The effect of physical therapy integrated with pharmacotherapy on tension-type headache and migraine in children and adolescents

BACKGROUND

Tension-type headache (TTH) and migraine are prevalent neurological conditions in children and adolescents that significantly impact activity of daily living (ADL) and quality of life (QOL). Although physical therapy targeting cervical myofascial trigger points (MTrPs) on TTH and migraine has been extensively studied in adults, the efficacy in pediatric patients remains unexplored. The aim of this study is to reveal the effect of physical therapy integrated with pharmacotherapy on TTH and migraine in children and adolescents.

METHODS

We conducted a prospective, observational cohort study recruiting consecutive patients aged 6 to 18 years with TTH and migraine with cervical MTrPs. They were classified into 4 types of headaches: frequent episodic TTH (FRTTH), chronic TTH (CTTH), episodic migraine (EM) and chronic migraine (CM). The once-weekly 40-minutes physical therapy session integrated with pharmacotherapy (integrated physical therapy) was continued until the treatment goals (headache days per week less than 2 days, headache impact test-6 (HIT-6) score to below of 50, and the ability to attend school daily) was achieved. Multifaceted assessments including headache frequency (headache days per week), headache intensity using the Visual Analogue Scale (VAS), pain catastrophizing score (PCS), hospital anxiety and depression scale (HADS) score, HIT-6 scores, and EuroQol 5 dimensions 5-level questionnaire (EQ-5D-5 L) scores, were conducted to evaluate the treatment effects.

RESULTS

161 patients were enrolled in this study. 106 patients (65.8%) were diagnosed with TTH: 70 (66.8%) with FETHH, 36 (34.0%) with CTTH, and 55 patients (34.2%) were diagnosed with migraine: 43 patients (78.2%) with EM, 12 patients (21.8%) with CM. We observed significant improvements in headache frequency, headache intensity, PCS, HADS score, HIT-6 scores, and EQ-5D-5 L scores before and after the treatment in all 4 types of headaches. The average number of sessions required to achieve the treatment goals was 4 times (weeks) for patients with FETTH and EM, 5.5 for those with CTTH, and 7.5 for those with chronic migraine.

CONCLUSION

The integrated physical therapy on pediatric TTH and migraine patients with the cervical MTrPs was significantly effective in reducing headache symptoms and improving ADL and QOL.

Onabotulinumtoxina in the Prevention of Migraine in Pediatric Population: A Systematic Review

Migraine is a leading cause of disability worldwide, yet it remains underrecognized and undertreated, especially in the pediatric and adolescent population. Chronic migraine occurs approximately in 1% of children and adolescents requiring preventive treatment. Topiramate is the only FDA-approved preventative treatment for children older than 12 years of age, but there is conflicting evidence regarding its efficacy. OnabotulinumtoxinA is a known and approved treatment for the management of chronic migraine in people older than 18 years. Several studies examine its role in the pediatric population with positive results; however, the clear-cut benefit is still unclear. OnabotulinumtoxinA seems not only to improve disability scores (PedMIDAS) but also to improve the quality, characteristics, and frequency of migraines in the said population. This systematic review aims to summarize the evidence on the efficacy, dosing, administration, long-term outcomes, and safety of onabotulinumtoxinA in pediatric and adolescent migraine. Eighteen studies met the eligibility criteria and were included in this review. The mean monthly migraine days (MMDs), decreased from of 21.2 days per month to 10.7 after treatment. The reported treatment-related adverse effects were mild and primarily injection site related and ranged from 0% to 47.0%. Thus, this review provides compelling evidence suggesting that OnabotulinumtoxinA may represent a safe and effective preventive treatment option for pediatric migraine.

Chronic Pediatric Headache as a Manifestation of Shunt Over-Drainage and Slit Ventricle Syndrome in Patients Harboring a Cerebrospinal Fluid Diversion System: A Narrative Literature Review

The main subject of the current review is a specific subtype of headache, which is related to shunt over-drainage and slit ventricle syndrome, in pediatric patients harboring an implanted shunt device for the management of hydrocephalus. This clinical entity, along with its impairment regarding the quality of life of the affected individuals, is generally underestimated. This is partly due to the absence of universally agreed-upon diagnostic criteria, as well as due to a misunderstanding of the interactions among the implicated pathophysiological mechanisms. A lot of attempts have been performed to propose an integrative model, aiming at the determination of all the offending mechanisms of the shunt over-drainage syndrome, as well as the determination of all the clinical characteristics and related symptomatology that accompany these secondary headaches. This subcategory of headache, named postural dependent headache, can be associated with nausea, vomiting, and/or radiological signs of slim ventricles and/or subdural collections. The ultimate goal of our review is to draw clinicians' attention, especially that of those that are managing pediatric patients with permanent, long-standing, ventriculoperitoneal, or, less commonly, ventriculoatrial shunts. We attempted to elucidate all clinical and neurological characteristics that are inherently related to this type of headache, as well as to highlight the current management options. This specific subgroup of patients may eventually suffer from severe, intractable headaches, which may negatively impair their quality of daily living. In the absence of any other clinical condition that could be incriminated as the cause of the headache, shunt over-drainage should not be overlooked. On the contrary, it should be seriously taken into consideration, and its management should be added to the therapeutic armamentarium of such cases, which are difficult to be handled.

Validity and reliability of Arabic version of pediatric migraine disability assessment scale (Child Self-Report versus Parent Proxy-Report): a multi-center study

BACKGROUND

Pediatric Migraine Disability Assessment (PedMIDAS) is one of the most frequently used questionnaires to assess disability from migraine in pediatric patients. This work aimed to evaluate the validity and test-retest reliability of the Arabic version of the child self-report versus the parent proxy report PedMIDAS. We also aimed to test the agreement between children's and parents' reports of the scale.

METHODS

PedMIDAS was subjected to translation and back-translation, then applied to 112 pediatric patients fulfilling the migraine diagnostic criteria. This cross-sectional study was conducted on two visits, one week apart. At visit 1, the following data were obtained from the included pediatric patients: disease duration, migraine type, current treatment regimen, monthly migraine days (MMD) during the last month preceding the enrollment, and migraine intensity using the visual analogue scale. Then, each child and his parent were independently asked to fill out PedMIDAS and Child Self-Report of the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™) to test the convergent validity of PedMIDAS. At visit 2, each child was requested to complete PedMIDAS again, and so was the parent to evaluate test-retest reliability.

