Psychiatric symptoms in children with primary headache

Associations between stress and migraine and tension-type headache: results from a school-based study in adolescents from grammar schools in Germany

INTRODUCTION

Stress is considered the major contributor to migraine and tension-type headache in adolescents. Previous studies have focused on general stressors, whereas the aim of the present study was to investigate associations between individuals' stressful experiences and different types of headache.

METHODS

Adolescents from 10th and 11th grades of grammar schools filled in questionnaires. Stressful experiences were measured with the Trier Inventory of Chronic Stress. Type of headache was classified according to the International Classification of Headache Disorders. Linear regressions, adjusted for sex and grade, were calculated to estimate differences in stress scores that can be attributed to migraine, tension-type headache or miscellaneous headache.

RESULTS

A total of 1260 questionnaires were analysed. Tension-type headache, migraine and co-existing migraine plus tension-type headache were found in 48.7%, 10.2% and 19.8% of the participants. In subjects with migraine or co-existing migraine plus tension-type headache, high increases in stress scores were found in all investigated dimensions, whereas much weaker and inconsistent associations were found in subjects with tension-type headache only.

CONCLUSIONS

The characteristic of migraine is more associated with stressful experiences than this is the case for tension-type headache. This suggests that adolescent migraine patients might especially benefit from behavioural interventions regarding stress.

Factors associated with internalizing or somatic symptoms in a cross-sectional study of school children in grades 1-10

BACKGROUND

School related factors that may contribute to children's subjective health have not been extensively studied. We assessed whether factors assumed to promote health and factors assumed to have adverse effects were associated with self-reported internalizing or somatic symptoms.

METHODS

In a cross-sectional study, 230 boys and 189 girls in grades 1-10 from five schools responded to the same set of questions. Proportional odds logistic regression was used to assess associations of school related factors with the prevalence of sadness, anxiety, stomach ache, and headache.

RESULTS

In multivariable analyses, perceived loneliness showed strong and positive associations with sadness (odds ratio, 1.94, 95% CI 1.42 to 2.64), anxiety (odds ratio, 1.78, 95% CI 1.31 to 2.42), and headache (odds ratio, 1.47, 95% CI 1.10 to 1.96), with consistently stronger associations for girls than boys. Among assumed health promoting factors, receiving necessary help from teachers was associated with lower prevalence of stomach ache in girls (odds ratio, 0.51, 95% CI 0.30 to 0.87).

CONCLUSIONS

These findings suggest that perceived loneliness may be strongly related to both internalizing and somatic symptoms among school children, and for girls, the associations of loneliness appear to be particularly strong.

Psychological factors in childhood headaches

Recurrent headaches in children are most often migraines and are based in a genetic predisposition with a low headache threshold. As with any pain experience, there is a large emotional component associated with an attack of migraines that grows in amplitude as the headaches become more frequent and resistant to medicine, sleep, or other agents that used to work. Childhood headaches are especially complicated for 3 reasons: (1) the parents' fear (communicated to the child that serious medical pathology underlies the head pain), (2) the lack of evidence-based pharmacologic treatment, and (3) the belief that these headaches are largely psychological. This article addresses the mystery surrounding childhood headaches by delving into the influence of school, friends, and family; the impact of divorce; the coping skills required for a child to manage a migrainous nervous system; the potential secondary gain from headaches; psychiatric comorbidities and how to treat them; and the role of psychological intervention.

Social functioning and peer relationships in children and adolescents with chronic pain: A systematic review

BACKGROUND

Peer relationships during childhood and adolescence are acknowledged to be negatively impacted by chronic pain; however, to date there has been no synthesis of this literature.

OBJECTIVE

To systematically review existing literature describing the social functioning and peer relationships in children and adolescents with recurrent or continuous chronic pain.

METHODS

Articles on peer relationship factors studied in samples of children and adolescents with chronic pain published in English or French were identified using EMBASE, Medline, CINAHL and PsycINFO. Two independent reviewers performed initial screenings using study titles and abstracts, and reviewed each eligible article in full.

