Psychiatric comorbidity in pediatric chronic daily headache

Subsume Pediatric Headaches in Psychiatric Disorders? Critiques on Delphic Nosology, Diagnostic Conundrums, and Variability in the Interventions

PURPOSE OF REVIEW

Tension-type headache (TTH) continues to be the most prevalent type of headache across all age groups worldwide, and the global burden of migraine and TTH together account for 7% of all-cause years lived with disability (YLDs). TTH has been shown to have a prevalence of up to 80% in several studies and presents a wide range and high variability in clinical settings. The aim of this review is to identify gaps in diagnostics, nosology, and variability in the treatment of children and adolescents who present with headaches without an identifiable etiology.

RECENT FINDINGS

Migraine and TTH have been debated to have more similarities than distinctions, increasing chances of misdiagnosis and leading to significant cases diagnosed as probable TTH or probable migraine. The lack of specificity and sensitivity for TTH classification often leads to the diagnosis being made by negating associated migraine symptoms. Although pathology is not well understood, some studies have suggested a neurological basis for TTH, in need of further validation. Some research indicates that nitric oxide signaling plays an integral part in the pain mechanisms related to TTH. Analgesics and non-steroidal anti-inflammatories are usually the first lines of treatment for children with recurring headaches, and additional treatment options include medication and behavioral therapies. With high prevalence and socioeconomic burden among children and adolescents, it's essential to further study Tension-type headaches and secondary headaches without known cause and potential interventions. Treatment studies involving randomized controlled trials are also needed to test the efficacy of various treatments further.

Clinic-Based Characterization of Adolescents and Young Adults With Migraine: Psychological Functioning, Headache Days, and Disability

Background and Objectives

This cross-sectional observational study retrospectively examined clinical data collected from adolescents and young adults (AYAs) seeking care in a specialty headache clinic. We characterized participants' headache characteristics and psychological functioning and examined the association between self-reported anxiety and depressive symptoms and headache frequency, severity, and disability.

Methods

During their clinic visit, AYAs (M age = 18.36; range = 14-32, 79.5% female) completed an intake questionnaire and reported about their headache characteristics (i.e., frequency, severity, and duration of symptoms in months), mental health history (i.e., previous diagnosis of an anxiety or depressive disorder), and utilization of emergency department (ED) services for migraine. AYAs also completed psychometrically validated screening tools for anxiety and depressive symptoms (i.e., the GAD-7 and PHQ-9). We computed descriptive statistics and examined associations among scores on psychological measures and headache characteristics, including migraine-related disability. We also tested whether individuals with clinically elevated GAD-7 and PHQ-9 scores had higher levels of disability relative to those with fewer/subclinical levels of anxiety and depressive symptoms.

Results

Participants (N = 283) reported more than 19 headache days per month on average, with more than 90% describing their average headache intensity as moderate or severe. Nearly half of AYAs reported severe headache-related disability. Approximately one-quarter of AYAs reported a previous diagnosis anxiety or depressive disorder diagnosis, and more than one-third scored above clinical cutoffs on the PHQ-9 and GAD-7. Higher scores on both psychological screening instruments were associated with greater headache frequency. More than 10% of patients endorsed current suicidal ideation; this was not related to headache-related disability. Participants reported a high degree of ED utilization for headache; these rates were unrelated to endorsement of psychological comorbidities.

Discussion

In this sample of AYAs, headache characteristics were generally unrelated to scores on measures on psychological functioning. However, the observed rates of clinically elevated anxiety/depressive symptoms and suicidality in this sample of AYAs underscore the importance of screening for psychological comorbidities in neurology clinics that serve this age group, irrespective of self-reported disability. Results also emphasize the need to expand access to behavioral health services for AYAs with headache disorders and the importance of incorporating a biopsychosocial perspective to the transition of health care from pediatrics to adult neurology practice.

Quality of life in children suffering from headaches: a systematic literature review

BACKGROUND

Headaches are the most common complaints among pediatric populations. Determining the cause and appropriate treatment for headaches may be challenging and costly, and the impact of headaches on the lives of patients and their families is not well understood.

