Headache and comorbidity in children and adolescents

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.

The Comorbidity of Migraine and Epilepsy in Children and Adolescents

Migraine and epilepsy share a number of clinical attributes, including pathophysiology and clinical expression. Both are paroxysmal in nature and thus constitute episodic disorders, yet either may be chronic and/or recurrent. Epileptic seizures and migraine headaches may be mistaken one for the other and may even overlap. In particular, occipital lobe seizures may be misdiagnosed as migraine auras. In this article, we review the relationship between migraine and epilepsy, including the known genetic contributions to both conditions, prodromal, ictal, and postictal headache and shared pathophysiology and treatment options. We describe clinical conditions in which both migraine and epilepsy are prominent features. Lastly, we discuss electronecephaographic abnormalities that have been known to occur in individuals with migraine.

Associated factors of headache in an unstudied cohort of elderly subjects

BACKGROUND

Headache and depression are prevalent among general population. The aim of this study was to determine the associated factors of headache in elderly subjects with emphasis to depression.

METHODS

All cohort of elderly individuals of the Amirkola Health Study Project were included. Data regarding several clinical and demographic characteristics were provided via fill in quesstionnaire, interview and clinical examination. Presence and duration as well as severity of headache were collected through an interview based on self-reported data. Diagnosis of depression was confirmed according to standard Geriatric Depression Scale (GDS) criteria. In statistical analyses chi-square test with logistic regression analysis was used for association.

RESULTS

A total of 832 men and 667 women aged >/= 60 years old were studied. Headache and depression were diagnosed in 42% and 42.4% respectively. In depressed subjects, headache was significantly higher by OR=3.1(95% CI, 2.5-3.83, P=0.001). Proportions of headache increased by severity of depression with a dose-response pattern of relationship from 53.3% in mild depression to 72.6% in severe depression. The magnitude of OR for headache increased from 2.59 (95% CI, 2.03-3.31) in patients with mild depression to 6.04 (95% CI, 3.54-10.3) in patients with severe depression. After adjustment for all covariates, headache was significantly associated with female gender and back pain as well as with depression with a significant dose-response relationship.

CONCLUSION

The findings of this study indicated an independent association between headache and psychological factors in elderly subjects, particularly in women.

Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine

Background

Psychiatric problems have been commonly reported in patients with migraine. This study investigated the reliability and validity of the Generalized Anxiety Disorder-7 (GAD-7) and Generalized Anxiety Disorder-2 (GAD-2) in patients with migraine.

Methods

Subjects were recruited from a headache clinic and a neuropsychologist examined their GAD using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI). Subjects completed several instruments, including the GAD-7, the Beck Anxiety Inventory (BAI), the Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test-6 (HIT-6), and the Migraine-Specific Quality of Life (MSQoL).

Results

Among 146 participants, 32 patients (21.9 %) had GAD as determined by the MINI. Cronbach’s α for the GAD-7 and GAD-2 were 0.915 and 0.820, respectively. At a cutoff score of 5, the GAD-7 had a sensitivity of 78.1 %, a specificity of 74.6 %, a positive predictive value (PPV) of 46.3 %, and a negative predictive value (NPV) of 92.4 %. At a cutoff score of 1, the GAD-2 had a sensitivity of 84.4 %, a specificity of 72.8 %, a PPV of 46.6 %, and a NPV of 94.3 %. The scores of the GAD-7 and GAD-2 well correlated with the BAI score, the MIDAS score, the HIT-6 score, and the MSQoL score.

Conclusions

The GAD-7 and GAD-2 are both reliable and valid screening instruments for GAD in patients with migraine.

Transition from Pediatric to Adult Specialty Care for Adolescents and Young Adults with Refractory Epilepsy: A Quality Improvement Approach

Adolescents and young adults with refractory epilepsy are particularly vulnerable to serious medical and psychosocial challenges during transition from pediatric to adult care. Quality improvement methods were used to address the transition process on an academic medical campus. Outcomes achieved were decreased time from referral to first appointment in the adult clinic, H=8.2, p=0.004, r=0.43; and increased social work referrals using decision support, z=10.0, p=0.0006, OR=6.13. As measured by the 13-item Patient Activation Measure, pre-post change in patient activation as an outcome of self-management education was not statistically significant.

Association between childhood eczema and headaches: An analysis of 19 US population-based studies

BACKGROUND

Atopic dermatitis (or eczema) is a chronic inflammatory disorder associated with sleep disturbances and quality-of-life impairment. Sleep disturbances have been shown to cause headaches in childhood. However, an association between eczema and headaches is not well established.

OBJECTIVES

We sought to determine whether childhood eczema is associated with increased headaches and whether such association is related to fatigue or sleep disturbance.

