Childhood chronic daily headache: a biopsychosocial perspective

Headache and Psychological Comorbidities: An Appraisal of the Evidence

BACKGROUND

It has been observed that there is a higher-than-expected risk of anxiety and depression in children with chronic headache and also an increased risk for the persistence of headache in patients with anxiety and depression.

OBJECTIVES

This review aims to identify and assess the relationships between primary headache disorders and comorbid emotional and psychological disorders.

METHODS

A targeted review of the literature was carried out.

RESULTS

The associations between the disorders are more pronounced in clinic patients, who may represent the severe end of the headache spectrum, but less clear in patients who were identified in population-based studies and who may represent the "average" child with headache or the "average" child with psychological disorders.

CONCLUSIONS

Understanding this bidirectional association of comorbid disorders is of great importance to offering a holistic biopsychosocial approach to the management of headache disorders in children and adolescents and in addressing the risks for and the co-existence of psychological comorbidities.

Perceptions, experiences, and understandings of cluster headache among GPs and neurologists: a qualitative study

BACKGROUND

Cluster headache is a severe primary headache with a similar prevalence to that of multiple sclerosis. Cluster headache is characterised by unilateral trigeminal distribution of pain, ipsilateral cranial autonomic features, and a tendency to circadian and circannual periodicity.

AIM

To explore the perceptions, experiences, and understandings of cluster headache among GPs and neurologists.

DESIGN AND SETTING

Qualitative interview study in primary care surgeries and neurology departments in the north of England.

METHOD

Semi-structured interviews were conducted with GPs and neurologists, recorded, and transcribed. A thematic analysis was applied to the dataset.

RESULTS

Sixteen clinicians participated in this study: eight GPs and eight neurologists. Four main themes were identified following thematic analysis: challenges with the cluster headache diagnosis; impact of cluster headache; challenges with treatment; and appropriateness of referrals to secondary care. Clinicians recognised the delays in the diagnosis of cluster headache, misdiagnosis, and mismanagement, and were aware of the potential impact cluster headache can have on patients' mental health and ability to remain in employment. Findings highlighted tensions between primary and secondary care around the cost of medication and the remit of prescribing treatment regimens. Patients' anxiety, their need for reassurance, and their insistence about seeing a specialist are some of the reasons for referrals.

CONCLUSION

Clinicians acknowledged delays in diagnosis, misdiagnosis, and mismanagement of cluster headache. The responsibility of prescribing causes ongoing tensions between primary and secondary care. Clear referral and management pathways for primary headaches are required to improve patient outcomes and healthcare costs.

Fifteen minute consultation: an approach to the child with chronic headaches

Children with chronic headache are a common referral to paediatric outpatients. This article suggests an approach to the assessment and management of chronic headaches, offering practical strategies for management as there is limited literature in paediatrics for this.

Reconsideration of the diagnosis and treatment of childhood migraine: A practical review of clinical experiences

OBJECTIVE

To provide insight into the wide spectrum of migraine during childhood to establish practical and comprehensive treatment strategies.

BACKGROUND

Although recent studies have confirmed the effect of anti-migraine agents in childhood headaches fulfilling the criteria of migraine without aura, there have been no studies regarding the efficacy of these drugs in childhood migraine without aura not filling the diagnostic criteria.

METHODS

In total, 154 patients with a clinical diagnosis of migraine, with onset of repetitive headaches at the age of ⩽15years, were retrospectively included from clinics in seven tertiary medical centers.

RESULTS

Patients' diagnoses included migraine with aura (n=49), migraine without aura (n=65), clinical migraine without aura not fulfilling International Classification of Headache Disorders-3 beta criteria (suspected migraine without aura; n=38), and hemiplegic migraine (n=2). Abortive medicine was effective in 74 of 97 patients, and preventive medicine was effective in 61 of 84 patients. Drugs with high efficacy were acetaminophen and ibuprofen for abortive therapy and cyproheptadine, amitriptyline, and propranolol for preventive therapy. Psychosocial problems were less common, and abnormalities on electroencephalography were more common in the suspected migraine without aura group. Otherwise, clinical features and drug responsibility were comparable among the migraine with aura, migraine without aura, and suspected migraine without aura groups. Retrospectively, experts clinically diagnosed childhood migraine without aura when the headache met at least one of the three criteria B, C, and D in International Classification of Headache Disorders-3 beta in addition to A and E. Abortive and preventive medication including paroxetine (n=2) benefited 10 and 15 of the 33 patients with daily headache, respectively. Psychotherapy/counseling (n=4), treatment for orthostatic dysregulation (n=4), and elimination of stressors (n=3) markedly alleviated headache in this group.

