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

The World Health Organization Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and the headache revolution: from headache burden to a global action plan for headache disorders

The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

Weekdays' sleeping condition and its influence on occurrence of general malaise in Japanese children aged 10 to 12 years

The present study aimed to elucidate weekdays' sleeping condition and its influence on occurrence of general malaise in children. A total of 761 Japanese children aged 10 to 12 years were surveyed regarding their weekdays' waking time and bedtime and general malaise using a self-administered questionnaire. As the result of hierarchical cluster analysis on the sleep condition, the participants were classified into three clusters. Sleep duration was significantly longer in cluster 1 (9.35 ± 0.52 h) than in clusters 2 (7.83 ± 0.77 h) and 3 (9.02 ± 0.30 h) and significantly longer in cluster 3 than in cluster 2. Waking time was significantly later in cluster 3 (7:01 ± 0:12) than in clusters 1 (6:22 ± 0:31) and 2 (6:24 ± 0:33, p < 0.001). Bedtime was significantly later in cluster 2 (22:34 ± 0:47) than in clusters 3 (21:59 ± 0:19) and 1 (21:01 ± 0:22) and significantly later in cluster 3 than in cluster 1. There were significantly more subjects in cluster 2 than in clusters 1 and 3 who responded "nearly every day" or "occasionally" to the five of seven questionnaires related to general malaise. The current results indicate that in Japanese children aged 10 to 12 years, (1) sleeping condition of weekdays are classified into three clusters with different mean values for each of sleep duration, bedtime, and waking time, and (2) the occurrence of general malaise may be enhanced in individuals whose sleep duration is less than 8 h.

Prospective evaluation of 24-hour movement behaviors among adolescents recovering from a sport-related concussion

This study aimed to describe the 24-hour composition of movement behaviors, including sleep, sedentary behavior, and physical activity (PA), among pediatric sports-related concussion (SRC) patients over their recovery period, assess the association between movement compositions and recovery time, and understand feasibility of 24-hour accelerometry in the study population. A cohort of 50 pediatric SRC patients were asked to wear a wrist-worn accelerometer continuously for the duration of their recovery. Among all enrolled participants, the sample was primarily 14 or 15 years of age (65%), female (55%), and recovered in under 28 days (88%). Accelerometer compliance was moderate; 35 participants (70%) were compliant with the protocol. Compositional analysis was used to address time-use objectives in 33 participants who provided adequate data for inclusion. Overall, participants spent an average of 50% of their 24-hour day sedentary, 33% sleeping, 11% in light intensity PA, and 6% in moderate or vigorous intensity PA. The 24-hour composition of movement behaviors was not associated with recovery time (p = .09-.99). However, the limited sample size may have contributed to null findings. Given recent evidence supporting the effects of sedentary behavior and PA on concussion recovery, future studies should aim to further validate these findings in a larger sample.

[Modern principles of primary headaches prevention in children and adolescents]

Headaches in children and adolescents are an actual problem of modern medicine. In most cases, headaches are regarded as a manifestation of vertebrogenic or cerebrovascular pathology, or as a manifestation of autonomic dystonia syndrome which leads to an erroneous diagnosis and treatment. The review considers the factors of occurrence and chronicity of primary headaches (hypodynamia, postural disorders, magnesium and vitamin D deficiency, anxiety and depression, central sensitization, alexithymia), methods for their diagnosis and treatment.

Migraine management: Non-pharmacological points for patients and health care professionals

Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.

Migraine Pathophysiology in Children and Adolescents: A Review of the Literature

Although migraine in adult and pediatric patients are overall very similar to each other, differences in prevalence, presentation, and treatment efficacy may reflect slight differences in the pathophysiological processes underlying migraine in these patient groups, perhaps because of ongoing development of the nervous system during childhood and adolescence. Although major gains have been made in understanding the pathophysiology of migraine in adults in recent years, equivalent research on migraine in pediatric patients continues to lag behind. In this review, we will describe the current state of migraine research in pediatric patients with regard to presentation and frequency of prodromal and postdromal symptoms, ictal and interictal calcitonin gene-related peptide elevation, and evidence for cortical spreading depression, thus covering all phases of migraine, and discuss how the findings seen here may relate to possible underlying pathophysiological mechanisms of migraine. We aim to elucidate possible differences between migraine in children and adults, and the need for further research specific to pediatric patients with migraine in order to improve treatment in this patient group.

Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches

Pediatric chronic orofacial pain (OFP) is an umbrella term which refers to pain associated with the hard and soft tissues of the head, face, and neck lasting >3 months in patients younger than 18 years of age. Common chronic pediatric OFP diagnoses include temporomandibular disorder, headaches, and neuropathic pain. Chronic OFP can adversely affect youth's daily functioning and development in many areas of well-being, and may be associated with emotional stress, depression, functional avoidance, and poor sleep, among other negative outcomes. In this mini-review, we will discuss common psychological comorbidities and familial factors that often accompany chronic pediatric OFP conditions. We will also discuss traditional management approaches for pediatric orofacial pain including education, occlusal appliances, and psychological treatments such as relaxation, mindfulness-based interventions, and cognitive-behavioral treatments. Finally, we highlight avenues for future research, as a better understanding of chronic OFP comorbidities in childhood has the potential to prevent long-term pain-related disability in adulthood.

Predicting quality of life outcomes in children with migraine

INTRODUCTION

Several studies have shown that the response of children with migraine to medications is suboptimum and inferior to the response reported in adults, despite the similar pathogenesis and biological mechanisms. The poor response may be related to the significant differences that make assessment and treatment of children with migraine more challenging than in adults.

AREAS COVERED

The purpose of this review is to discuss the whole process of assessment of children with migraine, the necessary skills for eliciting the clinical features, making the correct diagnosis and exploring lifestyle issues, co-morbid conditions (psychological and physical) and social influences on disease presentations. Also, to establish and address peculiarities of migraine in children that would enable clinicians to advise on lifestyle modifications, co-morbid conditions and the correct choice of treatment options including non-pharmacologic therapies and medications.

EXPERT OPINION

The choice of treatment should be based on an assessment of each individual child taking into account, age, gender, pubertal status, body weight, comorbid disorders and family history. Also considering the profile of migraine episodes, frequency, duration, associated symptoms and effects of nausea and vomiting. Using the appropriate medications in appropriate dosage, formulation and route and timing of administration may improve adherence to treatment and outcome.

The Effects of the COVID-19 Confinement on Screen Time, Headaches, Stress and Sleep Disorders among Adolescents: A Cross Sectional Study

BACKGROUND

Headache is a common symptom affecting children and adolescents. The medical literature over the last three decades reveals a variable prevalence and triggers in different countries, regions, circumstances and times. This study aims to assess the prevalence, frequency and quality of headaches in the Lebanese adolescent population under the COVID-19 confinement and study its triggers and relationship to screen time, self-reported anxiety, and sleep.

METHODS

A cross sectional design was used to collect two survey results by snowball distribution using social media targeting adolescents aged 15 to 17 years of age. The first survey included 13 questions with a single best answer about screen time, feeling anxious, sleep time, schedule and consistency, and headaches. The second survey included 3 questions about the quality of the headaches, anxiety and its triggers.

RESULTS

Among 433 responders to the first survey, the prevalence of headaches, especially pressure points and band-like pressure was higher than any previously reported among adolescents in the literature, reaching 93.4%. Screen time was also higher than any previous reports with 95.6% spending 9 hours or more on screen while 64% of adolescents spending at least 12 hours a day on screen. In addition, the majority (82%) don't have consistent sleep habits and 41.8% consider themselves anxious. School was considered the main source of stress by 82.8% of the responders. The frequency of headache correlated significantly with increased screen time, self-reported anxiety and inconsistent sleep habits.

