Nonpharmacologic Treatment Options in Pediatric Tension-Type Headache Patients: A Systematic Review

Objective: This systematic review aims to examine effects of nonpharmacologic treatment options for pediatric tension-type headache patients as well as evaluate current results from these treatment options. Background: Headache is a worldwide problem among both adults and children, with tension-type headache among the most common. Methods: Eighteen relevant studies were found using PubMed and evaluated in this review. These include therapy programs, biofeedback, alternative medicine, strength exercise, physical therapy, mindfulness therapy, and psychotherapy. Results: Several nonpharmacologic treatment methods showed improvement in pediatric headache patients, with few reported adverse effects. This suggests that nonpharmacologic treatment is safe for use and might have an effect in most cases. Conclusion: No single intervention has been proven superior to another, and some studies would need replication with a control group to confirm the findings. This study illustrates the variety of nonpharmacologic treatment options and the importance of future research on this topic.

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

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

The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review

OBJECTIVES

Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions.

METHODS

An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison.

RESULTS

From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating.

DISCUSSION

A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

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

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

Is It Worth It? A Comparison of an Intensive Interdisciplinary Pain Treatment and a Multimodal Treatment for Youths With Pain-related Disability

OBJECTIVE

The objective of this study was to evaluate the effectiveness of an intensive interdisciplinary pain treatment (IIPT) day-hospital program as compared with an outpatient multimodal treatment (MMT) for youth with chronic pain.

MATERIALS AND METHODS

A nonrandomized pretest posttest with control group design was used. A battery of patient-oriented measures assessing pain interference, quality of life, and depressive symptoms were completed at treatment commencement and at 3, 6, and 12 months after treatment by 44 youths enrolled in the IIPT and 138 youths engaged in the MMT, with various chronic pain conditions. Data were analyzed using longitudinal mixed-effects models.

RESULTS

The main outcomes were the score difference from baseline of patient-oriented measures across 3 timepoints within 12 months of intervention initiation for both treatment groups. IIPT participants demonstrated greater improvement in pain interference, as compared with MMT at 3 and 12 months. Initially, health-related quality of life scores improved similarly in both groups, but greater improvement was seen in the MMT group at 12 months. Depressive symptom scores did not improve with either intervention. Only pain interference scores reached statistically and clinically significant difference levels.

DISCUSSION

This study supports the benefits of specialized rehabilitation interventions, including both MMT and IIPT programs, for youths with chronic pain. The findings also suggest that IIPT might have a greater long-term effect for helping youths, in particular those with high pain interference scores.

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.

Tension-type headache

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

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

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

Does intensive interdisciplinary pain treatment improve pediatric headache-related disability?

Purpose: To examine the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache using the International Classification of Functioning, Disability and Health model as a conceptual framework for disability assessment.Materials and methods: Children with chronic headache (n = 50; ages 10-19 years; 62% female) attended an intensive interdisciplinary pain treatment program 8 h/day, 5 times/week for 2-7 weeks. Disability measures were administered at admission, discharge, and 6-8 week follow-up. Disability outcomes were analyzed retrospectively. Wilcoxon signed rank tests and Friedman's analyses of variance were used to compare scores across two and three longitudinal time points, respectively.Results: After rehabilitation, disability reduced on the Headache Impact Test-6 from severe impact at admission to some impact at follow-up (p < 0.001). Median time on the modified Bruce protocol increased from 13.1 min (interquartile range = 12.6-14.1) to 14.4 min (interquartile range = 12.9-16.3), p < 0.001, with gains maintained at follow-up. Improvements in pain and disability were associated with improvements in school participation.Conclusions: Findings of this study support the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache.Implication for rehabilitationIntensive interdisciplinary pain treatment is effective for improving pain and disability in children with chronic headaches.Application of the ICF model to disability assessment suggests that children with chronic headaches may experience significant disability, even when standardized assessments of physical capacity are normal.The modified Bruce protocol, Pediatric Evaluation of Disability Inventory - Computerized Adaptive Tests, and Headache Impact Test-6 appear particularly valuable in understanding the nature of disability in children with chronic headaches.