RESULTS

Cronbach's alpha was estimated to be 0.94 for each instrument. For the child-self report PedMIDAS, the average measure intraclass correlation coefficient (ICC) value was 0.992 (95%CI = 0.989-0.995), while it was estimated to be 0.990 for the parent-proxy report with 95%CI = 0.985-0.993, indicating excellent test-retest reliability for both instruments. The child-self report and the parent-proxy report PedMIDAS scores were significantly correlated with MMD, VAS, and all domains of the corresponding PedsQL, supporting convergent validity for both instruments. Agreement between parent and child on disability grading categories of PedMIDAS was substantial (κ = 0.644).

CONCLUSION

The Arabic version of PedMIDAS was a valid and reliable instrument to assess disability from migraine in Arabic-speaking pediatric patients with migraine. Parent reports can be valuable as a complement to child reports for a comprehensive assessment of migraine.

Association Between Migraine and Gastrointestinal Disease in Pediatric Patients: A Propensity Score Weighting Approach

Purpose

Migraine is a neurological disorder affecting pediatric patients of all age groups, with a prevalence ranging from approximately 5% to 15%. It significantly impacts the quality of life in children and adolescents, potentially hampering their learning abilities, school performance, and daily activities. This study investigated the association between migraine and several prevalent gastrointestinal (GI) diseases in pediatric patients.

Patients and Methods

We analyzed the Health Insurance Review and Assessment Service Pediatric Patient Sample (HIRA-PPS) dataset from South Korea. Propensity scores based on patient characteristics (age, sex, and insurance type) were employed through the inverse probability of treatment weighting (IPTW) in binary logistic regression. We included gastroesophageal disease (GERD), peptic ulcer disease (PUD), gastritis, dyspepsia, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD) as GI diseases.

Results

A total of 683,347 patients from the HIRA dataset were included in the study. After IPTW adjustment, the prevalence of GI diseases among pediatric patients with migraine remained significantly increased (OR 4.15; 95% CI 4.12-4.18). Migraine patients showed higher prevalence rates for all six individual GI diseases, with GERD (OR 4.11; 95% CI 4.05-4.16) and IBS (OR 3.79; 95% CI 3.74-3.84) showing the highest associations. We also confirmed a progressively increasing association between the presence of diagnosed migraine and GI diseases.

Conclusion

This study highlights a strong association between pediatric migraine and GI diseases, even after adjusting for patient characteristics. The elevated prevalence of various GI diseases in migraine patients suggests the need for comprehensive approaches to their prevention and treatment.

Cognitive Behavioral Therapy for Children With Headaches: Will an App Do the Trick?

Participants were enrolled into a pilot randomized-controlled 4-week trial comparing the efficacy and feasibility of app-based cognitive behavioral therapy (CBT) to a stretching program. Headache-related disability and quality of life were assessed using the Pediatric Migraine Disability Scale (PedMIDAS), Kidscree27, and Pediatric Quality of Life Inventory. Multivariable regression analysis were performed to assess the group effects in the presence of adherence and other covariates. Twenty participants completed the study. Adherence was significantly higher in the stretching than in the CBT app group (100% vs 54%, P < .034). When controlling for adherence and baseline scores, the stretching group showed greater reduction in PedMIDAS score (average: 29.2, P < .05) as compared to the CBT app group. However, in terms of the Quality-of-Life Indicators, pre- and postintervention raw scores were not significantly different between groups (P > .05). App-based CBT was not superior to a stretching program in reducing headache-related disability in a select population of pediatric headache patients. Future studies should assess if implementing features to the CBT app, like tailoring to pediatric age groups, would improve outcomes.

Tension-Type Headache in Children and Adolescents

In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors. The trajectories and outcomes of juvenile migraine and TTH, as well as the transition of one form to the other, have been investigated in several long-term prospective studies. Thus, the aim of this paper is to review the current literature on the differential diagnosis workout of TTH in pediatrics, the possible outcomes during the developmental age and the appropriate therapeutic strategies. Indeed, TTH represents a challenging diagnostic entity in pediatrics, both from a clinical and a therapeutic point of view, in which early diagnosis and appropriate treatment are recommended.

Primary headache epidemiology in children and adolescents: a systematic review and meta-analysis

INTRODUCTION

Headache is the most prevalent neurological manifestation in adults and one of the leading causes of disability worldwide. In children and adolescents, headaches are arguably responsible for a remarkable impact on physical and psychological issues, yet high-quality evidence is scarce.

MATERIAL AND METHODS

We searched cross-sectional and cohort studies in Embase, Medline, Web of Science, and Cochrane databases from January 1988 to June 2022 to identify the prevalence of headaches in 8-18 years old individuals. The risk of bias was examined with the Joanna Briggs Institute (JBI) scale. A random-effects model was used to estimate the pooled prevalence of pediatric headache. Subgroup analyses based on headache subtypes were also conducted.

RESULTS

Out of 5,486 papers retrieved electronically, we identified 48 studies that fulfilled our inclusion criteria. The pooled prevalence of primary headaches was 11% for migraine overall [95%CI: 9-14%], 8% for migraine without aura (MwoA) [95%CI: 5-12%], 3% for migraine with aura (MwA) [95%CI:2-4%] and 17% for tension-type headache (TTH) [95% CI: 12-23%]. The pooled prevalence of overall primary headache in children and adolescents was 62% [95% CI: 53-70%], with prevalence in females and males of 38% [95% CI: 16-66%] and 27% [95% CI: 11-53%] respectively. After the removal of studies ranked as low-quality according to the JBI scale, prevalence rates were not substantially different. Epidemiological data on less common primary headaches, such as trigeminal autonomic cephalalgias, were lacking.

CONCLUSION

We found an overall remarkably high prevalence of primary headaches in children and adolescents, even if flawed by a high degree of heterogeneity. Further up-to-date studies are warranted to complete the picture of pediatric headache-related burden to enhance specific public interventions.

Migraine and its association with pubertal maturation and behavioral traits among adolescent girls

OBJECTIVE

To determine if the ages at pubertal milestones are associated with the prevalence of adolescent migraine.

BACKGROUND

Migraine headaches are a common disease in adolescent girls. Past studies have evaluated the relationship between age of onset of menarche and migraine headache, but none have studied earlier pubertal milestones such as thelarche and pubarche.

