Psychopathology in children and adolescents with migraine in clinical studies: a systematic review

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.

Anxiety and depressive symptoms and migraine-related outcomes in children and adolescents

OBJECTIVE

The objective of this study was to explore the longitudinal relationship between anxiety and depressive symptoms and migraine outcomes in children and adolescents.

BACKGROUND

Children and adolescents with migraine experience more anxiety and depressive symptoms than their peers without migraine, but it is unknown if these symptoms are associated with differential migraine outcomes.

METHODS

In this prospective clinical cohort study, children and adolescents aged 8.0-18.0 years with migraine completed headache questionnaires and validated measures of anxiety and depressive symptoms (Patient-Reported Outcomes Measurement Information System) at an initial consultation and at their first follow-up visit with a neurologist. Changes in monthly headache frequency and changes in migraine-related disability (Pediatric Migraine Disability Assessment) were tracked at each time point. The relationships between these migraine outcomes and anxiety and depressive symptoms were estimated using models controlling for sex, age, headache frequency, and treatment type.

RESULTS

There were 123 consenting participants. In models adjusted for age, sex, baseline disability score, and treatment type, baseline anxiety and depressive symptom levels were not significantly associated with change in headache frequency (for anxiety symptoms: β = -0.05, 95% confidence interval [CI] = -0.268 to 0.166, p = 0.639; for depressive symptoms: β = 0.14, 95% CI = -0.079 to 0.359, p = 0.209). Similarly, in models adjusted for age, sex, baseline headache frequency, and treatment type, the change in disability was not associated with baseline anxiety (β = -0.45, 95% CI = -1.69 to 0.78, p = 0.470), nor with baseline depressive symptom scores (β = 0.16, 95% CI = -1.07 to 1.40, p = 0.796). In post hoc exploratory analyses (N = 84 with anxiety and N = 82 with depressive symptom data at both visits), there were also no significant associations between change in mental health symptoms and change in headache frequency (for anxiety symptoms: β = -0.084, 95% CI = -0.246 to 0.078, p = 0.306; for depressive symptoms: β = -0.013, 95% CI = -0.164 to 0.138, p = 0.865). Similarly, the change in disability scores between visits was not related to the change in anxiety (β = 0.85, 95% CI = -0.095 to 1.78, p = 0.077) nor depressive symptom scores (β = 0.32, 95% CI = -0.51 to 1.15, p = 0.446).

CONCLUSION

Baseline anxiety and depressive symptom levels were not associated with longitudinal migraine outcomes and neither were longitudinal changes in anxiety and depressive symptom levels; this contradicts popular clinical belief that mental health symptoms predict or consistently change in tandem with migraine outcomes.

Headache and Psychological Comorbidities: An Appraisal of the Evidence

BACKGROUND

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

OBJECTIVES

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

METHODS

A targeted review of the literature was carried out.

RESULTS

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

CONCLUSIONS

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

Risk-Taking Behaviors in Children with ADHD Compared to Children with Primary Headaches

The study examined the engagement in risk-taking behaviors and their onset in children with attention-deficit/hyperactivity disorder (ADHD) compared with children with primary headaches. Whether ADHD is associated with higher engagement in risk-taking behavior compared with other neurodevelopmental disorders (and not only typical development) has yet to be demonstrated. A sample of 189 children, 10 to 18 years old, undergoing neurological surveillance for ADHD (N = 144) or primary headaches (N = 45) participated in the study. The children and their parents reported the children's engagement in various risk-taking behaviors. The ADHD group reported a higher level of general risk-taking behavior relative to the headache group. The differences remained significant even after controlling for demographic and clinical variables. No differences in the age of onset of risk-taking behaviors were found. It is concluded that risk-taking behavior is more common in children with ADHD under active neurological surveillance than in children followed for primary headaches.

Early analgesic administration and headache presence 7 days post-concussion in children

OBJECTIVE

This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth.

METHODS

A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models.

RESULTS

2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)].

CONCLUSIONS

Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Psychological Disorders, Adverse Childhood Experiences and Parental Psychiatric Disorders in Children Affected by Headache: A Systematic Review

BACKGROUND

Pediatric headaches have been linked to adverse life events or psychological factors in children and their families, with a complex and bidirectional association. Moreover, it is well-known that psychological stress can trigger headaches.