Nonpharmacological Interventions Addressing Pain, Sleep, and Quality of Life in Children and Adolescents with Primary Headache: A Systematic Review

Purpose

Children and adolescents with primary headache are at risk of persistent somatic symptoms and reduced quality of life (Qol) due to pain and pain-related behaviors, such as avoiding school and activities. Sleep is essential to health, and children and adolescents with primary headaches have more sleep complaints than do healthy controls. A treatment approach that addresses multifactorial causes is likely important. Nonpharmacological interventions seem promising. However, knowledge about effective strategies is limited. The objective of this review is to assess the effect of nonpharmacological interventions in randomized controlled trials (RCTs) among children and adolescents with primary headache in order to identify useful strategies.

Patients and methods

Outcome measures are pain, sleep, Qol, and coping versus no intervention or control intervention. Medline, CINAHL, EMBASE, and PsycINFO were searched for eligible trials. ClinicalTrials.gov. was searched for ongoing trials. Initial searches yielded 2588 publications. After initial screening and subsequent full-text review and quality assessment, 13 RCTs reported in 15 articles were selected for review. All reviewers independently assessed study quality using the CONSORT criteria for nonpharmacological interventions.

Results

Cognitive behavioral therapy (CBT), including education on pain-related topics, sleep, coping, and stress management, is an effective strategy for reducing headache and pain within groups over time. Fifteen studies assessed pain, 3 studies assessed sleep, 6 studies assessed Qol, and 11 studies assessed coping.

Conclusion

Strategies identified as useful were parts of CBT interventions. However, it was not possible to identify a single effective intervention addressing pain, sleep, Qol, and coping in children and adolescents with headache, primarily because sleep was infrequently addressed. Various aspects of Qol and coping strategies were assessed, rendering comparison difficult. Strategies for future interventions should include descriptions of theory-driven CBT interventions, depending on clinical setting and based on local resources, to promote a solid evidence base for nonpharmacological interventions.

The construct validity of the Child Health Utility 9D-DK instrument

BACKGROUND

Relative to their application with adults there is currently little information about the application of preference-based health-related quality of life (HRQL) instruments among populations of young people. The Child Health Utility 9D (CHU9D) is a paediatric-specific generic preference-based HRQL instrument, recently translated and linguistically validated into Danish (CHU9D-DK). The purpose of this study was to investigate the construct validity of the CHU9D-DK in a sample of Danish high school students.

METHODS

All students attending a Danish High School were invited to participate in a web-based survey in January 2018 (N = 272). The survey included the CHU9D-DK, the young adult version of the Pediatric Quality of Life Inventory™ 4.0 Generic Core Scales (PedsQL), self-reported health status, presence/absence of disability/chronic diseases, life satisfaction, and socio-economic questions. CHU9D-DK utility scores were generated by employing the two scoring algorithms developed from adults in the UK and adolescents in Australia, respectively. Internal consistency, reliability and construct validity of the CHU9D-DK instrument were investigated.

RESULTS

Two hundred and twenty-eight (84%) students consented to participate and completed the survey. The mean ± (standard deviation) values of the CHU9D-DK utilities were 0.84 (0.11) when the UK adult algorithm was applied and 0.70 (0.22), when the Australian adolescent algorithm was applied. The mean PedsQL score was 82.32 (13.14). The CHU9D-DK showed good internal consistency reliability (Cronbach's alpha = 0.803). Higher levels of health status and life satisfaction were significantly associated with higher CHU9D-DK utility scores regardless of which scoring algorithm was applied (p-values < 0.001). Students living with a disability/chronic disease exhibited significantly lower utility scores relative to their healthy peers (p-values < 0.05). Higher socio-economic status (approximated by financial situation and frequency of family vacations) was also associated with higher utility scores (p-values < 0.005).

CONCLUSION

The CHU9D-DK demonstrated good psychometric performance overall and shows potential as a valid and reliable instrument for assessing the HRQL of Danish young people.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03391999, Registered 15 October 2017.

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.

Pediatric Headache Clinic Model: Implementation of Integrative Therapies in Practice

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

Atypical Facial and Head Pain in Childhood and Adolescence

PURPOSE OF REVIEW

This review will consider forms of atypical facial and head pain in children and adolescents. A brief and general overview of typical head and facial pains and treatments will be offered. Moreover, atypical head and face pain will be discussed with treatment options.