METHODS

In this cross-sectional study, a previously validated questionnaire was administered to girls (15-18 years) in Breast Cancer and the Environment Research Program puberty cohort to ascertain if they met criteria for migraine over the past year. Ages of pubertal development were ascertained by serial examinations beginning at 6-8 years of age and ending in late puberty. Logistic regression analyses determined if age of onset of each pubertal milestone (thelarche, pubarche, menarche separately) was associated with adolescent migraine after adjusting for other risk factors.

RESULTS

Of 761girls, 222 (29.2%) met the criteria for migraine. Later thelarche was associated with a lower odds of adolescent migraine (OR 0.83; 95% CI 0.72-0.97, p = 0.019). In models further adjusted for BASC-2 internalizing problems (n = 490), both later thelarche (OR 0.78; 95% CI 0.64-0.96, p = 0.016) and later menarche (OR 0.81; 95%CI 0.67-0.98, p = 0.026) were associated with a lower migraine prevalence. Internalizing problems (OR 1.05; 95% CI 1.03-1.07) externalizing problems (OR 1.05; 95% CI 1.02-1.07) and behavioral symptoms (OR 1.05; 95% CI 1.03-1.08) were associated with increased prevalence of migraine in separate models.

CONCLUSIONS

Age of onset of thelarche and menarche, and internalizing, externalizing, and behavioral symptoms were all associated with adolescent migraine.

Case report: Look at my eyes

The comorbidity of migraine and Autism Spectrum Disorder (ASD) still remain unclear. In spite of plausible evidences of such comorbidity, there is a scarcity of populational studies focusing this hypothesis. The diagnosis of migraine in children with ASD is very challenge due to the large clinical heterogeneity and limited communication skills, particularly verbal abilities in young children and those with intellectual disability. ASD and migraine are chronic prevalent disorders sharing some pathophysiological changes (neurotransmission dysregulation, altered immune response, abnormal findings in the cortical minicolumn organization, and dysfunctions in the gut–brain axis), susceptibility genes (including calcium channel mutations and polymorphisms), and atypical sensory processing. Herein, we take advantage of a prototypical case of an adolescent with episodic migraine transformed to chronic, not responsive to preventive treatment, to explore the diagnostic workup and successful personalized clinical and therapeutical management.

Anxiety and Depressive Symptoms and Disorders in Children and Adolescents With Migraine: A Systematic Review and Meta-analysis

Importance

Though it is presumed that children and adolescents with migraine are at risk of internalizing symptoms and disorders, high-level summative evidence to support this clinical belief is lacking.

Objective

To determine if there is an association between internalizing symptoms and disorders and migraine in children and adolescents.

Data Sources

A librarian-led, peer-reviewed search was performed using MEDLINE, Embase, PsycINFO, and CINAHL databases (inception to March 28, 2022).

Study Selection

Case-control, cohort, and cross-sectional studies on the association between internalizing symptoms and disorders and migraine in children and adolescents 18 years or younger were eligible.

Data Extraction and Synthesis

Two investigators independently completed abstract and full-text screening, data extraction, and quality appraisal using the Newcastle-Ottawa scales. Studies were pooled with random-effects meta-analyses using standardized mean differences (SMD) or odds ratios (OR) with 95% CIs. Where sufficient data for pooling were unavailable, studies were described qualitatively.

Main Outcomes and Measures

The primary outcome was migraine diagnosis; additional outcomes included migraine outcomes and incidence. Associations between these outcomes and internalizing symptoms and disorders were evaluated.

Results

The study team screened 4946 studies and included 80 studies in the systematic review. Seventy-four studies reported on the association between internalizing symptoms and disorders and migraine, and 51 studies were amenable to pooling. Meta-analyses comparing children and adolescents with migraine with healthy controls showed: (1) an association between migraine and anxiety symptoms (SMD, 1.13; 95% CI, 0.64-1.63); (2) an association between migraine and depressive symptoms (SMD, 0.67; 95% CI, 0.46-0.87); and (3) significantly higher odds of anxiety disorders (OR, 1.93, 95% CI, 1.49-2.50) and depressive disorders (OR, 2.01, 95% CI, 1.46-2.78) in those with, vs without, migraine. Stratification of results did not reveal differences between clinical vs community/population-based samples and there was no evidence of publication bias. Twenty studies assessing the association between internalizing symptoms or disorders and migraine outcomes (n = 18) or incident migraine (n = 2) were summarized descriptively given significant heterogeneity, with minimal conclusions drawn.

Conclusions and Relevance

In this study, children and adolescents with migraine were at higher risk of anxiety and depression symptoms and disorders compared with healthy controls. It may be beneficial to routinely screen children and adolescents with migraine for anxiety and depression in clinical practice. It is unclear whether having anxiety and depressive symptoms or disorders has an affect on migraine outcomes or incidence.

The influence of anxiety and depression on headache in adolescent migraineurs: a case-control study

BACKGROUND

Migraine is commonly linked to a range of psychiatric comorbidities, primarily anxiety and depression. The present study compared the frequency of anxiety and depression disorders in migraine and non-migraine adolescents and evaluated the relation of depression and anxiety to migraine characteristics.

METHODS

In this case-control study, 234 adolescents (112 migraineurs and 122 non-migraine adolescents) aged 13-18 years were evaluated. A headache questionnaire as well as the Beck Anxiety Inventory and Children's Depression Inventory were completed to investigate the prevalence of headache, anxiety, and depression.

RESULTS

The average age of participants was 15.77±2 years in the case group and 15.39±1.79 years in the control group. We found significantly higher levels of mild, moderate, and severe anxiety (38.4%, 23.2%and 23.2% respectively) in the migraine group compared to the control group (24.2%, 5.8%and 10.0% respectively) (p<0.001). Significantly more children in the control group (29.6%) than in the case group (10.1%) had a non-depressive CDI score (p=0.005). There was a significant difference between patients with moderate and severe anxiety in terms of attack frequency and duration. Depressed migraineurs recorded higher attack severities and frequencies than migraineurs without depression.

CONCLUSION

Anxiety and depression are common in adolescents with migraine and can be associated with more burdensome attacks.

