Migraine in childhood: an organic, biobehavioral, or psychosomatic disorder?

Understanding the gaps in headache and migraine treatment with psychological and behavioral interventions: A narrative review

OBJECTIVE

In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments.

BACKGROUND

Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence-based interventions may lead to improved outcomes.

METHODS

We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive-behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing.

RESULTS

Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive-behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts-common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment.

CONCLUSION

There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence-based interventions and addresses gaps by focusing on processing trauma-related emotions may improve chronic and debilitating symptoms.

Pediatric Migraine: Diagnosis and Management

The WHO recognizes migraine as one of the most disabling diseases [...].

Early maladaptive schemas differing according to sex may contribute to migraine among the youth

OBJECTIVE

Despite many diverse findings from studies about the comorbidity of psychiatric disorders and migraine, there are still unknown points. Schemas, which are the basic structures of cognition, are understudied. This study examined the effects of sex on early maladaptive schemas (EMSs) and the clinical characteristics of migraine in adolescents with migraine.

METHODS

The sample comprised 171 adolescents (67.3% females, n = 115) aged 12-18 years. The clinical characteristics of migraine (duration, severity, frequency of headaches, etc.), accompanying symptoms (nausea, vomiting, photophobia, etc.) and EMSs were evaluated depending on sex. Psychopathology and abuse history were analyzed as covariates in this study.

RESULTS

The mean age was 15.4 ± 1.9 among the females and 15.2 ± 2.0 among the males (p = 0.65). There was no difference in terms of migraine characteristics, and except for dizziness and pain relief by massage, all other symptoms were similar between the sexes. Female adolescent migraineurs significantly elevated scores for EMS of emotional deprivation, abandonment/instability, defectiveness/shame (disconnection/rejection domain), dependence/incompetence, vulnerability to harm/illness, failure (in impaired autonomy/performance domain) and negativity/pessimism (in hypervigilance/inhibition domain). On the other hand, male migraineurs had significantly elevated scores only in insufficient self-control/self-discipline (in impaired limits domain). Type of migraine and current psychopathology had no significant effect on the EMS domains, while sexual abuse history significantly affected some EMS.

CONCLUSION

Our study highlights the importance of screening for EMSs among adolescent patients with migraine. Schema therapy and similar therapeutic interventions may be used in the management of migraine in adolescents. Gender may also be important factor the schema therapy in adolescent migraine patients.

From the New Diagnostic Criteria to COVID-19 Pandemic Passing Through the Placebo Effect. What Have We Learned in the Management of Pediatric Migrane Over the Past 5 Years?

In 2018, the Food and Drug Administration (FDA) approval of anti-calcitonin gene-related peptide (CGRP) therapies for the treatment of migraine represented a milestone for the management of the disease in adults. On the contrary, the novelties in the field of pediatric migraine are inserted in a different scenario and still concern: (1) diagnostic criteria of the international classification of headache disorders-3 (ICHD-3) that show numerous limits of applicability in the developmental age; (2) the release of the results of the Childhood and Adolescent Migraine Prevention (CHAMP) study that raised doubts about the usefulness of traditional drugs for the treatment of pediatric migraine; (3) the Coronavirus disease 2019 (COVID-19) pandemic has put the spotlight on the importance of managing the psychological factors associated with the disease. In this mini review we discuss the most relevant news in pediatric migraine over the last 5 years.

Predicting quality of life outcomes in children with migraine

INTRODUCTION

Several studies have shown that the response of children with migraine to medications is suboptimum and inferior to the response reported in adults, despite the similar pathogenesis and biological mechanisms. The poor response may be related to the significant differences that make assessment and treatment of children with migraine more challenging than in adults.

AREAS COVERED

The purpose of this review is to discuss the whole process of assessment of children with migraine, the necessary skills for eliciting the clinical features, making the correct diagnosis and exploring lifestyle issues, co-morbid conditions (psychological and physical) and social influences on disease presentations. Also, to establish and address peculiarities of migraine in children that would enable clinicians to advise on lifestyle modifications, co-morbid conditions and the correct choice of treatment options including non-pharmacologic therapies and medications.

EXPERT OPINION

The choice of treatment should be based on an assessment of each individual child taking into account, age, gender, pubertal status, body weight, comorbid disorders and family history. Also considering the profile of migraine episodes, frequency, duration, associated symptoms and effects of nausea and vomiting. Using the appropriate medications in appropriate dosage, formulation and route and timing of administration may improve adherence to treatment and outcome.

