What Factors Contribute to Headache-Related Disability in Teens?

The relationship between depression severity and heart rate variability in children and adolescents: A meta-analysis

OBJECTIVE

Depression in children and adolescents has gradually attracted social attention. Heart rate variability (HRV) has been found to be influenced by depression severity, but results have not been uniformed in children and adolescents. This study investigated the relationship between depression severity and heart rate variability in children and adolescents, aiming to provide additional evidence for an objective, effective, and convenient depression screening tool in this population.

METHODS

Literature searching was conducted in China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, PubMed, ScienceDirect, and EBSCO. Relevant studies investigating the relationship between depression severity and HRV in children and adolescents were selected for meta-analysis.

RESULTS

31 articles were included in this meta-analysis, involving 4534 participants. Depression severity in children and adolescents was significantly negatively correlated with high frequency (HF) and root mean square of successive differences (RMSSD) in HRV (HF: r = -0.10, 95% CI: -0.17 to -0.04, p = 0.001; RMSSD: r = -0.18, 95% CI: -0.30 to -0.05, p = 0.01). The relationship between HF and depression severity was moderated by age, higher among those aged >12 than among those aged <12 (r = -0.17, -0.02, Q = 7.32, p = 0.007).

CONCLUSION

Heart rate variability is associated with depression severity in children and adolescents.

The relationship between trait mindfulness and resilience: A meta-analysis

Resilience is a positive psychological resource that promotes health. Trait mindfulness was found to be related to resilience. However, previous studies on this relationship have shown contradictory results. The current meta-analysis explored the relationship between trait mindfulness and resilience based on a three-level random-effects meta-analysis model. A significant and positive relationship between trait mindfulness and resilience (r = 0.385; p < 0.0001) was revealed by analyzing 197 effect sizes from 103 studies. Furthermore, the subsequent moderator analysis found that the facet of mindfulness (e.g., awareness, nonjudging) (F(6, 190)  = 6.181; p < 0.001), measurement of mindfulness (e.g., the Mindful Attention Awareness Scale) (F(7, 191)  = 4.758; p < 0.001), aspect of resilience (e.g., family resilience) (F(5, 191)  = 3.455; p < 0.05), measurement of resilience (e.g., the Connor-Davidson Resilience Scale) (F(11, 185)  = 2.256; p < 0.05), and age (F(1, 150)  = 4.588; p < 0.05) acted as significant moderators. Overall, this study confirmed the positive relationship between trait mindfulness and resilience, suggesting that people with higher levels of trait mindfulness were more likely to have higher levels of resilience. The current findings provided insightful information for interventions targeted at improving resilience.

Medication Overuse Headaches among Children-The Contribution of Migraine and TTH

Medication overuse headaches are a frequent phenomenon observed in individuals suffering from chronic headaches. It arises due to the excessive consumption of pain-relief medications, resulting in the escalation and continuous persistence of headache symptoms. Nevertheless, the prevalence and distinctive characteristics of medication overuse headaches in the pediatric population have not been comprehensively explored. The primary objective of this research is to delineate the features of medication overuse headaches in children, particularly emphasizing the investigation of its epidemiology and the diagnostic patterns for headaches. We conducted a retrospective study and analyzed the medical records of children and adolescents who were evaluated at the outpatient pediatric headache clinic at the Bnai Zion Medical Center for headaches during the period spanning 2007 to 2017. Our study encompassed a cohort of 1008 patients experiencing headaches. Among these participants, 268 individuals (26.6%) were diagnosed with migraine, 250 (24.8%) exhibited tension-type headaches (TTH), and 490 (48.6%) were classified as having undifferentiated headaches. Out of the whole group, 65 had chronic headaches: 35 (54%) with migraine, 20 (30%) with tension-type headaches (TTH), and 10 (15%) with the undifferentiated headache of childhood, with the majority (73%) being female. In summary, medication overuse headaches are a prevalent issue among children grappling with chronic headaches. Intriguingly, they appear to be more pronounced within the tension-type headache (TTH) group compared to migraine sufferers and exhibit a higher prevalence among females. This study underscores the significance of early detection and careful management of medication overuse headaches in pediatric cases, shedding light on its distinct characteristics in the realm of childhood headache disorders. Further research is warranted to elucidate the underlying factors contributing to the observed gender disparity and the distinct prevalence rates among different headache subtypes.