Emotional Experience and Regulation in Juvenile Primary Headaches: A Cross-Sectional Pilot Study

A headache is the most common neurological symptom in children. Its subtypes are migraine (MH) and tension-type headache (TTH). Internalizing rather than externalizing symptoms are more frequent in children with headaches, but little is known about the reasons why. We aim to: (a) examine the interplay between emotional experience, affective regulation, and internalizing symptoms in children suffering from primary headaches and their caregivers; (b) identify potential predictors of children with migraines' internalizing symptoms. Fifty children and adolescents with a diagnosis of primary headaches and their caregivers were compared to a sample of fifty-one healthy peers and caregivers. Self-reports and parent-reports were administered. Results indicate higher negative affect and internalizing symptoms and lower bodily awareness of emotions in the clinical sample (n = 50; Mage = 11.66, SD = 2.25) compared to controls (n = 51; Mage = 11.73, SD = 2.32); mothers of TTH children self-reported lower emotional awareness and higher difficulties in engaging in goal-directed behavior; a higher frequency of headaches was associated with greater emotional regulation difficulties. Internalizing symptoms were predicted by higher self-reported negative affect and parent-reported internalizing symptoms, and lower self-reported ability in the verbal sharing of emotions. These findings suggest the importance of assessing the psychological features linked to children with primary headaches' psychological well-being.

Management of Chronic Migraine in Children and Adolescents: Where are We in 2022?

Migraine is a neurological disorder that affects millions of children and adolescents worldwide. Chronic migraine is a subtype of migraine in which patients experience headaches for more days than not each month, with accompanying symptoms of phonophobia, photophobia, nausea or vomiting for most of these headaches. The burden and impact of chronic migraine in the daily lives of children and adolescents is substantial, requiring a holistic, multidisciplinary, and biopsychosocial approach to conceptualization and treatment. The purpose of this review is to provide a comprehensive “2022” overview of acute and preventive treatments for the management of chronic migraine in youth. We first describe diagnostic criteria for chronic migraine and highlight the state of evidence for acute and preventive treatment in children and adolescents. We then discuss emerging treatments currently receiving rigorous clinical research effort, special considerations for the treatment of chronic migraine in children and adolescents, and avenues for improving existing treatments and expanding access to evidence-based care.

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.

Headache in ADHD as comorbidity and a side effect of medications: a systematic review and meta-analysis

There is mixed evidence on the association between headache and attention-deficit/hyperactivity disorder (ADHD), as well as headache and ADHD medications. This systematic review and meta-analysis investigated the co-occurrence of headache in children with ADHD, and the effects of ADHD medications on headache. Embase, Medline and PsycInfo were searched for population-based and clinical studies comparing the prevalence of headache in ADHD and controls through January 26, 2021. In addition, we updated the search of a previous systematic review and network meta-analysis of double-blind randomized controlled trials (RCTs) on ADHD medications on June 16, 2020. Trials of amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with a placebo arm and reporting data on headache as an adverse event, were included. Thirteen epidemiological studies and 58 clinical trials were eligible for inclusion. In epidemiological studies, a significant association between headache and ADHD was found [odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.63-2.46], which remained significant when limited to studies reporting ORs adjusted for possible confounders. The pooled prevalence of headaches in children with ADHD was 26.6%. In RCTs, three ADHD medications were associated with increased headache during treatment periods, compared to placebo: atomoxetine (OR = 1.29, 95% CI = 1.06-1.56), guanfacine (OR = 1.43, 95% CI = 1.12-1.82), and methylphenidate (OR = 1.33, 95% CI = 1.09-1.63). The summarized evidence suggests that headache is common in children with ADHD, both as part of the clinical presentation as such and as a side effect of some standard medications. Monitoring and clinical management strategies of headache in ADHD, in general, and during pharmacological treatment are recommended.

Migraine and Mood in Children

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Primary Headache Disorder Among School Students in Kuwait

Background: Primary headaches are remarkably prevalent worldwide and are increasingly reported among children. However, the exact trend in this age group, particularly in the Gulf region, remains largely unknown. Aims and Objectives: To examine the prevalence of primary headache disorders among primary and middle school students in Kuwait. Methods: We conducted a cross-sectional study that included Kuwaiti primary and middle school children and adolescents of both genders in randomly selected schools located in two governorates in Kuwait in the 2018/2019 academic year. Prevalence and attributable burden of headaches, definite and probable migraines, definite and probable tension-type headaches, chronic headaches (≥15 days/month), and probable medication-overuse headaches were assessed using the Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation (HARDSHIP) questionnaire for children and adolescents. Results: Of 1,485 questionnaires that were distributed, 1,089 students completed the questionnaire with a respondent rate of 73.4%. The study population consisted of 420 boys (38.56%) and 669 girls (61.43%) students with a mean age of 11.5 ± 2.11 years. The 1-year prevalence of primary headache disorders was 42.78%, with more middle schoolers reporting headaches than primary schoolers (50.37 vs. 30.48%; p < 0.02). The mean age of students with primary headaches was 11.98 ± 2.03 years in both genders. When stratified according to diagnostic criteria, migraine headaches were the most frequently reported (20.75%), followed by tension type headaches (18.8%), chronic headaches (2.75%), and probable medication-overuse headaches (0.46%). Primary headaches were significantly higher in girls compared to boys among middle schoolers (66.46 vs. 38.49%; p < 0.001); however, no significant difference between genders was noted among primary school students (33.12 vs. 22.33%; p < 0.118). Conclusion: Primary headaches are remarkably common in Kuwaiti school students, with migraine headaches being the most frequently reported type. Age and female gender may play a role in the development of primary headaches. These findings necessitate the direction of health services and research efforts toward this age group and warrant the need for further epidemiological studies.

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

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

Impact of primary headache disorder on quality of life among school students in Kuwait

BACKGROUND

Primary headache disorders have being increasingly reported in younger populations. They can have significant effects on their quality of life and academic achievement and may cause significant distress to their families.

AIMS AND OBJECTIVES

To assess the burden of primary headache disorder and its impact on the quality of life on school student in Kuwait.

METHODS

A cross-sectional study was conducted among Kuwaiti primary and middle school students of both genders in randomly selected schools located in two governorates in 2018/2019 academic year. Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents was used to assess the impact of primary headaches on the quality of life.

RESULTS

One thousand and ninety-one questionnaires were completed by primary and middle school students of both genders; of whom 466 students (girls 321 (68.88%) were diagnosed with primary headache disorders with mean age 11.98 ± 2.03 years. In the month prior to the survey, the effect of the headache was variable. The students lost a mean of 1.99 ± 2.015 days of school while they could not perform their usual activities for a mean of 2.84 ± 4.28 days. Their parents lost a mean of 2 ± 2.03 days of work because of headaches of their children and parents prohibited 5.7% of the students to engage in any activity due to their headaches. Difficulties in concentrations were reported as never sometimes (39.1%), often (24.8%), and always (26%). Majority of the students (51.5%) experienced a feeling of sadness ranging from sometimes to always. Most of the students (67.3%) struggled to cope with the headache and 22.4% were never able to cope. Additionally, 19.4% of students reported they did not want others noticing their headache.

