Headache and ADHD in Pediatric Age: Possible Physiopathological Links

Pediatric hypnic headache: a systematic review

Introduction

Hypnic headache (HH) is a primary headache, and it is considered a rare condition in children. The underlying mechanisms of HH are not yet fully understood. This systematic review aims to provide a comprehensive description of the clinical features of all published cases of pediatric HH. It will also discuss the differences in headache features between children and adults, the increased diagnostic sensitivity of the new diagnostic criteria (ICHD-3), potential pathophysiological hypotheses explaining the higher incidence in adults, differential diagnoses, and therapeutic options for children.

Methods

A systematic search was conducted to identify and analyze articles reporting cases of HH in patients under the age of 18. The search was performed in major medical databases including Cochrane Library, EBSCO, Embase, Medline, PubMed, Science Direct, Scopus, and Web of Science. The search covered the period from 1988 to April 2023. Relevant studies were screened for eligibility, and data extraction was performed using a standardized approach.

Results

Seven children with HH were included in the analysis. The mean age of onset for headache attacks was 10 ± 4.3 years (range 3-15 years). The average time from the start of headaches to diagnosis was 15.8 ± 25.0 months (range 1-60 months). Headache features in children differed from those observed in adult HH patients. Children experienced throbbing/pulsating pain, while adults reported dull/pressure-like pain. Children also had lower frequency and shorter duration of attacks compared to adults. The use of ICHD-3 criteria appeared to be more sensitive and inclusive for diagnosing HH in children compared to the previous ICHD-2 criteria. The association of headache attacks with sleep suggests that HH may be a primary disorder with a chronobiological origin. Hypothalamic dysfunction and melatonin dysregulation, which are more prevalent in older individuals, could potentially explain the higher incidence of HH in adults. Other primary headaches and secondary causes should be ruled out. Melatonin prophylactic therapy may be considered for pediatric patients.

Discussion

Further evaluation of the clinical features of HH in children is needed. The development of specific diagnostic criteria for pediatric cases could improve diagnostic rates and enhance the management of children with HH.

ADHD and the avoidance of mental effort: the role of response inhibition and avoidance motivation

OBJECTIVE

The tendency of people with ADHD to avoid tasks that require mental effort impacts their academic achievement. Findings in the literature suggest that children with ADHD find cognitive tasks more effortful and uncomfortable than their typically developing peers. However, neuropsychological processes contributing to this remain unclear. The present study investigated whether the relationship between prepotent motor response inhibition and avoiding mental effort is mediated by the ability to resist avoidance motivation and whether this proposed mediation mechanism is contingent on ADHD diagnosis.

METHOD

40 children with ADHD and 40 gender and age-matched typically developing peers participated in the study. They completed the Cognitive Effort Avoidance Measure, the Go/No-go Task, and the Reinforcement Sensitivity Theory-Personality Questionnaire-Children. Mediation and moderated mediation analyses were employed to test the hypotheses.

RESULTS

Children with ADHD scored lower in response inhibition and resisting avoidance motivation. Poorer scores in these variables were associated with a higher avoidance rate. Moreover, the ability to resist avoidance motivation completely mediated the relationship between response inhibition and avoidance rate only among children with ADHD.

CONCLUSION

Findings imply that poorer response inhibition led to an increase in avoidance motivation among children with ADHD, which becomes challenging to regulate effectively due to an impairment in the ability to resist avoidance motivation. Theoretical and clinical implications are discussed.

Negative effects of accompanying psychiatric disturbances on functionality among adolescents with chronic migraine

Background

Chronic migraine is a condition with gradually increasing prevalence among adolescents which causes severe headaches resulting in functionality loss. Factors contributing to migraine becoming chronic and negatively affecting quality of life in adolescence are still unclear. Parallel with these, we aimed to examine the effect of psychiatric symptoms on headache severity and functionality loss among adolescents with chronic migraine.

Methods

We evaluated features of 50 adolescents who were diagnosed with chronic migraine according to International Classification of Headache Disorders-3 for the first time in their lives by an experienced neurologist. Sociodemographic and clinical data were collected and Pediatric Migraine Disability Assessment Score, Visual Analogue Score and DSM-5 Level 1 Cross-Cutting Symptom Measure Scores (CCSM-5) were evaluated. Semi-structured psychiatric interviews were done to those who scored higher than cut-off scores on CCSM-5. Healthy control group was constituted of cases which had similar age and sex distribution to case group.

Results

Majority of the case group was female (%78). There was a positive correlation between headache severity and computerized tomography history in emergency department. All of the psychiatric symptom scores were significantly higher in case group except for psychotic symptoms; but attention problems and manic symptoms clusters did not have significant difference according to the thresholds of CCSM-5. Receiving a psychiatric diagnosis did not affect frequency, severity or duration of headaches. There were also no relationship between depression/anxiety diagnosis and severity of headache/functionality loss.