RECENT FINDINGS

The most recent literature including case reports will be evaluated; possible pathophysiological mechanisms, resulting disabilities, and family and social impact will be discussed. General indications for pharmacological treatment will be reviewed, when needed in more disabling cases. Also, non-pharmacological treatments that are especially suitable for this category of patients will be illustrated and discussed.

Off-Label Prescribing for Children with Migraines in U.S. Ambulatory Care Settings

BACKGROUND

Migraines, Which Affect About 10% Of School-Age Children In The United States, Can Significantly Impair Quality Of Life. Despite Potential Disability, Many Children Do Not Receive Treatment Or Prophylaxis, Since Medications Specifically Approved For Children Are Significantly Less Than For Adults. There Is Also Controversy Surrounding The Apparent Widespread Practice Of Prescribing Off-Label Medications For Children With Migraines. However, Little Research Has Been Done To Identify Physician-Prescribing Patterns Of Migraine Medication For Children.

OBJECTIVE

To Investigate The Prevalence And Pattern Of Off-Label Prescribing For Children With Migraines.

METHODS

A Secondary Data Analysis Was Conducted Using The Pooled National Ambulatory Medical Care Survey (Namcs) 2011 And 2012. Patients Aged 17 Years Or Younger With A Migraine Diagnosis Were Included. A Series Of Weighted Descriptive Analyses Were Used To Estimate The Prevalence Of Migraine Drugs Prescribed During Pediatric Office Visits. A Weighted Logistic Regression Was Constructed To Compare The Prescribing Patterns Between Off-Label And Fda-Approved Medications. Analyses Used Sas 9.4 Methodology And Incorporated Sample Weights To Adjust For The Complex Sampling Design Employed By Namcs.

RESULTS

Of The 12.9 Million Outpatient Visits With A Migraine Diagnosis That Took Place Between 2010 And 2012, 1.2 Million Were Pediatric Visits. Females Accounted For Nearly Twice The Number Of Migraine Visits Than Males (66% Vs. 34%). Children Aged 12-17 Years Accounted For The Highest Frequency Of Visits (84%), Compared With Those Aged Under 12 Years (16%). 66.7% Of These Pediatric Patients Received At Least 1 Migraine Drug. Of These, Off-Label Medications Were Prescribed 1.5 Times More Than Fda-Approved Medications For Children (60.34% Vs. 39.65%). The Results Of Logistic Regression Showed A Significant Likelihood Of Prescribing Off-Label Medications Based On Physician Specialty, Patient Race, And Reason For Visit. Neurologists (Or = 0.028, P < 0.05) And Pediatricians (Or = 0.095, P < 0.05) Were Less Likely To Prescribe Off-Label Drugs Than General And Family Practitioners. Visits For Preventive Care (Or = 5.8, P < 0.05) And Flare-Ups From Chronic Migraines (Or = 5.0, P < 0.05) Were More Likely To Result In Off-Label Drug Prescriptions Than Visits For New Migraine Incidence.

CONCLUSIONS

This Study Provides Significant Real-World Evidence Of The Widespread Practice Of Prescribing Off-Label Drugs To Children With Migraines. Although Medical Literature Shows That Off-Label Prescribing May Not Be Harmful, There Is A Dearth Of Research And Practice Guidelines To Help Practitioners Uphold Safety Standards And Ensure The Prescription Of Age-Appropriate Medications To Children.

DISCLOSURES

No outside funding supported this study. The authors report no potential conflicts of interest relevant to this research. Lai and Ting contributed to study concept and design and collected the data, along with the other authors. Data interpretation was performed by Lai, Koh, Obi, Ho, and Ting. The manuscript was written and revised by Lai, Koh, and Ho, with assistance from Ting and Obi.

"Headache Tools to Stay in School": Assessment, Development, and Implementation of an Educational Guide for School Nurses

BACKGROUND

Headache is the most common type of pain reported in the pediatric population, and chronic headache is an increasingly prevalent and debilitating pain condition in children and adolescents. With large numbers of students experiencing acute headaches and more students with chronic headache reentering typical school settings, greater availability of tailored evidence-based practice guidelines for school nurses is imperative.

