Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study

Exploring the link between pediatric headaches and environmental noise exposure

BACKGROUND

Headaches are the most common neurologic symptoms in the pediatric population. Most primary headache in children and adolescents focuses on associated factors, including noise. Auditory discomfort is related to recognizing the pain. We aimed to analyze the headache profile of pediatric populations and the connection between noise exposure and head pain in children and adolescents.

METHODS

We reviewed retrospectively medical records of the pediatric population with headaches in Gyeongsang National University Changwon Hospital from January 2022 to April 2023. Personal headache profiling from self-questionnaires and environmental noise data from the National Noise Information System (NNIS) were used to analyze each variable, and chi-square tests and linear regression models by SAS were used to analyze the statistical correlation.

RESULTS

Of the 224 participants, 125 were clinically diagnosed with headaches. Of the 104 pubertal subjects, 56.7% were diagnosed with headaches, compared to 60% in the prepubertal group. Both daytime and nighttime noise was significantly higher in the diagnosed headache group than in the non-diagnosed group. Headache duration increased by daytime and nighttime noise with statistical significance in age-adjusted models.

CONCLUSION

We found that noise exposure is correlated to headaches in children and adolescents. Daytime and nighttime environmental noise exposure was significantly associated with the duration of headaches through our data. Therefore, we assume that noise exposure is vitally relevant to prolonged headaches in the pediatric population. Further research is needed to improve our data.

The kynurenine pathway of tryptophan metabolism in abdominal migraine in children - A therapeutic potential?

BACKGROUND

Abdominal migraine (AM) is a clinical diagnosis specified by Rome IV and ICHD III as a functional gastrointestinal disease (FGID) and a migraine associated syndrome, respectively. Abdominal migraine in childhood and adolescence may continue with migraine headaches in adulthood. This disease is undiagnosed and undertreated, and thus far the FDA has not approved any drug for AM treatment. It was shown that changes in the kynurenine (KYN) pathway of tryptophan (TRP) metabolism played an important role in the pathogenesis and treatment of FIGDs and associated mood disorders. Changes in the KYN pathway were shown in migraine and therefore it may be involved in AM pathogenesis.

FINDINGS

Abdominal migraine reflects an impairment in the communication within the gut-brain axis. Treatment approaches in AM are based on the experience of physicians, presenting personal rather than evidence-based practice, including efficacy of some drugs in adult migraine. Non-pharmacological treatment of AM is aimed at preventing or ameliorating AM triggers and is based on the STRESS mnemonic. Metabolic treatments with riboflavin and coenzyme Q10 were effective in several cases of pediatric migraine, but in general, results on metabolic treatment in migraine in children are scarce and nonconclusive. Modulations within the KYN pathway of TRP metabolism induced by changes in TRP content in the diet, may ameliorate FGIDs and support their pharmacological treatment. Pharmacological manipulations of brain KYNs in animals have brought promising results for clinical applications. Obese children show a higher headache prevalence and may be especially predisposed to AM, and KYN metabolites showed an alternated distribution in obese individuals as compared with their normal-weight counterparts.

CONCLUSIONS

In conclusion, controlled placebo-based clinical trials with dietary manipulation to adjust the amount of the product of the KYN pathway of TRP metabolism are justified in children and adolescents with AM, especially those with coexisting obesity. Further preclinical studies are needed to establish details of these trials.

Diagnostic Algorithm for Pediatric Headaches: A Clinical Improvement Initiative

BACKGROUND

The widespread variation in diagnosing primary headache disorders in children and adolescents results in reduced quality and high costs. Defining an algorithm for primary headache diagnoses in children and adolescents is part of a larger initiative to standardize and improve care. The aim of this algorithm was to increase the accuracy of headache diagnosis by formal criteria to more than 80% of patient encounters.

METHODS

A team of headache specialists, nurse practitioners, nurses, data analysts, and business specialists developed an algorithm based on available scientific evidence. This algorithm was vetted and adapted by the neurology faculty and headache specialists until final consensus was reached. Following three months of testing and validation, the algorithm was disseminated to general pediatric neurology clinics. The following information was gathered: percent of encounters utilizing the algorithm, percentage of encounters with appropriate diagnosis by formal criteria, percentage of encounters with appropriate testing ordered, and average cost per headache visit.

RESULTS

Correct diagnosis of primary headache by International Classification of Headache Disorders-3 criteria improved from 72% to 90% and appropriate testing improved from 80% to 94%. By the end of analysis, 94% of encounters were correctly implementing the algorithm. A year-long tracking revealed decreased cost of headache evaluation by 6% compared with the year prior.

CONCLUSIONS

A standardized algorithm improved the diagnostic accuracy in general child neurology clinics. Expanding the algorithm to primary care and pediatric emergency rooms could have a greater impact on headache evaluation and diagnosis; this should result in improved care and outcomes with reduced cost.

Hippocampal volume changes across developmental periods in female migraineurs

Brain-related plasticity can occur at a significant rate varying on the developmental period. Adolescence in particular has been identified as a period of growth and change across the structure and function of the nervous system. Notably, research has identified migraines as common in both pediatric and adult populations, but evidence suggests that the phenotype for migraines may differ in these cohorts due to the unique needs of each developmental period. Accordingly, primary aims of this study were to define hippocampal structure in females (7-27 years of age) with and without migraine, and to determine whether this differs across developmental stages (i.e., childhood, adolescence, and young adulthood). Hippocampal volume was quantified based on high-resolution structural MRI using FMRIB's Integrated Registration and Segmentation Tool. Results indicated that migraine and age may have an interactional relationship with hippocampal volume, such that, while hippocampal volumes were lower in female migraineurs (compared to age-matched controls) during childhood and adolescence, this contrast differed during young adulthood whereby hippocampal volumes were higher in migraineurs (compared to age-matched controls). Subsequent vertex analysis localized this interaction effect in hippocampal volume to displacement of the anterior hippocampus. The transition of hippocampal volume during adolescent development in migraineurs suggests that hippocampal plasticity may dynamically reflect components of migraine that change over the lifespan, exerting possible altered responsivity to stress related to migraine attacks thus having physiological expression and psychosocial impact.

Visual Disturbances Spectrum in Pediatric Migraine

Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.

Evolution of Pediatric Migraine Patients Admitted at an Emergency Department after a 10-Year Follow-Up

BACKGROUND

Despite its high prevalence, the clinical course of pediatric migraine has not been fully understood, and previous studies present conflicting results. We present here the findings of a 10-year follow-up study involving children with severe migraine pain admitted to our emergency department. Furthermore, all studies were carried out on selected outpatient clinical case studies. Our aim was to evaluate a population of migraine children admitted to an emergency department because of increased severity or frequency of pain or even because of very anxious parents concerning their child's headache in order to describe their long-term outcomes, whether it differed from that of outpatient populations and to identify possible predictors of prognosis.

METHODS

We recruited 80 subjects with migraine headaches (mean age 8 years with a range of 4-14 years, 50% females), attending the baseline examination of a population admitted for a headache to the Emergency Department in the first half year of 2012. Of the 80 subjects, 48 (60%) were eligible for follow-up in 2022. We included in our study only patients diagnosed with migraine, according to the diagnostic criteria of the International Classification of Headache Disorders. All were contacted by telephone, and a semi-structured questionnaire was provided to them by email. The association between several possible prognostic factors (gender, familiar neurologic disorders, prenatal and perinatal disorders, social activities, sleep disorders, etc.) and the long-term persistence of migraine headaches were explored using logistic regression analysis.