RESULTS

Of 1740 published papers yielded by the search, 42 articles met the inclusion criteria and were included in the present review. Nine studies had peer relationship investigation as the primary purpose of the study; the remaining 33 examined peer relationships as part of a broader study. A range of specific and more general measures was used to examine peer relationships. Across studies, children and adolescents with chronic pain were reported to have fewer friends, be subjected to more peer victimization, and were viewed as more isolated and less likeable than healthy peers.

CONCLUSIONS

Children and adolescents with chronic pain have peer relationship deficiencies. However, the majority of studies to date measure peer relationships as part of a broader study and, thus, little attention has been paid specifically to peer relationships in this group. Additional research examining the quality of peer relationships of children and adolescents with chronic pain, as well as development of measures specifically designed to assess these relationships, is needed.

Psychiatric comorbidity and suicide risk in patients with chronic migraine

The aim of this study was to explore the impact of mental illness among patients with migraine. We performed MedLine and PsycINFO searches from 1980 to 2008. Research has systematically documented a strong bidirectional association between migraine and psychiatric disorders. The relationship between migraine and psychopathology has often been clinically discussed rather than systematically studied. Future research should include sound methodologically-based studies focusing on the interplay of factors behind the relationship between migraine, suicide risk, and mental illness.

Child and family psychiatric and psychological factors associated with child physical health problems: results from the Boricua youth study

To examine associations among Puerto Rican children's physical health problems and children's internalizing disorders, parental psychopathology and acculturative stress, and family factors. A population-based probability sample of 2491 Puerto Rican children, aged between 5 and 13 years, and caregivers from the South Bronx and the U.S. Commonwealth of Puerto Rico participated in this study. The parent version of the Diagnostic Interview Schedule for Children-IV was used to assess children's internalizing disorders. Children's anxiety disorders, parental psychopathology, and acculturative stress were associated with childhood asthma, abdominal pain, and headaches. Children's depressive disorders, maternal acceptance, and family functioning were associated with abdominal pain and headaches. Parents of children living in Puerto Rico were more likely to report physical health problems in their children than in the Bronx. Children's internalizing disorders, parental psychopathology, and acculturative stress may be important areas to target among Puerto Rican children with physical health problems.

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.

Parent-teen interactions as predictors of depressive symptoms in adolescents with headache

This study investigated parent-adolescent conflict, family functioning, and adolescent autonomy as predictors of depressive symptoms in adolescents with primary headache. Frequent headaches during adolescence can have a negative impact on activity levels and psychological functioning. Depression is particularly prevalent in adolescents with headache but little research has examined the role of parent-teen interactions in predicting depressive symptoms. Thirty adolescents diagnosed with migraine or chronic daily headache completed self-report measures of pain intensity, parent-adolescent conflict, family functioning, and depression. Adolescents and their parents also participated in three videotaped interaction tasks, scored by independent raters to assess adolescent autonomy. Regression models revealed that pain intensity, parent-adolescent conflict, and autonomy predicted depressive symptoms. Higher levels of conflict, poorer family functioning and lower levels of autonomy were associated with more depressive symptoms. This study highlights the association between parent-teen interactions and psychological functioning in adolescents with primary headache. Implications for intervention are discussed.

Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk

Studies on the prevalence and impact of psychiatric disorders among headache patients have yielded findings that have clarified the relationship between migraine and major affective disorders, anxiety, illicit drug abuse, nicotine dependence, and suicide attempts. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. In large-scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Although a strong association has been demonstrated consistently for migraine and major depression, especially for migraine with aura, there has been less systematic research on the links between migraine and bipolar disorder. This review will focus on the way in which psychiatric disorders decrease the quality of life and result in a worse prognosis, chronicity of the disease, and a worse response to treatment. Short-term pharmaceutical care intervention improves the patients' mental health, but it does not significantly change the number and severity of headaches. The increase in self-efficacy and mental health associated with pharmaceutical care may be instrumental in improving the long-term pharmacotherapy of patients with migraine and headache.