OBJECTIVE

A systematic literature review was conducted to examine what PROMs are currently used, and to identify quality of life (QoL) concepts important to children suffering from headaches and any known determinants of QoL.

METHODS

Embase, Medline, Web of Science, CINAHL, EBSCOhost, PsychINFO, Cochrane CENTRAL and Google Scholar were searched from their inception through to June 2021. Studies investigating QoL, using a validated outcome measure in pediatric patients with headaches, were included. Relevant studies were identified through title and abstract screening and full text review by two independent reviewers. A citation review of included studies was performed. QoL concepts were extracted from the outcome measures that were used in each study to develop a preliminary conceptual model of QoL in children suffering from headaches. Determinants of QoL were also identified and categorized.

RESULTS

A total of 5421 studies were identified in the search. Title and abstract screening resulted in the exclusion of 5006 studies. Among the 415 studies included for full text review, 56 were eligible for final analysis. A citation review resulted in the addition of five studies. Most studies were conducted in high-income countries and included a patient-sample accordingly (n = 45 studies). Sixteen different PROMs were identified in the included studies, of which the PedsQL was used the most often (n = 38 studies). The most common health concepts reported were physical functioning (n = 113 items), social and psychological wellbeing (N = 117, n = 91 resp.). Twenty-five unique determinants of QoL were extracted from the included studies.

CONCLUSION

There is a need for a condition-specific PROM to facilitate the measurement of QoL outcomes in the pediatric headache population. A conceptual model was developed based on the findings from the health concepts. Findings from this review could be used for future qualitative interviews with pediatric patients with headaches to elicit and refine important QoL concepts.

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.

Multimodal Assessment of Medication Adherence Among Youth With Migraine: An Ancillary Study of the CHAMP Trial

OBJECTIVE

Examine preventive medication adherence among youth with migraine.

METHODS

Adherence (self-report, pill count, and blood serum drug levels) was assessed as an ancillary study that utilized data from 328 CHAMP Study participants (ages 8-17). CHAMP was a multisite trial of preventive medications. Participants completed a prospective headache diary during a six-month active treatment period during which youth took amitriptyline, topiramate, or placebo pill twice daily. Self-reported medication adherence was collected via daily diary. At monthly study visits, pill count measures were captured. At trial month 3 (trial midpoint) and 6 (end of active trial), blood serum drug levels were obtained. Self-report and pill count adherence percentages were calculated for the active trial period, at each monthly study visit, and in the days prior to participants' mid-trial blood draw. Percentages of nonzero drug levels were calculated to assess blood serum drug level data. Adherence measures were compared and assessed in context of several sociodemographic factors. Multiple regression analyses investigated medication adherence as a predictor of headache outcomes.

RESULTS

Self-report and pill count adherence rates were high (over 90%) and sustained over the course of the trial period. Serum drug level adherence rates were somewhat lower and decreased significantly (from 84% to 76%) across the trial period [t (198) = 3.23, p = .001]. Adherence measures did not predict headache days at trial end; trial midpoint serum drug levels predicted headache-related disability.

CONCLUSIONS

Youth with migraine can demonstrate and sustain relatively high levels of medication adherence over the course of a clinical trial.

Headache in Children and Adolescents

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Obesity, Migraine, and Overlapping Comorbidities in a Rural Pediatric Population