RESULTS

Of 48 subjects with migraine headaches at baseline, 31 (65%) had persistent migraine, and 17 (35%) experienced remission. The preliminary results showed that the presence of neurologic disorders in parents (p < 0.01-odds ratio 9.34 (2.53-41.64) and sleep disorders (p < 0.01-odds ratio 13.18 (2.25-252.74) significantly predicted the 10-year persistence of migraine headaches, while the other considered predictors were found not to influence prognosis.

CONCLUSIONS

To our knowledge, this was the first study conducted on a selected pediatric population upon admission to the emergency room. Our study suggests that a population of pediatric migraine selected for admission to the emergency department also shows a favorable long-term prognosis, like the studies conducted in the outpatient sample. Familial neurological comorbidity and sleep disorders were unfavorable factors for predicting good outcomes.

Association of obesity with headache among US children and adolescents: Evidence from NHANES 1999-2004

Background

Children and adolescents increasingly commonly suffer from obesity and headache. It has been confirmed that there is an association between obesity and headache in adults; however, evidence of such an association in paediatric populations is still controversial. Therefore, this study examined the relationship between obesity and headache among children and adolescents in the US.

Methods

The cross-sectional data of 3948 participants were obtained from the National Health and Nutrition Examination Survey 1999-2004. Weighted logistic regression models were applied to investigate the association between obesity and headache. Subgroup analysis stratified by sex and age was performed to explore the potential difference in the association of paediatric obesity with headache. The performance of paediatric obesity on headache was assessed by receiver operating characteristic (ROC) curve.

Results

The present study involved 3948 participants, of whom 713 (18.1%) had headache. Compared to those without headache, participants with headache tended to be girls and adolescents, have less calcium intake, and have higher levels of body mass index (BMI), C-reactive protein (CRP), serum ferritin and triglycerides (TGs) (all P < 0.05). After fully adjusting for potential confounders, the ORs with 95% CIs for headache were 1.03 (0.58-1.54) and 1.25 (0.68-2.30) for overweight and obese participants in comparison with normal-weight controls, respectively, implying no association of paediatric obesity with headache independent of other potential confounding factors. In addition, although higher odds of headache were noted in girls and adolescents (aged 10-17 years), no statistically significant difference was found across any subgroups. The area under the ROC (AUC) of paediatric obesity on headache was 0.634.

Conclusions

In summary, our study indicated that obesity is not associated with headache among US children and adolescents. Further prospective studies with larger sample size are needed to validate our findings.

Psychological Disorders, Adverse Childhood Experiences and Parental Psychiatric Disorders in Children Affected by Headache: A Systematic Review

BACKGROUND

Pediatric headaches have been linked to adverse life events or psychological factors in children and their families, with a complex and bidirectional association. Moreover, it is well-known that psychological stress can trigger headaches.

METHODS

We searched three databases for studies focusing on headaches and adverse events or psychological factors in children up to 12 years old or in their caregivers.

RESULTS

We included 28 studies. Child psychological factors, including internal and external symptoms, were commonly associated with all types of headaches. Sleep disturbances showed a positive association with headaches in 3 out of 5 studies. Family conflict and unhappiness were frequently found in children suffering with headaches, while single-parent families and divorce were not associated. Stressful environments and adverse life events, particularly bullying, were also found to be linked with headaches.

CONCLUSIONS

Childhood headaches represent an alarm bell for clinicians to investigate and treat psychological or psychiatric disorders in children and their family. Further studies are needed to elucidate the role of early-life adverse events in children and their families.

Diagnostic accuracy of an artificial intelligence online engine in migraine: A multi‐center study

Objective

This study assesses the concordance in migraine diagnosis between an online, self‐administered, Computer‐based, Diagnostic Engine (CDE) and semi‐structured interview (SSI) by a headache specialist, both using International Classification of Headache Disorders, 3rd edition (ICHD‐3) criteria.

Background

Delay in accurate diagnosis is a major barrier to headache care. Accurate computer‐based algorithms may help reduce the need for SSI‐based encounters to arrive at correct ICHD‐3 diagnosis.

Methods

Between March 2018 and August 2019, adult participants were recruited from three academic headache centers and the community via advertising to our cross‐sectional study. Participants completed two evaluations: phone interview conducted by headache specialists using the SSI and a web‐based expert questionnaire and analytics, CDE. Participants were randomly assigned to either the SSI followed by the web‐based questionnaire or the web‐based questionnaire followed by the SSI. Participants completed protocols a few minutes apart. The concordance in migraine/probable migraine (M/PM) diagnosis between SSI and CDE was measured using Cohen’s kappa statistics. The diagnostic accuracy of CDE was assessed using the SSI as reference standard.

Results

Of the 276 participants consented, 212 completed both SSI and CDE (study completion rate = 77%; median age = 32 years [interquartile range: 28–40], female:male ratio = 3:1). Concordance in M/PM diagnosis between SSI and CDE was: κ = 0.83 (95% confidence interval [CI]: 0.75–0.91). CDE diagnostic accuracy: sensitivity = 90.1% (118/131), 95% CI: 83.6%–94.6%; specificity = 95.8% (68/71), 95% CI: 88.1%–99.1%. Positive and negative predictive values = 97.0% (95% CI: 91.3%–99.0%) and 86.6% (95% CI: 79.3%–91.5%), respectively, using identified migraine prevalence of 60%. Assuming a general migraine population prevalence of 10%, positive and negative predictive values were 70.3% (95% CI: 43.9%–87.8%) and 98.9% (95% CI: 98.1%–99.3%), respectively.

Conclusion

The SSI and CDE have excellent concordance in diagnosing M/PM. Positive CDE helps rule in M/PM, through high specificity and positive likelihood ratio. A negative CDE helps rule out M/PM through high sensitivity and low negative likelihood ratio. CDE that mimics SSI logic is a valid tool for migraine diagnosis.

Prognosis of headache in children: a 25-year follow-up

AIM

To describe the natural history, evaluate the long-term prognosis, and identify predictors of a favorable outcome of childhood migraines in a cohort of children who had been diagnosed with migraine 25 years before.

METHODS

One hundred eighteen children with headache (ages 2 to 15), observed in a headache outpatient clinic of a University Hospital in 1994, by one of the authors, were revaluated in 2019/2020 by a standardized telephone interview specifying headache characteristics, treatment, precipitants, and family history. Headache diagnosis at follow-up was based on ID-Migraine and confirmed by a semistructured interview.

RESULTS

Revaluation was achieved for 88 (75%) patients (43 with migraine), 47 women and age average 41.2 ± 3.2. Over the follow-up (average 25.5 years), 33% of the patients had experienced remission, 41% maintained the same diagnosis, and 26% evolved into a different headache. Sixty six percent reported an improvement. Only eight patients were attending regular consultations because of headache. Male sex came out as the only predictor of a favorable outcome.

CONCLUSION

Most patients (66%) with pediatric headache continue to experience headache although reporting a significant improvement. Boys tended to remit more often than girls. This data suggests that age, genetics, and hormonal factors may play an important role in migraine phenotypic expression.

Migraine and Its Equivalents: What Do They Share? A Narrative Review on Common Pathophysiological Patterns

Migraine is the first in order of frequency of the neurological disorders, affecting both adult and paediatric populations. It is also the first cause of primary headaches in children. Migraine equivalents are periodic disorders that can be associated with migraine or considered as prognostic features of a future migraine manifestation. Despite the mechanisms underlying migraine and its equivalents are not entirely clear, several elements support the hypothesis of common pathophysiological patterns shared by these conditions. The aim of this review is thus to analyze the literature in order to highlight which currently known mechanisms may be common between migraine and its equivalents.