CONCLUSIONS

Headaches among adolescents are associated with increased screen use, sleep disorders, and self-reported anxiety. It is one of the primary somatization symptoms in this group expressing their extreme stress under the current economic, political, and health crisis. The present trends are likely to have major long term implications on adolescents' health and academic achievements and should alarm educators and health officials to intervene in this situation.

How to Assess the Headache-Sleep Disorders Comorbidity in Children and Adolescents

Sleep disorders and primary headaches are frequent health problems in childhood, and they are often comorbid in an individual, linked by a mutual and complex relationship. This comorbidity is frequent and well-documented, but the available literature is usually biased in favor of one aspect or another, mainly depending on the expertise of the authors. The aim of this paper is to review existing literature on the diagnostic assessment of comorbid primary headaches and sleep disorders, so as to propose practical suggestions to accurately investigate the presence of comorbid conditions in children evaluated for primary headaches or for sleep disorders.

Headache and Sleep Disturbances in the Pediatric Population

The relationship between sleep disturbances and headaches in the pediatric population is bidirectional. Common underlying molecular mechanisms of sleep and headaches have been speculated to explain the clinical connection. We will summarize various sleep disturbances and their known relationships to headache, focusing on the pediatric population. Careful recognition and assessment of sleep disturbances in patients with headache is critical and may help guide treatment. First line therapies for sleep disturbances consist of behavioral approaches, though surgical and pharmacologic strategies are utilized in particular circumstances.

Lifestyle Modifications to Help Prevent Headache at a Developmental Age

Headache is the world's seventh most significant cause of disability-adjusted-life in people aged between 10 and 14 years. Therapeutic management is based on pharmacological approaches and lifestyle recommendations. Many studies show associations between each migraine-promoting lifestyle, behavioral triggers, frequency, and intensity of headaches. Nevertheless, the overall aspects of this topic lack any definitive evidence. Educational programs advise that pediatric patients who suffer from migraines follow a correct lifestyle and that this is of the utmost importance in childhood, as it will improve quality of life and assist adult patients in avoiding headache chronicity, increasing general well-being. These data are important due to the scarcity of scientific evidence on drug therapy for prophylaxis during the developmental age. The "lifestyle recommendations" described in the literature include a perfect balance between regular sleep and meal, adequate hydration, limited consumption of caffeine, tobacco, and alcohol, regular physical activity to avoid being overweight as well as any other elements causing stress. The ketogenic diet is a possible new therapeutic strategy for the control of headache in adults, however, the possible role of dietary factors requires more specific studies among children and adolescents. Educational programs advise that the improvement of lifestyle as a central element in the management of pediatric headache will be of particular importance in the future to improve the quality of life of these patients and reduce the severity of cephalalgic episodes and increase their well-being in adulthood. The present review highlights how changes in different aspects of daily life may determine significant improvements in the management of headaches in people of developmental age.

Later high school start time is associated with lower migraine frequency in adolescents

OBJECTIVE

To determine whether high school start time is associated with headache frequency in adolescents with migraine.

BACKGROUND

Adolescence is marked by a physiologic delayed circadian phase, characterized by later bedtimes and wake times. The American Academy of Pediatrics (AAP) recommends that high schools start no earlier than 8:30 a.m., but most high schools in the United States start earlier. The study hypothesis was that adolescents with migraine whose high schools start at 8:30 a.m. or later (late group) would have lower headache frequency than those whose schools start earlier than 8:30 a.m. (early group).

METHODS

This was a cross-sectional Internet survey study of US high schoolers with migraine recruited online through social media. Comparisons were made between the late group and the early group. The primary outcome measure was self-reported headache days/month.