Objective  This study aims to report the prevalence of obesity and overlapping comorbidities in a rural population of children and adolescents with migraine. Design and Methods  A cross-sectional, descriptive, secondary data analysis using a comprehensive patient database from the West Virginia University (WVU) Medicine Epic Clarity system will be reported. A review of electronic medical records of 990 children and adolescents, ages 7 to 17 years, evaluated for headache at a rural clinic from December 1, 2009 to December 31, 2017 was completed. The Chi-square test was used to identify any differences in demographic characteristics (age, gender, and race) and distribution of comorbidities (obstructive sleep apnea syndrome [OSAS], depression, and anxiety) among obese versus nonobese adolescents with migraine. Student's t -test was used to identify any differences in the number of comorbidities between the two groups. Results  A total of 648 children and adolescents with a diagnosis of migraine were identified. Approximately 26.4% of the children and adolescents diagnosed with migraine ( n = 648) met the criteria for being obese with a mean body mass index (BMI) of 30.6 kg/m ² (standard deviation [SD] = 6.5), ranging from 20.0 to 58.5 kg/m ² . There were no significant differences between migraineurs who were categorized as obese versus nonobese in terms of gender ( p = 0.8587), age ( p = 0.1703), race ( p = 0.7655), anxiety ( p = 0.1841), or depression ( p = 0.2793). Obese individuals have more comorbidities than nonobese individuals ( p = 0.015). Additionally, the prevalence of OSAS was significantly higher among obese versus nonobese migraineurs (20 vs. 9.9%, p = 0.0007). Conclusion  Given the prevalence of obesity in rural pediatric populations and the reported neurobiological links between migraine and obesity, BMI needs to be monitored and weight management interventions included in plans of care for rural children and adolescents with migraine.

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.

Evaluating the psychometric properties of the Widespread Pain Index and the Symptom Severity scale in youth with painful conditions

Background

Assessing features of centralized pain may prove to be clinically meaningful in pediatric populations. However, we are currently limited by the lack of validated pediatric measures.

Aim

We examined the psychometric properties of the Widespread Pain Index (WPI) and Symptom Severity (SS) scale, to assess features of centralized pain, in youth with painful conditions from three clinical samples: (1) musculoskeletal surgery, (2) headache, and (3) chronic pain.

Methods

Participants were 240 youth aged 10-18 years (Mage=14.8, SD=1.9) who completed the WPI and SS scale. Subsets of participants also completed additional measures of pain region, pain intensity, quality of life, pain interference and physical function.

Results

Increased features of centralized pain by age were seen for the WPI (r=0.27, p<0.01) and SS scale (r=0.29, p<0.01). Expected differences in sex were seen for the WPI (sex:t₁₃₂=-3.62, p<0.01), but not the SS scale (sex:t₂₂₃=-1.73, p=0.09). Reliability for the SS scale was adequate (α=.70). Construct validity was demonstrated through relationships between the WPI and pain regions (r=.57, p<0.01), and between the SS scale and quality of life (r=-.59, p<0.01) and pain interference (r=.56, p<0.01). Criterion validity was demonstrated by differences on the WPI between the surgery sample and the headache and chronic pain samples (F_2,237=17.55, p<0.001). Comprehension of the SS scale items was problematic for some youth.

Conclusions

The WPI showed adequate psychometric properties in youth; however the SS scale may need to be modified. Our findings support the need to develop psychometrically sound instruments for comprehensive assessment of pain in pediatric samples.

Guidelines of the International Headache Society for controlled trials of preventive treatment of migraine in children and adolescents, 1st edition

Background

Because the results of clinical trials of investigational treatments influence regulatory policy, prescribing patterns, and use in clinical practice, high quality trials are an essential component of the evidence base for migraine. The International Headache Society has published guidelines for clinical trials in adults with migraine since 1991. With multiple issues specific to children and adolescents with migraine, as well as the emergence of novel trial designs and advances in pharmaceuticals, biologics, devices, and behavioural interventions, there is a need for guidance focusing on issues specific to the conduct of clinical trials in children and adolescents with migraine.

Objectives

The objective of these guidelines is to provide a contemporary, standardized, and evidence-based approach to the design, conduct, and reporting of well-controlled clinical trials of preventive treatment of migraine in children and adolescents.

Methods

The development of these guidelines was based on guidelines previously published by the International Headache Society and regulatory bodies. The recommendations are evidence-based, where available. The process included consultations among various committees, roundtable discussions among stakeholders (lay people and the pharmaceutical industry), and open consultation with the IHS membership on the final draft.

