Headache in German children and adolescents: a population-based epidemiological study

Region-specific changes in brain glutamate and gamma-aminobutyric acid across the migraine attack in children and adolescents

ABSTRACT

In patients with migraine, an excitation-inhibition imbalance that fluctuates relative to attack onset has been proposed to contribute to the underlying pathophysiology of migraine, but this has yet to be explored in children and adolescents. This prospective, observational, cohort study examined glutamate and gamma-aminobutyric acid (GABA) levels across the phases of a migraine attack and interictally in children and adolescents using magnetic resonance spectroscopy. Macromolecule-suppressed GABA (sensorimotor cortex and thalamus) and glutamate (occipital cortex, sensorimotor cortex, and thalamus) were measured in children and adolescents (10-17 years) with a migraine diagnosis with or without aura 4 times over 2 weeks. Linear mixed-effects models examined changes in glutamate and GABA during the 72 hours leading up to, and after the onset of an attack. We found significant region-specific changes in glutamate and GABA. Specifically, sensorimotor GABA significantly increased leading up to the headache phase, whereas glutamate significantly decreased following the headache onset in the occipital cortex and the thalamus. Post hoc analyses examined the 24 hours leading up to or following the onset of the headache phase. In the 24 hours before the headache onset, sensorimotor glutamate, occipital glutamate, and thalamic GABA decreased. In the 24 hours post headache onset, sensorimotor glutamate continued to decrease. Our results suggest changes in glutamate and GABA that are consistent with the thalamocortical dysrhythmia hypothesis. These findings provide insight into developmental migraine pathophysiology and may open future avenues for treatment targets specific to children and adolescents.

Lifestyle Factors Associated With Frequent Recurrent Headaches in Children and Adolescents: A Canadian Population-Based Study

BACKGROUND AND OBJECTIVES

Lifestyle behaviors have been postulated to affect headache frequency in youth and are often the primary target of self-management recommendations. Our study aimed to assess the association between various lifestyle factors and frequent recurrent headaches in children and youth.

METHODS

Children and adolescents aged 5-17 years were enrolled in a large cross-sectional Canadian population-based health survey, completed on January 31, 2019. Headache frequency was dichotomized into "approximately once/week or less" or ">once/week" (defined as frequent recurrent headaches). The association between frequent headaches and meal schedules, screen exposure, physical activity, chronotype, and frequent substance use/exposure (alcohol, cigarettes, electronic cigarettes, and cannabis) was assessed using both unadjusted logistic regression models and models adjusted for age/sex. Fully adjusted models examined the odds of frequent headaches according to all exposures. Survey design effects were accounted for using bootstrap replicate weighting.

RESULTS

There were an estimated nweighted = 4,978,370 eligible participants in the population. The mean age was 10.9 years (95% CI 10.9-11.0); 48.8% were female; 6.1% had frequent headaches. Frequent headaches were associated with older age (odds ratio [OR] = 1.31, 95% CI 1.28-1.34, p < 0.001) and female sex (OR = 2.39, 95% CI 2.08-2.75, p < 0.001). In models adjusted for age/sex, the odds of frequent headaches decreased with meal regularity (adjusted OR [aOR] = 0.90, 95% CI 0.89-0.92, p < 0.001) and increased with later chronotype (aOR = 1.10, 95% CI 1.05-1.15, p < 0.001) and excess screen exposure (≥21 hours vs none in past week: aOR = 2.97, 95% CI 1.53-5.77, p = 0.001); there was no significant association with reported physical activity (aOR = 0.95, 95% CI 0.67-1.34, p = 0.77). In 12- to 17-year-olds, frequent headaches were associated with frequent alcohol use (≥1/wk vs never: aOR = 3.50, 95% CI 2.18-5.62, p < 0.001), binge drinking (≥5 times in past month vs never: aOR = 5.52, 95% CI 2.95-10.32, p < 0.001), smoking cigarettes (daily vs never: aOR = 3.81, 95% CI 1.91-7.62, p < 0.001), using e-cigarettes (daily vs never: aOR = 3.10, 95% CI 2.29-4.20, p < 0.001), and cannabis use (daily vs never: aOR = 3.59, 95% CI 2.0-6.45, p < 0.001). In the entire sample, daily exposure to smoking inside the house was associated with frequent headaches (aOR = 2.00, 95% CI 1.23-3.27, p = 0.005).