Brain to Belly: Abdominal Variants of Migraine and Functional Abdominal Pain Disorders Associated With Migraine

Migraine is one of the most frequent causes of primary headache and 9% of children suffer from migraines. Most children will continue to experience migraine attacks as adults, therefore it is imperative that we have a thorough understanding of this major health issue. This article considers the so-called abdominal variants of migraine, which are more commonly seen in children rather than adults: abdominal migraine, cyclic vomiting syndrome, and infantile colic. Other functional abdominal pain disorders such as irritable bowel syndrome and functional dyspepsia have also been linked to migraine in clinical studies. The common pathophysiological root of these diseases seems to be the gut-brain axis mechanism. Abdominal variants of migraine are considered pediatric precursors of migraine whereas the functional abdominal pain disorders related to migraine seem to share a pathophysiological root with no temporarily link as for today. In this review we aim to describe the epidemiological background, the current pathophysiological theories and the relationship of each disease to migraine. This review is the first to compile abdominal variants of migraine and functional abdominal pain disorders associated with migraine and we endeavor to elucidate the broad spectrum of migraine-related episodes in children.

Outcomes of Migraine and Tension-Type Headache in Children and Adolescents

The aim of our study was to evaluate the long-term outcomes of pediatric migraine and TTH in a clinical setting. We conducted a cohort study. Pediatric patients who visited the pediatric neurology clinic due to diagnoses of migraine or TTH were contacted by phone 8–10 years after their initial diagnosis and interviewed about their outcomes. Of 147 children, we were able to reach 120 (81%) patients. Of these 120 patients, 59 were seen initially due to migraine and 61 due to TTH. For the migraine patients, headaches improved in 48 (81.4%) and worsened in four (6.8%). Regarding diagnosis at follow-up, 59% still had migraine, 17% had TTH, and 23% were headache-free. Aura and photophobia were significantly associated with persistence of a migraine diagnosis. For the TTH patients, headaches improved in 49 (81.7%) and worsened in nine (15.0%). Regarding diagnosis at follow-up, 36.7% still had TTH, 18.3% had migraine, and 45% were headache-free. Of the patients with TTH, 36.7% retained their initial diagnosis compared to 59.3% among the migraine patients. Most pediatric patients presenting with migraine or TTH will experience a favorable outcome over 10 years, with TTH patients having twice the chance of complete resolution.

Migraine and Tension-Type Headache Among Children and Adolescents: Application of International Headache Society Criteria in a Clinical Setting

INTRODUCTION

The International Headache Society criteria were written in order to help physicians establish a headache diagnosis. However, sometimes children with headache do not seem to fit any diagnosis. The purpose of our study was to assess the application of the criteria in a clinical setting.

METHODS

Medical records of children referred for primary headache to the pediatric neurology clinic at Bnai Zion Medical Center from 2008 to 2017 were assessed.

RESULTS

A total of 989 patients (range 6-18 years; 53% female) were assessed at our neurology clinic. Twenty-four percent (n = 241) were diagnosed with tension-type headache, 26% (n = 256) with migraine, and 4.5% (45) with mixed headache. In 41.5% (410), we were unable to reach a specific diagnosis. No differences in gender or age were found between the groups. Children in the migraine group used more analgesic treatments to stop the headache attacks compared with the tension-type headache group (50% vs 38%, P = .001). Patients diagnosed with tension-type headache reported having more emotional difficulties (P = .001). No significant differences were found in headache characteristics (ie, location, sidedness, character), frequency, or intensity between the younger children (ages 6-11) and the adolescents (ages 12-18) within either the tension-type headache or migraine groups.

CONCLUSIONS

Retrospective application of International Headache Society criteria in a large cohort of children with headaches failed to diagnose a specific type of headache in 41.5% of children. Migraine and tension-type headache were equally prevalent, and both constituted a major burden on our patients' everyday lives. We found no major differences in frequency, intensity, and characteristics of pain between younger children and adolescents.

The childhood migraine syndrome

Migraine is a complex genetic brain disorder with an intricate pathogenesis and polymorphous clinical presentations, particularly in children. In this Perspective, we describe the different phenotypes of migraine in children, including conditions that have been referred to in the International Classification of Headache Disorders as "syndromes that may be related to migraine''. Evidence is presented for the integration of abdominal migraine, cyclical vomiting syndrome, benign paroxysmal vertigo, benign paroxysmal torticollis and infantile colic into the unified diagnosis of 'childhood migraine syndrome' on the basis of clinical and epidemiological characteristics, and shared inheritance. In our opinion, such integration will guide clinicians from specialities other than neurology to consider migraine in the assessment of children with these disorders, as well as stimulate research into the genetics, pathophysiology and clinical features of all disorders within the syndrome. A diagnosis of childhood migraine syndrome would also enable patients to benefit from inclusion in clinical trials of old and new migraine treatments, thus potentially increasing the number of treatment options available.

Headache in Children and Adolescents

PURPOSE OF REVIEW

This article reviews the approach to a child or adolescent with headache, the criteria for common diagnoses, and the evidence base for treatments.

RECENT FINDINGS

The guidelines for acute and preventive treatment of migraine were updated in 2019. These guidelines summarize the available evidence and outline the questions that should be addressed in future research. The US Food and Drug Administration (FDA) approval of several new classes of drugs and devices to treat adult migraine in the past few years has resulted in ongoing or planned pediatric trials.

SUMMARY

Headache is a common symptom in children, and it is important to take a detailed history and perform a thorough physical examination to make the diagnosis. Nearly 1 in 10 children experience recurrent headaches due to migraine, which cause significant impairment in school performance and quality of life. The acute and preventive treatments that are currently available will help at least two-thirds of children with migraine, and several trials of new therapies offer hope for the future.

Subclinical post-traumatic stress symptomology and brain structure in youth with chronic headaches

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ACEs and PTSS did not significantly differ between patients and healthy controls.

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Patients demonstrated greater corticolimbic connectivity compared to controls.

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Greater PTSS and less corticolimbic connectivity increased headache frequency.

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Less corticolimbic connectivity may indicate greater disease progression.

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Patients may be more vulnerable to the effects of PTSS compared to controls.

Background/aims

Post-traumatic stress symptoms (PTSS) and chronic pain often co-occur at high rates in youth. PTSS may alter brain structure thereby contributing to headache chronicity. This study examined whether PTSS and altered limbic circuitry were associated with headache frequency in youth.

Methods

Thirty youth aged 10–18 years with chronic headaches and 30 age- and sex-matched controls underwent a 3T MRI scan. Volumes of the hippocampus and amygdala were obtained from T1-weighted images. Mean fractional anisotropy (FA, an index of white matter structure) axial and radial diffusivity values of the cingulum and uncinate fasciculus were extracted from diffusion-weighted images. Youth reported on their headaches daily, for one-month, and self-reported pubertal status, emotion regulation, adverse childhood experiences (ACEs) and PTSS using validated measures. Volumes of the hippocampus and amygdala and diffusivity values of the cingulum and uncinate were compared between patients and controls. Hierarchical linear regressions were used to examine the association between PTSS, subcortical volumes and/or diffusivity values and headache frequency.

