Childhood periodic syndromes: a population-based study

The prevalence of chronic pain in children and adolescents: a systematic review update and meta-analysis

ABSTRACT

Chronic pain, defined as persistent or recurring pain or pain lasting longer than 3 months, is a common childhood problem. The objective of this study was to conduct an updated systematic review and meta-analysis on the prevalence of chronic pain (ie, overall, headache, abdominal pain, back pain, musculoskeletal pain, multisite/general pain, and other) in children and adolescents. EMBASE, PubMed, CINAHL, and PsycINFO were searched for publications between January 1, 2009, and June 30, 2023. Studies reporting population-based estimates of chronic nondisease related pain prevalence in children or adolescents (age ≤ 19 years) were included. Two independent reviewers screened articles based on a priori protocol. One hundred nineteen studies with a total of 1,043,878 children (52.0% female, mean age 13.4 years [SD 2.4]) were included. Seventy different countries were represented, with the highest number of data points of prevalence estimates coming from Finland and Germany (n = 19 each, 4.3%). The overall prevalence of chronic pain in children and adolescents was 20.8%, with the highest prevalence for headache and musculoskeletal pain (25.7%). Overall, and for all types of pain except for back pain and musculoskeletal pain, there were significant differences in the prevalence between boys and girls, with girls having a higher prevalence of pain. There was high heterogeneity (I 2 99.9%). Overall risk of bias was low to moderate. In summary, approximately 1 in 5 children and adolescents experience chronic pain and prevalence varies by pain type; for most types, there is higher pain prevalence among girls than among boys. Findings echo and expand upon the systematic review conducted in 2011.

Narrative review of the prevalence and distribution of acute pain in children in the self-care setting

Acute pain among children is common, yet it may be underestimated and undertreated if the pain is not recognized. Assessing and managing pediatric pain can be complicated, and as such, measuring the prevalence of acute pain in children can be challenging. We sought to provide a consolidated review of the available data on the prevalence of commonly occurring acute pain in children in the self-care setting. An extensive literature search was performed to determine the prevalence of acute pain at multiple bodily locations in children aged between 3 months and 18 years. We considered the influence of age, sex, and sociodemographic factors on prevalence estimates. We also sought to identify some of the challenges involved in assessing and managing pediatric pain, thus shedding light on areas where there may be clinical and medical unmet needs. In general, a high prevalence of acute pain in children was detected, particularly headache, menstruation-related pain, and dental and back pain. Older age, female sex, and lower socioeconomic status were associated with increased pain prevalence. Risk factors were identified for all pain types and included psychological issues, stress, and unhealthy lifestyle habits. Owing to the heterogeneity in study populations, the prevalence estimates varied widely; there was also heterogeneity in the pain assessment tools utilized. The paucity of information regarding pain prevalence appears to be out of proportion with the burden of acute pain in children. This could indicate that clinicians may not be equipped with an optimal pain management strategy to guide their practice, especially regarding the use of developmentally appropriate pain assessment tools, without which prevalence data may not be captured. If acute pain is not accurately identified, it cannot be optimally treated. Further investigation is required to determine how the information from prevalence studies translates to the real-world setting.

Sleep disorder-related headaches

Migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicranias are each reported as intrinsically related to sleep. Chronic migraine, chronic tension-type headache, and medication overuse headache may cause sleep disturbance. Otherwise, both headache and sleep disorder may be manifestations of a same systemic dysfunction. There is a vicious cycle linking sleep disorders and migraine. The poor quality or poor duration of sleep could be a trigger of migraine attack and migraineurs with poor sleep reported a higher headache frequency. Moreover, coping behaviors of migraineurs (e.g., going to sleep early to relieve migraine attacks) can be factors precipitating and perpetuating sleep disturbances themselves. During cluster headache, patients report a poor quality of sleep correlated with the amount of daylight. In particular, it was demonstrated that melatonin levels have influences on cluster headache attacks. Concerning the pathophysiology of hypnic headache, it has been hypothesized a possible role of obstructive sleep apnea in triggering nocturnal attacks: an increased number of apnea episodes has been reported in hypnic headache patients, but a lack of a temporal correlation of headache attacks with the drop of oxygen saturation has been observed. Tension-type headache is the most common headache with sleep dysregulation (lack of sleep or oversleeping) frequently reported as a triggering factor for acute attacks: management of sleep disturbances seems crucial in this form of headache.