Correlation Between Abnormal Brain Excitability and Emotional Symptomatology in Paediatric Migraine

We investigated a possible correlation between brain excitability in children with migraine and tension-type headache (TTH) and their behavioural symptomatology, assessed by using the Child Behaviour Checklist (CBCL). The mismatch negativity (MMN) and P300 response were recorded in three successive blocks to test the amplitude reduction of each response from the first to the third block (habituation). MMN and P300 habituation was significantly lower in migraineurs and TTH children than in control subjects (two-way ANOVA: P < 0.05). In migraineurs, but not in TTH patients, significant positive correlations between the P300 habituation deficit and the CBCL scores were found ( P < 0.05), meaning that the migraineurs with the most reduced habituation showed also the worst behavioural symptomatology. To the best of our knowledge, this is the first study showing a correlation between neurophysiological abnormality and emotional symptomatology in migraine, suggesting a role of the latter in producing the migrainous phenotype.

Chronic tension-type headache in adolescents. Clinical and psychological characteristics analyzed through self- and parent-report questionnaires

OBJECTIVES

To analyze the relation between the symptoms reported by adolescents with chronic tension-type headache (CTTH) and their perception of their emotional and behavioral functioning.

METHODS

Two groups of adolescents (clinical group, n = 48; control group, n = 135) and their parents (clinical group, n = 42; control group, n = 128) were studied, respectively, with the Youth Self-Report Questionnaire and the Child Behavior Checklist. Moreover, a secondary analysis was performed, identifying another subgroup of adolescents who reported having headaches.

RESULTS

The clinical group of adolescents obtained higher scores than the control group in Internalizing Syndrome; Aggressive Behavior for Externalizing Syndrome; Social, Thought, and Attention Problems; and in all Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)-oriented scales (except conduct problems). Differences between the two groups of parents were found in all the scales. The controls reporting headaches obtained interesting intermediate scores.

CONCLUSIONS

Adolescents with CTTH show greater emotional and behavioral problems than their healthy peers. Consequently, clinical approaches for proper diagnosis and treatment need to adopt a multidisciplinary prospective.

[Hospital admissions in adolescents with psychosomatic illnesses]

OBJECTIVES

To determine the prevalence of hospital admissions due to psychosomatic diseases in the adolescents. To define the most frequent symptomatology that accompanies these disorders, the triggering factors, the complementary tests made and the possible existence of psychiatric illness in the parents.

PATIENTS AND METHOD

A retrospective study was carried out with patients of 10 to 18 years who were admitted to the Niño Jesús Children's Hospital during the period from January 2002 to August 2006, whose discharge diagnosis included symptomatology of psychosomatic origin.

RESULTS

The number of medical histories was 33. In this period the frequency of admissions due to psychosomatic diseases was 2.6 %. We found a predominance of female patients, with an average age of 11.5 years; the most frequent symptom was abdominal pain, isolated or accompanied by other pathology. The duration of the symptom before going to the hospital was 11 days. In 13/33 (39.4 %) of the cases previous symptoms of psychosomatic aetiology existed. The complementary study to discard organic disease was negative in all cases. The average stay was 5 days. The existence of triggering factors was found in 21/33 (63.6 %), school problems being the most common. In 7/33 (21 %) there was a family history of psychiatric disease.

CONCLUSIONS

The most frequent somatic symptom was abdominal pain, being the triggering factor in most of the patients. The complementary study did not find significant abmormalities. In one out of five cases there was a family history of psychiatric disease. It is recommended to give these patients multidisciplinary care from the beginning of the stay, using consultation and link technique.

Idiopathic Headache in Children Under Six Years of Age: A Follow‐Up Study

OBJECTIVE

To assess the evolution of idiopathic headache with early onset and to investigate the influence of early somatic disorders, "life events," and psychiatric disorders on the onset and the course of headache. We also studied the possible prognostic role of gender, headache diagnosis at onset, and history of headache in family members on the course of headache. We also investigated the applicability of the ICHD-II criteria to idiopathic headache in preschool children.