METHODS

We searched three databases for studies focusing on headaches and adverse events or psychological factors in children up to 12 years old or in their caregivers.

RESULTS

We included 28 studies. Child psychological factors, including internal and external symptoms, were commonly associated with all types of headaches. Sleep disturbances showed a positive association with headaches in 3 out of 5 studies. Family conflict and unhappiness were frequently found in children suffering with headaches, while single-parent families and divorce were not associated. Stressful environments and adverse life events, particularly bullying, were also found to be linked with headaches.

CONCLUSIONS

Childhood headaches represent an alarm bell for clinicians to investigate and treat psychological or psychiatric disorders in children and their family. Further studies are needed to elucidate the role of early-life adverse events in children and their families.

Cross-Sectional Study of Headache in Flemish Children and Adolescents

Background: Although headache is common in pediatrics, data for the Flemish population are missing. We explored headache-prevalence, and its association with communication-technology (CT) and physical activity (PA) in Flemish children and adolescents. Methods: A cross-sectional exploratory school-based questionnaire study was designed. Flemish boys and girls (5–18 years) completed a symptom-questionnaire. Primary outcomes: sociodemographic background, headache-prevalence, headache-characteristics, CT-use and PA characteristics (self-report). Secondary outcomes: associations between headache-characteristics, age, gender, and CT-use and PA-characteristics. Results: Four hundred twenty-four questionnaires were analysed: 5–7-years: n = 58; 8–11-years: n = 84; 12–15-years: n = 137; 16–18-years: n = 145. Fifty-five percent suffered from headache. Prevalence increased with age. More 16–18-year girls versus boys had headache. CT-use was the main headache-provocateur. Headache prevalence was significantly higher in a frequently physical active population. Conclusion: Our results suggest presence of headache in Flemish children and adolescents. PA-level associates with headache prevalence. However, children and adolescents with headache did not report more CT-use compared to controls.

Emotional and behavioral problems in pediatric patients with migraine and tension-type headache

OBJECTIVE

This study aimed to investigate the associations between psychopathological characteristics of children and adolescents with primary headache, as measured by the Strengths and Difficulties Questionnaire (SDQ), and treatment outcomes.

METHODS

A cohort study was conducted on 124 pediatric patients with primary headache. At the first consultation, the SDQ was completed by the parents. The analysis of treatment efficacy was conducted on 90 patients with a follow-up period of at least one year. Treatment responders were defined as those who showed 50% reduction in the headache frequency. First, an analysis of the SDQ total scores and five subscales, among the migraine and tension-type headache groups, was conducted for 124 participants. Second, the association between the SDQ scores and treatment outcomes in the groups with periods of improvement of less than three months and three months or more were analyzed in 90 patients.

RESULTS

Migraine patients displayed more difficulties than strengths in terms of the total score (p = .004) and in the emotional symptoms subscale (p = .012) compared with tension-type headache patients. Migraine patients who required more than three months to show improvement displayed more peer problems (p = .020), while tension-type headache patients who required more than three months to show improvement displayed fewer conduct problems (p = .007).

CONCLUSION

Evaluation of patient characteristics using the SDQ at first consultation can predict the treatment outcome. Moreover, it can help provide appropriate initial treatment and improve outcome of primary headache in children.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

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.

Primary Headache Disorder Among School Students in Kuwait

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

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

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

Conduct disorder and somatic health in children: a nationwide genetically sensitive study

BACKGROUND

Conduct disorder (CD), a serious behavioral and emotional disorder in childhood and adolescence, characterized by disruptive behavior and breaking societal rules. Studies have explored the overlap of CD with neurodevelopmental problems (NDP). The somatic health of children with NDP has been investigated; however, the prevalence of these problems in children with CD has not been sufficiently studied. Holistic assessment of children with CD is required for establishing effective treatment strategies.

AIMS

(1) Define the prevalence of selected neurological problems (migraine and epilepsy) and gastrointestinal problems (celiac disease, lactose intolerance, diarrhea, and constipation) in a population of twins aged 9 or 12; (2) Compare the prevalence of somatic problems in three subpopulations: (a) children without CD or NDP, (b) children with CD, and (c) children with both CD and NDP; (3) Select twin pairs where at least one child screened positive for CD but not NDP (proband) and map both children's neurological and gastrointestinal problems.