The impact of resilience on headache disability as measured by the Migraine Disability Assessment (MIDAS)

OBJECTIVE

Our objectives were to examine cross-sectional correlations of headache disability with measures of resilience, anxiety, and depression, and to determine if resilience modified the association between headache severity/frequency and disability.

BACKGROUND

Resilience is associated with quality of life and functioning among patients with chronic conditions. We investigated whether resilience strongly mitigates headache-related disability as measured by the Migraine Disability Assessment (MIDAS).

METHODS

We prospectively recruited 160 patients with primary headache disorders seen in a tertiary headache medicine program between February 20, 2018 and August 2, 2019. Each participant completed the MIDAS, Conner Davidson Resilience Scale (CDRS-25), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and WHO-5 Well-Being Index.

RESULTS

The CDRS-25 score was negatively correlated with the total MIDAS (r = -0.21, p = 0.009), GAD-7 (r = -0.56, p < 0.001), and PHQ-9 scores (r = -0.34, p < 0.001). Well-being inversely correlated with disability (r = -0.37, p < 0.001). Increases in anxiety and depression increased the odds of disability. A 1 point increase in the CDRS-25 score decreased the odds of being severely disabled by 4% (OR = 0.96, 95% CI: 0.94 to 0.99, p = 0.001). However, the CDRS-25 score did not significantly moderate the association between headache days and disability.

CONCLUSION

Traits associated with resilience decreased the odds of severe disability from headaches, whereas anxiety, depression, and headache frequency were strongly associated with higher disability from headache.

A Review of Self-Compassion as an Active Ingredient in the Prevention and Treatment of Anxiety and Depression in Young People

Previous meta-analyses have found higher self-compassion is associated with lower anxiety and depression. The aim of this study was to investigate the efficacy of self-compassion as an active ingredient in the treatment and prevention of anxiety and depression in youth. This was conducted through (i) a systematic review of the literature and (ii) qualitative consultation with young people and researchers in self-compassion. Fifty studies met our inclusion criteria. Eight studies evaluated self-compassion interventions among youth aged 14-24, and the remaining studies measured the association between self-compassion and anxiety, and/or depression among this age group. Qualitative interviews were conducted with four self-compassion researchers. Interviews were also conducted in two rounds of consultation with 20 young people (M age = 18.85 years, age range 14-24 years). Higher self-compassion was related to lower symptoms of anxiety, r =  - 0.49, 95% CI (- 0.57, - 0.42), and depression, r =  - 0.50, 95% CI (- 0.53, - 0.47). There was evidence for self-compassion interventions in decreasing anxiety and depression in young people. Consultation with young people indicated they were interested in self-compassion interventions; however, treatment should be available in a range of formats and tailored to address diversity. Self-compassion experts emphasised the importance of decreasing self-criticism as a reason why self-compassion interventions work. The importance of targeting self-criticism is supported by the preferences of young people who said they would be more likely to engage in a treatment reducing self-criticism than increasing self-kindness. Future research is required to add to the emerging evidence for self-compassion interventions decreasing symptoms of anxiety and depression in young people.

How to Assess the Headache-Sleep Disorders Comorbidity in Children and Adolescents

Sleep disorders and primary headaches are frequent health problems in childhood, and they are often comorbid in an individual, linked by a mutual and complex relationship. This comorbidity is frequent and well-documented, but the available literature is usually biased in favor of one aspect or another, mainly depending on the expertise of the authors. The aim of this paper is to review existing literature on the diagnostic assessment of comorbid primary headaches and sleep disorders, so as to propose practical suggestions to accurately investigate the presence of comorbid conditions in children evaluated for primary headaches or for sleep disorders.