Results

Mean FA values of the cingulum were higher in patients compared to controls (P = 0.02, Cohen’s d = 0.69). Greater PTSS (P = 0.04), smaller amygdala volumes (P = 0.01) and lower FA of the cingulum (P = 0.04) were associated with greater headache frequency, after accounting for age, puberty, pain duration, emotion regulation, and ACEs (Adjusted R² ≥ 0.15). Headache frequency was associated with increases in radial diffusivity (P = 0.002, Adjusted R² = 0.59), as opposed to axial diffusivity (n.s.).

Conclusions

PTSS, smaller amygdalar volume, and poorer cingulum structural connectivity were associated with headache frequency in youth, and may underlie headache chronicity.

Association of Genetic Variants With Migraine Subclassified by Clinical Symptoms in Adult Females

Migraine is heritable and formally diagnosed by structured criteria that require presence of some but not all possible migraine symptoms which include aura, several distinct manifestations of pain, nausea/vomiting, and sensitivity to light or sound. The most recent genome-wide genetic association study (GWAS) for migraine identified 38 loci. We investigated whether 46 single-nucleotide polymorphisms (SNPs), i.e., genetic variants, at these loci may have especially pronounced, i.e., selective, association with migraine presenting with individual symptoms compared to absence of migraine. Selective genetic associations of SNPs were evaluated through a likelihood framework in the Women's Genome Health Study (WGHS), a population-based cohort of middle-aged women including 3,003 experiencing migraine and 18,108 not experiencing migraine, all with genetic information. SNPs at 12 loci displayed significant selective association for migraine subclassified by specific symptoms, among which six selective associations are novel. Symptoms showing selective association include aura, nausea/vomiting, photophobia, and phonophobia. The selective associations were consistent whether the women met all formal criteria for diagnostic for migraine or lacked one of the diagnostic criteria, formally termed probable migraine. Subsequently, we performed latent class analysis of migraine diagnostic symptoms among 69,861 women experiencing migraine from the WGHS recruitment sample to assess whether there were clusters of specific symptoms that might also have a genetic basis. However, no globally robust latent migraine substructures of diagnostic symptoms were observed nor were there selective genetic associations with specific combinations of symptoms revealed among weakly supported latent classes. The findings extend previously reported selective genetic associations with migraine diagnostic symptoms while supporting models for shared genetic susceptibility across all qualifying migraine at many loci.

GABA and glutamate in pediatric migraine

Migraine is one of the top 5 most prevalent childhood diseases; however, effective treatment strategies for pediatric migraine are limited. For example, standard adult pharmaceutical therapies are less effective in children and can carry undesirable side effects. To develop more effective treatments, improved knowledge of the biology underlying pediatric migraine is necessary. One theory is that migraine results from an imbalance in cortical excitability. Magnetic resonance spectroscopy (MRS) studies show changes in GABA and glutamate levels (the primary inhibitory and excitatory neurotransmitters in the brain, respectively) in multiple brain regions in adults with migraine; however, they have yet to be assessed in children with migraine. Using MRS and GABA-edited MRS, we show that children (7-13 years) with migraine and aura had significantly lower glutamate levels in the visual cortex compared to controls, the opposite to results seen in adults. In addition, we found significant correlations between metabolite levels and migraine characteristics; higher GABA levels were associated with higher migraine burden. We also found that higher glutamate in the thalamus and higher GABA/Glx ratios in the sensorimotor cortex were associated with duration since diagnosis, i.e., having migraines longer. Lower GABA levels in the sensorimotor cortex were associated with being closer to their next migraine attack. Together, this indicates that GABA and glutamate disturbances occur early in migraine pathophysiology and emphasizes that evidence from adults with migraine cannot be immediately translated to pediatric sufferers. This highlights the need for further mechanistic studies of migraine in children, to aid in development of more effective treatments.

Longitudinal Impact of Parent Factors in Adolescents With Migraine and Tension-Type Headache

OBJECTIVE

To examine longitudinal associations between parent factors (parent headache frequency and disability, protective parenting behaviors, parent catastrophizing) with adolescent headache-related disability and headache frequency over 6 months.

BACKGROUND

Theoretical models propose bidirectional, longitudinal relationships between parent factors and adolescent headache. Few studies have examined this using prospective study designs.

DESIGN AND METHODS

Participants were a cohort of 239 youth ages 11-17 years with recurrent migraine (with and without aura; chronic migraine) or tension-type headache (episodic and chronic) and their parents recruited from a pediatric neurology clinic and the community who completed assessments at baseline and 6-month follow-up.

RESULTS

After controlling for demographic and clinical covariates, we found that every point increase in baseline protective parenting behavior corresponded with a 2.19-point increase in adolescent headache frequency at follow-up (P = .026, 95% CI [0.27, 4.10]). Similarly, every point increase in baseline parent catastrophizing corresponded with a 0.93-point increase in adolescent headache-related disability (P = .029, 95% CI [0.09, 1.77]) and a .13-point increase in adolescent headache frequency (P = .042, 95% CI [0.01, 0.25]) at follow-up. We also found support for the reverse association, where every point increase in baseline adolescent headache-related disability predicted a 0.03-point increase in parent catastrophizing (P = .016, 95% CI [0.01, 0.05]) and a 0.02-point increase in protective parenting behavior (P = .009, 95% CI [0.01, 0.03]) at follow-up. The remaining bidirectional, longitudinal associations tested between parent factors and adolescent headache were not statistically significant.

CONCLUSION

Findings suggest that family-based psychological interventions targeting modifiable adolescent and parent factors may lead to improvements in adolescent headache-related disability and reductions in adolescent headache frequency.

Prevalence and burden of headache in children and adolescents in Austria - a nationwide study in a representative sample of pupils aged 10-18 years

BACKGROUND

Headache disorders are highly prevalent worldwide, but not so well investigated in children and adolescents as in adults: few studies have included representative nationwide samples. No data exist for Austria until now. In a representative sample of children and adolescents in Austria, we estimated the prevalence and attributable burden of headache disorders, including the new diagnostic category of "undifferentiated headache" (UdH) defined as mild headache lasting less than 1 hour.

METHODS

Within the context of a broader national mental health survey, children and adolescents aged 10-18 years were recruited from purposively selected schools. Mediated self-completed questionnaires included sociodemographic enquiry (gender, age, socioeconomic status, family constellation, residence [urban or rural] and migration background). Prevalence and attributable burden of all headache, UdH, migraine (definite plus probable), tension-type headache (TTH: definite plus probable) and headache on ≥15 days/month (H15+) were assessed using the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents. Health-related quality of life (HrQoL) was assessed using the KIDSCREEN questionnaire.

RESULTS

Of 7643 selected pupils, 3386 (44.3%) completed the questionnaires. The 1-year prevalence of headache was 75.7%, increasing with age and higher in girls (82.1%) than in boys (67.7%; p < 0.001). UdH, migraine, TTH and H15+ were reported by 26.1%, 24.2%, 21.6% and 3.0% of participants. Attributable burden was high, with 42% of those with headache experiencing restrictions in daily activities. Medication use (50% overall) was highest in H15+ (67%) and still considerable in UdH (29%). HrQoL was reduced for all headache types except UdH. Participants in single parent or patchwork families had a higher probability of migraine (respectively, OR 1.5, p < 0.001; OR 1.5, p < 0.01). Participants with a migration background had a lower probability of TTH (OR 0.7, p < 0.01).