CONCLUSION

Our results indicated that those with suspected migraine without aura not filling International Classification of Headache Disorders diagnostic criteria should be included in the treatment for migraine. Treatment should also be targeted to comorbid developmental disorders, orthostatic dysregulation, and psychosocial problems in patients with refractory daily headaches.

Chronic Daily Headache in Children and Adolescents: A Multi-Faceted Syndrome

Chronic daily headache (CDH) is a multi-faceted, often complex pain syndrome in children and adolescents. Chronic daily headache may be primary or secondary. Chronic migraine and chronic tension-type are the most frequent subtypes. Chronic daily headache is co-morbid with adverse life events, anxiety and depressive disorders, possibly with other psychiatric disorders, other pain syndromes and sleep disorders; these conditions contribute to initiating and maintaining CDH. Hence, early management of episodic headache and treatment of associated conditions are crucial to prevention. There is evidence for the benefit of psychological therapies, principally relaxation and cognitive behavioral, and promising information on acupuncture for CDH. Data on drug treatment are based primarily on open label studies. The controversies surrounding CDH are discussed and proposals for improvement presented. The multifaceted nature of CDH makes it a good candidate for a multi-axial classification system. Such an approach should facilitate biopsychosocial management and enhance consistency in clinical research.

Alexithymic characteristics in pediatric patients with primary headache: a comparison between migraine and tension-type headache

Background

Alexithymia is a personality construct characterized by difficulties in verbal emotional expression and a limited ability to use one’s imagination. Evidence of alexithymic characteristics was found in adults suffering from headache, while little is known about children. The aim of this study was to establish the prevalence of alexithymia in two different subgroups of children and adolescents suffering from primary headache. We also looked for correlation between alexithymia in children and in their mothers.

Methods

This study involved 89 participants: 47 (11 males, 36 females, aged 8 to 17 years) suffering from tension-type headache (TTH), and 42 (18 males, 24 females, aged 8 to 17 years) suffering from migraine (M), based on the International Classification of Headache Disorders (ICHD 2013). A control group of 32 headache-free subjects (26 females and 6 males, aged 8 to17 years) was also considered. Two questionnaires were administered to measure alexithymia: the Alexithymia Questionnaire for Children to young patients and controls, and the Toronto Alexithymia Scale (TAS-20) to the mothers.

Results

Higher rates of alexithymia emerged in the TTH group compared to the M group. In particular, TTH sufferers had difficulty identifying their feelings. The mothers of children with headaches didn’t score higher in alexithymia compared to other mothers. In the M and in the control group, there was a significant correlation between the rates of alexithymia in young people and in their mothers.

Conclusions

To date no other study has investigated alexithymia in subgroups of primary headaches in developmental age. Our results suggest that patients suffering from TTH are more alexithymic than M patients. This pave the way to etiopathogenetic and clinical considerations, calling for a comprehensive and multidisciplinary approach to tackle the problem of headache.

Pediatric Headaches

Pediatric headaches are common, and many may never require intervention by a health care provider. However, migraines can become more difficult to treat, especially if they become chronic daily headaches. Pediatric headache is a subjective and unique experience that requires attention to both psychological and physiologic components in diagnosis and treatment. A biopsychosocial, multidisciplinary approach, including both medication management and psychological treatment, is considered essential for effective management.

Multimodal compared to pharmacologic treatments for chronic tension-type headache in adolescents