METHODS

Prospective evaluation of 25 consecutive headache patients referred before the age of 6 years. Headache diagnosis was based on the IHS 1988 criteria, on the ICHD-II criteria, and on "alternative" clinical criteria [eg, duration less than 1 hour in migraine without aura (MWA), less than 30 minutes in tension-type headache (TTH)]. All patients were assessed by a structured interview to detect early developmental disorders (eg, feeding difficulties or sleep disorders) and "life events" (eg, parents' separation and others according to DSM-IV). All patients underwent clinical observations and assessment of psychiatric comorbidity (ICD-10) by means of interviews and the Child Behaviour Check List. All the above-mentioned evaluations were performed at recruitment (T0) and at the end of the follow-up period (T1).

RESULTS

A total of 25 children with headache (12 males; 13 females) were monitored through long-term clinical follow-up (mean duration: 4.2 years; range: 2.8 to 6.6 years). The "definite" diagnosis of migraine without aura or TTH at T0 was possible in only 6/25 (24%) and 9/25 patients (36%) applying the IHS 1988 criteria and the ICHD-II criteria respectively, but in 20/25 (80%) applying the "alternative" clinical criteria. Evaluation of headache at T1 revealed: remission in 16/25 (64%) patients and persistence in 9/25 (36%). At T1, the ICHD-II diagnosis was possible in 100% of the children with headache persistence (1/9 migraine without aura and 8/9 TTH) and these diagnoses were found to be perfectly concordant with those obtained applying the "alternative criteria." Early developmental disorders were present in 11/25 children, with a significantly higher prevalence in children with headache persistence compared to children showing headache remission (78% vs. 25%; P < .05). No significant differences were found between patients with headache persistence and patients with headache remission with regard to gender, history of headache in family members, headache diagnosis at onset, psychiatric comorbidity at T0, and with regard to "life events" at both T0 and T1. Conversely, the children presenting psychiatric disorders at T1 were more frequently affected by headache than those without psychiatric disorders (59% vs. 15%; P < .05).

CONCLUSIONS

Our results suggest that the ICHD-II criteria are too restrictive to allow the classification of migraine without aura and TTH in preschool children. Nevertheless, a diagnosis based on these criteria was possible in all the patients with headache persistence at the end of several years' follow-up. We found a significant association between early somatic disorders and persistence of headache and also between the presence of psychiatric disorders at the end of follow-up and the persistence of headache. "Life events," on the other hand, while not showing a statistically significant association with the evolution of the headache, may nevertheless influence the course of the headache in some patients. Our results suggest that environmental and psychological factors play an important role in idiopathic headache with onset in preschool age, and thus that the diagnostic-therapeutic approach must take these factors into account.

Friendships and social interactions of school-aged children with migraine

We set out to evaluate the friendships and social behaviour of school-aged children with migraine. Concern exists regarding the impact of paediatric migraine on daily activities and quality of life. We hypothesized that children with migraine would have fewer friends and be identified as more socially sensitive and isolated than comparison peers. Sixty-nine children with migraine participated in a school-based study of social functioning. A comparison sample without migraine included classmates matched for gender, race and age. Children with migraine had fewer friends at school; however, this effect was limited to those in elementary school. Behavioural difficulties were not found. Middle-school students with migraine were identified by peers as displaying higher levels of leadership and popularity than comparison peers. Concern may be warranted about the social functioning of pre-adolescent children with migraine; however, older children with migraine may function as well as or better than their peers.