CONCLUSIONS

Headache disorders are both very common and highly burdensome in children and adolescents in Austria. This study contributes to the global atlas of headache disorders in these age groups, and corroborates and adds knowledge of the new yet common and important diagnostic category of UdH. The findings call for action in national and international health policies, and for further epidemiological research.

Effectiveness of chiropractic manipulation versus sham manipulation on recurrent headaches in children aged 7-14 years, Protocol for a randomized clinical trial

Background

Headache is one of the most common pain symptoms in childhood having a negative impact on many aspects of the lives of affected children, both short-term and long-term. Therefore, it is important to document safe and effective treatment options. Chiropractic spinal manipulation is a commonly used treatment option for these patients, although there are no randomized clinical trials documenting the effectiveness of this in pediatric headache. However, there is moderate evidence for effectiveness of spinal manipulation for adults with tension-type and cervicogenic headaches.This paper describes the protocol for a two-armed randomized superiority clinical trial aiming to investigate the effectiveness of chiropractic manipulation versus sham manipulation in the treatment of recurrent headache in children aged 7-14.

Methods

Children with weekly headaches for at least six months will be included if they have indications for chiropractic manipulation. The participants will be randomized to either chiropractic manipulation or sham manipulation. Both children and parents will be blinded for allocation. There will be 100 children in each arm and they will answer weekly text messages four weeks prior to treatment and during a four months treatment period. Potential primary outcomes are weekly number of headaches, intensity of headache, medication use and global perceived effect. Secondary outcomes include side-effects and headache status after one year.An initial outcome data analysis will be performed to inform the choice of primary outcome (adaptive design). Intervention effects will be reported as the difference in mean values between the two treatment arms, Cohen's effect size and numbers needed to treat.

Discussion

A major strength of this study is its pragmatic nature, where the active treatment group receives chiropractic manipulation according to their individual needs, while both groups continue their use of medication for headache according to their pre-trial habits. Other strengths include an elaborate sham procedure and the weekly outcome reports, reducing recall bias.If it is possible to develop effective treatment for headache in children, a life course of recurring problems may be altered with potential positive implications for both individuals and society.

Trial registration

ClinicalTrials.gov, identifier NCT02684916.

The persistence versus interchangeability of migraine and tension-type headaches in a 5-year population-based validated survey

OBJECTIVE

The aim of this population-based validated study was to determine the course of tension-type headache and migraine and to evaluate the predictors of persistence.

METHODS

We evaluated the course of headache in a large population from the first assessment in 2008 through a second assessment in 2013. Then we examined the factors associated with persistent migraine and persistent tension-type headache.

RESULTS

Our study in 2013 revealed that only 42.9% of definite migraineurs in 2008 received the same diagnosis again, and of the remaining migraineurs 23.3% were newly diagnosed as definite tension-type headache; 11.6% evolved into probable tension-type headache, 6.4% changed to probable migraine, and 15.8% were headache free. The 17.7% of patients with definite tension-type headache in 2008 were newly diagnosed as having probable tension-type headache, 14.7% as having definite migraine, 6.4% as having probable migraine, and 28.9% as headache free in 2013, and only 32.3% received the definite tension-type headache diagnosis again. Binary logistic regression analysis showed nausea, throbbing and severe headache were the significant parameters for persistent migraine. A multiple regression analysis model with stepwise variable selection revealed that nausea, throbbing and severe headache and osmophobia remained in the final model as predictors of migraine persistence. We found no predictive factor for persistent tension-type headache.

CONCLUSION

Migraine and tension-type headache did not seem to show a simple bidirectional linear worsening from headache-free state to definite migraine or vice versa, hence the transitions between them are more chaotic, reflecting that there are still unknown modifiers and modulators. Certain headache characteristics of migraine might predict persistent migraine.

Age- and sex-specific first health care use for migraine in 2016 in children and adolescents from prospectively collected health insurance data in Germany

BACKGROUND

Migraine in children and adolescents is associated with significant disability and a high risk of persistence into adulthood.

OBJECTIVE

Data on migraine incidence in children and adolescents are few and relatively coarse. To tailor interventions starting shortly after disease onset, detailed information on age- and sex-specific incidence of migraine in children and adolescents is needed.

METHODS

We used health care data prospectively collected by the BARMER statutory health insurance, representing ∼11% of the German population. The incidence of migraine diagnoses (International Classification of Diseases (ICD)-10 code G43) in the year 2016 was assessed in subjects aged 0-19 years, who had been continuously insured with the BARMER between 2005 and 2016 or during their entire lifespan.

RESULTS

Data from ∼1.2 million children and adolescents were available. The incidence of migraine diagnoses steadily increased with age, reaching ∼1% per year around the age of 10 for both sexes, and 3.49% per year in females and 1.72% per year in males at the age of 19. Incidences in males and females were similar up to the age of 13 and higher in females from there on. The proportion of incident migraine diagnoses specified as "definite" versus "probable" migraine increased with age.

CONCLUSION

The present study provides a representative estimation of the first documented health care use for migraine in children and adolescents in Germany within 1-year age bins, separately for boys and girls. These data will be helpful for tailoring early healthcare interventions to reduce disability and prevent migraine chronification.

Clinical manifestations of headache in children younger than 7 years

PURPOSE

Headache is a common symptom during childhood. It is usually persistent and requires special care. This study aimed to identify the characteristics of headache in children <7 years of age.

METHODS

We reviewed 3 years of clinical files on children <7 years of age with a chief complaint of headache.

RESULTS

This study included 146 children (66 males, 80 females; mean age, 5.5±1.0 years). Mean symptom duration was 5.8±7.9 months. Attack durations were longer than 2 hours in 31 patients, shorter than 2 hours in 70 patients, and unchecked in 45 patients. Attack frequency was 15.1±10.6 times per month. Pain locations and characteristics were also variable. Mean pain severity score was 5.1±2.2 on the visual analog scale. Of 38 patients who underwent electroencephalography, 9 showed positive findings. Of 41 who underwent brain magnetic resonance imaging, 20 showed positive findings. The diagnoses were migraine (including probable migraine) in 34, tension-type headache in 5, and congenital malformations in 3. Medications were used in 29 patients: acetaminophen in 17, ibuprofen in 8, naproxen sodium in 1, and topiramate or amitriptyline in 3.

CONCLUSION

In children aged <7 years, headache has a relatively benign course, but detailed history taking is needed for more accurate diagnosis.

Features of aura in paediatric migraine diagnosed using the ICHD 3 beta criteria

Background In children and adolescents, the prevalence rate of migraine with aura is 1.6%. Few studies concerning migraine with aura features in paediatric population have been reported. Aim The aim of our study was to investigate clinical features of aura in a retrospective cohort of children with migraine with aura. Furthermore, we studied whether the International Classification of Headache Disorder (ICHD) 3 beta version criteria could efficiently detect migraine with aura in a paediatric population. Results We included 164 patients who experienced aura associated with headache (mean age 9.92 ± 2.64 years). When the ICHD-II criteria were used, a final diagnosis of migraine with typical aura was obtained in 15.3% of patients, probable migraine with typical aura in 13.4%, and typical aura with headache in 61.8%, while in in 9.5% of patients the diagnosis was undetermined. According to ICHD-3 beta, we diagnosed migraine with typical aura in 77.7% of patients, probable migraine with typical aura in 13.4%, and an undetermined diagnosis in 9.5% (less than two attacks). Conclusion Aura features did not depend on age and were similar to those of adults. However, the headache could be difficult to classify if headache duration was considered. In this view, the ICHD-3 beta offers the advantage of not considering headache features, including pain duration, for the diagnosis of migraine with typical aura, thus making this diagnosis easier in children and adolescents.

Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

Temporal change in headache and its contribution to the risk of developing first-onset temporomandibular disorder in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study

While cross-sectional studies have demonstrated an association between headache and temporomandibular disorder (TMD), whether headache can predict the onset of TMD is unknown. The aims of this study were to evaluate the contribution of headache to the risk of developing TMD and describe patterns of change in headache types over time. An initially TMD-free cohort of 2410 persons with low frequency of headache completed quarterly questionnaires assessing TMD and headache symptoms over a median 3.0-year follow-up period. First-onset TMD was confirmed by clinical examination in 199 participants. Baseline reports of migraine (hazard ratio [HR] = 1.67, 95% confidence interval [CI]: 1.06-2.62) or mixed headache types (HR = 4.11, 95% CI: 1.47-11.46), or headache frequency (HR = 2.13, 95% CI: 1.31-3.48) predicted increased risk of developing TMD. In addition, headache dynamics across the follow-up period before the TMD onset were evaluated in a nested case-control study where 248 incident TMD cases were matched to 191 TMD-free controls. Both headache prevalence and frequency increased across the observation period among those who developed TMD but not among controls. Patients with TMD were more likely to experience worsening in the headache type compared with that by controls, eg, prevalence of definite migraine among TMD cases increased 10-fold. Among all headache types experienced by patients with TMD before the TMD onset, migraine had the highest odds of progression relative to remission (odds ratio = 2.8, 95% CI: 1.6-4.8), whereas for controls this ratio was significant only for the tension-type headache (odds ratio = 2.1, 95% CI: 1.2-3.9). The important clinical implication of these findings is that adequate treatment of migraine may reduce the risk for developing TMD.

Pediatric Headache and Seizures

Headache and seizures are two of the most common complaints seen in the field of pediatric neurology with headache being number one. Both these conditions may coexist. Where the difficulty begins is when the symptoms are not clear cut in making a diagnosis, and conditions are possible as either an atypical seizure or migraine variant. What further complicates matters is the fact that there are many underlying neurologic conditions that carry with them a higher likelihood of developing both headaches and seizures, making each a distinct possibility when obtaining a history from a parent about unusual spells. Although differentiating between seizure and headache may not be easy, with a focused yet thorough history and appropriate use of investigative tools, it can be done. Coming to the correct diagnosis is only the start; once seizures and or headaches have been appropriately diagnosed then the real challenge begins and that is finding a way to successfully treat the headaches and seizures. Within pediatric neurology, the acute options tend to be more diagnosis specific whereas the prophylactic ones may overlap and treat both headaches and seizures. In the following review, we will discuss the epidemiology of pediatric headaches and seizures, the overlap between these 2 conditions in diagnosis, as well as how to tell them apart, and the treatment options and prognosis of both common neurologic disorders in children.

Long term outcome of childhood onset headache: A prospective community study

Purpose

To examine prevalence, course, and long-term outcome of childhood migraine and other headaches.

Method

Using questionnaires, 1185 children were followed for recurrent headaches at ages seven, 14 and 32 years, respectively.

Results

At age seven years, 4.0% of the 1185 children (girls 3.7%, boys 4.3%) had migraine and 24% (25%/23%) had nonmigrainous headache. In adulthood, 16% (22%/8%) had migraine and 60% (64%/54%) nonmigrainous headache. Childhood migraine persisted into adulthood in 65% of females and 21% of males, and nonmigrainous headache in 62% and 59%, respectively. After childhood, 17% of females and 7% of males started to have episodes of migraine. No recurrent headache during the follow-up was reported by 11% (6%/16%). In a multivariate analysis, compared with no childhood headache, childhood migraine increased the risk of adulthood migraine by 3.36-fold (95% CI 1.94–5.82) and that of nonmigrainous headache by 1.72-fold (1.14–2.60).

Discussion and conclusions

Headaches are generally as common in preschool girls as boys. From early school years, headaches steadily increase up to young adulthood, but among boys the prevalence levels off after adolescence. About two thirds of children experienced changes in their headache status during a 25-year follow-up. Any kind of recurrent headache at school entry predicts an increased risk of headache in young adulthood. Special attention should be paid to girls and particularly those girls who have recurrent headache when they start school.

Age- and sex-related differences in the presentation of paediatric migraine: A retrospective cohort study

Introduction Although migraine is a common headache complaint in children and adolescents there remains a significant gap in understanding the unique aspects of the disease in these age groups and their evolution with development. The aim of this retrospective cohort study was to identify migraine features that are influenced by age and sex. Methods The headache characteristics of 359 paediatric patients with a clinical diagnosis of migraine from a tertiary paediatric headache clinic were assessed. Patients retrospectively reported headache characteristics during a structured intake interview and clinical exam. Headache characteristics, description and associated symptoms were compared between children (age ≤ 12 years) and adolescents (age > 12 years), and between male and female migraineurs. Results Several migraine features differed significantly with age and/or sex, including: (i) a marked change from a 1:1 sex ratio in children to a 2:1 predominance of girls in adolescents; (ii) a higher frequency of headache attacks per month in adolescents and female migraineurs; (iii) a higher proportion of adolescents endorsed a 'throbbing' pain quality; (iv) a higher proportion of children reporting nausea and vomiting; and (v) a higher proportion of adolescents, particularly female migraineurs, had a diagnosis of a co-morbid anxiety. Conclusion The presentation of migraine, both in terms of its headache characteristics and associated symptoms, appear to vary as a function of age and sex. Given that migraine symptoms have a neural basis, it is not surprising that during the key period of neurodevelopment from childhood to adolescence this may impact their presentation.

Paediatric headache trajectories – a reappraisal after nine years

Background

The long-term consequences of paediatric headache can involve functional disabilities and mental health problems in adulthood.

Objective

To analyse the predictive power of paediatric headache trajectory classes for headache and related outcomes in adulthood.

Methods

In a previous study, a population-based sample (N = 3227, 9–14 years of age at first assessment) was followed across four annual assessment points, and sex-specific headache trajectory classes were identified (girls: “no pain”, “moderate pain”, “increasing pain”, “high pain”; boys: “no pain”, “moderate pain”). These trajectory classes were used to predict headache frequency, functional disability, depression, quality of life and self-efficacy nine years later (N = 994). Negative binomial regression analyses and pairwise comparisons were computed.

Results

Women showing an elevated trajectory (“increasing pain” or “high pain”) had a higher adult headache frequency and a poorer outcome on associated variables (functional disability, depression, quality of life, and self-efficacy) than women having a lower-level trajectory. Men of the “no pain” and “moderate pain” trajectory classes differed significantly from one another in their headache frequency and related variables.

Conclusion

Belonging to an elevated paediatric headache trajectory class involves a considerable risk for headache and headache-related problems in adulthood.

Multimodal Chiropractic Care for Pain and Disability in a Patient Diagnosed With Ehlers-Danlos Syndrome-Hypermobility Type: A Case Report

OBJECTIVE

The purpose of this article is to describe the clinical response to multimodal chiropractic treatment of a patient diagnosed with Ehlers-Danlos syndrome, hypermobility type (EDS-HT), and chronic pain.

CLINICAL FEATURES

A 22-year-old woman presented with severe chronic neck and low back pain, headaches, and bilateral hand pain and stiffness. In addition to these pain complaints, the patient had a family history of EDS, weekly or daily recurring joint dislocations, and upper and lower extremity joint hypermobility. As a result of her significant history and examination findings, which met the Brighton and Villefranche criteria, she was diagnosed with EDS-HT.