METHODS

We analyzed data from 401,002 children and adolescents in 19 US population-based cross-sectional studies from the National Survey of Children's Health 2003/2004 and 2007/2008 and the National Health Interview Survey 1997-2013.

RESULTS

In multivariate models controlling for age, sex, race/ethnicity, household income, highest level of education in the family, insurance coverage, number of persons in the household, birthplace in the United States, ever history of asthma, hay fever, and food allergy, eczema was found to be associated with headaches in 14 of 19 studies. In a pooled analysis of all 19 studies, children with eczema compared with those without eczema had a significantly higher prevalence (10.7% [95% CI, 10.3% to 11.0%] vs 5.4% [95% CI, 5.3% to 5.5%]) and odds (1.52 [95% CI, 1.45-1.59]) of headaches. Mild (1.79 [95% CI, 1.07-2.98]) and severe (2.72 [95% CI, 1.33-5.57]) eczema were associated with significantly higher odds of headaches. In particular, eczema associated with atopy, fatigue, excessive daytime sleepiness, insomnia, and only 0 to 3 nights of sufficient sleep had even higher odds of headache than eczema alone.

CONCLUSIONS

Eczema is associated with increased headaches in childhood, particularly in patients with severe disease accompanied by atopy, fatigue, and sleep disturbances.

Cross-sectional time trends in psychological and somatic health complaints among adolescents: a structural equation modelling analysis of 'Health Behaviour in School-aged Children' data from Switzerland

PURPOSE

This study examined cross-sectional time trends in health complaints among adolescents living in Switzerland, including differences between population subgroups and sources of differential response to items.

METHODS

Swiss data were analysed from the Health Behaviour in School-aged Children (HBSC; including 11-15 years old) from 1994 (n = 7008), 1998 (n = 8296), 2002 (n = 9066) and 2006 (n = 9255). Structural equation modelling was used to assess (1) the structure of the HBSC Symptom Checklist (HBSC-SCL; questionnaire, which asks about the frequency of eight health complaints) and (2) associations between the HBSC-SCL with year of data collection and demographic characteristics of the participants.

RESULTS

Two correlated factors fitted the data better than a single factor. The psychological factor included the items 'feeling low,' 'irritability and bad temper,' 'nervousness' and 'difficulties in getting to sleep,' and the somatic factor the items 'headache', 'backache', 'stomach ache' and 'dizziness'. Relative to 1994, lower levels of psychological health complaints were experienced in 1998, 2002 and 2006. However, the changes were only minor. In contrast, somatic health complaints increased monotonically over the years of the survey. Experiencing psychological and somatic health complaints was more pronounced with age among females relative to males and was associated with living in particular language regions of Switzerland.

CONCLUSIONS

Different cross-sectional time trends were identified for the psychological and somatic latent variables, indicating that both factors should be investigated when studying period effects.

Migraine equivalents and related symptoms, psychological profile and headache features: which relationship?

Background

Migraine equivalents are common clinical conditions in children suffering from headache. Very few studies dealt with the psychological profile of children/adolescents with migraine equivalents. Our main aim was to compare the psychological profile between migraine children with and without migraine equivalents. Moreover, as secondary aim, exclusively in children with migraine equivalents, we investigated the possible relationship between migraine attack frequency and intensity and psychological factors.

Methods

We enrolled 136 young migraineurs. They were divided in two groups (patients with and without migraine equivalents). The psychological profile was assessed by means of SAFA Anxiety and Somatization questionnaires.

Results

Migraine equivalents were present in 101 patients (74.3 %). Anxiety (p = 0.024) and somatization (p = 0.001) levels, but not hypochondria (p = 0.26), were higher in patients with migraine equivalents. In children with migraine equivalents, a low frequency of attacks was related to separation anxiety (p = 0.034).

Conclusions

Migraine equivalents patients tend to feel more fearful and to experience more shyness. This, together with the tendency to somatization, may lead them to become vigilant in attachment relationships with their caregivers.

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.

High risk of developing subsequent epilepsy in young adults with migraine: a nationwide population-based cohort study in Taiwan

BACKGROUND AND PURPOSE

This study evaluated the effect of migraine on the subsequent development of epilepsy.

METHODS

A total of 10,016 patients diagnosed with migraine [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) 346] during the period between 2000 and 2009 who were aged older than 20 years were identified as the migraine cohort. A comparison cohort including 40 064 people were enrolled in this study. We calculated the adjusted hazard ratio (aHR) for developing epilepsy (ICD-9-CM 345) in the two cohorts after adjusting for age, sex and comorbidities. Kaplan-Meier analysis was used to measure the cumulative epilepsy incidence, and the log-rank test was used to estimate the differences between two curves.