CONCLUSION

Primary headache disorder can have a significant impact on the quality of life in children. It can affect their engagement in activities and academic achievement. Implementing strategies to properly manage schoolchildren with primary headaches can have profound effects on their quality of life.

ADHD Is Comorbid to Migraine in Childhood: A Population-Based Study

Objective: Recurrent headaches and ADHD are prevalent in the pediatric population. Herein, we assess if ADHD is comorbid to headaches overall, to headache subtypes (e.g., migraine), and to headache frequency. Method: Informed consent and analyzable data were obtained for 5,671 children aged 5 to 12 years (65.9% of the target sample). Parents and teachers were interviewed using validated questionnaires based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). Relative risks were modeled using univariate and multivariate analyses. Results: As contrasted to nonheadache controls, the prevalence of ADHD was significantly higher in children with migraine (p < .001) but not in those with tension-type headaches. In children with migraine, risk of ADHD increased as a function of headache frequency (p < .05). Conclusion: Migraine and frequent migraine are comorbid to ADHD. Future studies should focus on the impact of the association on the burden to the children and their families.

Effects of dietary supplementations and herbs on migraine – a systematic review

Background

Migraine is a disabling disease and conventional treatment has many side effects. Dietary supplements and various herbs have reported valuable effects on migraine.

Aim

The present study systematically review the effects of these dietary supplements and herbs on migraine.

Methods

The literature search was done on electronic databases PubMed, Google Scholar and Science direct (2005–2015). The quality of articles was assessed through a criteria list of methodological quality assessment of randomized controlled trials (RCTs). The papers got C50 points considered to be of good quality methodology. The maximum score was 100.

Results

Fourteen RCTs on migraine were included in this review. The range of quality score varied from 37 to 65 points.

Conclusion

Various RCTs suggested that dietary and vitamin supplementation and different herbs might be effective in treatment of migraine. Evaluated RCTs have various methodological shortcomings. So, a firm conclusion can’t be made for the efficacy of dietary supplementation and herbs in the treatment of migraine.

The influence of allergic rhinoconjunctivitis on migraine disability in children

OBJECTIVE

Migraine is a common condition in the pediatric population and causes a significant impact on the quality of life. Atopic disorders are some of the migraine comorbidities. We hypothesized that allergic rhinitis could aggravate migraine in the pediatric population.

METHODS

This cross-sectional study consecutively evaluated 90 pediatric outpatients (46 children 6-12 years of age; 44 adolescents up to 18 years of age) who sought medical assistance because of migraine at a general neurology clinic in Passo Fundo, RS, Brazil. They, and their parents, were given three questionnaires, to evaluate the diagnosis of current allergic rhinitis, allergic rhinoconjunctivitis and seasonal allergic rhinitis, as well as the disability caused by headache (ISAAC - International Study of Asthma and Allergies in Childhood; CARATkids - Control of Allergic Rhinitis and Asthma Test for Children; PedMIDAS - Pediatric Migraine Disability Assessment). The study was approved by the local ethics committee.

RESULTS

According to the ISAAC questionnaire, children with current allergic rhinoconjunctivitis in the last year showed higher scores on the PedMIDAS than those patients without atopy (median and interquartile range 26 [10-58] vs. 5 [1-13], p = 0.008). A significant positive correlation of CARATkids scores with PedMIDAS scores was found (p = 0.007, rho = 0.39). After including other putative predictors of migraine disability (age, body mass index, time since onset of migraine) in a multiple regression analysis, only the scores on the CARATkids remained a significant independent variable correlated with PedMIDAS scores (p = 0.001; R = 0.55; R2 = 0.30).

CONCLUSIONS

Current allergic rhinoconjunctivitis is related to enhanced disability caused by headache in childhood migraine.

Chronic tension-type headache and coping strategies in adolescents: A qualitative interview study

OBJECTIVE

Headache is the most common cause of chronic pain in children and adolescents and may influence on several of the life's arenas such as high absence from school and inability to maintain leisure time activities. Adolescents with chronic headache also report co-morbidities such as anxiety, depression, insomnia, and reduced quality of life. This study aimed to explore which strategies adolescents use to cope with chronic tension-type headache in everyday life.

METHODS

A qualitative design with semistructured individual interviews was used. A strategic sample of 17 adolescents aged 14-19 with tension-type headache participated in the study. The interviews were audiotaped and transcribed verbatim. Transcripts were analysed using systematic text condensation.

RESULTS

To deal with the headache in everyday life, the adolescence expressed that it is important to have a good structure during the day, especially regarding regular meals and enough sleep. Sufficient rest and relaxation were also highlighted as crucial. Some of the adolescence had tried different therapies to help ease the pain but with varying effect. All of the adolescents had used or were using pain relievers, but they were ambivalent to the benefits. Low-intensity physical activity was perceived as beneficial and gave increased overall well-being. Such activity also gave release and distraction from the headache.

CONCLUSION

The adolescents used both problem-focused active strategies and emotion-focused passive strategies to deal with their headache in daily life. Through exploration and awareness of the types of behaviour that worked and did not work, they had arrived at strategies that helped them cope with their headache and its consequences.

Physical-Mental Comorbidity of Pediatric Migraine in the Philadelphia Neurodevelopmental Cohort

OBJECTIVE

To examine the associations between headaches and migraine with physical and mental disorders in a large pediatric registry.

STUDY DESIGN

In total, 9329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort were included. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Mental disorders were assessed using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia.

RESULTS

Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%. Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (OR 1.2 [95% CI 1.1-1.4]), and behavior disorders (1.3 [1.1-1.5]). Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with nonmigraine headache (OR ranged from 1.3 to 1.9).

CONCLUSIONS

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. Comorbidity may be an important index of heterogeneity of migraine that can guide clinical management, genetic investigation, and future research on shared pathophysiology with other disorders.

Sociodemographic Factors Associated With Hospital Care for Pediatric Migraine: A National Study Using the Kids' Inpatient Dataset

BACKGROUND

Although migraine often starts in childhood or adolescence, hospital care for migraine in children is not well described. We examined patient and hospital characteristics associated with hospital care for migraine among children in the United States.