Headache in children's drawings

Headache is a common health problem in childhood. Children's drawings are helpful in the diagnosis of headache type. Children, especially younger ones, communicate better through pictures than verbally. The aim of the present study is to evaluate the usefulness of drawings of the child's headache in the diagnostic process carried out by a pediatrician and a pediatric neurologist. At the beginning of a visit in a neurological clinic, or on the first day of hospitalization, the child was asked, "Please draw your headache," or "How do you feel your headache?" without any additional explanations or suggestions. Clinical diagnosis of headache type was made on the basis of the standard diagnostic evaluation. For the purpose of this study, children's headaches were categorized as migraine, tension-type headache, or "the others." One hundred twenty-four drawings of children with headaches were analyzed by 8 pediatricians and 8 pediatric neurologists. The analysts were unaware of the clinical history, age, sex, and diagnosis of the patients. The clinical diagnosis was considered the "gold standard" to which the headache drawing diagnosis was compared. There were 68 girls 5-18 years of age and 56 boys 7-18 years of age. Of the 124 children, 40 were clinically diagnosed with migraine (32.2%), 47 with tension-type headache (37.9%), and 37 (29.8%) as the others. Children with migraine most frequently draw sharp elements. Children with tension-type headache mainly drew compression elements and pressing elements. In the group of "the other" headaches, 21 children were diagnosed with somatoform disorders. The most frequent element in this group's drawings was a whirl in the head. Colors used most frequently were black and red, which signify severe pain. There was no difference in sensitivity of diagnoses between neurologists and pediatricians. Because the evaluation of drawings by children with headaches done both by pediatricians and pediatric neurologists was correct for approximately half of the children, the authors decided to prepare a set of test pictures, including characteristic presentations of pain. Preparing a ready set of test drawings may facilitate differentiation for the inexperienced doctors and encourage those children who refuse to draw.

Psychiatric symptoms in children and adolescents with cyclic vomiting syndrome and their parents

OBJECTIVE

To conduct a pilot study to evaluate the prevalence of psychiatric symptoms in children and adolescents with cyclic vomiting syndrome and to assess family history of psychiatric disorder.

BACKGROUND

Little is known about psychiatric comorbidity in youth with cyclic vomiting syndrome, a periodic syndrome.

METHODS

Eighty-five parents, of children aged 3-18 years with cyclic vomiting syndrome confirmed in a multidisciplinary clinic, completed the age-appropriate Children's Symptom Inventory, a questionnaire that screens for psychiatric symptoms in pediatric patients. Twenty-one adolescents aged 13-18 years completed the Youth's Report, a self-report form of this questionnaire. Sixty-two parents completed a family psychiatric history checklist.

RESULTS

These children and their parents evidenced a high prevalence of anxiety and mood symptoms compared to norms of the Children's Symptom Inventory and population norms for internalizing psychiatric disorders. On the age-appropriate Children's Symptom Inventory, 47% of subjects (40/85) met diagnostic cut-off for an anxiety disorder, and 14% (12/85) for an affective disorder. Discrepancies were found in parent and adolescent reports for symptoms of panic disorder (chi-square = 4.83, df = 1, P = .028), posttraumatic stress disorder (chi-square = 6.87, df = 1, P = .009), and somatization disorder (chi-square = 6.41, df = 1, P = .01), with parents reporting significantly more symptoms than the adolescents. Internalizing disorders were also prevalent in the parents with 59% (36/62) endorsing either an anxiety and/or an affective disorder. Mothers reported a significantly higher prevalence of anxiety disorders (35%) than did fathers (13%) (chi-square = 8.43, df = 1, P < .004).

CONCLUSION

Children and adolescents with cyclic vomiting syndrome appear to be at increased risk for internalizing psychiatric disorders, especially anxiety disorders. Further research using standardized psychiatric interviews and a control group are indicated to further assess psychiatric disorders in children and adolescents with cyclic vomiting syndrome.

Adolescent Autonomy and Family Functioning Are Associated With Headache-related Disability

OBJECTIVES

The aims of this study were to examine the relationships between a range of family factors, including autonomy and general family functioning, on headache outcomes (ie, pain and functional impairment) in adolescents with recurrent headaches.

METHODS

Forty nine adolescents, ages 11 to 16 years, (mean age=13.5 y, 63% female) receiving treatment through pediatric neurology for recurrent headaches were enrolled. Adolescents and their parents completed measures of pubertal status, pain, functional impairment, parental solicitousness, behavioral autonomy, depressive symptoms, and family functioning.