METHOD

Telephone interviews with parents of 20,302 twins in a cross-sectional, nationwide, ongoing study. According to their scores on the Autism-Tics, AD/HD, and Comorbidities inventory, screen-positive children were selected and divided into two groups: (1) children with CD Only, (2) children with CD and at least one NDP.

RESULTS

Children with CD had an increased prevalence of each neurological and gastrointestinal problem (except celiac disease), and the prevalence of somatic problems was further increased among children with comorbid CD and NDP. The presence of CD (without NDP) increased the odds of constipation for girls and the odds of epilepsy for boys. Girls with CD generally had more coexisting gastrointestinal problems than boys with CD. Female co-twins of probands with CD were strongly affected by gastrointestinal problems. Concordance analyses suggested genetic background factors in neurological and gastrointestinal problems, but no common etiology with CD could be concluded.

CONCLUSION

Co-occurring NDP could explain most of the increased prevalence of somatic problems in CD. Our results raise a new perspective on CD in children and adolescents; their CD seems to be linked to a number of other health problems, ranging from neurodevelopmental and psychiatric disorders to somatic complaints.

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.

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

BACKGROUND

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

AIMS AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Internalizing Symptoms in Pediatric Migraine: A Systematic Review Protocol

OBJECTIVES

The primary objective of the proposed systematic review is to determine if there is an association between internalizing disorders and symptoms (ie, subclinical symptoms) and migraine in children and adolescents.

METHODS

We will perform a peer-reviewed Peer Review of Electronic Search Strategies search of MEDLINE, Embase, PsycINFO, and CINAHL from inception to December 2019. The authors will also review all reference lists of included studies for relevant citations. Observational studies on the association of pediatric migraine with internalizing disorders and symptoms will be included in this review. Case-control, cohort, and cross-sectional studies that include participants aged 18 years and under will be eligible for inclusion. The primary outcome for this systematic review will be migraine and the exposures of interest will include internalizing disorders (eg, major depressive disorder, dysthymia, generalized anxiety disorder, and post-traumatic stress disorder) and internalizing symptoms (depression symptoms, anxiety symptoms, obsessive compulsive symptoms, and post-traumatic stress symptoms). Two investigators will independently carry out an initial screen of abstracts, followed by a second screen of full-text manuscripts. Data extraction will be completed by 2 independent investigators. Study quality will be assessed using the Newcastle-Ottawa criteria for case-control and cohort studies and using a modified version of the Newcastle-Ottawa criteria for cross-sectional studies. A narrative synthesis of the data will be provided and, if possible, data will be quantitatively summarized using appropriate meta-analytic methods. Throughout the manuscript, the Preferred Reporting Items for Systematic Review and Meta-Analysis reporting standards will be followed.

RESULTS

The goal of this systematic review will be to provide a narrative, and if possible, quantitative summary on the association between pediatric migraine and internalizing disorders and symptoms.

CONCLUSIONS

The methods applied in this systematic review protocol can be used to inform the design of future systematic reviews of observational studies in headache medicine. The results of this systematic review will be used to inform the clinical community on the association between pediatric migraine and internalizing disorders and symptoms and may also be used to inform the design of future research studies in this area.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

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

What Are the Psychosocial Factors Associated With Migraine in the Child? Comorbid Psychiatric Disorders, Family Functioning, Parenting Style, or Mom's Psychiatric Symptoms?

OBJECTIVE

Psychiatric diagnoses, parenting style, family functioning among children and adolescents with migraine, and psychiatric symptoms of their mothers were examined.

METHODS

The K-SADS and other measurements were used to assess psychiatric disorders in 50 children with migraine (aged 8-18) and matched 50 controls.

RESULTS

At least one psychiatric disorder was diagnosed in 56% of the migraine group. The presence of any psychiatric disorder in children (odds ratio [OR] = 2.765, P = .027) and somatization symptoms in their mothers (OR = 2.061, P = .025) were increasing the risk of migraine diagnosis. The parenting style scale assessments revealed that parents in the migraine group grant their children less autonomy.

CONCLUSION

Psychiatric comorbidity, especially depression and anxiety disorders, is more common in children with migraine. The frequency of eating disorder is also higher. Evaluating comorbidity, family functioning, and particularly affective responsiveness in migraine families may guide the clinician to a targeted treatment plan.