RESULTS

In total, 1012 respondents constituted the analytic set: n = 503 in the late group versus n = 509 in the early group. Mean (SD) self-reported headache days/month was 4.8 (4.6) versus 7.7 (6.1) in the late and early groups, respectively (p < 0.001); mean difference -2.9 (95% CI -2.2 to -3.6). Mean (SD) self-reported hours of sleep on a school night was 7.9 (0.9) versus 6.9 (1.3), p < 0.001. Adjusting for total hours of sleep, sex, taking a migraine preventive, days of acute medication use, hours of homework, grade level, and missing breakfast, mean (SD) self-reported headache days/month remained lower in the late group than in the early group: 5.8 (95% CI 5.3-6.2) versus 7.1 (95% CI 6.7-7.4), (p < 0.001); mean difference -1.3 (95% CI -1.9 to -0.7).

CONCLUSION

Adolescents with migraine who attend high schools that follow AAP recommendations for start times have lower self-reported headache frequency than those whose high schools start before 8:30 a.m. If prospective studies confirm this finding, shifting to a later high school start time may be an effective strategy for migraine prevention in adolescents.

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.

Sleep Disorders and Headache: A Review of Correlation and Mutual Influence

The review is devoted to the complex relationship between headache and sleep disorders. The shared neuroanatomical structures of the nervous system involved in pain perception and sleep are shown, and mechanisms of comorbidity between headaches and sleep disorders are considered. Various types of headaches in the continuum of the sleep–wake cycle are described. Both pharmacological and non-pharmacological approaches to treatment are examined in detail, with the biochemical basis of the drug action.

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.

Clinical presentation, diagnosis and polysomnographic findings in children with migraine referred to sleep clinics

OBJECTIVE

An association between migraine and sleep disturbances in children was reported, yet limited clinical data exist. The current study addresses the clinical presentation, polysomnographic (PSG) characteristics, and comorbid sleep diagnoses of children with migraine referred to the sleep clinic.

PATIENTS

A retrospective review was performed of headache center patients evaluated by the sleep center between 2007 and 2017. Children ≤18 years old, diagnosed with migraine headache, and who had PSG within one year of evaluation in the headache clinic, were included. PSG findings, as well as demographics, were compared to a group of controls aged 5-14 years-old.

RESULTS

In sum, 185 children with a diagnosis of migraine were included: 39% males, 75% Caucasian, mean age 13.5 ± 3.4, and 57% obese. Additionally, 180 children were included in the control group. The common presenting sleep symptoms were snoring (66%), sleep onset and sleep maintenance problems (25%), and excessive daytime sleepiness (20%). For the sleep diagnosis, 40% had obstructive sleep apnea (OSA), 27% had insomnia, 15% had periodic limb movement disorder (PLMD), and 6% had a central disorder of hypersomnolence. In terms of sleep architecture, children with migraine had significantly higher NREM 2 (p < 0.001) and a lower percentage of NREM3 (p < 0.001) compared to controls after adjustment for demographics and the presence of sleep-disordered breathing.

CONCLUSIONS

Children referred to the sleep clinic who also had migraine, experience various types of sleep complaints. OSA, insomnia, and PLMD were relatively common in this population. Changes in sleep architecture, specifically increased NREM2 and decreased slow wave sleep compared to the control group, were also observed.

High School Start Time and Migraine Frequency in High School Students

OBJECTIVE

To investigate whether later high school start time is associated with lower migraine frequency in high school students with migraine.

BACKGROUND

Adequate sleep is thought to be important in managing adolescent migraine. The American Academy of Sleep Medicine recommends teenagers sleep ≥8 hours/night. Adolescents have a physiologically delayed sleep phase, going to bed, and waking later than children and adults. The American Academy of Pediatrics (AAP) accordingly recommends high schools start no earlier than 8:30 AM.

METHODS

Cross-sectional observational study of U.S. high schoolers with migraine. Participants were recruited nationally using social media. Respondents attending high schools starting at 8:30 AM or later were compared to those attending earlier start time schools. The primary outcome was headache days/month.