Pediatric Medication-overuse Headache and Global Headache Research. A Systematic Review

Medication-overuse headache (MOH) is a relevant topic of interest but pediatric studies are scarce. Some authors have expressed their opinion regarding geographical differences in the perceived importance of adult MOH between European and North American research. To determine if there is a geographic difference in the research efforts on pediatric MOH; and to study pediatric MOH prevalence of published studies. An analysis of the Global Burden of Disease database focusing on Headache disorders prevalence per region was correlated with the region where research was conducted via PubMed search on pediatric MOH from 2006-2021. Analysis of databases from PubMed, HINARI, and ScienceDirect found 13 studies that fulfilled inclusion criteria to evaluate pediatric MOH prevalence. 6 regions were analyzed North America, Latin America, Europe, Asia, Africa, Oceania. Regions with higher prevalence of headache disorders were North America (28.45%) and Europe (28.54%).  Most pediatric MOH publications were from North America (44.2%) and Europe (37.2%). The prevalence found of pediatric MOH among pediatric headache patients is 4-11%. Prevalence increases to 20-70% among patients having a diagnosis of chronic headache. Higher prevalence was found in patients suffering post traumatic headaches. The perceived importance for pediatric MOH is similar between North America and Europe based on the research published. The prevalence varies greatly between published studies. Relationship between Post-traumatic headache and pediatric MOH prevalence should be further studied.

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.

Effect of a Mindfulness-Based Intervention for Chronic Migraine and High Frequency Episodic Migraine in Adolescents: A Pilot Single-Arm Open-Label Study

In this single-arm pilot open-label study we examined the effect of a mindfulness-based intervention on reduction of headache frequency after 12 months in adolescents aged 12-18 with chronic or high-frequency migraine without aura. Adolescents were recruited at the headache center of the C. Besta Neurological Institute and followed-up for 12 months. The mindfulness-based intervention was delivered in small groups and consisted of six weekly group sessions of guided meditation, and one booster session 15 days after. Patients filled in questionnaires assessing headache frequency (primary endpoint), medication intake, disability, anxiety, depression, catastrophizing, and caregivers' burden. Within-person ANOVA was used to address variation of endpoints over time. Thirty-five out of 37 patients completed the study for primary endpoints, and 33 for secondary endpoints. Headache frequency dropped from 21.3 (95% CI 18.5; 24.1) to 9.6 (95% CI 6.1; 13.1) days per month at 12 months (F = 30.5, p < 0.001); 23 patients out of 35 (65.7%) achieved a headache frequency reduction greater than or equal to 50%. Significant improvements were also reported for medication intake (F = 18.7, p < 0.001), disability (F = 3.8, p = 0.027), trait anxiety (F = 5.1, p = 0.009), symptoms of depression (F = 9.5, p < 0.001), and catastrophizing (F = 23.6, p < 0.001). In conclusions, our study shows a reduction of headache attacks in adolescents who follow a mindfulness-based program, suggesting benefit of this nonpharmacological approach.

Migraine and Mood in Children

Migraine is one of the most prevalent headache disorders in children and negatively influences their quality of life. Physical, social, and school functioning are negatively affected. Mood changes are common in migraineurs and may happen before, during, or after a migraine headache. Children with migraine are not exempt from mood swings. The majority of mood changes occur during the prodromal phase, manifesting as a psychobiological response, e.g., difficulty thinking, trouble concentrating, irritability, higher or lower energy, confusion, and depression. A bi-directional relationship between migraine and mood has been proposed, but mechanisms are not clear. Collectively, a maladaptive stress response has been suggested to explain the inability to balance homoeostatic changes when facing various stressors. Recognizing mood changes and monitoring mood patterns in children with migraine, for example, by various apps and so-called mood monitors, is valuable for better management. A multidisciplinary intervention has been recommended to reduce migraine disability, improve coping strategies, and reduce chronification risks in children with migraine. Pharmacological and non-pharmacological strategies are both available and effective. Biofeedback, relaxation, and cognitive-behavioral therapy yield positive outcomes in pediatric migraine. Developing healthy lifestyle habits (diet, exercise, sleep) also seems to improve migraine in this population.