RESULTS

Lower levels of adolescent autonomy (r=0.53, P<0.01) and less healthy family functioning (r=0.32, P<0.01) were significantly related to higher levels of functional impairment. In multivariate regression analyses controlling for pain intensity, pubertal status, and depressive symptoms, parent and family variables added significant variance in the prediction of functional impairment (r change=0.21, P<0.05). Both adolescent autonomy (beta=0.38, P<0.05) and general family functioning (beta=0.34, P<0.05) were significant individual predictors of adolescent functional impairment.

DISCUSSION

This study extends research on family factors and adolescent headache-related pain and disability. Future research is needed to discover whether family based interventions helping adolescents to acquire appropriate and supportive levels of autonomy may be useful in reducing headache-related disability.

Recommendations for the management of migraine in paediatric patients

Migraine is a common and disabling condition in children and adolescents. The complexity of migraine on a pathogenetic and clinical level results from the interaction between biological, psychological and environmental factors. Appropriate management requires an individually tailored strategy giving due consideration to both pharmacological and non-pharmacological measures. Ibuprofen (7.5-10.0 mg/kg) and acetaminophen (15 mg/kg) are safe and effective, and should be considered for symptomatic treatment. Sumatriptan nasal spray (5 and 20 mg) is also likely to be effective, but at the moment, should be considered for the treatment of adolescents only. With reference to prophylactic drug treatment, the available data suggest that flunarizine (5 mg/day) is likely to be effective and pizotifen and clonidine are likely to be ineffective. The efficacy data regarding propranolol, nimodipine and trazodone are conflicting. Insufficient evidence is available on cyproheptadine, amitriptyline, divalproex sodium, topiramate, levetiracetam, gabapentin or zonisamide. The management of migraine in children needs an individualised therapeutic approach, directed to the whole person of the child, taking into account the developmental perspective and the high rate of psychiatric comorbidities. It is the authors' opinion that for the prophylaxis of migraine, interventions such as identification and avoidance of trigger factors, regulation of lifestyle, relaxation, biofeedback, cognitive behavioural treatment and psychological or psychotherapeutic interventions (e.g., psychodynamics) could be much more effective than pharmacotherapy.

Psychiatric comorbidity of migraine

Migraine affects nearly 12% of the adult population in the United States and causes significant lost productivity and decrements in health-related quality of life. The burden of migraine and the challenge in managing it are increased by the comorbid psychiatric conditions that occur in association with it. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder. In large scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Migraine is also comorbid with generalized anxiety disorder (Odds Ratio [OR] 3.5 to 5.3), panic disorder (OR 3.7), and bipolar disorder (OR 2.9 to 7.3). A diagnosis of migraine should lead to a heightened level of diagnostic suspicion for these comorbid psychiatric disorders. Similarly, a diagnosis of one of these psychiatric disorders should increase vigilance for migraine. Treatment plans for migraine should be mindful of the comorbid conditions.

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.

Sleep disturbance in children with migraine

The objectives of this study were to determine if (1) children with migraine experience greater sleep disturbances than their siblings, (2) those with more severe migraine have greater levels of sleep disruption, and (3) these sleep disturbances lead to greater behavioral problems and more missed school. Children aged 6 to 18 years with a diagnosis of migraine for > 6 months, who had at least one sibling without migraine in the same age range, were identified through our neurology clinic database or at the time of the clinic visit. Parents completed the (1) demographic, general health, and migraine information questionnaire; (2) Child Sleep Habits Questionnaire; and (3) Behavior Assessment System for Children: Second Edition (BASC-2) Parent Rating Scales for each child. Cases with migraine had higher total sleep (P < .02), sleep delay (P < .03), and daytime sleepiness scores (P < .001) than controls. Cases with more severe migraines had higher total sleep (P < .01) and sleep duration scores (P < .03) than those with milder headaches. In cases, higher total sleep scores predicted greater behavior problems on all four composite scales on the Behavior Assessment System for Children: Second Edition (Externalizing Problems, P < .05; Internalizing Problems, P < .005; Behavior Systems Index, P < .003; and Adaptability Skills, P < .006). We conclude that children with migraine are prone to greater sleep and behavioral disturbances than children without headache. Sleep disorders should be routinely queried and appropriate advice on sleep hygiene provided.