Sleep Disorders and Migraine: Review of Literature and Potential Pathophysiology Mechanisms

Migraine shares a complex and poorly understood relationship with sleep. Patients consistently report poor sleep prior to migraine attacks and during them, identifying poor sleep as a migraine trigger. However, anecdotally, sleep is reported to serve a therapeutic role in terminating headache. Are the associations between migraine and sleep simply the result of various bidirectional relationships? A growing body of evidence suggests there may be a common underlying etiology as well. Our objective was to review studies of sleep and migraine from the last 2 decades utilizing validated subjective and objective measures of sleep and to explore potential mechanisms underlying this complex relationship by incorporating recent advances in neuroscience. We specifically focus on insomnia, obstructive sleep apnea, parasomnias, sleep related movement disorders, and REM sleep related disorders and their relationship to migraine. Parts of brainstem-cortical networks involved in sleep physiology are unintentionally being identified as important factors in the common migraine pathway. Recent discoveries on anatomic localization (the hypothalamus as a key and early mediator in the pathophysiology of migraine), common mediating signaling molecules (such as serotonin and dopamine), and the discovery of a new CNS waste removal system, the glymphatic system, all point to a common pathophysiology manifesting in migraine and sleep problems.

Pediatric abdominal migraine: current perspectives on a lesser known entity

Background

Abdominal migraine (AM) is a common cause of chronic and recurrent abdominal pain in children. It is characterized by paroxysms of moderate to severe abdominal pain that is midline, periumbilical, or diffuse in location and accompanied by other symptoms including headache, anorexia, nausea, vomiting, or pallor. Despite the presence of comprehensive diagnostic criteria under Rome IV classification of functional gastrointestinal disorders (FGIDs) and International Classification of Headache Disorders, it continues to be an underdiagnosed entity.

Overview

The average age of diagnosis is 3–10 years with peak incidence at 7 years. Most of the patients have a personal or family history of migraine. Pathophysiology of the condition is believed to be similar to that of other FGIDs and cephalic migraine. It is also well recognized as a type of pediatric migraine variant. A careful history, thorough physical examination, and use of well-defined, symptom-based guidelines are needed to make a diagnosis. Selective or no testing is required to support a positive diagnosis. It resolves completely in most of the patients. However, these patients have a strong propensity to develop migraine later in life. Explanation and reassurance should be the first step once the diagnosis is made. Nonpharmacologic treatment options including avoidance of triggers, behavior therapy, and dietary modifications should be the initial line of management. Drug therapy should be considered only if symptoms are refractory to these primary interventions.

Conclusion

More research focused on pathophysiology and management of AM needs to be carried out to improve outcomes in affected children.

Recent advances in the management of chronic migraine in children

INTRODUCTION

Migraine is a chronic-recurrent disorder that progresses in some adults and also in many children. Chronic migraine (CM) is the clinical result of this process. Since migraine does not progress in most children, identifying the risk factors for progression is an important public health priority that should be matched by evidence-based treatment. Areas covered: Herein we conduct a systematic review on the comorbidities and treatment of CM in children and adolescents in the last ten years, summarizing evidence-based recommendations for disease management. Expert commentary: By conceptualizing CM as the result of migraine progression from an episodic form, we suggest avoiding CM at the outset through development of aggressive, preventive interventions as the goal of headache management in the pediatric population. Key interventions include: Decreasing headache frequency with behavioral and pharmacologic interventions; Monitoring body mass index and encouraging maintenance of normal weight; Avoiding medication overuse; Screening and treating comorbidities.

Spectrum of migraine variants and beyond: The individual syndromes in children

"Migraine-related conditions" are probably the second most common condition after seizure encountered in pediatric neurology requiring frequent Emergency Department visits. Among migraines, migraine-related condition presents with an acute onset sign or symptom other than headache or visual aura of unknown etiology. A delay in diagnosis is a common occurrence. Previously, the authors proposed a common clinical profile and suggested that the future review should seek the applicability of the common profile in aid to clinical diagnosis of migraine-related individual syndromes. Authors describe the clinical characteristics and differential diagnosis of the spectrum of migraine variants and beyond in children.

Migraine equivalents and related symptoms, psychological profile and headache features: which relationship?

Background

Migraine equivalents are common clinical conditions in children suffering from headache. Very few studies dealt with the psychological profile of children/adolescents with migraine equivalents. Our main aim was to compare the psychological profile between migraine children with and without migraine equivalents. Moreover, as secondary aim, exclusively in children with migraine equivalents, we investigated the possible relationship between migraine attack frequency and intensity and psychological factors.

