network and a more negative family climate.