Chronic tension-type headache (CTTH) in children and adolescents is a serious medical condition, with considerable morbidity and few effective, evidence-based treatments. We performed a chart review of 83 adolescents (age range = 13-18 years; 67 girls and 16 boys) diagnosed with CTTH. Two treatment protocols were compared: multimodal (osteopathic manipulative treatments, mindfulness, and qi gong) and pharmacologic (amitriptyline or gabapentin). Four outcomes (headache frequency, pain intensity, general health, and health interference) were assessed at three time points (baseline, 3 months, and 6 months). A fifth outcome, number of bilateral tender points, was recorded at baseline and 6 months. All five were evaluated statistically with a linear mixed model. Although both multimodal and pharmacologic treatments were effective for CTTH (time effects for all measures were significant at p < .001), results from each analysis favored multimodal treatment (the five group by time interaction effects were significant at or below the p < .001 level). Headache frequency in the pharmacologic group, for example, reduced from a monthly average (95% Confidence Interval shown in parentheses) of 23.9 (21.8, 26.0) to 16.4 (14.3, 18.6) and in the multimodal group from 22.3 (20.1, 24.5) to 4.9 (2.6, 7.2) (a substantial group difference). Pain intensity (worst in the last 24 hours, 0-10 scale) was reduced in the pharmacologic group from 6.2 (5.6, 6.9) to 3.4 (2.7, 4.1) and from 6.1 (5.4, 6.8) to 2.0 (1.2, 2.7) in the multimodal group (a less substantial difference). Across the other three assessments, group differences were larger for general health and number of tender points and less so for pain restriction. Multimodal treatment for adolescent CTTH appears to be effective. Randomized controlled trials are needed to confirm these promising results.

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.

Bringing psychosocial support to headache sufferers using information and communication technology: lessons learned from asking potential users what they want

BACKGROUND

Headaches are a major concern for which psychosocial interventions are recommended. However, headache sufferers do not always have ready access to these interventions. Technology has been used to improve access, especially in young people.

OBJECTIVES

To examine user preferences to inform the development of an Internet-based psychosocial intervention including smartphone technology, referred to as the Wireless Headache Intervention.

METHODS

The methodology followed a participatory design cycle, including 25 headache sufferers (14 to 28 years of age) who informed the prototype design. All participants were familiar with smartphones and the Internet. Through two iterative cycles of focus groups stratified according to age, qualitative data were collected by asking user preferences for the different planned components of the intervention (ie, smartphone pain diary, Internet-based self-management treatment, social support) and other relevant aspects (ie, smartphone versus computer delivery, and ways of reaching target audience). NVivo 8 with content analysis was used to analyze data and reflect themes as guided by the thematic survey.

RESULTS

Participants reported a preference for completing the smartphone pain diary on a daily basis. Participants believed that the program should facilitate easy access to information regarding headaches and management strategies. They also wanted access to other headache sufferers and experts. Participants believed that the program should be customizable and interactive. They reinforced the need and value of an integrated smartphone and Internet-based application.

CONCLUSIONS

The results provide insight into a participatory design to guide design decisions for the type of intervention for which success relies largely on self-motivation. The results also provide recommendations for design of similar interventions that may benefit from the integration of mobile applications to Internet-based interventions. The present research contributes to the theoretical frameworks that have been formulated for the development of Internet-based applications.

Anxiety, depression and school absenteeism in youth with chronic or episodic headache

Chronic daily headache (CDH) is relatively common among children. Although comorbid conditions have been extensively studied in adults, they have not been assessed in the pediatric CDH population. Accordingly, the authors assessed several conditions known to be associated with CDH in adult patients in children with either CDH or episodic headache. The influence of CDH or episodic headache on the number of school days missed was also assessed.

BACKGROUND:

Chronic daily headache (CDH) in children has been documented in general and clinical populations. Comorbid psychological conditions, risk factors and functional outcomes of CDH in children are not well understood.

OBJECTIVES:

To examine anxiety and depression, associated risk factors and school outcomes in a clinical population of youth with CDH compared with youth with episodic headache (EH).

METHODS:

Data regarding headache characteristics, anxiety, depression and missed school days were collected from 368 consecutive patients eight to 17 years of age, who presented with primary headache at a specialized pediatric headache centre.

RESULTS:

A total of 297 patients (81%) were diagnosed with EH and 71 were diagnosed with CDH. Among those with CDH, 78.9% presented with chronic tension-type headache and 21.1% with chronic migraine (CM). Children with CDH had a higher depression score than the standardized reference population. No difference was observed for anxiety or depression scores between children with CDH and those with EH. However, children with CM were more anxious and more depressed than those with chronic tension-type headache. Youth experiencing migraine with aura were three times as likely to have clinically significant anxiety scores. Headache frequency and history were not associated with psychopathological symptoms. Children with CDH missed school more often and for longer periods of time.