DISCUSSION

Several lifestyle behaviors were associated with frequent headaches in children and youth, such as meal irregularity, late chronotype, prolonged screen exposure, and frequent substance use/exposure, suggesting that these are potential modifiable risk factors to target in this population.

The Prevalence of Headache Disorders in Children and Adolescents in Istanbul: A School-Based Study

BACKGROUND

Headache among children and adolescents is an important health problem. In this school-based epidemiological study conducted in Istanbul, we aimed to reveal the frequency of headaches in this population, define the risk factors associated with headaches, and establish the effect of headaches on the quality of life in this population.

METHODS

The child and adolescent versions of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation structured questionnaire were conducted in 30 schools in Istanbul. The diagnosis was made based on the International Classification of Headache Disorders III-(ICHD-3) beta version. Risk factors associated with headaches were analyzed in a binary logistic regression model.

RESULTS

Among the 5944 students (boys = 3011 [50.7%], girls 2933 [49.3%]) who completed the survey and were enrolled in this study, 3354 (56.4%) reported a headache ever. The prevalence of headaches was significantly higher in girls (62.6% vs. 50.4%, P < 0.001). Migraine prevalence was found to be 5.2%, whereas tension-type headache (TTH) prevalence was 26.1%. Being a female, age, living on the European side, and headache history in the family were found to be associated with an increased risk of having a headache. Pupils with headaches reported that they missed an average of 0.5 ± 1.5 school days due to headaches.

CONCLUSION

TTH was found to be the most common headache syndrome in Istanbul metropolitan area. Considering the effect of headaches on school success and quality of life in childhood, it is clear that the correct diagnosis of headaches and careful handling of risk factors are crucial for this population.

Association Between Peer Victimization, Gender Diversity, Mental Health, and Recurrent Headaches in Adolescents: A Canadian Population-Based Study

BACKGROUND AND OBJECTIVES

It is unknown whether bullying and gender diversity are associated with increased headache frequency in adolescents. Our study aimed to assess the association between peer victimization, gender diversity, and frequent recurrent headaches in adolescents, while controlling for age, sex, socioeconomic status, and potential confounders (mood and anxiety disorders, suicidality).

METHODS

This was a cross-sectional observational study of adolescents aged 12-17 years using data from a Canadian population-based health survey. Headache frequency was dichotomized into "≤once/wk" or ">once/wk" (i.e., frequent recurrent headaches). Logistic regression was used to quantify the association between frequent peer victimization (overt or relational), gender diversity (female sex at birth + male gender, male sex at birth + female gender, or gender diverse), mood/anxiety disorder, suicidality, and the odds of frequent recurrent headaches. The fully adjusted multivariable logistic regression model included all exposures and was controlled for age, sex, and socioeconomic status. Bootstrap replicate weighting was used to account for survey design effects.

RESULTS

There were an estimated 2,268,840 eligible participants (weighted sample size) (mean age = 14.4 years, 48.8% female, 0.5% gender diverse), and 11.2% reported frequent recurrent headaches. Frequent recurrent headaches were associated with older age (odds ratio [OR] = 1.26 per year of age, 95% CI 1.20-1.31), female sex (OR = 2.89, 95% CI 2.47-3.37), and being gender diverse (OR = 3.30, 95% CI 1.64-6.63, adjusted for age/sex). Youth with frequent headaches had higher odds of experiencing both overt and relational bullying compared with peers (OR = 2.69, 95% CI 2.31-3.14, and OR = 3.03, 95% CI 2.58-3.54, adjusted for age/sex). In the fully adjusted model, frequent headaches were no longer associated with gender diversity (OR = 1.53, 95% CI 0.63-3.69) but were still associated with frequent overt and relational peer victimization (OR = 1.82, 95% CI 1.41-2.34, and OR = 1.54, 95% CI 1.17-2.03, respectively), suicidality (OR = 1.83, 95% CI 1.44-2.32), and having a mood or anxiety disorder (OR = 1.50, 95% CI 1.01-2.21, and OR = 1.74, 95% CI 1.24-2.45, respectively). In a model adjusted for age, sex, and mood/anxiety disorders, the risk of suicidality increased incrementally with headache frequency.