RESULTS

Two hundred and fifty-six subjects constituted the analysis set: 115 later group vs 141 earlier group. Age and sex did not differ. Mean (SD) self-reported headache days/month were 7 (5) vs 8 (7), respectively, (P = .985); mean difference (95% CI for the difference) was -0.8 (-2.3-0.7) days. Median (IQR) self-reported total hours of sleep/school night were: 5.6 (5.0-6.6) vs 5.6 (4.5-6.4), P = .058. Students attending later start time schools woke later (median [IQR] 6:38 AM [55 minutes] vs 6:09 AM [59 minutes], P < .0001) and left home later (median [IQR] 7:28 AM [28 minutes] vs 7:02 AM [60 minutes], P < .0001). Average commute time was also longer: 41 (21) minutes vs 28 (16), P < .0001. The vast majority in both groups reported missing breakfast at least once/week: 103/114 (90.4%) vs 128/141 (90.8%), P = .907. Hours of sleep did not correlate with headache days per month.

CONCLUSION

High school start time does not have a large effect on headache frequency in high schoolers with migraine. Given the high variance in headache days/month observed in this study, a larger study would be needed to determine whether there might still be a small effect of starting high school at/after 8:30 AM. More research is needed to establish evidence-based recommendations about lifestyle factors in adolescent migraine management.

Headaches and sleep problems in US adolescents: Findings from the National Comorbidity Survey - Adolescent Supplement (NCS-A)

BACKGROUND

There is limited research on the association of sleep problems with International Classification of Headache Disorders (ICHD-II)-defined headache subtypes in youth, particularly from community-based samples. This cross-sectional study examines the associations of sleep patterns, symptoms and disorders with specific headache subtypes among adolescents from the general population of the United States.

METHODS

The sample includes 10,123 adolescents in the National Comorbidity Survey - Adolescent Supplement, a face-to-face survey of adolescents aged 13-18 years in the continental USA. Headache subtype diagnoses were based on modified ICHD-III criteria, and mood and anxiety disorders were based on Diagnostic and Statistical Manual of Mental Disorders criteria. The associations of self-reported sleep patterns and insomnia symptoms and headache status were estimated with multivariate regression models that adjust for demographic characteristics and comorbid anxiety and mood disorders.

RESULTS

There was no significant difference in bedtime between youth with and without headache. However, adolescents with migraine headache reported significantly shorter sleep duration (p = .022) and earlier wakeup time (p = .002) than those without headache. Youth with any headache, particularly migraine, had significantly more sleep disturbances than those without headache. With respect to headache subtypes, youth with migraine with aura were more likely to report difficulty maintaining sleep, early morning awakening, daytime fatigue, and persistent insomnia symptoms than those with migraine without aura. However, these associations were largely accounted for by comorbid anxiety and mood disorders. There was a monotonic increase in the number of insomnia symptoms with increasingly restrictive definitions of migraine.

CONCLUSION

Pervasive sleep disturbances in adolescents with headache have important implications for the evaluation, treatment and etiology of pediatric headache.

Diagnosing and managing migraine in children and young people

This article gives an overview of migraine in children. It outlines the epidemiology of the condition and describes presentation with headache and other symptoms and linked conditions. It aims to raise awareness of the diagnosis of migraine and its impact on children and young people, their families and school life. The author also describes methods of diagnosis and management, and the importance of recognising and of avoiding medication overuse.

Pediatric Integrative Medicine in Academia: Stanford Children's Experience

Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States. Early research of pediatric integrative medicine modalities shows promise for the treatment of common pediatric conditions such as irritable bowel syndrome, acute and chronic pain, headache, and allergy, among others. In light of the growing prevalence of pediatric illnesses and patient complexity, it is crucial to emphasize the patient's overall well-being. As academic centers around the world start to develop pediatric integrative medicine programs, the aim of this manuscript is to briefly highlight evidence of effective integrative treatments in pediatric subspecialties, to describe the establishment of our integrative medicine program, to summarize its early efforts, and to discuss potential barriers and keys to success.

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.