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.

[Predisposing factors of the migraine syndrome in children]

INTRODUCTION

The aim of this paper was to define characteristics which could be used to recognize groups of children at risk for migraine syndrome.

MATERIAL AND METHODS

Predisposing factors of migraine syndrome were investigated by conducting a poll among 24.828 children aged 3-16, in Vojvodina, during the period between 1988-2004.

RESULTS

For the purpose of defining recognizable characteristics of children with migraine syndrome, a comparison of children with migraine headaches, non-migraine headaches, and those without headaches was done among 24.828 children. Apart from direct heredity, the following factors should be accepted as predisposing factors of migraine syndrome: child's order of birth (second child), length of breast-feeding, age at which the ready-made industrial food was introduced, as well as the age at which the child started the whole-day stay (which is in inverse proportion to the risk of migraine attacks and the age of the first symptoms), particularities in behaviour pattern, family social status, atmosphere in the family, previous paroxysmal torticollis, episodic vertigo of unknown etiology, recurrent abdominal pain, and lack of cerebral hemisphere dominance.

CONCLUSION

Children with migraine headaches have particularities, not clear enough for the time being, but recognition of which is necessary for early prevention of migraine syndrome in childhood.

Tension-type headache in childhood and adolescence

The prevalence of non-migrainous headache is 10-25% in childhood and adolescence. Although tension-type headache and migraine are the two most common types of headache in children and adolescents, most articles address migraine headache. The distinction of tension-type headache from migraine can be difficult; use of The International Classification of Headache Disorders criteria helps. However, these criteria might be too restrictive to differentiate tension-type headache from migraine without aura in children. The pathophysiology of tension-type headache is largely unknown. The smaller genetic effect on tension-type headache than on migraine suggests that the two disorders are distinct. However, many believe that tension-type headache and migraine represent the same pathophysiological spectrum. Some indications of effective treatment exist. For children with frequent headache, the antidepressant amitriptyline might be beneficial for prophylaxis, although no placebo-controlled studies have been done. Restricted studies have suggested the efficacy of psychological and cognitive behavioural approaches in the treatment of childhood tension-type headache.

Adolescents' perception of epilepsy compared with other chronic diseases: "through a teenager's eyes"

Adolescent perception of physical and social impact of chronic illness was assessed to determine (1) if there is greater prejudice toward epilepsy than other chronic disease and (2) if adolescents with chronic disease have less prejudice toward similarly affected peers with all types of chronic disease or just their specific chronic disease. Cognitively normal teens aged 13 to 18 years without chronic disease (n = 41) and with epilepsy (n = 32), asthma (n = 38), diabetes (n = 21), and migraine (n = 17) were interviewed in the outpatient clinics of a tertiary care pediatric center regarding their perceptions of the physical and social impact of eight chronic diseases (epilepsy, asthma, diabetes, Down syndrome, arthritis, migraine, leukemia, human immunodeficiency virus [HIV] infection). Epilepsy was perceived to have a more adverse physical impact than all chronic illnesses except Down syndrome. The perception was that it more frequently caused mental handicap, injured the afflicted individual and bystanders, and led to death. Epilepsy was also perceived to have a more negative social impact, particularly on behavior, honesty, popularity, adeptness at sports, and fun. Significantly more adolescents expressed reluctance to befriend peers with epilepsy, both from their own and their perceived parental perspectives. Having a chronic disease did not generally alter the adolescents' perceptions of peers with chronic disease. However, cases with epilepsy ranked this disease to have less social impact than teens with other chronic diseases. In conclusion, adolescents consider epilepsy to have a greater physical and social impact than most chronic diseases. Educational efforts should focus on the "normality" of most persons with epilepsy and emphasize the low risk of injury when proper first aid is followed.