Resilience and vulnerability in adolescents with primary headaches: A cross-sectional population-based study

BACKGROUND

A scarcity of studies on the role of resilience resources (RRs) and vulnerability risk (VR) in children and adolescents with primary headache hampers the development of a risk-resilience model for pediatric headaches.

OBJECTIVE

To examine the extent to which headache frequency and diagnosis are associated with RRs and VR and explore possible predictors of low RRs and high VR in a cross-sectional population-based study in adolescents.

METHODS

This is a cross-sectional population study conducted in a small city in Brazil (Delfinópolis). Consents and analyzable data were obtained from 339/378 adolescents (89.7%). RRs and VR were assessed using the validated Brazilian version of the Resiliency Scales for Children and Adolescents, completed by the adolescents. Parents filled a structured questionnaire assessing sociodemographic and headache characteristics, as well as the Brazilian-validated version of the Strengths and Difficulties Questionnaire added to the impact supplement to evaluate the adolescent's psychosocial adjustment skills. Teachers completed a structured questionnaire about the students' school performance.

RESULTS

A higher frequency of headache was associated with lower RRs (F_3,335  = 2.99, p = 0.031) and higher VR (F_3,335  = 4.05, p = 0.007). Headache diagnosis did not significantly influence the risk of having lower RRs or higher VR. In the exploratory analyses, females (OR 3.07; 95% CI: 1.16-9.3) and individuals with psychosocial adjustment problems (OR 7.5; 95% CI: 2.51-22.4) were predictors of low RRs, and prenatal exposure to tobacco (OR 5.6; 95% CI: 1.57-20.9) was a predictor of high VR in adolescents with primary headache.

CONCLUSIONS

The risk of low RRs and high VR was associated with a higher headache frequency, but not with headache diagnosis. These findings may contribute to the development of a risk-resilience model of headaches in the pediatric population and help identify novel targets and develop effective resources for successful interventions.

Comparison of Children with Migraine and Those with Tension-Type Headache for Psychiatric Symptoms and Quality of Life

This study compared the severity of depression, anxiety, somatization, anxiety sensitivity, sleep disturbances, and quality of life (QoL) among children with migraine, children with tension-type headache (TTH), and healthy children. A total of 37 children with migraine, 22 with TTH, and a healthy control group (n = 35) participated in this study. Children with migraine exhibited higher depression and somatization and lower QoL scores than those in the control group. General sleep disturbances, bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night wakings, sleep-disordered breathing, and daytime sleepiness scores were also higher in those in the migraine group than in the control group. Regression models indicated that the severity of headache and depression scores significantly affected the QoLs of children with headache disorder as a whole. Migraine is associated with depression, somatization, sleep disturbances, and poor QoL, whereas TTH is associated with only sleep disturbances in childhood. The impact of headache on the QoL occurs mainly through the headache-specific and psychiatric factors.

A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education

Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.

A systematic review of the relation between self-compassion and depressive symptoms in adolescents

Research on self-compassion and depressive symptoms is growing at an exponential pace. This systematic review provides an in-depth exploration of the relation between self-compassion and depressive symptoms in adolescents. In accordance with PRISMA guidelines, MEDLINE, CINAHL, and PsycINFO databases were systematically searched and 18 studies were identified. Results demonstrate the potentially pertinent role that self-compassion may play in the development, maintenance, and treatment of depression in adolescents, yet reflect on the paucity of research on this topic with respect to mechanisms of change. These studies further highlight how the impact of self-compassion may differ according to gender and age and underscore the need to account for other diversity-related variables, such as ethnic-racial group, socioeconomic status, and sexual orientation. Despite such limitations in the literature, the current findings extend research in adults by providing support for the relevance of self-compassion in adolescence, particularly with respect to the prevention of depressive symptoms.