RESULTS

The cumulative incidence of epilepsy was significantly high in the migraine cohort. The aHR for developing epilepsy in the migraine cohort was 1.85 (95% CI = 1.22-2.81). The aHR for developing epilepsy in the female migraineurs was significantly different compared with that of the non-migraine cohort (aHR = 2.04, 95% CI = 1.20-3.48) and male migraineurs (aHR = 1.53, 95% CI = 0.78-3.00). The incidence of developing epilepsy was increased in patients aged 20-44 years, yielding an aHR of 2.14 (95% CI = 1.24-3.68). The comorbidity-specific aHR for developing epilepsy associated with migraine was 2.33 (95% CI = 1.25-4.34) in patients without any comorbidities, and 1.73 (95% CI = 1.02-2.93) in those with comorbidities.

CONCLUSION

This population-based retrospective cohort study revealed a significant increase in subsequent epilepsy risk in young adults with migraine.

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.

A review of episodic and chronic pediatric headaches of brief duration

BACKGROUND

Headaches that last less than an hour in duration are uncommon, except for atypical migraine, and without a practitioner's appropriate knowledge, may result in misdiagnosis. Although most of these headaches are classified as primary headache syndromes, some have secondary etiologies such as structural lesions.

METHODS

This pediatric-specific review updates these headache syndromes. Included are atypical migraine, the trigeminal autonomic cephalgias, idiopathic stabbing headache, cranial neuralgias, occipital neuralgia, thunderclap headache, nummular headache, the red ear syndrome, and the numb-tongue syndrome.

CONCLUSION

Knowledge of the clinical characteristics of these headache patterns in children allows physicians to quickly establish the headache diagnosis and develop the optimal treatment plan.

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.

Migraine genetics: current findings and future lines of research

In the last two decades, migraine research has greatly advanced our current knowledge of the genetic contributions and the pathophysiology of this common and debilitating disorder. Nonetheless, this knowledge still needs to grow further and to translate into more effective treatments. To date, several genes involved in syndromic and monogenic forms of migraine have been identified, allowing the generation of animal models which have significantly contributed to current knowledge of the mechanisms underlying these rare forms of migraine. Common forms of migraine are instead posing a greater challenge, as they may most often stem from complex interactions between multiple common genetic variants, with environmental triggers. This paper reviews our current understanding of migraine genetics, moving from syndromic and monogenic forms to oligogenic/polygenic migraines most recently addressed with some success through genome-wide association studies. Methodological issues in study design and future perspectives opened by biomarker research will also be briefly addressed.

Efficacy and pharmacokinetic activity of frovatriptan compared to rizatriptan in patients with moderate-to-severe migraine

BACKGROUND

Migraine is a painful neurological disorder that affects over 10% of the general population. Frovatriptan and rizatriptan are antimigraine agents belonging to the triptan class. Although previous studies have independently compared the efficacy of these agents, contemporaneous data examining both pharmacokinetic (PK) properties and efficacy in parallel have not previously been available.

MATERIALS AND METHODS

In this single-center double-blind study, 18 subjects (ten female) were treated for a single migraine attack with frovatriptan 2.5 mg or rizatriptan 10 mg. Plasma concentrations were measured predose and at 2, 4, 6, 12, 24, 48, and 72 hours after drug administration. The primary end point of this study was to evaluate the association between PK parameters and efficacy measures and recurrence rate. Secondary end points were pain-free and pain-relief episodes at 2 and 4 hours, recurrent episodes within 48 hours, and cumulative hazard of recurrence within 72 hours.

RESULTS

At baseline, approximately 17% of patients had mild migraine, while 83% had moderate-severe migraine. Although the time to maximum concentration was similar for both drugs (2.7 versus 2.3 hours), the terminal half-life for frovatriptan was longer than rizatriptan (29.3 versus 3.2 hours, P<0.0001). The proportion of patients who were pain-free at 4 hours without rescue medication was higher in the frovatriptan-treated group, (38.9 versus 5.6%, P=0.045). The cumulative hazard of recurrence over 72 h was reduced by frovatriptan compared to rizatriptan-treated patients (log-rank test, P=0.04). Pain-free and pain-relief episodes for the study period were positively correlated with the concentration:maximum concentration (Cmax) ratio for frovatriptan (r=0.52, P=0.028), but not rizatriptan. Recurrence rate was negatively correlated with the concentration:Cmax ratio for both frovatriptan (r=-0.96, P=0.0024) and rizatriptan (r=-0.98, P=0.0004). Fewer adverse events were observed for frovatriptan compared to rizatriptan (one versus eight, P=0.021).