Headache in schoolchildren: association with other pain, family history and psychosocial factors

Limited information exist about associations between different headache types and other pains, family history of pain, and psychosocial factors among children from the general population suffering from less severe headache. We interviewed 130 schoolchildren together with a parent to find out whether such factors differ between children with mainly infrequent and moderate migraine or tension-type headache as compared to those without primary headache. Children with headache, especially those with migraine reported other pains and physical symptoms more frequently than children without primary headache. Coherently, parents of children suffering from migraine reported their children to have significantly more somatic symptoms than parents of children without primary headache. In addition, first-degree relatives of children with headache suffered from more migraine, other pains, and physical symptoms compared with first-degree relatives of children without primary headache. Children with migraine visited the school nurse, used medication and were absent from school because of headache more often than those with tension-type headache. Few other differences in psychosocial factors were found between the three groups. Migraine among first-degree relatives and the total sum of physical symptoms in children were the strongest predictors of headache in logistic regression analysis. It is concluded that in schoolchildren with mainly infrequent and moderate headache, pain and physical symptoms cluster within individuals as well as their families, however, psychological and social problems are uncommon.

The "other" primary headaches in children and adolescents

Headache represents one of the most common reasons why children and adolescents are referred to pediatric neurology practices where the most common headache syndromes diagnosed are migraine and its variants, and chronic daily headache. The bulk of recent literature regarding headache in children has focused on these two clinical entities even though large epidemiologic studies have demonstrated that tension-type headache may be two to three times more common in children. Why has so little attention been given to these other disorders? The purpose of this review is to examine the "other" primary headache disorders in children and adolescents.

Headache symptoms in pediatric sickle cell patients

The purposes of this study were to determine the characteristics of headaches in children with sickle cell disease (SCD) and to assess the relationship between headache symptoms and children's physical and emotional status. A detailed headache questionnaire using International Classification of Headache Disorders (ICHD-2) criteria was mailed to a cohort (n = 50) of children with SCD, ages 9 to 17 years. Respondents also completed measures of functional disability and psychological distress. Headaches had occurred over the previous 3-month period in 76.2% of the patients. Frequent headaches were common, occurring greater than once a week in 31.2% of children. Average pain severity was reported as moderate on a 0-to-10 scale (mean = 5.8). Duration of headaches ranged from 30 minutes to several days, with a mean of 5 hours. Based on ICHD-2 criteria, 43.8% of children had headache symptoms consistent with migraines, 6.2% with migraine with aura, and 50.0% with tension-type headaches. Children with symptoms of migraine had significantly greater functional disability compared with children with symptoms of tension-type headaches (P < 0.01). Further studies to determine the characteristics and determinants of headaches experienced in SCD patients will help maximize treatment of headaches and enhance daily functioning in these patients.

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.

Tension-type headache in children and adolescents

Although tension-type headache is at least as prevalent as migraine in children and adolescents, in contrast to migraine, childhood tension-type headache has received limited research attention. Follow-up studies have shown that migraine may reverse in tension-type headache and vice versa. In addition, children with frequent episodic tension-type headache may be at increased risk of chronic tension-type headache. It is very important to recognize these children and to intervene. Further studies are needed to clarify the pathophysiology of pediatric tension-type headache.

Somatic Symptoms in Headache Patients: The Influence of Headache Diagnosis, Frequency, and Comorbidity

BACKGROUND

Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache.

METHODS

Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME-MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow-up data were obtained 6 months after consultation.

RESULTS

Clinical diagnoses and PRIME-MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P<.001) and chronic daily headache (CDH) (6.3, P=.008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to <or=2 days per week (6.15 vs. 4.15, P<.001); and in patients with a clinical diagnosis of anxiety or depression, or both, compared to no anxiety or depression, (5.7, P=.05, 5.2, P<.05, and 6.8, P<.001, respectively, vs. 4.5). The most common specific symptoms were fatigue (73%), sleep difficulty (60%), and nausea/indigestion (55%). Compared to a primary care sample, patients with severe headache >2 days per week had significantly higher somatic counts (P=.01). Six-month follow-up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P=.01 and 0.8, P=.003, respectively).

CONCLUSION

Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.