METHODS

We queried the Kids' Inpatient Database (2003 to 2009) for hospitalizations of children aged 3-20. Sociodemographic and hospital characteristics were compared between hospitalizations for migraine and for other common medical conditions. Multivariate logistic regression models estimated the associations between patient, hospital, and socioeconomic characteristics and inpatient migraine care.

RESULTS

We identified 11,696 pediatric migraine hospitalizations, the majority (68.7%) occurring at teaching hospitals, involving a female (68.8%) child, ages 13-20 (71%, mean age: 14.6 years). As compared to the overall inpatient sample, migraine hospitalizations were less likely to involve children who were Black (adjusted odds ratio [AOR] 0.54, 95% confidence interval [CI] 0.49 to 0.60), Hispanic (AOR = 0.58, 95% CI 0.50 to 0.68), or Asian (AOR = 0.42, 95% CI 0.32 to 0.55), and more likely to involve females (AOR = 1.49, 95% CI 1.40 to 1.59). Migraine inpatients were more likely to live in higher income postal ZIP code areas (versus lowest ZIP code income quartile: AOR = 1.32, 95% CI 1.18 to 1.48). The average length of stay for migraine was 2.54 (SEM 0.6) days.

CONCLUSIONS

Children who are hospitalized for migraines have distinct sociodemographic characteristics and a short length of stay. Understanding the reasons for these variations will inform the design of interventions aimed at reducing the need for pediatric migraine hospitalization.

Headache, comorbidities and lifestyle in an adolescent population (The TEENs Study)

OBJECTIVE

To evaluate the prevalence and characteristics of headache and its relationship with comorbidities and lifestyle in a teenage population.

METHODS

This is a cross-sectional study. Data was collected from students aged 12-18 years from six different schools in Catalonia, Spain. They completed an anonymous questionnaire with demographic, lifestyle, medical data, presence of recurrent headaches and its features, and completed the Strengths and Difficulties Questionnaire. We defined probable migraine if headache presented ≥ 3 ICHD-3 beta criteria for migraine. An analysis was performed to evaluate headache characteristics and compare lifestyles between those with or without headache.

RESULTS

1619 out of 1873 students completed the survey (response rate 86.4%). From these, 30.5% suffered from recurrent headache and 11.3% had migraine features; 32.9% of adolescents with headache had at least one episode per week and 44.1% showed some degree of headache-related disability measured by the PedMIDAS scale. In a univariate analysis, headache was significantly more frequent in girls (35.1% vs. 25.5%, p < 0.001), teenagers with poor sleeping habits (36.6% vs. 27.6%, p < 0.001), lower physical activity ( p = 0.002), those who did not have breakfast (37.3 vs. 28.4%, p = 0.001), smokers (10.5% vs. 4.9%, p < 0.001) and caffeine overusers (30.9% vs. 24.7%, p = 0.009). Comorbidities significantly associated with headache were: allergies (38.8% vs. 29.3%, p = 0.007), other chronic pain disorders (44.7% vs. 27.6% p < 0.001), mental health problems (53.2% vs. 29.0%, p < 0.001) and worse SDQ scores ( p < 0.001).

CONCLUSIONS

Headache is a common health problem among adolescents which impacts their quality of life. Headache is associated with presence of "unhealthy lifestyle" and other medical comorbidities. Educational initiatives should be started.

A pilot educational intervention for headache and concussion: The headache and arts program

OBJECTIVE

Using a science, technology, engineering, arts, and mathematics (STEAM) curriculum, we developed, piloted, and tested the Headache and Arts Program. This program seeks to increase knowledge and awareness of migraine and concussion among high school students through a visual arts-based curriculum.

METHODS

We developed a 2-week Headache and Arts Program with lesson plans and art assignments for high school visual arts classes and an age-appropriate assessment to assess students' knowledge of migraine and concussion. We assessed students' knowledge through (1) the creation of artwork that depicted the experience of a migraine or concussion, (2) the conception and implementation of methods to transfer knowledge gained through the program, and (3) preassessment and postassessment results. The assessment was distributed to all students prior to the Headache and Arts Program. In a smaller sample, we distributed the assessment 3 months after the program to assess longitudinal effects. Descriptive analyses and p values were calculated using SPSS V.24 and Microsoft Excel.

RESULTS

Forty-eight students participated in the research program. Students created artwork that integrated STEAM knowledge learned through the program and applied creative methods to teach others about migraine and concussion. At baseline, students' total scores averaged 67.6% correct. Total scores for the longitudinal preassessment, immediate postassessment, and delayed 3-month postassessment averaged 69.4%, 72.8%, and 80.0% correct, respectively.

CONCLUSION

The use of a visual arts-based curriculum may be effective for migraine and concussion education among high school students.

Rorschach Evaluation of Personality and Emotional Characteristics in Adolescents With Migraine Versus Epilepsy and Controls

The literature examining primary headache, including migraine, in adolescents, has pointed out the key role played by a wide range of psychiatric disorders in reducing the patients’ quality of life. Moreover, pioneering studies showed that preexisting personality characteristics, specific emotion regulation styles and psychological-psychiatric difficulties are likely to increase the risk of the onset, maintenance, and outcome of headache. Still personality issues in migraine have been poorly studied, in particular in children and adolescents. This study aims, therefore, to investigate the specific characteristics of personality, and in particular emotion regulation and coping strategies, in adolescent with migraine, comparing them with age-matched patients with idiopathic epilepsy and healthy adolescents. 52 adolescents (age: 11–17) were assessed using a multi-method test battery, which included a self-report questionnaire (the youth self-report), a proxy-report (child behavior checklist) along with a projective personality test, the Rorschach Test, administered and scored according to the Exner comprehensive system. The results showed specific personality characteristics in adolescents with migraine, revealing a marked difficulty in modulating and regulating affections through thoughts and reflections, resorting instead to impulsive acts and maladaptive coping strategies, thus revealing a vague and immature perception of reality. Differently from adolescents belonging to the general population, but similarly to patients with epilepsy, adolescents with migraine perceive a high situational stress, probably related to the condition of suffering from chronic disease. They have, therefore, a lower self-consideration and self-esteem along with a poorer insight regarding themselves as well as the relations with others. In line with previous findings, these preliminary results suggest the need for further research on ample samples, using also standardized projective test in order to better understand the pathogenesis of psychological difficulties in patients with migraine. As a clinical implication, the results seem to indicate that providing a psychological integrated approach can play a pivotal role in the assessment and treatment of adolescent with migraine, in order to improve the outcome and the quality of life of the young patients.