CONCLUSION

This pilot study indicates that a similar extent of initial pain relief is afforded by both triptans in migraine treatment. The longer duration of action of frovatriptan parallels and correlates with its PK profile.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Pharmacoinformatics elucidation of potential drug targets against migraine to target ion channel protein KCNK18

Migraine, a complex debilitating neurological disorder is strongly associated with potassium channel subfamily K member 18 (KCNK18). Research has emphasized that high levels of KCNK18 may be responsible for improper functioning of neurotransmitters, resulting in neurological disorders like migraine. In the present study, a hybrid approach of molecular docking and virtual screening were followed by pharmacophore identification and structure modeling. Screening was performed using a two-dimensional similarity search against recommended migraine drugs, keeping in view the physicochemical properties of drugs. LigandScout tool was used for exploring pharmacophore properties and designing novel molecules. Here, we report the screening of four novel compounds that have showed maximum binding affinity against KCNK18, obtained through the ZINC database, and Drug and Drug-Like libraries. Docking studies revealed that Asp-46, Ile-324, Ile-44, Gly-118, Leu-338, Val-113, and Phe-41 are critical residues for receptor–ligand interaction. A virtual screening approach coupled with docking energies and druglikeness rules illustrated that ergotamine and PB-414901692 are potential inhibitor compounds for targeting KCNK18. We propose that selected compounds may be more potent than the previously listed drug analogs based on the binding energy values. Further analysis of these inhibitors through site-directed mutagenesis could be helpful for exploring the details of ligand-binding pockets. Overall, the findings of this study may be helpful for designing novel therapeutic targets to cure migraine.

Orthodontic treatment need for adolescents in the Campania region: the malocclusion impact on self-concept

BACKGROUND

Dental malocclusions can be considered not only as an oral health problem, because they are linked to quality of life perception. Many factors related to malocclusion have strong influences on the perception of facial esthetics (eg, anterior tooth alignment, tooth shape and position, lip thickness, symmetric gingival or tooth contour, lip profile, and overjet). Many reports have shown that the perception of facial esthetics can influence psychological development from early childhood to adulthood. The aim of this study is to investigate the effect of dental malocclusion on self-esteem in a sample of adolescents.

MATERIALS AND METHODS

The study population was composed of 516 orthodontically untreated subjects (256 males) mean ages 13.75±1.977 years recruited from schools in the Campania region of Italy between January 2011 and July 2011. To evaluate the self-esteem grade in our population, all subjects filled out the Multidimensional Self Concept Scale questionnaire and attended an orthodontic clinical evaluation to estimate dental occlusal aspects.

RESULTS

Pearson's analysis shows the relationship in our sample between some occlusal characteristics (crossbite and dental crowding) and aspects of self-concept evaluation (social, competence, academic, physical, and global score) of the Multidimensional Self Concept Scale questionnaire. Moreover, logistic regression analysis shows the potential role of dental crowding (odds ratio 5.359; 95% confidence interval 3.492-8.225) and crossbite (odds ratio 6.153; 95% confidence interval 3.545-10.678) as risk factors for development of global self-concept score abnormalities.

CONCLUSION

Our findings confirm the relationship between psychosocial well-being, self-esteem, and dental malocclusion among adolescents.

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.

Effectiveness and safety of Nintendo Wii Fit Plus™ training in children with migraine without aura: a preliminary study

BACKGROUND

Migraine without aura (MoA) is a painful syndrome, particularly in childhood; it is often accompanied by severe impairments, including emotional dysfunction, absenteeism from school, and poor academic performance, as well as issues relating to poor cognitive function, sleep habits, and motor coordination.

MATERIALS AND METHODS

The study population consisted of 71 patients affected by MoA (32 females, 39 males) (mean age: 9.13±1.94 years); the control group consisted of 93 normally developing children (44 females, 49 males) (mean age: 8.97±2.03 years) recruited in the Campania school region. The entire population underwent a clinical evaluation to assess total intelligence quotient level, visual-motor integration (VMI) skills, and motor coordination performance, the later using the Movement Assessment Battery for Children (M-ABC). Children underwent training using the Wii-balance board and Nintendo Wii Fit Plus™ software (Nintendo Co, Ltd, Kyoto, Japan); training lasted for 12 weeks and consisted of three 30-minute sessions per week at their home.

RESULTS

The two starting populations (MoA and controls) were not significantly different for age (P=0.899) and sex (P=0.611). M-ABC and VMI performances at baseline (T0) were significantly different in dexterity, balance, and total score for M-ABC (P<0.001) and visual (P=0.003) and motor (P<0.001) tasks for VMI. After 3 months of Wii training (T1), MoA children showed a significant improvement in M-ABC global performance (P<0.001), M-ABC dexterity (P<0.001), M-ABC balance (P<0.001), and VMI motor task (P<0.001).

CONCLUSION

Our study reported the positive effects of the Nintendo Wii Fit Plus™ system as a rehabilitative device for the visuomotor and balance skills impairments among children affected by MoA, even if further research and longer follow-up are needed.