Hypnotherapy or transcendental meditation versus progressive muscle relaxation exercises in the treatment of children with primary headaches: a multi-centre, pragmatic, randomised clinical study

Many children suffer from headaches. Since stress may trigger headaches, effective techniques to cope with stress are needed. We investigated the effectiveness of two mind-body techniques, transcendental meditation (TM) or hypnotherapy (HT), and compared them with progressive muscle relaxation (PMR) exercises (active control group). Children (9-18 years) suffering from primary headaches more than two times per month received either TM (N = 42), HT (N = 45) or PMR (N = 44) for 3 months. Primary outcomes were frequency of headaches and ≥ 50% reduction in headaches at 3 and 9 months. Secondary outcomes were adequate relief, pain coping, anxiety and depressive symptoms, somatisation and safety of treatment. Groups were comparable at baseline. Headache frequency was significantly reduced in all groups from 18.9 days per month to 12.5 and 10.5 at respectively 3 and 9 months (p < 0.001), with no significant differences between the groups. Clinically relevant headache reduction (≥ 50%) was observed in 41% and 47% of children at 3 and 9 months respectively, with no significant differences between the groups. No differences were observed in secondary outcome measures between the intervention groups. No adverse events were reported.Conclusion: All three techniques reduced primary headache in children and appeared to be safe.Trial registration: NTR 2955, 28 June 2011 ( www.trialregister.nl ) What is Known: • Stress may be an important trigger for both tension type headache and migraine in children. • Good data are lacking on the effect of transcendental meditation, hypnotherapy or progressive muscle relaxation as possible stress-reducing therapies in children with primary headaches. What is New: • Three non-pharmacological techniques, i.e., transcendental meditation, hypnotherapy and progressive muscle relaxation exercises, all result in a clinically significant reduction of headaches and use of pain medication. • No large differences between the three techniques were found, suggesting that children can choose either one of the three techniques based on personal preferences.

Migraine in children: presentation, disability and response to treatment

PURPOSE OF REVIEW

The current review presents findings from investigations of migraine in children. The presentation of pediatric migraine, related consequences, and medication treatments are reviewed.

RECENT FINDINGS

A number of advancements have been made in the study of the presentation, disability, and treatments for migraine in children. However, recent research suggests that not all approaches are equally effective in the treatment of migraine in children. Specifically, a recent study comparing pharmacological interventions found that preventive medications were not statistically more effective than placebo in children. Consistent findings showing clinically meaningful placebo response rates, shorter duration of headaches and other characteristic features (e.g. frontal, bilateral location) have been barriers to the design of randomized clinical trials in children and adolescents with migraine. Better understanding of treatment mechanisms for medication interventions is needed.

SUMMARY

Several migraine treatments have determined to be effective for use in children but few controlled studies have evaluated the effectiveness of medication treatments. Recent research suggests that preventive medications may not be more effective than placebo. Additional research is needed to evaluate the effectiveness of medication treatment in migraine headache care.

Pediatric Headache Clinic Model: Implementation of Integrative Therapies in Practice

The demand for integrative medicine has risen in recent years as research has demonstrated the efficacy of such treatments. The public has also become more conscientious of the potential limitations of conventional treatment alone. Because primary headache syndromes are often the culmination of genetics, lifestyle, stress, trauma, and environmental factors, they are best treated with therapies that are equally multifaceted. The Children’s Mercy Hospital, Kansas City, Missouri Headache Clinic has successfully incorporated integrative therapies including nutraceuticals, acupuncture, aromatherapy, biofeedback, relaxation training, hypnosis, psychology services, and lifestyle recommendations for headache management. This paper provides a detailed review of the implementation of integrative therapies for headache treatment and discusses examples through case studies. It can serve as a model for other specialty settings intending to incorporate all evidenced-based practices, whether complementary or conventional.