The Psychiatric Comorbidities of Migraine in Children and Adolescents

PURPOSE OF REVIEW

Understanding comorbidities in migraine is important because it can help us understand disease pathophysiology while also aiding the development of more effective treatment strategies. Additionally, it can provide greater awareness about appropriate diagnosis, the need for additional disease screening, and the natural history of migraine. Psychiatric comorbidities have been independently studied in both adults and children with migraine because their presentations can be distinct, and the physiology in these two groups can be different.

RECENT FINDINGS

While symptoms of anxiety and depression seem to be comorbid with migraine in children, clinically significant disease does not appear to be, though the clarity of these data is limited by overlap between migraine symptomatology and that assessed by many screening tools. Functional neurologic disorders like psychogenic non-epileptic episodes (PNEE) and other functional movement disorders are not common but can be comorbid with migraine in this population and tend to improve with migraine treatment. The number of adverse childhood experiences (ACEs) a child is exposed to seems to be near-linearly associated with risk of migraine, but not with tension-type headache (TTH). The findings from these studies underscore the importance of utilizing appropriate screening methodologies for identifying psychiatric disorders in children with migraine. Additionally, the role of the insula, the hypothalamic-pituitary-adrenal axis, the serotonergic system, and the instability of hyperactivated neural networks may underlie the pathophysiology of both migraine and its psychiatric comorbidities.

Psychological factors associated with headache frequency, intensity, and headache-related disability in migraine patients

Background

Several psychological cofactors of migraine have been identified, but relationships to different headache parameters (e.g., headache frequency vs. headache-related disability) are only incompletely understood.

Methods

We cross-sectionally assessed 279 migraine patients at their first presentation at our tertiary headache center. We obtained headache and acute medication frequency, pain intensity, the Migraine Disability Assessment Scale (MIDAS), and the Pain Disability Index (PDI) as headache-related outcomes as well as scores of the Hospital Anxiety and Depression Scale (HADS), the Pain Catastrophizing Scale (PCS), Pain-Related Control Scale (PRCS), and Avoidance Endurance Questionnaire (AEQ) as psychological factors.

Results

Linear regression models revealed the highest associations of the psychological factors with the PDI (adjusted R² = 0.296, p < 0.001, independent predictors: PCS, AEQ social avoidance, depression) followed by the MIDAS (adjusted R² = 0.137, p < 0.001, predictors: depression, AEQ social avoidance) and headache frequency (adjusted R² = 0.083, p < 0.001, predictors: depression, AEQ humor/distraction). Principal component analysis corroborated that psychological factors were preferentially associated with the PDI, while the MIDAS loaded together with headache frequency.

Conclusion

Our results suggest that psychological factors are more strongly associated with the subjective degree of headache-related disability measured by the PDI than with the days with disability (MIDAS) or the more objective parameter of headache frequency. This once again highlights the need for comprehensive assessment of migraine patients with different headache parameters and the need for considering psychological treatment, especially in patients with high disability.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05453-2.

Attachment representation to caregivers and mentalizing ability in early adolescents with primary headache

Primary headache (PH) is a common somatic disorder in childhood with a strong impact in terms of quality of life. There are several risk factors related to the development of this disorder including environmental factors as attachment bonds. However, studies in this direction are relatively few and have often used self-report or semi-projective measures looking at the only maternal attachment. Moreover, several studies have shown a link between somatoform pains and mentalizing abilities, but the relation between mentalizing and PH in childhood is unexplored. Therefore, this study aims at exploring attachment bonds, focusing on both maternal and paternal representations and mentalizing abilities in early adolescents with and without PH within a cross-sectional case-controlled design. A sample of 94 early adolescents aged 10-14 years (47 with PH and 47 without PH as a comparison group) completed the Child Attachment Interview to assess attachment representations to caregivers. Mentalizing abilities were assessed applying to the interviews in the Child and Adolescent Reflective Functioning Scale. PH adolescents showed a greater percentage of insecure-preoccupied attachment to both parents, with higher level of preoccupied anger especially to father than the comparison group (p values from 0.000 to 0.014, effect size values from.31 to.45), while no differences emerged about mentalizing (p values from.264 to 0.312). The over-representation of insecure-preoccupied attachment to both parents suggests a key role of parent-child interaction in early adolescents with PH, while the role of mentalizing abilities remains controversial and further studies are needed to address this issue. Clinical implications are discussed.