Methods

We enrolled 136 young migraineurs. They were divided in two groups (patients with and without migraine equivalents). The psychological profile was assessed by means of SAFA Anxiety and Somatization questionnaires.

Results

Migraine equivalents were present in 101 patients (74.3 %). Anxiety (p = 0.024) and somatization (p = 0.001) levels, but not hypochondria (p = 0.26), were higher in patients with migraine equivalents. In children with migraine equivalents, a low frequency of attacks was related to separation anxiety (p = 0.034).

Conclusions

Migraine equivalents patients tend to feel more fearful and to experience more shyness. This, together with the tendency to somatization, may lead them to become vigilant in attachment relationships with their caregivers.

Higher risk of developing a subsequent migraine in adults with nonapnea sleep disorders: A nationwide population-based cohort study

OBJECTIVE

This nationwide population-based cohort study evaluated the effect of nonapnea sleep disorders (NSDs) on the subsequent development of a migraine.

METHODS

We identified 46,777 patients aged 20 years and older who were diagnosed with an NSD (ICD-9-CM: 307.4 or 780.5) and without coding for apnea-sleep disorders (ICD-9-CM: 780.51, 780.53, or 780.57) between 2000 and 2002 as the sleep disorder (SD) cohort. A comparison cohort of 93,552 people was enrolled. We calculated the adjusted hazard ratio (aHR) for developing a migraine (ICD-9-CM: 346) after adjusting for age, sex, comorbidity, and drug use. A Kaplan-Meier analysis was used to measure the cumulative incidence of a migraine between 2 curves until the end of 2011.

RESULTS

The cumulative incidence of a migraine was significantly higher in the SD cohort. The aHR for developing a migraine in the SD cohort was 3.52 (95% CI=3.28-3.79). The risk of developing a migraine with an NSD was higher in men (aHR=4.31) than in women (aHR=3.35). The age-stratified effect of an NSD on developing a migraine was highest among patients aged 55 years and younger. Higher risks of developing a migraine were observed among the participants without any comorbidity and without any drug treatment for their insomnia.

CONCLUSION

The findings of this population-based cohort study indicate a higher risk of developing a subsequent migraine in patients with an NSD, which could be considered an independent, predisposing factor for developing subsequent a migraine in adulthood.

Headache in school children: prevalence and risk factors

BACKGROUND

Recurrent headache is a common problem in school children. Evaluation generally leads to the diagnosis of a primary headache syndrome (migraine or tension-type headache). This review is addressed to the question whether headaches in school children are becoming more common and, if so, what risk factors are associated with the rise in frequency.

METHOD

We selectively searched the PubMed database for pertinent publications that contained the terms "primary headache AND children/adolescent AND risk factors/prevalence." Articles published in either English or German up to April 2013 were considered. Articles on secondary types of headache were excluded.

RESULTS

Headaches are becoming more common among school children. At present, 66% to 71% of 12- to 15- year-olds have at least one headache every three months, and 33% to 40% have at least one per week. Headache is often accompanied by other physical and/or emotional manifestations. Studies from Scandinavia reveal increasing prevalence in age groups from 8 years of age and upward. Various studies have identified the following risk factors for headache or for its chronification (up to 5.8-fold elevation of risk): a dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, smoking, a low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school, and insufficient leisure time.

CONCLUSION

Headaches are becoming more common among children and adolescents. They are often associated with other physical and emotional complaints.

Headache in school age

Headache, especially migraine and tension-type headache, is one of the most frequently reported somatic complaints by children and adolescents. Different population-based studies have been conducted to study the correlation between headache and lifestyles in pediatric age, nevertheless, the obtained results are often controversial and these relationship still remain unclear. Likewise, is still strongly debated the burden of headache during school age, its impact on school performances and on quality of life of children and their families. Consequently, larger studies are necessary to evaluate the degree of disability due to pediatric headache. We summarize the ongoing knowledge about these concepts, with the intent to provide useful data to neurologists but also to primary care providers, to further improve the management of pediatric headaches by preventing the headache progression, the disabling effects associated and improving the long-term outcome.