CONCLUSIONS:

These findings document the prevalence of anxiety, depression and school absenteeism in youth with CDH or EH. The present research also extends recent studies examining the impact of aura on psychiatric comorbidity and the debate on CM criteria.

Potentially traumatic interpersonal events, psychological distress and recurrent headache in a population-based cohort of adolescents: the HUNT study

OBJECTIVES

Recurrent headache co-occurs commonly with psychological distress, such as anxiety or depression. Potentially traumatic interpersonal events (PTIEs) could represent important precursors of psychological distress and recurrent headache in adolescents. Our objective was to assess the hypothesised association between exposure to PTIEs and recurrent migraine and tension-type headache (TTH) in adolescents, and to further examine the potential impact of psychological distress on this relationship.

DESIGN

Population-based, cross-sectional cohort study. The study includes self-reported data from youth on exposure to potentially traumatic events, psychological distress and a validated interview on headache.

SETTING

The adolescent part of the Nord-Trøndelag Health Study 2006-2008 (HUNT), conducted in Norway.

PARTICIPANTS

A cohort of 10 464 adolescents were invited to the study. Age ranged from 12 to 20 years. The response rate was 73% (7620), of whom 50% (3832) were girls.

MAIN OUTCOME MEASURES

Data from the headache interview served as the outcome. Recurrent headache was defined as headache recurring at least monthly during the past year, and was subclassified into monthly, weekly and daily complaints. Subtypes were classified as TTH, migraine, migraine with TTH and/or non-classifiable headache, in accordance with the International Classification of Headache Disorders criteria, second edition.

RESULTS

Multiple logistic regression analysis, adjusted for sociodemographics, showed consistently significant associations between exposure to PTIEs and recurrent headache, regardless of the frequency or subtype of headache. Increasing exposure to PTIEs was associated with higher prevalence of recurrent headache, indicating a dose-response relationship. The strength of associations between exposure to PTIEs and all recurrent headache disorders was significantly attenuated when psychological distress was entered into the regression equation.

CONCLUSIONS

The empirical evidence of a strong and cumulative relationship between exposure to PTIEs, psychological distress and recurrent headache indicates a need for the integration of somatic and psychological healthcare services for adolescents in the prevention, assessment and treatment of recurrent headache. Prospective studies are needed.

Chronic daily headache in children and adolescents: science and conjecture

SUMMARY Chronic daily headache comprises a group of headache disorders in which headaches occur almost daily or continuously over several months. Although chronic daily headache is one of the most common chronic pain disorders in pediatrics, data on pathophysiological mechanisms and relative efficacy of treatments remain sparse. In this review, we aim to provide contemporary information on classification, epidemiology, etiology and treatment of pediatric chronic daily headache based on extant empirical data when available, or general consensus in the field when not.

Characteristics of highly impaired children with severe chronic pain: a 5-year retrospective study on 2249 pediatric pain patients

BACKGROUND

Prevalence of pain as a recurrent symptom in children is known to be high, but little is known about children with high impairment from chronic pain seeking specialized treatment. The purpose of this study was the precise description of children with high impairment from chronic pain referred to the German Paediatric Pain Centre over a 5-year period.

METHODS

Demographic variables, pain characteristics and psychometric measures were assessed at the first evaluation. Subgroup analysis for sex, age and pain location was conducted and multivariate logistic regression applied to identify parameters associated with extremely high impairment.

RESULTS

The retrospective study consisted of 2249 children assessed at the first evaluation. Tension type headache (48%), migraine (43%) and functional abdominal pain (11%) were the most common diagnoses with a high rate of co-occurrence; 18% had some form of musculoskeletal pain disease. Irrespective of pain location, chronic pain disorder with somatic and psychological factors was diagnosed frequently (43%). 55% of the children suffered from more than one distinct pain diagnosis. Clinically significant depression and general anxiety scores were expressed by 24% and 19% of the patients, respectively. Girls over the age of 13 were more likely to seek tertiary treatment compared to boys. Nearly half of children suffered from daily or constant pain with a mean pain value of 6/10. Extremely high pain-related impairment, operationalized as a comprehensive measure of pain duration, frequency, intensity, pain-related school absence and disability, was associated with older age, multiple locations of pain, increased depression and prior hospital stays. 43% of the children taking analgesics had no indication for pharmacological treatment.