Results

A series of recommendations addressing the major issues in clinical trials in children and adolescents with migraine is provided. Recommendations are supported by evidence-based practice and validated methodologies, where available. Supporting comments are provided to clarify ambiguities.

Conclusions

These guidelines should be consulted and used in designing and conducting clinical trials of preventive treatments in children and adolescents with migraine.

Current perspectives on the development and treatment of chronic daily headache in children and adolescents

Headache disorders subsumed under the term chronic daily headache (CDH), including chronic migraine, chronic tension-type headache and new daily persistent headache, affect up to 4% of the pediatric population and can be highly disabling and challenging to effectively treat. Although historically the knowledge base about this group of headache disorders in children primarily was derived from clinical observation and extrapolation from adult studies, over the past several years there have been important research findings relevant to the development and management of pediatric CDH that can help inform clinical practice. The intent of this paper is to provide a focused review on recent empirical work done on pediatric CDH and suggest avenues for future work.

Migraine in children: presentation, disability and response to treatment

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Associations Between Depression/Anxiety and Headache Frequency in Migraineurs: A Cross-Sectional Study

BACKGROUND

While migraines have been associated with emotional disturbances, it remains unknown whether the intensity of emotional expression is directly related to migraine frequency.

OBJECTIVE

The present study investigated depression/anxiety among migraineurs.

METHODS

This cross-sectional study included 588 clinical outpatients in Taiwan. Migraines were stratified by attack frequency, with and without auras, and with well-controlled confounding variables. Demographic and clinical data, including sleep characteristics, were collected. Multivariable linear regressions were employed to examine whether migraine frequency (1-4 headache days per month, 5-8 headache days per month, 9-14 headache days per month, or >14 headache days per month) was associated with depression/anxiety symptoms, as indicated by the Beck's Depression Inventory (BDI) and Hospital Anxiety and Depression Subscales (HADS).

RESULTS

BDI total scores were highest in patients with chronic migraines (mean ± SD: 13.2 ± 8.5), followed by those with high frequency (12.1 ± 8.5), medium frequency (10.6 ± 8.0), low frequency (9.1 ± 7.1), and lowest in nonmigraine controls (6.6 ± 5.9), with a significant trend in frequency (P trend < .001); similar results were obtained for HADS scores. BDI and HADS scores were independently related to high-frequency episodic and chronic migraine frequency and to poor sleep quality. The relationship between BDI score and migraine frequency was present in both aura-present (P trend = .001) and aura-absent subgroups (P trend = .029).

CONCLUSION

Higher migraine frequency, either with or without auras, correlated with higher symptom scores of anxiety and depression.

Behavioral Treatment for Headaches in Children: A Practical Guide for the Child Psychologist

Headache is a highly prevalent condition and is the leading cause for school absences. Despite the rich literature supporting behavioral treatments for headache, many child psychologists mistakenly perceive that they lack appropriate training to treat children with headache. Likewise, many physicians feel underprepared to refer the child for behavioral treatments. This article serves as a primer, providing tools for the general child psychologist or mental health provider by answering frequently asked questions. First, we provide a concise background on pathophysiology and medical care for headache. We then detail aspects of behavioral interventions for headache, including a case example. We included a limited list of up-to-date references most relevant to the child psychologist who does not treat headache on a regular basis to support further reading. By reviewing this primer, local mental health professionals can provide children with headache access to high-quality, evidence-based clinical care closer to home.

Predicting Multiple Facets of School Functioning in Pediatric Chronic Pain: Examining the Direct Impact of Anxiety

OBJECTIVES

The relationships among chronic pain, anxiety, and school functioning are complex, and school functioning is often negatively impacted in youth with chronic pain. The objective of this study was to empirically test a model of associations between constructs predicting school functioning in youth with chronic pain to examine the direct effect of anxiety on school attendance and other indicators of school-related disability.