A Medical Food Formulation of Griffonia simplicifolia/Magnesium for Childhood Periodic Syndrome Therapy: An Open-Label Study on Motion Sickness

Motion sickness (MS) is a disabling condition dominated by disagreement between visually perceived movement and the vestibular system's sense of movement, with symptoms like dizziness, fatigue, and nausea, and other autonomic disabling symptoms. Preparations of Griffonia simplicifolia, containing high concentrations of 5-HTP, might be effective for serotonin-related disorders, including MS. Therefore, the aim of the present study is to assess the efficacy and safety of the G. simplicifolia/magnesium complex in a pediatric population with MS. The Griffonia/magnesium complex (50 and 200 mg, respectively) was orally administered as a prophylactic therapy for MS twice a day for 3 months to group A, and no therapy for MS was administered to group B. The MS clinical signs were recorded by parents or, where possible, directly from children by a specific module, which included validated questions for the diagnoses that were administered to all subjects and parents of both groups. Two study groups were matched for age (P=.224), sex (P=.801), and z-score body-mass index (P=.173). At T0, all recruited subjects in both groups complained about MS. After 3 months (T1), group A showed an MS prevalence of 36%, significantly lower than MS prevalence in group B (73%) (P<.001). The findings of the present study suggest the role of the Griffonia/magnesium complex as a potential treatment with middle-term efficacy even for MS.

Pediatric migraine and episodic syndromes that may be associated with migraine

Importance

Migraine is a common disorder and a frequent cause of medical consultation in children. Many childhood episodic syndromes have been described as common precursors of migraine.

Objective

To review current knowledge on migraine and childhood episodic syndromes, and to discuss future directions for research and clinical practice.

Findings

For most children it is difficult to describe a headache and fully verbalize symptoms such as photophobia and phonophobia that must be inferred from behaviour. Classical migraine features are rare before the age of 6 years, but some migraine-related syndromes have been described. Benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of childhood, cyclic vomiting syndrome and abdominal migraine are currently classified as childhood episodic syndromes, and therefore common precursors of migraine. A strong association between infantile colic and migraine has recently been reported. There are similarities between children with episodic syndromes and children with migraine, regarding social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurologic, and vasomotor features. The real pathophysiological mechanisms of migraine are not fully understood. Current data obtained through molecular and functional studies provide a complex model in which vascular and neurologic events cooperate in the pathogenesis of migraine attacks. Genetic factors causing disturbances in neuronal ion channels, make a migraineur more sensitive to multiple trigger factors that activate the nociception cascade. The expanding knowledge on migraine genetics and pathophysiology may be applicable to childhood episodic syndromes. Migraine preventive strategies are particularly important in children, and could be beneficial in childhood episodic syndromes. Nonspecific analgesics like ibuprofen and acetaminophen are widely used in pediatrics to control pain and have been found to be effective also in the treatment of acute migraine attacks. Triptans are the specific fist-line drugs for acute migraine treatment.

Conclusions and relevance

Migraine phenotype differs somewhat in the developing brain, and childhood episodic syndromes may arise before typical migraine headache. Diagnosing pediatric migraine may be difficult because of children’s language and cognitive abilities. The risk of underestimating migraine in pediatric age is high. An adequate diagnosis is important to maintain a good quality of life and to avoid inappropriate therapy.

Migraine equivalents as part of migraine syndrome in childhood

BACKGROUND

Migraine equivalents are common clinical conditions without a headache component, occurring as repeated episodes with complete remission between episodes. They include abdominal migraine, cyclical vomiting, benign paroxysmal vertigo, and benign paroxysmal torticollis. Other clinical entities, such as motion sickness and limb pain have been associated with migraine. We aimed to investigate the prevalence of migraine equivalents in a large population of children referred to a pediatric headache center and to analyze the possible relationship between migraine equivalents and headache features.

METHODS

A total of 1134 of children/adolescents (73.2% with migraine and 26.8% with tension-type headache) were included. Patients were divided into two groups according to the episode frequency (high and low). Pain intensity was rated on a three-level graduate scale (mild, moderate, and severe pain).

RESULTS

Migraine equivalents were reported in 70.3% of patients. Abdominal migraine (48.9%), limb pain (43.9%), and motion sickness (40.5%) were the most common migraine equivalents. Although headache type (migraine or tension-type headache) did not correlate with migraine equivalents presence (χ(2) = 33.2; P = 0.27), high frequency of headache episodes correlated with the occurrence of migraine equivalents. Moreover, migraine equivalents indicated a protective role for some accompanying feature of the headache episode.

CONCLUSIONS

Our results suggest that migraine equivalents should not be considered merely as headache precursors, but they as part of the migrainous syndrome. Thus, their inclusion among the diagnostic criteria for pediatric migraine/tension-type headache is useful.