Longitudinal study shows that depression in childhood is associated with a worse evolution of headaches in adolescence

AIM

The aim of this study was to examine the course of headache diagnosis, headache frequency, anxiety, comorbid depressive symptoms and school absenteeism in adolescents with migraine and tension-type headaches five years after baseline.

METHODS

We followed a group of 122 children with a mean age of 10.1 (±1.3) years, with headache from a paediatric migraine centre in Paris who had taken part in a previous study from September 2007 to June 2008. This five-year longitudinal study took place in January to June 2012. The measures that were used included demographic variables, headache diagnosis, headache data and a psychological assessment.

RESULTS

At the five-year point, about 22% of the children had become headache free, 34% had little to no disability, and 36% had a changed diagnosis. Moreover, a longer history of headache at baseline was associated with a worse evolution of headache at follow-up. Lastly, high depression scores, but not anxiety, were a predictor of more headache disability at follow-up.

CONCLUSION

High depression scores in childhood were a risk factor that was associated with persistence and worsening of headaches in adolescence. This suggests that mental health assessments should be carried out in paediatric headache pain clinics.

The role of attachment insecurity in the emergence of anxiety symptoms in children and adolescents with migraine: an empirical study

Background

It is widely recognised that there are associations between headache, psychiatric comorbidity and attachment insecurity in both adults and children. The aims of this study were: 1) to compare perceived attachment security and anxiety in children and adolescents with migraine without aura and a healthy control group; 2) to test whether the child’s perceived security of attachment to the mother and the father mediated the association between migraine and anxiety.

Methods

One hundred children and adolescents with Migraine without Aura were compared with a control group of 100 children without headache. The Security Scale (measures perceived security of attachments) and the Self-Administered Psychiatric Scales for Children and Adolescents, a measure of anxiety symptoms, were administered to all participants.

Results

The clinical group had lower attachment security than the control group and higher scores on all anxiety scales. Anxiety was negatively correlated with attachment. Children’s attachment to their mother mediated the increase in global anxiety in the clinical group. Insecure paternal attachment was associated with greater insecurity in maternal attachment, suggesting that there is a complex pathway from migraine to anxiety symptoms mediated by perceived insecurity of paternal attachment and hence also by perceived insecurity of maternal attachment.

Conclusion

These results suggest that insecure parental attachment may exacerbate anxiety in children and adolescents with migraine and point to the importance of multimodal interventions, perhaps taking account of family relationships, for children and adolescents with migraine.

Psychological and Behavioral Issues in the Management of Migraine in Children and Adolescents

PURPOSE OF REVIEW

It is sometimes assumed that children and adolescents with migraine have a psychiatric or behavioral comorbidity, a belief that can be stigmatizing. This review will examine the recent literature addressing this area to determine if pediatric and adolescent migraineurs are at increased risk for psychiatric comorbidity and to discuss management strategies.

RECENT FINDINGS

A large systematic review of pediatric and adolescent studies concluded anxiety and depression were not associated with onset of recurrent headaches. Children with increasing migraine frequency have reduced school attendance. Pediatric migraineurs have mildly lower quality of life (QOL) scores than healthy peers but not abnormally low. Finally, children with higher migraine frequency as well as migraineurs with aura were more likely to report suicidal ideation. Migraine is a primary neurologic disorder. Migraine and psychiatric disorders may be comorbid; however, at this time, it can be difficult to clearly delineate some migraine features from psychiatric diagnoses with the current screening tools available. The majority of pediatric migraineurs do not have behavioral comorbidities; however, when such comorbidities occur, they should be addressed and appropriately managed. We need more accurate ways of delineating psychiatric and behavioral comorbidities from the migraine phenotype.

Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity disorders: a systematic review

Somatic disorders occur more often in adult psychiatric patients than in the general adult population. However, in child and adolescent psychiatry this association is unclear, mainly due to a lack of integration of existing data. To address this issue, we here present a systematic review on medical comorbidity in the two major developmental disorders autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) and formulate clinical recommendations. The literature was searched using the PubMed and PsycINFO databases (2000-1 May 2016) with the keywords "[((child and adolescent) AND (Autism OR Attention Deficit Hyperactivity Disorder* OR ADHD)) AND ("Cardiovascular Diseases" [Mesh] OR "Endocrine System Diseases" [Mesh] OR "Immune System Diseases" [Mesh] OR "Neurobehavioral Manifestations" [Mesh] OR "Gastrointestinal Disorders" [Mesh] OR Somatic OR Autoimmune disease OR Nervous system disease OR Infection OR Infectious disease)]. Two raters independently assessed the quality of the eligible studies. The initial search identified 5278 articles. Based on inclusion and exclusion criteria 104 papers were selected and subsequently subjected to a quality control. This quality was assessed according to a standardized and validated set of criteria and yielded 29 studies for inclusion. This thorough literature search provides an overview of relevant articles on medical comorbidity in ADHD and/or ASD, and shows that medical disorders in these children and adolescents appear to be widespread. Those who work with children with ASD and/or ADHD should be well aware of this and actively promote routine medical assessment. Additionally, case-control studies and population-based studies are needed to provide reliable prevalence estimates. Future studies should furthermore focus on a broader evaluation of medical disorders in children and adolescents with ADHD and/or ASD to improve treatment algorithm in this vulnerable group.

Migraine and Mental Health in a Population-Based Sample of Adolescents

OBJECTIVE

To explore the relationship between migraine and anxiety disorders, mood disorders and perceived mental health in a population-based sample of adolescents.

METHODS

The Canadian Community Health Survey (CCHS) is a cross-sectional health survey sampling a nationally representative group of Canadians. In this observational study, data on all 61,375 participants aged 12-19 years from six survey cycles were analyzed. The relationships between self-reported migraine, perceived mental health, and mood/anxiety disorders were modeled using univariate and multivariate logistic regression. The migraine-depression association was also explored in a subset of participants using the Composite International Diagnostic Interview-Short Form (CIDI-SF) depression scale.

RESULTS

The odds of migraine were higher among those with mood disorders, with the strongest association in 2011-2 (adjusted odds ratio [aOR]=4.59; 95% confidence interval [CI 95%]=3.44-6.12), and the weakest in 2009-10 (aOR=3.06, CI 95%=2.06-4.55). The migraine-mood disorders association was also significant throughout all cycles, other than 2011-2, when the CIDI-SF depression scale was employed. The odds of migraine were higher among those with anxiety disorders, with the strongest association in 2011-2 (aOR=4.21, CI 95%=3.31-5.35) and the weakest in 2010 (aOR=1.87, CI 95%=1.10-3.37). The inverse association between high perceived mental health and the odds of migraine was observed in all CCHS cycles, with the strongest association in 2011-2 (aOR=0.58, CI 95%=0.48-0.69) and the weakest in 2003-4 (aOR=0.75, CI 95%=0.62-0.91).

CONCLUSIONS

This study provides evidence, derived from a large population-based sample of adolescents, for a link between migraine and mood/anxiety disorders.

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.

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.

Psychiatric comorbidity in childhood and adolescence headache

Primary headaches among children and adolescents have a substantial impact on quality of life, daily activities, social interaction, and school performance in combination with psychopathological symptoms. The main purpose of the present paper is to summarize clinical and epidemiological evidence for psychiatric comorbidity among children and adolescents with headaches, to describe how evidence in headache research suggest different pathways involved in the development and maintenance of these comorbid conditions, and finally suggest some elements professionals may find helpful to assess the scope of complaints, related functional impairment, and potential precipitating factors in planning of more targeted treatments.

Headache in school children: prevalence and risk factors

BACKGROUND

Recurrent headache is a common problem in school children. Evaluation generally leads to the diagnosis of a primary headache syndrome (migraine or tension-type headache). This review is addressed to the question whether headaches in school children are becoming more common and, if so, what risk factors are associated with the rise in frequency.

METHOD

We selectively searched the PubMed database for pertinent publications that contained the terms "primary headache AND children/adolescent AND risk factors/prevalence." Articles published in either English or German up to April 2013 were considered. Articles on secondary types of headache were excluded.