Migraine in Children Under 7 Years of Age: a Review

PURPOSE OF REVIEW

Despite the accumulation of a significant amount of data on pediatric headache, few studies have been conducted on its occurrence in children under 7 years of age. Within primary headaches in this age, migraine especially, turns out to be a disorder affecting up to 4% of the general population. An underestimate of its true prevalence can be due to lack of specific diagnostic markers, the frequent difficulty of describing pain in childhood, and the necessity of reliable parents' reports. Thus, migraine in children under 7 years of age represents an important challenge for clinicians. The objective of this manuscript is to provide a comprehensive review of epidemiologic, clinic, and therapeutic aspects of migraine in this age.

RECENT FINDINGS

Current literature data show that migraine has some differences, especially in clinical and therapeutic terms, in this age group compared to subsequent ages. Furthermore, some evidences showing that an early onset of migraine may play an unfavorable role in its natural history, suggest an early identification and management of migraine in younger children. Moreover, we highlight the role that factors of prenatal and perinatal development can play in the predisposition and anticipation of migraine onset. Finally, open questions related to the several undefined features of migraine in this age are reported. Migraine in this pediatric population is absolutely not rare, represents an importan clinical challenge and probably has a negative predictive role.

I stay at home with headache. A survey to investigate how the lockdown for COVID-19 impacted on headache in Italian children

Objective

The present Italian multicenter study aimed at investigating whether the course of primary headache disorders in children and adolescents was changed during the lockdown necessary to contain the COVID-19 emergency in Italy.

Methods

During the lockdown, we submitted an online questionnaire to patients already diagnosed with primary headache disorders. Questions explored the course of headache, daily habits, psychological factors related to COVID-19, general mood and school stress. Answers were transformed into data for statistical analysis. Through a bivariate analysis, the main variables affecting the subjective trend of headache, and intensity and frequency of the attacks were selected. The significant variables were then used for the multivariate analysis.

Results

We collected the answers of 707 patients. In the multivariate analysis, we found that reduction of school effort and anxiety was the main factor explaining the improvement in the subjective trend of headache and the intensity and frequency of the attacks (p < 0.001). The greater the severity of headache, the larger was the clinical improvement (p < 0.001). Disease duration was negatively associated with the improvement (p < 0.001). It is noteworthy that clinical improvement was independent of prophylaxis (p > 0.05), presence of chronic headache disorders (p > 0.05) and geographical area (p > 0.05).

Conclusions

Our study showed that lifestyle modification represents the main factor impacting the course of primary headache disorders in children and adolescents. In particular, reduction in school-related stress during the lockdown was the main factor explaining the general headache improvement in our population.

Evidence for hyperprolactinemia in migraineurs: a systematic review and meta-analysis

BACKGROUND

One of the hypothalamus-pituitary axis hormones which may play a crucial role in pathophysiology of migraine is prolactin which is secreted from anterior pituitary gland and synthesized by various immune system cells as well. Whether prolactin blood levels can affect the migraine pathogenesis is an open question. Therefore, investigating prolactin circulatory levels in migraineurs may pave the way to underpin the mechanisms of migraine pathophysiology at biochemical levels. In the current investigation, the prolactin blood levels in the migraine subjects were investigated using systematic review and meta-analysis.

METHODS

Using online and specialized biomedical databases including Google Scholar, Medline, Pubmed, Pubmed Central, Embase, and Scopus, without the beginning date restriction until Feb 2019, the systematic review retrieved 11 publications in this systematic review after fulfilling for the inclusion and exclusion criteria. For heterogeneity, extent calculation statistical testing was applied. In the present study, the levels of circulatory prolactin in migraineurs assessed using standardized mean difference (SMD) as the effect size.

RESULTS

Q quantity and I²% statistic index showed a high heterogeneity in the 13 selected publications (188.370 and 92.568, respectively) and random-effects model was chosen for further analyses. The meta-analysis on a total number of 460 migraineurs and 429 healthy controls found that the weighted pooled SMD for the effects of prolactin blood concentrations on migraine pathogenesis was as follows: SMD = 1.435 (95% confidence interval, 0.854-2.015).

CONCLUSION

The current investigation presents evidence that prolactin blood levels are higher in migraineurs than healthy subjects.