METHODS

A 2-armed study was developed to assess the need for and evaluate the use and favorability of a headache-driven school nurse guide. Students and their parents were first surveyed on their school nurse's headache knowledge and management skills. School nurses were also interviewed on their desire for a headache educational tool. This feedback aided in developing a headache resource guide. Next, the guide was distributed to school nurses who provided feedback after a 3-month trial.

RESULTS

Results indicate that "Headache Tools to Stay in School" is a useful resource in facilitating communication among health care providers, students, families, and school personnel on how to best meet the complex needs of students with headaches.

CONCLUSIONS

Given the guide's favorability, we encourage school nurses to demand the creation of additional evidence-based resources. Continued dissemination of this guide may improve students' headache management under the informed care of school nurses, and may encourage the development of more evidence-based guides across various medical conditions.

Specific strength training compared with interdisciplinary counseling for girls with tension-type headache: a randomized controlled trial

BACKGROUND

Childhood tension-type headache (TTH) is a prevalent and debilitating condition for the child and family. Low-cost nonpharmacological treatments are usually the first choice of professionals and parents. This study examined the outcomes of specific strength training for girls with TTH.

METHODS

Forty-nine girls aged 9-18 years with TTH were randomized to patient education programs with 10 weeks of strength training and compared with those who were counseled by a nurse and physical therapist. Primary outcomes were headache frequency, intensity, and duration; secondary outcomes were neck-shoulder muscle strength, aerobic power, and pericranial tenderness, measured at baseline, after 10 weeks intervention, and at 12 weeks follow-up. Health-related quality of life (HRQOL) questionnaires were assessed at baseline and after 24 months.

RESULTS

For both groups, headache frequency decreased significantly, P=0.001, as did duration, P=0.022, with no significant between-group differences. The odds of having headache on a random day decreased over the 22 weeks by 0.65 (0.50-0.84) (odds ratio [95% confidence interval]). For both groups, neck extension strength decreased significantly with a decrease in cervicothoracic extension/flexion ratio to 1.7, indicating a positive change in muscle balance. In the training group, shoulder strength increased $10% in 5/20 girls and predicted [Formula: see text] increased $15% for 4/20 girls. In the training group, 50% of girls with a headache reduction of $30% had an increase in [Formula: see text] >5%. For the counseling group, this was the case for 29%. A 24-month follow-up on HRQOL for the pooled sample revealed statistically significant improvements. Fifty-five percent of the girls reported little to none disability.

CONCLUSION

The results indicate that both physical health and HRQOL can be influenced significantly by physical exercise and nurse counseling. More research is needed to examine the relationship between physical exercise, [Formula: see text], and TTH in girls. Thus, empowering patient education to promote maximum possible outcomes for all children needs more attention.

Update of Inpatient Treatment for Refractory Chronic Daily Headache

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15 days per month) and last for more than 3 months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4 h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

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

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

The relationship between sleep and headache in children: implications for treatment

BACKGROUND

The existence of a correlation and/or comorbidity between sleep disorders and headache, related to common anatomical structures and neurochemical processes, has important implications for the treatment of both conditions.

METHODS

The high prevalence of certain sleep disorders in children with migraine and the fact that sleep is disrupted in these patients highlight the importance of a specific therapy targeted to improve both conditions.

FINDINGS

The treatment of sleep disorders like insomnia, sleep apnea, sleep bruxism and restless legs syndrome, either with behavioral or pharmacological approach, often leads to an improvement of migraine. Drugs like serotoninergic and dopaminergic compounds are commonly used for sleep disorders and for migraine prophylaxis and treatment: Insomnia, sleep-wake transition disorders and migraine have been related to the serotonergic system abnormality; on the other hand prodromal symptoms of migraine (yawning, drowsiness, irritability, mood changes, hyperactivity) support a direct role for the dopaminergic system that is also involved in sleep-related movement disorders.

CONCLUSIONS

Our review of the literature revealed that, beside pharmacological treatment, child education and lifestyle modification including sleep hygiene could play a significant role in overall success of the treatment. Therefore comorbid sleep conditions should be always screened in children with migraine in order to improve patient management and to choose the most appropriate treatment.