Comorbidity of Migraine, Major Depressive Disorder, and Generalized Anxiety Disorder in Adolescents and Young Adults

PURPOSE

Depression and anxiety are highly comorbid psychiatric conditions and both are common in adult patients with migraine. This study aims to examine the unique associations between major depressive disorder (MDD) and generalized anxiety disorder (GAD) in a well-characterized group of older adolescents and college-age individuals with migraine.

METHOD

Participants (N =  227), between 15 and 20 years old, who were unmedicated or within 1 month of beginning antidepressant treatment underwent a comprehensive psychiatric assessment to establish the presence of MDD and GAD, according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision, and to rate their symptom severity using the Longitudinal Interval Follow-up Evaluation for Adolescents (A-LIFE). They then completed the ID-Migraine. The Student's t test and chi-square test were used to compare continuous and categorical variables, respectively, across participants with vs. without migraine. Logistic regression analysis examined the association between the presence of migraine and psychopathology.

RESULTS

A diagnosis of MDD was associated with significantly increased risk of having migraine. Moreover, more severe and persistent ratings of depression were associated with an even higher likelihood of having migraine. A diagnosis of GAD was also significantly associated with the presence of migraine. The prevalence of comorbid MDD and GAD was significantly higher in participants with migraine than those without migraine (55 vs. 22%, p < 0.0001). When examined concurrently, GAD remained significantly associated with migraine, with a statistical trend for MDD to be associated with it.

CONCLUSION

The comorbidity of migraine, MDD, and GAD has important clinical and research implications. Patients who suffer from any of these problems should be screened for all three in order to receive comprehensive care. Shared psychological and biological vulnerabilities may be involved in the three conditions. Greater understanding of the shared vulnerabilities can lead to unified treatments.

Recent advances in the management of chronic migraine in children

INTRODUCTION

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

Headache and Alexithymia in Children and Adolescents: What Is the Connection?

Background: Headache is one of the most common complaints in children and adolescents and comorbidity rates are very high and the major associated diseases are depression, anxiety, atopic disorders, sleep, and behavioral disorders. In recent years, it has been highlighted that difficulties regulating emotions such as alexithymia have also been associated with diagnosis of somatization. Methods: We carried out a mini review analyzing the relation between alexithymia and primary headache (e.g., migraine and tension type headache) in children and adolescents by synthesizing the relevant studies in the literature on PubMed, PsycINFO, and Google Scholar. Search terms were "alexithymia" combined with the "primary headache," "migraine," "tension type headache," "children," and "adolescents." Results: All analyzed studies found higher levels of alexithymia in children and adolescents with headache than control groups but there are different opinions about the relationship between headache and alexithymia. For example, some studies suggest that the association between headache and alexithymia in children may be due to an incomplete development of emotive competency or a general immature cognitive development, instead other studies found a correlation between headache symptoms, insecure attachment, and alexithymia. There seems to be also differences between children with migraine compared to those with tension type headache (TTH). Conclusion: There are some studies on adults suffering from headache or migraine and alexithymia, but there is only a moderate amount of research on pediatric age with different opinions and theories about this relationship. Further studies on children and adolescents are necessary to effectively understand this relationship and to help children to reduce headache and improve emotional consciousness.

The Sleep Hygiene Inventory for Pediatrics: Development and Validation of a New Measure of Sleep in a Sample of Children and Adolescents With Chronic Headache

Sleep plays a pivotal role in children and adolescents with headache. Although several sleep measures exist, no developed measures target the sleep issues common in pediatric patients with headache. The Sleep Hygiene Inventory for Pediatrics (SHIP) was developed for clinical purposes to fulfill this need. The aim of this study was to validate the SHIP for potential research applications in a sample of 1078 children and adolescents (7-17 years) with a primary headache diagnosis. Measure validation included assessments of internal consistency, construct validity, and criterion validity. The SHIP demonstrated strong internal consistency (Cronbach α = 0.84). The SHIP differentiated well between participants for whom sleep was and was not a clinical concern ( P < .001; d =1.65), and was positively correlated with anxiety, depression, and disability. These analyses suggest that the SHIP is a psychometrically strong and valid assessment of sleep habits in pediatric patients with headache.

Efficacy of transdiagnostic cognitive-behavioral group therapy for anxiety disorders and headache in adolescents

Anxiety disorders and headache are both among the most prevalent disorders among adolescents. Although cognitive behavioral therapy (CBT) has proved its efficacy with each of these disorders individually, there are several barriers to its utilization, including cost, gaps in knowledge about treatment delivery and modes, and its utility with comorbid disorders. The current study examined the comparative efficacy of a 12 week TCBT Group treatment (n=32) versus treatment as usual group (n=31) (TAU) in adolescents with anxiety disorders and headache in a north Indian hospital based setting. Results from 63 adolescents suggested while both conditions improved significantly on the Headache Impact Test and Children's Global Assessment Scale, those receiving TCBT showed significantly greater improvement than those in the TAU condition. Participants receiving TCBT, but not those in the TAU condition, showed significant improvement on the State Trait Anxiety Inventory. The study provides evidence supporting the efficacy of TCBT in adolescents with anxiety disorders and headache. Further, group TCBT has the benefits of easy dissemination and increased access to evidence-based treatment, thus, lowering costs and therapist time.

Headache symptoms consistent with migraine and tension-type headaches in children with anxiety disorders

OBJECTIVE

To examine the incidence of headache symptoms consistent with migraine and tension-type headache (TTH) in children with anxiety disorders.

METHOD

Parents of children with anxiety disorders (n=27) and children without anxiety disorders (n=36) completed a headache questionnaire based on the International Classification of Headache Disorders (2nd edition) criteria.

RESULTS

Children with anxiety disorders had a higher incidence of headache symptoms consistent with migraine and TTH compared to children without anxiety disorders. Girls with anxiety disorders and children with separation anxiety disorder had a higher incidence of headaches compared to girls without anxiety disorders and children with other anxiety disorders respectively. Children with anxiety disorders and headaches had higher self-reported anxiety symptom severity compared to children with anxiety disorders without headaches and children without anxiety disorders.

CONCLUSION

Findings highlight an overlap in anxiety and headaches in children and warrant further research on factors that contribute to the etiology and maintenance of these co-occurring problems.