INTERVENTIONS AND OUTCOMES

Treatment primarily consisted of low force joint manipulative therapy and soft tissue therapy intermittently over 21 months concurrently with conventional and complementary medical care. Multiple outcome questionnaires were administered pragmatically at follow-up intervals of 3, 5½, 8½, 19, and 21 months, including but not limited to the Headache and Neck Disability Indices and the Oswestry Low Back Questionnaire. The patient had clinically meaningful improvements on the Neck Disability Index, the Headache Disability Index, and the Revised Oswestry after 3, 5½, 8½, and 21 months from baseline.

CONCLUSION

This patient with EDS-HT had clinically meaningful decreases in disability, headache, and spine pain after a course of multimodal chiropractic care combined with conventional and complementary medical care.

Prevalence of headache and its interference in the activities of daily living in female adolescent students

OBJECTIVE:

To describe the prevalence of headache and its interference in the activities of daily living (ADL) in female adolescent students.

METHODS:

This descriptive cross-sectional study enrolled 228 female adolescents from a public school in the city of Petrolina, Pernambuco, Northeast Brazil, aged ten to 19 years. A self-administered structured questionnaire about socio-demographic characteristics, occurrence of headache and its characteristics was employed. Headaches were classified according to the International Headache Society criteria. The chi-square test was used to verify possible associations, being significant p<0.05.

RESULTS:

After the exclusion of 24 questionnaires that did not met the inclusion criteria, 204 questionnaires were analyzed. The mean age of the adolescents was 14.0±1.4 years. The prevalence of headache was 87.7%. Of the adolescents with headache, 0.5% presented migraine without pure menstrual aura; 6.7%, migraine without aura related to menstruation; 1.6%, non-menstrual migraine without aura; 11.7%, tension-type headache and 79.3%, other headaches. Significant associations were found between pain intensity and the following variables: absenteeism (p=0.001); interference in ADL (p<0.001); medication use (p<0.001); age (p=0.045) and seek for medical care (p<0.022).

CONCLUSIONS:

The prevalence of headache in female adolescents observed in this study was high, with a negative impact in ADL and school attendance.

Lifestyle Factors and Migraine in Childhood

Migraine is one of the most common pain symptoms in children. Indeed, a high percentage of adult migraine patients report to have suffered from recurrent headache during the childhood. In particular, children could experience the so-called childhood periodic syndromes (such as cyclic vomiting, abdominal migraine, and benign paroxysmal vertigo) that have been usually considered precursors of migraine or they could develop overt migraine headaches. However, typical cohort of migraine symptoms could be absent and children could not achieve all clinical features necessary for a migraine attack diagnosis according to classification criteria. Nevertheless, migraine is characterized also in childhood by a significant negative impact on the quality of life and a high risk of developing chronic and persistent headache in adulthood. Several studies have emphasized the role of different risk factors for migraine in children. Among these, obesity and overweight, particular food or the regular consumption of alcohol or caffeine, dysfunctional family situation, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school, and insufficient leisure time seem to be strictly related to migraine onset or progression. Consequently, both identification and avoidance of triggers seem to be mandatory in children with migraine and could represent an alternative approach to the treatment of migraine abstaining from pharmacologic therapies.

Psychological predictors of headache remission in children and adolescents

OBJECTIVE

Longitudinal studies on headaches often focus on the identification of risk factors for headache occurrence or "chronification". This study in particular examines psychological variables as potential predictors of headache remission in children and adolescents.

METHODS

Data on biological, social, and psychological variables were gathered by questionnaire as part of a large population-based study (N=5,474). Children aged 9 to 15 years who suffered from weekly headaches were selected for this study sample, N=509. A logistic regression analysis was conducted with remission as the dependent variable. In the first step sex, age, headache type, and parental headache history were entered as the control variables as some data already existed showing their predictive power. Psychological factors (dysfunctional coping strategies, internalizing symptoms, externalizing symptoms, anxiety sensitivity, somatosensory amplification) were entered in the second step to evaluate their additional predictive value.

RESULTS

Highly dysfunctional coping strategies reduced the relative probability of headache remission. All other selected psychological variables reached no significance, ie, did not contribute additionally to the explanation of variance of the basic model containing sex and headache type. Surprisingly, parental headache and age were not predictive. The model explained only a small proportion of the variance regarding headache remission (R(2) =0.09 [Nagelkerke]).

CONCLUSION

Successful coping with stress in general contributed to remission of pediatric headache after 2 years in children aged between 9 and 15 years. Psychological characteristics in general had only small predictive value. The issue of remission definitely needs more scientific attention in empirical studies.

Developmental trajectories of paediatric headache - sex-specific analyses and predictors

BACKGROUND

Headache is the most common pain disorder in children and adolescents and is associated with diverse dysfunctions and psychological symptoms. Several studies evidenced sex-specific differences in headache frequency. Until now no study exists that examined sex-specific patterns of change in paediatric headache across time and included pain-related somatic and (socio-)psychological predictors.

METHOD

Latent Class Growth Analysis (LCGA) was used in order to identify different trajectory classes of headache across four annual time points in a population-based sample (n = 3 227; mean age 11.34 years; 51.2 % girls). In multinomial logistic regression analyses the influence of several predictors on the class membership was examined.

RESULTS

For girls, a four-class model was identified as the best fitting model. While the majority of girls reported no (30.5 %) or moderate headache frequencies (32.5 %) across time, one class with a high level of headache days (20.8 %) and a class with an increasing headache frequency across time (16.2 %) were identified. For boys a two class model with a 'no headache class' (48.6 %) and 'moderate headache class' (51.4 %) showed the best model fit. Regarding logistic regression analyses, migraine and parental headache proved to be stable predictors across sexes. Depression/anxiety was a significant predictor for all pain classes in girls. Life events, dysfunctional stress coping and school burden were also able to differentiate at least between some classes in both sexes.

CONCLUSIONS

The identified trajectories reflect sex-specific differences in paediatric headache, as seen in the number and type of classes extracted. The documented risk factors can deliver ideas for preventive actions and considerations for treatment programmes.

Are migraine and tension-type headache diagnostic types or points on a severity continuum? An exploration of the latent taxometric structure of headache

The objective of this study was to assess whether migraine and tension-type headache (TTH) are best viewed as discrete entities or points on a severity continuum using taxometric analysis. Historically, classification systems have conceptualized the primary headache disorders of migraine and TTH as fundamentally different disorders that are differentiated by their characteristic symptom profiles and, as such, imply differing pathophysiologies and required treatments. Despite this categorical nosology, findings continue to emerge suggesting that migraine and TTH instead reflect dimensions of severity within the same headache construct. However, few studies have assessed this issue using taxometric statistical analyses or investigated how this taxonomic structure varies as a function of age and headache frequency. We conducted a latent-mode factor analysis of headache symptomatology obtained from 3449 individuals with headache from 2 previous, large-scale cross-sectional studies of primary headache sufferers (Martin et al., 2005, and Smitherman and Kolivas, 2013). Stratified taxometric analyses suggest that the validity of a categorical vs dimensional classification varies as a function of sample characteristics. Specifically, graphical results revealed that high headache frequency (>15 d/mo) and younger age (<24 years old) were associated with unimodal distributions suggestive of a dimensional construct of primary headache, whereas lower headache frequency and older age were associated with bimodal distributions characteristic of discrete diagnostic entities. Conceptualizing primary headache as a severity continuum was supported for young adults and those with frequent headaches. The distinctions of a categorical classification system were supported for adults (>24 years old) and those with infrequent headache.