MATERIALS AND METHODS

Participants included 349 youth and their parents (311 mothers and 162 fathers) who attended a multidisciplinary pain clinic. Youth, mothers, fathers, and clinicians completed assessments of clinical outcomes important to family and clinician perceptions of school functioning; youth, mothers, and fathers completed an assessment of youth anxiety. Structural equation modeling was used to examine interrelations among predictors.

RESULTS

Measurement and structural models for predicting youth school functioning provided a very good fit of the data to the conceptual model. Anxiety was directly related to problems with school attendance and avoidance, concentration, and keeping up with schoolwork.

DISCUSSION

Anxiety was a robust predictor of school functioning across a range of domains. Evaluating anxiety symptoms in pediatric chronic pain will likely facilitate case conceptualization and treatment planning. This study supports a shift in focus from pain to anxiety as the driving force of school impairment in youth with chronic pain.

Comorbid Psychological Conditions in Pediatric Headache

Children and adolescents with chronic daily headaches (CDH) often have comorbid psychological conditions, though their prevalence is unclear. Pediatric patients with CDH may have higher rates of disorders such as anxiety and depression. However, some researchers have found that scores on depression and anxiety screening measures for pediatric patients with migraine are within reference range. Barriers to identify patients with psychiatric disorders have included limited validated screening tools and lack of available mental health resources. Several validated screening tools have recently been used in studies of pediatric patients with CDH. Once identified, treatment of comorbid psychological conditions may lead to improved functioning and headache outcomes.

Managing Migraine Headaches in Children and Adolescents

The diagnosis and management of migraine headaches can be challenging in children and adolescents. The description of migraine in this population may include symptoms that are not typically described in adults. Treatment options for pediatric migraine is increasing, however remain limited. This article will go through the key components to diagnosing migraine in pediatric patients as well as give options for short and long-term management.

Headache in school age

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

Relationship of childhood headaches with preferences in leisure time activities, depression, anxiety and eating habits: A population-based, cross-sectional study

OBJECTIVES

The objective of this article is to determine the relationship between headache frequency and socio-demographic data, personal characteristics, habits, daily activities, daily loss of ability, depression and anxiety in the headache subtypes in the pediatric population.

PATIENTS AND METHODS

Our sample group was composed of approximately 5355 children aged between 9 and 18 years. An eight-stage questionnaire was administered to the children. In the second stage of the study, headache subtypes were created according to the ICHD-II criteria. The resulting data were compared according to the results of the headache subtypes.

RESULTS

In school-age children, the prevalence of recurrent headaches was 39.4%, and the prevalence of migraine was 10.3%. The subjects with migraine mostly preferred sedentary activities in their leisure time, and preferred less exercise than the subjects with the other headache types. The PedMIDAS score of the children who preferred to play sports was significantly lower than those who did not prefer to play sports. In the group that preferred reading books, an opposite relationship was found. In overweight and obese migraine sufferers, other types of headache were found to be significantly higher.

CONCLUSIONS

In the management of treating childhood headaches, the association of psychiatric comorbidities should be considered. To minimize disability, children should be directed to more useful physical activities.

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.

Fear of pain in pediatric headache

OBJECTIVE

The current study provides the first measure of pain-related fear for pediatric headache patients.

METHODS

From a large pediatric headache clinic, a cross-sectional cohort of 206 children and adolescents completed measures of pain-related fear, anxiety sensitivity, catastrophizing, pain acceptance, functional disability, and school functioning.

RESULTS

The two-factor solution of the Fear of Pain Questionnaire (FOPQ) was confirmed from the originally derived structure with pediatric headache patients. Simultaneously regressing FOPQ subscales fear of pain and activity avoidance on theorized construct validity measures demonstrated that fear of pain was more closely linked with anxiety sensitivity and pain catastrophizing while activity avoidance had a strong negative association with pain acceptance (activity engagement and pain willingness). Pain-related fear was not significantly associated with pain level. After controlling for demographic factors and pain, fear of pain and activity avoidance accounted for an additional 26% of the variance in functional disability and school functioning outcomes, with activity avoidance accounting for much of this relationship.