Zolmitriptan Nasal Spray: A Review in Acute Migraine in Pediatric Patients 12 Years of Age or Older

The intranasal formulation of zolmitriptan, a selective serotonin 5-HT1B/1D agonist, was recently approved by the US Food and Drug Administration for the treatment of acute migraine in pediatric patients 12 years of age or older. This article summarizes the efficacy and tolerability of zolmitriptan (Zomig(®)) nasal spray (NS) in acute migraine in this patient group. Zolmitriptan NS 5 mg was more effective in relieving headache pain than placebo in two double-blind studies in pediatric patients 12-17 years of age with acute migraine. Furthermore, zolmitriptan NS 2.5 and 5 mg effectively relieved photophobia and phonophobia, and was associated with a faster return to normal daily activities than placebo. Zolmitriptan NS is rapidly absorbed from the nasal mucosa and is associated with a fast onset of action, with one study showing a significant difference versus placebo with regard to headache response 15 min after administration. In both trials, zolmitriptan NS was generally well tolerated, with no serious adverse events. In conclusion, zolmitriptan NS provides rapid, effective and generally well tolerated treatment of acute migraine in pediatric patients 12 years of age or older and may be of particular benefit for those with nausea or not easily able to swallow tablets.

Headache in school children: is the prevalence increasing?

The objectives of this systematic review were to examine age dependency of headache prevalence in school age children and to assess secular trends of headache prevalence in the last decade, gender and regional differences. A literature search was performed in MEDLINE to identify all prevalence studies in children and adolescents. Five hundred seventy studies were found, of which 37 studies could be included for this review. Headache prevalence in school children increases with their age as demonstrated in cohorts of identical children and cross-sectional surveys covering different age groups of children in one population. Regarding a potential general increase in the prevalence of headache in children and adolescents in the last decade, there are four studies which all show some increase of headache prevalence; however, the degree of increase is varying. Prevalence of headache in girls appears to be higher than in boys. There were no clear regional differences in the prevalence of headache.

Pain and Moderate to Vigorous Physical Activity in Adolescence: An International Population-Based Survey

OBJECTIVE

To evaluate whether individual types of pain (headache, stomach-ache, and backache) or multiple pains affect the odds of young people achieving the recommended 60 minutes of moderate to vigorous physical activity (MVPA) per day in a large representative sample.

DESIGN

Multicenter cross-sectional survey.

SETTING

Twenty-eight countries across Europe and North America.

SUBJECTS

Adolescents (N = 242,103).

METHODS

An analysis of data collected in two waves (2001/02 and 2005/06) of the health behavior in school-aged children (HBSC) study was performed. Survey questions included the HBSC symptoms checklist and the amount of regular physical activity. Multilevel logistic regression was used to account for clustering effect of MVPA within countries. Models investigated the relationship between pain and physical activity, adjusted for the HBSC study year. Six models were conducted separately for gender and age-group (11, 13, and 15 years) strata.

RESULTS

In general, the presence of pain was associated with reduced physical activity. Headache alone was associated with reduced physical activity in all six strata (odd ratios 0.77-0.84), stomach-ache alone in five strata (0.77-0.92), and backache alone in four strata (0.86-0.96). In 11- and 13-year-old girls, headache, stomach-ache, and backache, individually and in combination, were associated with decreased odds of being physically active (odds ratios ranging from 0.73 to 0.91). Within the other four age and gender strata, the relationship was less consistent.

CONCLUSION

Pain is associated with reduced physical activity in adolescents but this association varies according to gender, age, and the type of pain experienced.

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.

Psychotherapy versus usual care in pediatric migraine and tension-type headache: a single-blind controlled pilot study

Background

Despite growing interest in psychotherapy in child and adolescent headache, efficacy studies in this research field have focused mainly on cognitive-behavioral therapies. Whereas relaxation and cognitive-behavioral techniques, in particular, have been found to reduce the intensity and frequency of headache in children and adolescents, data on psychodynamic psychotherapy in this population are lacking.

Our aim was to explore the effectiveness of a brief psychodynamic psychotherapy program in the treatment of idiopathic headache in childhood and adolescence.

Methods

Thirty-three newly diagnosed idiopathic headache sufferers aged 6–18 years, consecutively referred to our outpatient services, were randomized to receive either a brief cycle of psychodynamic psychotherapy (eight sessions administered at two-week intervals) or usual care (clinical interview, neurological examination, counselling, symptomatic therapy).

The two groups were evaluated at baseline (T0) and at six months (T1) to be assessed for headache characteristics (i.e. frequency, intensity and duration), quality of life (i.e. the EuroQoL score), patient’s global health status (i.e. the Clinical Global Impression score), and emotional-behavioral symptoms (i.e. Child Behavior Checklist scores).

Results

The two groups were fairly similar with reference to the main demographic and clinical variables. The T0/T1 comparison showed a statistically significant improvement in headache frequency (p = 0.005), intensity (p < 0.001) and duration (p = 0.002), a statistically significant improvement in the CGI score (p = 0.018), and a borderline improvement in the EuroQoL score (p = 0.053) in the group receiving psychotherapy.

Conclusions

According to our pilot findings, a brief psychodynamic psychotherapy program may be more effective than usual care in children and adolescents with idiopathic headache.

The presence of migraines and its association with sensory hyperreactivity and anxiety symptomatology in children with autism spectrum disorder

Migraine headaches are associated with sensory hyperreactivity and anxiety in the general population, but it is unknown whether this is also the case in autism spectrum disorders. This pilot study asked parents of 81 children (aged 7–17 years) with autism spectrum disorders to report their child’s migraine occurrence, sensory hyperreactivity (Sensory Over-Responsivity Inventory), and anxiety symptoms (Spence Child Anxiety Scale). Children with autism spectrum disorders who experienced migraine headaches showed greater sensory hyperreactivity and anxiety symptomatology (p < 0.01; medium effect size for both) than those without migraines. Sensory hyperreactivity and anxiety symptomatology were additionally correlated (ρ = 0.31, p = 0.005). This study provides preliminary evidence for a link between migraine headaches, sensory hyperreactivity, and anxiety symptomatology in autism spectrum disorders, which may suggest strategies for subtyping and exploring a common pathogenesis.

Headache and comorbidity in children and adolescents

Headache is one of the most common neurological symptom reported in childhood and adolescence, leading to high levels of school absences and being associated with several comorbid conditions, particularly in neurological, psychiatric and cardiovascular systems. Neurological and psychiatric disorders, that are associated with migraine, are mainly depression, anxiety disorders, epilepsy and sleep disorders, ADHD and Tourette syndrome. It also has been shown an association with atopic disease and cardiovascular disease, especially ischemic stroke and patent foramen ovale (PFO).