RESULTS

Headaches are becoming more common among school children. At present, 66% to 71% of 12- to 15- year-olds have at least one headache every three months, and 33% to 40% have at least one per week. Headache is often accompanied by other physical and/or emotional manifestations. Studies from Scandinavia reveal increasing prevalence in age groups from 8 years of age and upward. Various studies have identified the following risk factors for headache or for its chronification (up to 5.8-fold elevation of risk): a dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, smoking, a low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school, and insufficient leisure time.

CONCLUSION

Headaches are becoming more common among children and adolescents. They are often associated with other physical and emotional complaints.

Effects of protein intake on blood pressure, insulin sensitivity and blood lipids in children: a systematic review

High protein intake in early childhood is associated with obesity, suggesting possible adverse effects on other cardiometabolic outcomes. However, studies in adults have suggested beneficial effects of protein intake on blood pressure (BP) and lipid profile. Whether dietary protein intake is associated with cardiovascular and metabolic health in children is unclear. Therefore, we aimed to systematically review the evidence on the associations of protein intake with BP, insulin sensitivity and blood lipids in children. We searched the databases Medline, Embase, Cochrane Central and PubMed for interventional and observational studies in healthy children up to the age of 18 years, in which associations of total, animal and/or vegetable protein intake with one or more of the following outcomes were reported: BP; measures of insulin sensitivity; cholesterol levels; or TAG levels. In the search, we identified 6636 abstracts, of which fifty-six studies met all selection criteria. In general, the quality of the included studies was low. Most studies were cross-sectional, and many did not control for potential confounders. No overall associations were observed between protein intake and insulin sensitivity or blood lipids. A few studies suggested an inverse association between dietary protein intake and BP, but evidence was inconclusive. Only four studies examined the effects of vegetable or animal protein intake, but with inconsistent results. In conclusion, the literature, to date provides insufficient evidence for effects of protein intake on BP, insulin sensitivity or blood lipids in children. Future studies could be improved by adequately adjusting for key confounders such as energy intake and obesity.

The relationship of anxiety, depression and behavioral problems with recurrent headache in late adolescence – a Young-HUNT follow-up study

Background

The comorbidity of headache and psychiatric symptoms is a well-recognized clinical phenomenon, but there are only limited data regarding the temporal relationship between headache and symptoms of anxiety and depression as well as behavioral problems in adolescents. This study investigates the relationship of anxiety and depressive symptoms and behavioral problems at baseline with recurrent headache at follow-up four years later.

Methods

Within the Nord-Trøndelag Health Study (HUNT), including repeated population-based studies conducted in Norway, 2399 adolescents in junior high schools aged 12–16 years (77% of the invited) participated in Young-HUNT1 (1995–1997) and again at follow-up four years later, in Young-HUNT2 (2000–2001). The same comprehensive questionnaire that included assessment of symptoms of anxiety and depression and behavioral problems, i.e. conduct and attention difficulties was completed in both studies. In addition 1665 of the participants were interviewed about their headache complaints in Young-HUNT2.

Results

In adjusted multivariate analyses we found that higher scores of anxiety and depressive symptoms at baseline were associated with recurrent headache at follow-up four years later (OR: 1.6, 95% CI: 1.2-2.1, p = 0.001), evident for migraine (OR: 1.8, 95% CI: 1.2-2.7, p = 0.008) and non-classifiable headache (OR: 1.7, 95% CI: 1.0-2.8, p = 0.034), but not statistically significant for tension-type headache (OR: 1.4, 95% CI: 1.0-1.9, p = 0.053). Higher scores of anxiety and depressive symptoms at baseline were significantly associated with more frequent headache at follow-up (monthly vs. no recurrent headache OR: 1.8, 95% CI: 1.3-2.5, p = 0.001, weekly or daily vs. no recurrent headache OR: 1.9, 95% CI: 1.2-2.9, p = 0.005). Among adolescents without recurrent headache at baseline, higher scores for symptoms of anxiety and depression were associated with new onset migraine four years later (OR: 2.6, 95% CI: 1.1-4.8, p = 0.036). Higher scores of attention problems at baseline were associated with non-classifiable headache at follow-up (OR: 2.0, 95% CI: 1.3-3.4, p = 0.017).

Conclusions

Results from the present study showed that symptoms of anxiety and depression in early adolescence were associated with recurrent headache four years later. Recognizing anxiety and depressive symptoms should be considered part of the clinical assessment in young headache patients, as early identification of these associated factors may lead to improved headache 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.