Non-Rapid Eye Movement Sleep Parasomnias and Migraine: A Role of Orexinergic Projections

Introduction

Sleep and migraine share a common pathophysiological substrate, although the underlying mechanisms are unknown. The serotonergic and orexinergic systems are both involved in the regulation of sleep/wake cycle, and numerous studies show that both are involved in the migraine etiopathogenesis. These two systems are anatomically and functionally interconnected. Our hypothesis is that in migraine a dysfunction of orexinergic projections on the median raphe (MR) nuclei, interfering with serotonergic regulation, may cause Non-Rapid Eye Movement parasomnias, such as somnambulism.

Hypothesis/theory

Acting on the serotonergic neurons of the raphe nuclei, the dysfunction of orexinergic neurons would lead to a higher release of serotonin. The activation of serotonergic receptors located on the walls of large cerebral vessels would lead to abnormal vasodilatation and consequently increase transmural pressure. This process could activate the trigeminal nerve terminals that innervate vascular walls. As a consequence, there is activation of sensory nerve endings at the level of hard vessels in the meninges, with release of pro-inflammatory peptides (e.g., substance P and CGRP). Within this hypothetical frame, the released serotonin could also interact with trigeminovascular afferents to activate and/or facilitate the release of the neuropeptide at the level of the trigeminal ganglion. The dysregulation of the physiological negative feedback of serotonin on the orexinergic neurons, in turn, would contribute to an alteration of the whole system, altering the sleep–wake cycle.

Conclusion

Serotonergic neurons of the MR nuclei receive an excitatory input from hypothalamic orexin/hypocretin neurons and reciprocally inhibit orexin/hypocretin neurons through the serotonin 1A receptor (or 5-HT1A receptor). Considering this complex system, if there is an alteration it may facilitate the pathophysiological mechanisms involved in the migraine, while it may produce at the same time an alteration of the sleep–wake rhythm, causing sleep disorders such as sleepwalking. Understanding the complex mechanisms underlying migraine and sleep disorders and how these mechanisms can interact with each other, it would be crucial to pave the way for new therapeutic strategies.

Sleep disturbances in tension-type headache and migraine

Current research into the pathogenesis of tension-type headache (TTH) and migraine is focused on altered nociceptive pain processing. Among the potential factors that influence sensitization mechanisms, emotional stress, depression, or sleep disorders all have an essential role: they increase the excitability of nociceptive firing and trigger hyperalgesic responses. Sleep disturbances and headache disorders share common brain structures and pathogenic mechanisms and TTH, migraine, and sleep disturbances often occur together; for example, 50% of individuals who have either TTH or migraine have insomnia. Moreover, insomnia and poor sleep quality have been associated with a higher frequency and intensity of headache attacks, supporting the notion that severity and prevalence of sleep problems correlate with headache burden. It should be noted that the association between headaches and sleep problems is bidirectional: headache can promote sleep disturbances, and sleep disturbances can also precede or trigger a headache attack. Therefore, a better understanding of the factors that affect sleep quality in TTH and migraine can assist clinicians in determining better and adequate therapeutic programs. In this review, the role of sleep disturbances in headaches, and the association with depression, emotional stress, and pain sensitivity in individuals with TTH or migraine are discussed.

Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta

Background

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

Methods

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

Results

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

Conclusions

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

The relationship between bruxism, sleep quality, and headaches in schoolchildren

[Purpose] Present study aimed to evaluate the relationship between sleep bruxism and headache in school children. [Subjects and Methods] This study was conducted with 103 children aged 3-6 years. The exclusion criteria were early tooth loss, dental appliance was used, physical or psychological limitations, chronic disease and continuous medication. Sleep bruxism was diagnosed based on an indication by parents of the occurrence of teeth clenching/grinding and incisor/occlusal tooth wear, following the criteria of the American Academy of Sleep Medicine. Sleep quality was evaluated by a questionnarie, detailing the child's sleep characteristics. [Results] Forty-nine children (47.6%) were diagnosed with sleep bruxism. Those with sleep bruxism were 3.25-fold more likely to present headache. Children whose parents were separated had a significantly greater frequency of sleep bruxism and primary headache. The relative risk of exhibiting primary headache was 13.1 among children with sleep bruxism whose parents were separated. [Conclusion] Children with SB demonstrated a greater risk of having primary headache and those whose parents were separated had a greater chance of having headache. Only sleep bruxism was associated with headache, clenching the teeth during waking hours was not correlated with primary headache.