CONCLUSION

Children with chronic pain are a diagnostic and therapeutic challenge as they often have two or more different pain diagnoses, are prone to misuse of analgesics and are severely impaired. They are at increased risk for developmental stagnation. Adequate treatment and referral are essential to interrupt progression of the chronic pain process into adulthood.

Psychological interventions for headache in children and adolescents

Headache in children and adolescents represents a number of complex and multifaceted pain syndromes that can benefit from psychological intervention. There is good evidence for the efficacy of cognitive behavioral therapy, relaxation training, and biofeedback. The choice of intervention is influenced by patients' age, sex, family and cultural background, as well as the nature of stressors and comorbid psychiatric symptoms. Management must always be family-centered. Psychological treatments are essential elements of the multidisciplinary, biopsychosocial management of primary headache disorders, particularly for those with frequent or chronic headache, a high level of headache-related disability, medication overuse, or comorbid psychiatric symptoms. Future studies of efficacy and effectiveness of psychological treatment should use the International Headache Society's definition and classification of headache disorders, and stratify results by headache type, associated conditions, and treatment modality.

Chronic daily headache: helping adolescents help themselves with self-hypnosis

Although the evidence is clear that hypnosis has been an effective treatment for recurrent headaches in children, review of the literature revealed no previous reports of hypnosis for youth with the condition of chronic daily headache. Two adolescents with continuing chronic daily headaches were taught self-hypnosis through careful attention to individual strengths and finding the hypnotic elements within the clinical encounters. Self-reports of intensity, frequency, and duration of headaches described substantial benefit from learning and practicing self-hypnosis after little to no benefit from pharmacologic and other nonpharmacologic therapies. These results and analogous success with several other adolescents with chronic daily headache support the further use of self-hypnosis training for this condition. As a self-regulation technique that is quickly and easily learned by most young people, self-hypnosis training holds considerable promise for effectively treating and perhaps preventing chronic daily headaches in children and adolescents.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.

The classification of chronic headache: room for further improvement?

In this commentary, the authors briefly discuss their views on some of the limitations in the current terminology and classification of chronic headache. Suggestions for consideration and further debate include the acceptance of chronic daily headache as the umbrella term for this group of headache disorders, a more consistent definition of 'chronic' and the use of a multi-axial classification approach.

Headache diagnosis, disability and co-morbidities in a multi-ethnic, heterogeneous paediatric Asian population

This was a questionnaire survey on headache and migraine prevalence in 2873 Singaporean schoolchildren aged 6 to 16 years. ICHD-II headache classification, disability assessment with PedMIDAS and screening of psychosocial co-morbidities with the Paediatric Symptom Checklist were conducted. Lifetime headache prevalence was high at 80.6%, migraine prevalence was 8.6% and tension headache prevalence was 10.0%. Headache and migraine prevalence was high compared with that found in other Asian studies. Factors significantly associated with headache included adolescent age (OR = 1.5 [95% CI 1.3–1.9], p < .001), female gender at primary (OR = 1.4 [95% CI 1.1–1.8], p = .003) and secondary (OR = 1.8 [95% CI 1.3–2.5], p < .001) levels and Malay ethnicity at the primary level (OR = 2.8 [95% CI 1.6–4.9], p < .001). The average PedMIDAS score for headache disability was 3.2 ± 8.4, and migraine disability (PedMIDAS 8.1 ± 11.2–15.2 ± 29.6) was lower than in some studies. Self-medication (20.5%) and use of alternative therapy (59.0%) were high among chronic daily headache sufferers. Routine sleep and stress screening is recommended for children with headaches. Recognition of the influence of genetics, lifestyle and cultural factors on headache management should be emphasized.

Chronic daily headaches in children and adolescents

Headaches, which are common in children and adolescents, represent a significant portion of patient complaints in a child neurology practice. Patients with episodic headaches, such as migraines with interval-free periods, and patients with chronic daily headaches with very few headache-free days, are often evaluated and treated differently from each other. The evolution of the classification of chronic daily headache has aided epidemiologic efforts. The disorder can be primary or related to other neurologic or systemic conditions. Comorbid conditions should be identified, and the contributing variables in the child's social, emotional, medical, and educational arenas should be assessed. The level of disability in terms of school attendance and function can help clinicians determine to what extent and how aggressively to treat these children. Rescue medications, such as barbiturates and narcotics, which can cause worsening of headaches, should be avoided.