Sex and the migraine brain

The brain responds differently to environmental and internal signals that relate to the stage of development of neural systems. While genetic and epigenetic factors contribute to a premorbid state, hormonal fluctuations in women may alter the set point of migraine. The cyclic surges of gonadal hormones may directly alter neuronal, glial and astrocyte function throughout the brain. Estrogen is mainly excitatory and progesterone inhibitory on brain neuronal systems. These changes contribute to the allostatic load of the migraine condition that most notably starts at puberty in girls.

Why does sleep stop migraine?

The relationship between sleep and migraine headaches is complex. Changes in sleep patterns can trigger migraine attacks, and sleep disorders may be associated with increased migraine frequency. Furthermore, migraine patients and their doctors very consistently report that sleep relieves already established migraine attacks. Herein we will try to answer the question, "Why does sleep stop migraine?" Since evidence for this relationship is largely based on empirical clinical observation, we will not provide a clinical review of the association. Instead, we will focus on the pathophysiology of migraine attacks and its intersections with sleep biology.

Comorbidity of Migraine

Migraine is a common neurological disorder and can be severely disabling during attacks. The highest prevalence occurs between the ages of 25 and 55 years. Prior studies have found that migraine occurs together with other illnesses at a greater coincidental rate than is seen in the general population. These occurrences are called "comorbidities". To delineate the comorbidities of migraine is important, because it can help improve treatment strategies and the understanding of the possible pathophysiology of migraine.

Migraine and sleep disorders

The burden of migraine strongly increases, considering its linkage with sleep disorders. Migraine is positively associated with many sleep-complaint disorders; some are confirmed by several studies, such as restless leg syndrome, whereas others still remain uncertain or controversial, e.g. narcolepsy. Many studies have investigated the association between headache and other sleep disturbances such as daytime sleepiness, insomnia, snoring and/or apnea, but only a few have focused on migraine. Highlighting the comorbidity between migraine and sleep disorders is important to improve treatment strategies and to extend the knowledge of migraine pathophysiology.

Community based study of sleep bruxism during early childhood

OBJECTIVES

The aims for this study were to determine the prevalence of sleep-bruxism among young children, explore child behavior problems that may be associated with sleep-bruxism, and identify relations among sleep-bruxism, health problems, and neurocognitive performance.

METHODS

The current study was a retrospective analysis of parent report surveys, and behavioral and neurocognitive assessments. Parents of 1953 preschool and 2888 first grade children indicated their child's frequency of bruxism during sleep. A subsample of preschool children (n=249) had additional behavioral, as well as neurocognitive assessments. Among the subsample, parents also reported on their child's health, and completed the Child Behavioral Checklist; children were administered the Differential Ability Scales, and Pre-Reading Abilities subtests of the Developmental Neuropsychological Assessment.

RESULTS

36.8% of preschoolers and 49.6% of first graders were reported to brux ⩾1time per week. Among the preschool subsample, bruxing was independently associated with increased internalizing behaviors (β=.17). Bruxism was also associated with increased health problems (β=.19), and increased health problems were associated with decreased neurocognitive performance (β=.22).

CONCLUSIONS

The prevalence of sleep-bruxism was high. A dynamic and potentially clinically relevant relation exists among sleep-bruxism, internalizing behaviors, health, and neurocognition. Pediatric sleep-bruxism may serve as a sentinel marker for possible adverse health conditions, and signal a need for early intervention. These results support the need for an interdisciplinary approach to pediatric sleep medicine, dentistry, and psychology.

Prevalence of recurrent symptoms and their association with epilepsy and febrile seizure in school-aged children: a community-based survey in Iceland

We determined the prevalence of common recurrent symptoms in a community-based study of children and investigated whether these symptoms were associated with epilepsy and febrile seizure. A questionnaire was developed and sent to parents of all children attending school in the Reykjavik school district, grades 1-10. The questions assessed personality traits, headache, epilepsy, febrile seizure, and recurrent symptoms. Of the 13,044 questionnaires distributed, 10,578 were returned (81%). We analyzed the subset of 9679 (91%) questionnaires with complete information on relevant factors. The prevalence of epilepsy was 7.7/1000; febrile seizures were reported in 5.1% of children. Prevalence estimates of recurrent symptoms were similar to the published literature. In our cohort, recurrent dizzy spells and recurrent visual disturbances were associated with epilepsy after adjustment for age, migraine and febrile seizure. This association could reflect, only in part, the occurrence of auras in children with epilepsy.