Pediatric Headache and Sleep Disturbance: A Comparison of Diagnostic Groups

OBJECTIVE

To examine whether sleep disturbance differs by headache diagnosis in a pediatric sample, and whether this effect remains when other factors affecting sleep are included.

BACKGROUND

Primary headache disorders can be severe and disabling, impacting a child's functioning and quality of life. Many children and adolescents with chronic headaches also experience sleep difficulties, and there is likely a bidirectional relationship between headaches and sleep difficulties. Sleep problems may intensify functional and developmental difficulties in youth with chronic headaches. Despite this, research on sleep has largely been conducted only on those with migraines, with a dearth of studies including samples with tension-type headache (TTH) or new daily persistent-headache (NDPH).

METHODS

This retrospective chart review included 527 patients, ages 7-17 years, with a primary headache diagnosis of migraine (n = 278), TTH (n = 157), and NDPH (n = 92). Patients completed measures of disability, anxiety, and depression and their parents completed measures of sleep disturbance.

RESULTS

Sleep disturbance was greater in patients with TTH (10.34 ± 5.94, P = .002) and NDPH (11.52 ± 6.40, P < .001) than migraine (8.31 ± 5.89). Across patient groups, greater sleep disturbance was significantly associated with higher levels of functional disability (rs ≥ .16), anxiety (rs ≥ .30), and depression (rs ≥ .32). Additionally, higher pain levels were significantly associated with greater sleep disturbance among TTH patients (r = .23), with this association non-significant among the other headache groups. When simultaneously examining demographic, pain-related, and emotional distress factors, older age, higher levels of disability and depression, and NDPH diagnosis were all significant predictors of greater sleep disturbance (r²  = .25).

CONCLUSIONS

Assessment and treatment of sleep problems in pediatric patients with chronic headache is important with several contextual and headache diagnostic factors influencing the severity of sleep disturbance.

Associations Between Sleep Quality and Migraine Frequency: A Cross-Sectional Case-Control Study

Migraine has been associated with sleep disturbances. Relationship between sleep quality and migraine frequency is yet to be determined. The present study aimed to investigate sleep disturbances among low-frequency, moderate-frequency, high-frequency, and chronic migraineurs, with and without auras, with well-controlled confounding variables.This cross-sectional controlled study included 357 subjects from an outpatient headache clinic in Taiwan. Standardized questionnaires were utilized to collect demographic, migraine, sleep, depression, anxiety, and restless leg syndrome characteristics in all participants. According to frequency of migraine attacks, patients were divided into 4 groups: with 1 to 4 migraine days per month, 5 to 8 migraine days in a month, 9 to 14 migraine days in a month, and >14 migraine days per month. The Pittsburgh Sleep Quality Index (PSQI) and subgroup items were used to evaluate sleep quality. The association between migraine frequency and sleep quality was investigated using multivariable linear regression and logistic regression.The PSQI total score was highest in patients with high frequent migraine (10.0 ± 3.4) and lowest in controls (7.0 ± 3.4) with a significant trend analysis (P for trend = 0.006). Migraine frequency had an independent effect on the items "Cannot get to sleep within 30 minutes" (P < 0.001), "Wake up in the middle of the night or early morning" (P < 0.001), "Bad dreams" (P = 0.001), "Pain" (P = 0.004), and "Quality of sleep" (P < 0.001). The result showed the effect of migraine frequency in both the aura-present (P for trend = 0.008) and the aura-absent subgroups (P for trend = 0.011).High migraine frequency correlates with poor sleep quality and a higher prevalence of poor sleepers. These associations occur in migraine with aura and without aura.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science

BACKGROUND

Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality.

FINDINGS

To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies.