CONCLUSIONS

Although typically considered an influential construct among musculoskeletal patients, pain-related fear is also an important factor influencing functioning among pediatric headache patients, with the dimension of activity avoidance particularly salient.

Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: a randomized clinical trial

IMPORTANCE

Early, safe, effective, and durable evidence-based interventions for children and adolescents with chronic migraine do not exist.

OBJECTIVE

To determine the benefits of cognitive behavioral therapy (CBT) when combined with amitriptyline vs headache education plus amitriptyline.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial of 135 youth (79% female) aged 10 to 17 years diagnosed with chronic migraine (≥15 days with headache/month) and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points were assigned to the CBT plus amitriptyline group (n = 64) or the headache education plus amitriptyline group (n = 71). The study was conducted in the Headache Center at Cincinnati Children's Hospital between October 2006 and September 2012; 129 completed 20-week follow-up and 124 completed 12-month follow-up.

INTERVENTIONS

Ten CBT vs 10 headache education sessions involving equivalent time and therapist attention. Each group received 1 mg/kg/d of amitriptyline and a 20-week end point visit. In addition, follow-up visits were conducted at 3, 6, 9, and 12 months.

MAIN OUTCOMES AND MEASURES

The primary end point was days with headache and the secondary end point was PedMIDAS (disability score range: 0-240 points; 0-10 for little to none, 11-30 for mild, 31-50 for moderate, >50 for severe); both end points were determined at 20 weeks. Durability was examined over the 12-month follow-up period. Clinical significance was measured by a 50% or greater reduction in days with headache and a disability score in the mild to none range (<20 points).

RESULTS

At baseline, there were a mean (SD) of 21 (5) days with headache per 28 days and the mean (SD) PedMIDAS was 68 (32) points. At the 20-week end point, days with headache were reduced by 11.5 for the CBT plus amitriptyline group vs 6.8 for the headache education plus amitriptyline group (difference, 4.7 [95% CI, 1.7-7.7] days; P = .002). The PedMIDAS decreased by 52.7 points for the CBT group vs 38.6 points for the headache education group (difference, 14.1 [95% CI, 3.3-24.9] points; P = .01). In the CBT group, 66% had a 50% or greater reduction in headache days vs 36% in the headache education group (odds ratio, 3.5 [95% CI, 1.7-7.2]; P < .001). At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education group; 88% of the CBT group had a PedMIDAS of less than 20 points vs 76% of the headache education group. Measured treatment credibility and integrity was high for both groups.

CONCLUSIONS AND RELEVANCE

Among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with use of headache education plus amitriptyline. These findings support the efficacy of CBT in the treatment of chronic migraine in children and adolescents.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00389038.

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).

Relationship between daily mood and migraine in children

BACKGROUND

Retrospective and cross-sectional studies have suggested a bidirectional relationship between migraine and mood disturbance.

OBJECTIVE

The present prospective daily diary study examined the prevalence and temporal associations between migraine and daily mood, mood and next-day headache, and headache and next-day mood.

METHODS

Sixty-nine children (50 females, 19 males) between the ages of 7 and 12 years and their parents attending neurology clinic appointments and having a diagnosis of migraine as defined by International Headache Classification 2nd edition criteria completed measures on the quality of life, headache disability, child emotions, and child behaviors. Children and parents then recorded children's headache occurrence, headache duration, headache severity, mood, daily hassles, and medication use on paper diaries once a day for 2 consecutive weeks. "Mood" was defined using the Facial Affective Scale, which is a visual representation of negative and positive affect. Data were analyzed using multilevel models.

RESULTS

Controlling for age, sex, quality of life, headache disability, and medication use, worse mood was associated with same-day occurrence, longer duration, and more severe headache in both child and parent report. Today's mood was not consistently associated with next-day headache, and today's headache was not associated with next-day mood in either child or parent report.

CONCLUSIONS

Results of this study lend support to a complex relationship between mood and headache in children with migraine. More research is needed to further elucidate the temporal nature of this relationship within a given day and over an extended period of time.

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.