Neurodevelopmental and mental health comorbidities in children and adolescents with epilepsy and migraine: a response to identified research gaps

AIM

To determine the distribution and risk characteristics of comorbid neurodevelopmental and mental health comorbidities among children and adolescents (6-18y) with epilepsy or migraine (i.e. a neurological condition with shared features and potential etiology) compared with lower extremity fracture (LEF).

METHOD

This case-control study involved a subset analysis of surveillance data in South Carolina, USA. Hospital admission, outpatient, and emergency department visits for individuals with an International Classification of Disease, 9th revision Clinical Modification diagnosis of epilepsy (n=6730; 54.5% females, 45.5% males; mean age [SD] 14y 2mo [4y 5mo]); migraine (n=10 495; 74.5% females, 25.5% males; 15y 6mo [2y 6mo]), or LEF (n=15 305; 40.3% females, 59.7% males; 13y 11mo [2y 11mo]) from January 1 2000 to December 31 2011 were identified. The association of epilepsy, migraine, or LEF with any mental health comorbidity was evaluated with univariate and multivariate polytomous logistic regression.

RESULTS

Comorbidities were highly prevalent in children and adolescents, with epilepsy with a rate of 29.7% (95% confidence interval [CI]: 28.6-30.8) for mental health comorbidities and 30.8% (95% CI: 29.7-31.9) for neurodevelopmental comorbidities. The odds of mental health comorbidity was 2.20 (95% CI: 2.02-2.39) for children and adolescents with epilepsy and 1.60 (95% CI: 1.48-1.73) for migraine, in reference to children and adolescents with LEF after adjusting for potential confounders. Prevalence and risk for specific comorbidities are presented.

INTERPRETATION

Neuropathophysiological and psychosocial factors specific to epilepsy may provide more risk for adolescents with epilepsy compared to migraine.

Anxiety, depression and behavioral problems among adolescents with recurrent headache: the Young-HUNT study

Background

It is well documented that both anxiety and depression are associated with headache, but there is limited knowledge regarding the relation between recurrent primary headaches and symptoms of anxiety and depression as well as behavioral problems among adolescents. Assessment of co-morbid disorders is important in order to improve the management of adolescents with recurrent headaches. Thus the main purpose of the present study was to assess the relationship of recurrent headache with anxiety and depressive symptoms and behavioral problems in a large population based cross-sectional survey among adolescents in Norway.

Methods

A cross-sectional, population-based study was conducted in Norway from 1995 to 1997 (Young-HUNT1). In Young-HUNT1, 4872 adolescents aged 12 to 17 years were interviewed about their headache complaints and completed a comprehensive questionnaire that included assessment of symptoms of anxiety and depression and behavioral problems, i.e. conduct and attention difficulties.

Results

In adjusted multivariate analyses among adolescents aged 12–14 years, recurrent headache was associated with symptoms of anxiety and depression (OR: 2.05, 95% CI: 1.61-2.61, p < 0.001), but not with behavioral problems. A significant association with anxiety and depressive symptoms was evident for all headache categories; i.e. migraine, tension-type headache and non-classifiable headache. Among adolescents aged 15–17 years there was a significant association between recurrent headache and symptoms of anxiety and depression (OR: 1.64, 95% CI: 1.39-1.93, p < 0,001) and attention difficulties (OR: 1.25, 95% CI: 1.09-1.44, p =0.001). For migraine there was a significant association with both anxiety and depressive symptoms and attention difficulties, while tension-type headache was significantly associated only with symptoms of anxiety and depression. Non-classifiable headache was associated with attention difficulties and conduct difficulties, but not with anxiety and depressive symptoms. Headache frequency was significantly associated with increasing symptoms scores for anxiety and depressive symptoms as well as attention difficulties, evident for both age groups.

Conclusions

The results from the present study indicate that both anxiety and depressive symptoms and behavioral problems are associated with recurrent headache, and should accordingly be considered a part of the clinical assessment of children and adolescents with headache. Identification of these associated factors and addressing them in interventions may improve headache management.