Migraine and lifestyle in childhood

Migraine is one of the most frequently reported somatic complaints in childhood, with a negative impact on health-related quality of life. The incidence of migraine in childhood has substantially increased over the past 30 years, probably due to both increased awareness of the disease and lifestyle changes in this age group. Indeed, several conditions have been identified as risk factors for migraine in childhood. Amongst these, dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school and insufficient leisure time seem to play a critical role. Nevertheless, there are only few studies about the association between migraine and lifestyle in childhood, due to previous observations specifically focused on "headache" in children. In this brief review, we will concentrate upon recent studies aimed to explore migraine and lifestyle risk factors in childhood.

Early Diagnosis of Migraine Necessary in Children: 10-Year Follow-Up

BACKGROUND

The prevalence of migraine in individuals younger than 20 years old is 8%, with a mean age at onset of younger than 8 years. However, the long-term prognosis of migraine attacks has not been clearly established.

OBJECTIVE

Our main objective was to evaluate disease course 10 years after migraine diagnosis in a cohort of children and adolescents.

METHODS

Migraine was diagnosed in 1999 in a pediatric headache reference center using International Headache Society criteria. In 2009, all patients were interviewed by telephone on the persistence and characteristics of any headaches. The main end point was prevalence of persistent migraine attacks in 2009. Variables associated with persistent attacks were analyzed.

RESULTS

Overall, 142 children were diagnosed with migraine in 1999. Of these, 84 were interviewed by telephone in 2009. In 1999, the mean age was 11.6 ± 3.1 years, 54% were male, and 50% had migraine without aura. Migraine attacks were common (1-3 attacks/week in 38%). Mean age at onset was 7 years and 4 months (±3 years). In 2009, migraine prevalence was 39/84 (46% [95% confidence interval 36-56]), 12 patients (14%) were headache-free, and 62 patients (74%) had tension-type headaches that were isolated headaches in 33 (39%) patients. The rate of patients with at least one migraine attack per week fell from 37% to 8% (P = 0.001) over the 10-year period. Age at the first visit to the center was significantly higher in 2009 migraine sufferers than nonsufferers (12.5 ± 3.0 versus 10.9 ± 3.1 years (P = 0.02)). In multivariate analysis, age ≥12 years at the time of first presentation was the only significant factor associated with long-term chronic migraine (odds ratio = 3.0 [1.1-8.0]).

CONCLUSIONS

Ten years after first presentation, 46% of patients had migraine but the frequency of attacks had diminished. The only factor associated with chronic migraine was age ≥12 years at first presentation.

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.

Tension-Type Headache in Children: The Cinderella of Headache Disorders!

Tension-type headache (TTH) may be as common a headache disorder as migraine in children and adolescents. TTH has a neurobiological basis with genetic and environmental factors making variable contributions to the different sub-types. The diagnostic criteria for TTH in the second edition of the “International Classification of Headache Disorders” appear to be applicable to children. Anxiety and mood disorders may be co-morbid with frequent episodic and chronic TTH. Psychosocial stressors play an important role in precipitating and maintaining TTH. Hence, a biopsychosocial approach should be adopted for care. Standardized histories and examinations together with prospective headache diaries are the foundations for good management; attention to ‘red flags’ will help identify secondary causes that present with headache similar to TT. There are no randomized controlled drug trials for the treatment of TTH. Relaxation and cognitive behavioral therapies are effective. TTH in children and adolescents warrants greater recognition from the clinician and scientist. Studies focusing on TTH are overdue.

Temperament and behavioral problems of preschool children with headache--a controlled study

The purpose of this study was to compare differences in temperament and emotional and behavioral problems in a community sample of young children who experience headaches to those without such complaints. The whole sample was comprised 75 non-referred, preschool-aged children (3-5 years old), including 22 with headache complaints and 53 without headaches (control group). The children's headache symptoms were assessed with a questionnaire that was given to the mothers. Rothbart's Children's Behavior Questionnaire was used to assess temperament, and the Child Behavior Checklist 1 ½-5 was used to assess emotional and behavioral problems. Compared with the control group, children with headache complaints showed more discomfort, which is the amount of negative affect induced by the sensory qualities of stimulation, including intensity, rate, or complexity of light, movement, sound, texture, or a combination of these modes of stimuli. These children also had higher scores for externalizing and internalizing emotional and behavioral problems compared to children without headaches. These findings show that the preschool-aged children with headaches presented more emotional and behavioral problems than the control group.

High diagnostic stability of confirmed migraine and confirmed tension-type headache according to the ICHD-3 beta in adolescents

BACKGROUND

Stable headache diagnosis classification is a prerequisite for identification of headache type specific risk factors. Does the stability of a headache diagnosis over time vary between migraine and tension-type headache (TTH)? Are there differences in diagnosis stability between a probable and a definite headache diagnosis?

FINDINGS

In a sample of 783 students (ages 12 to 18 years) participating in a headache intervention study in greater Munich, the stability of headache classification according to the International Classification of Headache Disorder - third edition (beta version) (ICHD-3 beta) after a follow-up of 7 months was examined. Differences in stability of probable or definite migraine and probable or definite TTH were assessed. The stability of the headache diagnosis was assessed as predictive value of headache diagnosis with regard to confirmation of the headache type using the same diagnostic instrument 7 months later. Predictive values with 95% confidence intervals (CI) are reported.Of students with initial migraine, a diagnosis of migraine was confirmed in 65.71% of students after 7 months (95%-CI [59.40-71.64]). A clear distinction between probable (44.71%, 95%-CI [33.91-53.89]) and confirmed diagnosis (76.88% 95%-CI [69.56-83.17]) of migraine was observed. For TTH the predictive value was 62.66% (95%-CI [57.07-68.01]) overall with a lower stability for probable (46.10%, 95%-CI [37.68-54.69]) compared to the confirmed diagnosis (69.71%, 95%-CI [23.58-37.67]).

CONCLUSION

While confirmed migraine and confirmed TTH diagnoses seem stable over time, stability of a probable diagnosis for either headache type was lower.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trial Register with the ID DRKS00003308.

Enxaqueca e Estresse em Mulheres no Contexto da Atenção Primária

O presente estudo teve por objetivo verificar a associação entre enxaqueca e estresse em mulheres, assim como examinar o melhor modelo de predição da enxaqueca, considerando variáveis pessoais e do contexto ambiental. A enxaqueca foi identificada pelo Teste de Cefaleia em 75 mulheres sem antecedentes psiquiátricos. O estresse foi avaliado por meio do Inventário de Sintomas de Stress para adultos. Paralelamente, foram avaliados: eventos vitais, nível socioeconômico e características da amostra. Verificou-se que 55% das mulheres apresentaram enxaqueca e 59% sintomas de estresse. O modelo de predição identificou que o estresse foi o único preditor da enxaqueca em mulheres. Os achados mostram associação entre enxaqueca e estresse, a qual precisa ser levada em conta na assistência à saúde da mulher.

Multimodal chiropractic care of pain and disability for a patient diagnosed with benign joint hypermobility syndrome: a case report

OBJECTIVE

The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.

CLINICAL FEATURES

A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.

INTERVENTIONS AND OUTCOMES

The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.

CONCLUSION

This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.