Metacognition and Headache: Which Is the Role in Childhood and Adolescence?

Headache, in particular migraine, is one of the most frequent neurological symptoms in children and adolescents and it affects about 60% of children and adolescents all over the world. Headache can affect several areas of child’s functioning, such as school, physical activities, peer, and family relationship. The global and severe burden of this disease requires a multidisciplinary strategy and an effective treatment addressed all of the patient’s needs and based on cutting-edge scientific research. In recent years, research has focused on cognitive factors specifically in functions called metacognitive processes. Metacognition can be defined as the knowledge, beliefs, and cognitive processes involved in monitoring, control, and assessment of cognition. Metacognition seems to be closely related to the ability of theory of mind, the ability to infer, and reason about the mental states of other people in order to predict and explain own behavior. Recent studies found a relationship between metacognitive skills and anxiety, depression, motivation, academic performance, human social interactions, and stress symptoms. This relationship is very interesting for headache treatment, because these factors are the most commonly reported triggers in this disorder and there is a high comorbidity with anxiety and depression in children and adolescents with headache. So, headache and these comorbidities, in particular anxiety and depression, may have in common persistent and maladaptive patterns of thinking which are related to maladaptive metacognitive beliefs. Further research should assess metacognitive processes of children and adolescents with headache in order to increase their ability to control their own cognitive processes and consequently monitor factors which may trigger the attacks.

Self-compassion and Psychological Distress in Adolescents-a Meta-analysis

Research indicates that self-compassion is relevant to adolescents' psychological well-being, and may inform the development of mental health and well-being interventions for youth. This meta-analysis synthesises the existing literature to estimate the magnitude of effect for the association between self-compassion and psychological distress in adolescents. Our search identified 19 relevant studies of adolescents (10-19 years; N = 7049) for inclusion. A large effect size was found for an inverse relationship between self-compassion and psychological distress indexed by anxiety, depression, and stress (r = - 0.55; 95% CI  - 0.61 to - 0.47). The identified studies were highly heterogeneous, however sensitivity analyses indicated that correction for publication bias did not significantly alter the pattern of results. These findings replicate those in adult samples, suggesting that lack of self-compassion may play a significant role in causing and/or maintaining emotional difficulties in adolescents. We conclude that self-compassion may be an important factor to target in psychological distress and well-being interventions for youth.

The Experience of Adolescents Living With Headache

There is little qualitative literature that addresses the adolescent experience of living with headache. The purpose of this study was to determine the dimensions of the health challenge of adolescent headache; the high points, low points, and turning points of living with headache; and the approaches used to resolve the challenge of living with headache. Story theory was used as the qualitative framework to guide data collection, and story inquiry provided the structure for analyzing the data. The Pediatric Migraine Disability Scale (PedMIDAS) quantitatively measured the impact of headaches on daily functioning. Of the 8 participants, 6 reported moderate to severe disability. From the stories, a theme for the complicating health challenge of living with adolescent headache was "an enduring distress manifested by pain, uncertainty, distancing self from family and friends, challenges with school, and not knowing how to resolve." Themes descriptive of the high points, low points, and turning points included "Contentment with school achievement, supportive relationships, and comforting engagement"; "Interruption in pursuing sports/exercise, time with others, and family relationships"; and "A developing realization, through hope and insight, of the possibilities for moving toward resolution." Stories revealed approaches used to resolve the challenge of living with headache, which included self-management through medication, sleep, and transcendence. The findings offer insight into the challenges faced by adolescents with headache and provide evidence of the importance for developing holistic plans of care that address the individual needs of the patient rather than relying on medication management alone.