Relationship between alexithymia and coping strategies in patients with somatoform disorder

PURPOSE

A multidimensional intervention integrating alexithymia, negative affect, and type of coping strategy is needed for the effective treatment of somatoform disorder; however, few studies have applied this approach to the three different dimensions of alexithymia in patients with somatoform disorder. The purpose of this study was to determine the relationship between type of coping strategy and three different dimensions of alexithymia expressed in patients.

PATIENTS AND METHODS

A total of 196 patients with somatoform disorder completed the 20-item Toronto Alexithymia Scale, the Zung Self-Rating Depression Scale, the Spielberger State-Trait Anxiety Inventory, the Somatosensory Amplification Scale, and the Lazarus Stress Coping Inventory. The relationships between alexithymia (Toronto Alexithymia Scale - 20 score and subscales), demographic variables, and psychological inventory scores were analyzed using Pearson's correlation coefficients and stepwise multiple regression analysis.

RESULTS

The mean Toronto Alexithymia Scale - 20 total score (56.1±10.57) was positively correlated with the number of physical symptoms as well as with psychopathology scores (Self-Rating Depression Scale, State-Trait Anxiety Inventory trait, state, and Somatosensory Amplification Scale), but negatively correlated with planful problem solving, confrontive coping, seeking social support, and positive reappraisal coping scores. With respect to coping strategy, multiple regression analyses revealed that "difficulty in identifying feelings" was positively associated with an escape-avoidance strategy, "difficulty in describing feelings" was negatively associated with a seeking social support strategy, and "externally oriented thinking" was negatively associated with a confrontive coping strategy.

CONCLUSION

Alexithymia was strongly associated with the number of somatic symptoms and negative affect. Patients with high "difficulty in describing feelings" tend to rely less on seeking social support, and patients with high "externally oriented thinking" tend to rely less on confrontive coping strategies. The coping skills intervention implemented should differ across individuals and should be based on the alexithymia dimension of each patient.

Screening for psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain

BACKGROUND

Recurrent pain symptoms in children are associated with psychiatric comorbidities that could complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA).

METHODS

Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n = 32), tension-type headache (n = 32), or recurrent abdominal pain (n = 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments.

RESULTS

The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003).

CONCLUSION

Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients.

Psychiatric symptoms may contribute to poor quality of life in adolescents with migraine

BACKGROUND

The impact of migraine on quality of life (QOL) can be aggravated by other comorbid factors. The aim of the present study was to assess the differences in the QOL of adolescents with chronic migraine, episodic migraine, and healthy adolescents, and whether the differences in QOL among the diagnostic groups were associated with the presence of self-reported psychiatric symptoms, such as depression and anxiety.

METHODS

A total of 157 adolescents (aged 15-19 years old) were included in the study. Fifty patients had episodic migraine, 56 patients suffered from chronic migraine, and 51 healthy adolescents were controls. All of the participants responded to a detailed headache questionnaire, the Medical Outcomes Trust 36-Item Short-form Health Survey, the State-Trait Anxiety Inventory and the Beck Depression Inventory.

RESULTS

Chronic migraine patients showed a significantly lower QOL than the control subjects in five dimensions of the Medical Outcomes Trust 36-Item Short-form Health Survey, and lower QOL than the episodic migraine patients in four dimensions. High levels of self-reported depressive symptoms were associated with lower QOL in five dimensions and high levels of self-reported anxiety were associated with lower QOL in four dimensions.

CONCLUSIONS

The QOL of adolescent migraine sufferers may be aggravated not only by migraine but also by other factors, such as anxiety and depressive symptoms, which may contribute to the poor QOL in adolescents suffering from migraine.

Pediatric headache: associated psychosocial factors and psychological treatment

All relevant databases (i.e., Pubmed, PsycINFO) were searched for studies published in 2011-2013 focusing on the association of behavioral, cognitive-emotional, and psychosocial factors with recurrent headache in children and adolescents. Only 3 studies were found dealing with psychological intervention for headache; only 2 of them presented empirical data but were not conducted as a RCT. Eleven studies (clinical and population) were concerned with the association of psychosocial factors, dysfunctional psychological traits, and symptoms and headache or examined certain pain features (triggers, course over time, disability). Most studies were interested in the association of cognitive-emotional symptoms (e.g., internalizing symptoms, anxiety) and their relation to headache, including a meta-analysis. In nearly all studies, a close bond between negative affectivity and headache, especially migraine, was revealed.

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.