Conclusion

Findings suggest that; more rational treatment methods with lesser functionality loss should be developed by adopting multidisciplinary and prospective approach via psychiatric screening for adolescents with chronic migraine.

Auditory attention alterations in migraine: A behavioral and MEG/EEG study

OBJECTIVES

To evaluate alterations of top-down and/or bottom-up attention in migraine and their cortical underpinnings.

METHODS

19 migraineurs between attacks and 19 matched control participants performed a task evaluating jointly top-down and bottom-up attention, using visually-cued target sounds and unexpected task-irrelevant distracting sounds. Behavioral responses and magneto- and electro-encephalography signals were recorded. Event-related potentials and fields were processed and source reconstruction was applied to event-related fields.

RESULTS

At the behavioral level, neither top-down nor bottom-up attentional processes appeared to be altered in migraine. However, migraineurs presented heightened evoked responses following distracting sounds (orienting component of the N1 and Re-Orienting Negativity, RON) and following target sounds (orienting component of the N1), concomitant to an increased recruitment of the right temporo-parietal junction. They also displayed an increased effect of the cue informational value on target processing resulting in the elicitation of a negative difference (Nd).

CONCLUSIONS

Migraineurs appear to display increased bottom-up orienting response to all incoming sounds, and an enhanced recruitment of top-down attention.

SIGNIFICANCE

The interictal state in migraine is characterized by an exacerbation of the orienting response to attended and unattended sounds. These attentional alterations might participate to the peculiar vulnerability of the migraine brain to all incoming stimuli.

Pain, Bullying Involvement, and Mental Health Problems Among Children and Adolescents With ADHD in Taiwan

OBJECTIVE

The aim of this study was to examine the relationships of pain and pain-induced functional impairment with bullying involvement, as well as the relationships between pain and mental health problems among 474 children and adolescents with ADHD.

METHOD

The levels of pain, pain-induced functional impairment, involvement in bullying, depression, anxiety, ADHD symptoms, and sleep quality were assessed.

RESULTS

Both victims of verbal and relational bullying and victims of physical bullying were more likely to have pain and pain-induced functional impairment than nonvictims. The perpetrators of verbal and relational bullying were more likely to have pain than the nonperpetrators. Participants with pain and pain-induced functional impairment experienced more severe depression and anxiety and worse sleep quality than did those without pain or pain-induced functional impairment.

CONCLUSION

Clinical and educational professionals should consider the possibility of involvement in bullying and comorbid depression, anxiety, and poor sleep quality among ADHD children and adolescents with pain problems.

An open/pilot trial of cognitive behavioral therapy in Turkish patients with refractory chronic migraine

Cognitive behavioral therapy (CBT) for pain management is a therapy that aims to modify thoughts and behavior to be more realistic and balanced. There are limited number of studies to assess the efficacy of CBT for patients with pharmacotherapy-resistant chronic migraine in our population. We aimed to invstigate the effects of CBT for patients with refractory chronic migraine on pain attack frequency, disability, severity, anxiety and depression. Fourteen patients with refractory chronic migraine who were referred from the headache clinic to the psychiatry department and regularly attended CBT sessions at least once every 2 weeks for at least 6 months, were included in the study. After 2 sessions of psychiatric evaluation, the subjects had 12 40-min CBT sessions and were given relaxation exercises. The Hamilton depression and anxiety inventories, visual analogue scale for assessing the severity of pain, and the Migraine disability assessment (MIDAS) test were used before and after CBT. The mean Hamilton depression scores before and after CBT were 29.07 ± 7.74 and 14.21 ± 7.7, respectively (p < 0.0001). The mean Hamilton anxiety scores before and after CBT were 26.8 ± 11.7 and 11.7 ± 2.6, respectively (p < 0.0001). The mean VAS scores before and after CBT were 8.07 ± 0.91 and 3.71 ± 1.32, respectively (p < 0.0001). The mean MIDAS scores before and after CBT were 55.5 ± 20.4 and 20.12 ± 16.6, respectively (p < 0.0001). Our results showed that CBT had made a statistically significant difference on pain severity, number of migraine attacks and disability in patients with refractory chronic migraine. CBT should be considered in this patient group.

ADHD is associated with migraine: a systematic review and meta-analysis

An association between primary headaches and attention-deficit/hyperactivity disorder (ADHD) has long been suggested. Moreover, headache is regarded as a common side effect of stimulants, the most effective treatment for ADHD. So far, no systematic review has evaluated the potential association between ADHD and headache. We performed a systematic review of the literature and a meta-analysis of all reported studies on ADHD and primary headaches. Our analysis showed a positive association between ADHD and migraine (OR 1.322, 95% CI 1.018-1717, p value 0.036), but not with tension-type headache. There is a significant association between migraine and ADHD. The mechanisms underlying this association remain to be elucidated, warranting further studies.