CONCLUSIONS

While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Migraine and lifestyle in childhood

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

Medical Comorbidities in Pediatric Headache

Comorbid conditions frequently occur in pediatric headaches and may significantly affect their management. Comorbidities that have been associated with pediatric headaches include attention-deficit or hyperactivity disorder, autism, developmental disabilities, depression, anxiety, epilepsy, obesity, infantile colic, atopic disorders, inflammatory bowel disease, and irritable bowel syndrome. The goal of this article is to review these comorbidities associated with pediatric headache, thereby empowering child neurologists to identify common triggers and tailor management strategies that address headache and its comorbidities.

Sleep and Headache

The interaction between sleep and headache or migraine is powerful and an elevated comorbidity between these 2 disorders has been reported in either adults or children. This comobidity is linked to common neurophysiological and neuroanatomical substrates that are genetically based strongly. The first reports on this relationship were related to the prevalence of parasomnias and sleep-disordered breathing in headache but recent research has expanded the comorbidity to several other sleep disorders, such as restless legs syndrome, periodic limb movements during sleep, and narcolepsy. The assessment of children with headache should always include an accurate anamnesis for the presence of sleep problems either in the child or in the relatives; no correct approach for treating children and adolescents is possible without an integrated method of evaluation and management.

Current role of melatonin in pediatric neurology: clinical recommendations

BACKGROUND/PURPOSE

Melatonin, an indoleamine secreted by the pineal gland, plays a key role in regulating circadian rhythm. It has chronobiotic, antioxidant, anti-inflammatory and free radical scavenging properties.

METHODS

A conference in Rome in 2014 aimed to establish consensus on the roles of melatonin in children and on treatment guidelines.

RESULTS AND CONCLUSION

The best evidence for efficacy is in sleep onset insomnia and delayed sleep phase syndrome. It is most effective when administered 3-5 h before physiological dim light melatonin onset. There is no evidence that extended-release melatonin confers advantage over immediate release. Many children with developmental disorders, such as autism spectrum disorder, attention-deficit/hyperactivity disorder and intellectual disability have sleep disturbance and can benefit from melatonin treatment. Melatonin decreases sleep onset latency and increases total sleep time but does not decrease night awakenings. Decreased CYP 1A2 activity, genetically determined or from concomitant medication, can slow metabolism, with loss of variation in melatonin level and loss of effect. Decreasing the dose can remedy this. Animal work and limited human data suggest that melatonin does not exacerbate seizures and might decrease them. Melatonin has been used successfully in treating headache. Animal work has confirmed a neuroprotective effect of melatonin, suggesting a role in minimising neuronal damage from birth asphyxia; results from human studies are awaited. Melatonin can also be of value in the performance of sleep EEGs and as sedation for brainstem auditory evoked potential assessments. No serious adverse effects of melatonin in humans have been identified.

Spectrum of complicated migraine in children: A common profile in aid to clinical diagnosis

Complicated migraine encompasses several individual clinical syndromes of migraine. Such a syndrome in children frequently presents with various neurological symptoms in the Emergency Department. An acute presentation in the absence of headache presents a diagnostic challenge. A delay in diagnosis and treatment may have medicolegal implication. To date, there are no reports of a common clinical profile proposed in making a clinical diagnosis for the complicated migraine. In this clinical review, we propose and describe: (1) A common clinical profile in aid to clinical diagnosis for spectrum of complicated migraine; (2) How it can be used in differentiating complicated migraine from migraine without aura, migraine with aura, and seizure; (3) We discuss the status of complicated migraine in the International Headache Society classification 2013; and (4) In addition, a common treatment strategy for the spectrum of migraine has been described. To diagnose complicated migraine clinically, it is imperative to adhere with the proposed profile. This will optimize the use of investigation and will also avoid a legal implication of delay in their management. The proposed common clinical profile is incongruent with the International Headache Society 2013. Future classification should minimize the dissociation from clinically encountered syndromes and coin a single word to address collectively this subtype of migraine with an acute presentation of a common clinical profile.