DISCUSSION

Peer victimization and suicidality may be associated with higher headache frequency in adolescents with headaches, independently of mood and anxiety symptoms. Gender-diverse adolescents may have a higher risk of experiencing frequent headaches when compared with cisgender peers, and this may be explained by associated psychosocial factors (anxiety, depression, suicidality, and peer victimization).

Potential effect modifiers for treatment with chiropractic manipulation versus sham manipulation for recurrent headaches in children aged 7-14 years: development of and results from a secondary analysis of a randomised clinical trial

BACKGROUND

A recent randomized controlled trial (RCT) investigating the effect of chiropractic manipulation in 199 children aged 7-14 years with recurrent headaches demonstrated a significant reduction of number of days with headache and a better global perceived effect (GPE) in the chiropractic manipulation group compared to a sham manipulation group. However, potential modifiers for the effectiveness of chiropractic manipulation of children with recurrent headaches have never been identified. The present study is a secondary analysis of data from that RCT and will investigate potential effect modifiers for the benefit of chiropractic manipulation for children with headache.

METHODS

Sixteen potential effect modifiers were identified from the literature and a summary index was prespecified based on clinical experience. Relevant variables were extracted from baseline questionnaires, and outcomes were obtained by means of short text messages. The modifying effect of the candidate variables was assessed by fitting interaction models to the data of the RCT. In addition, an attempt to define a new summary index was made.

RESULTS

The prespecified index showed no modifying effect. Four single variables demonstrated a treatment effect difference of more than 1 day with headache per week between the lower and the upper end of the spectrum: intensity of headache (p = 0.122), Frequency of headache (p = 0.031), sleep duration (p = 0.243), and Socioeconomic status (p = 0.082). Five variables had a treatment effect difference of more than 0.7 points on the GPE scale between the lower and the upper end of the spectrum: Frequency of headache (p = 0.056), Sport activity (p = 0.110), Sleep duration (p = 0.080), History of neck pain (p = 0.011), and Headache in the family (0.050). A new summary index could be constructed giving highest weight to History of neck pain and Headache in the family and Frequency of headache. The index suggests a difference of about 1 point in GPE between low and high values of the index.

CONCLUSION

Chiropractic manipulation offers a moderate benefit for a broad spectrum of children. However, it cannot be excluded that specific headache characteristics, family factors, or a history of neck pain may modify the effect. This question must be addressed in future studies.

TRIAL REGISTRATION

ClinicalTrials.gov (Albers et al in Curr Pain Headache Rep 19:3-4, 2015), identifier NCT02684916, registered 02/18/2016-retrospectively registered.

Description of recurrent headaches in 7-14-year-old children: Baseline data from a randomized clinical trial on effectiveness of chiropractic spinal manipulation in children with recurrent headaches

BACKGROUND

Headaches in children are poorly described and diagnosing can be challenging. Objectives are: (1) to describe headache characteristics and child characteristics, (2) to explore whether data can suggest a more diverse way to categorize headaches than traditionally.

METHODS

Baseline data for a clinical trial included a questionnaire and a physical screening. Children's characteristics and detailed description of headache symptoms were provided. Children were classified for migraine or tension-type-headache based on questionnaire data reported by children and parents. This required to apply slightly modified classification criteria and a "non-classifiable" group was added. Severity and symptoms, related to the migraine versus tension type distinction, were investigated to define a migraine-tension-type-index.

RESULTS

253 children were included. Mean pain intensity was 5.9/10. Over 2/3 of the children had headache for > 1 year, and > 50% for several days/week. Half of the children were non-classifiable, 22% were classified as migraine and 23% as tension-type headache. A migraine-tension-type-index was constructed and describes a continuous spectrum rather than two distinct groups.

CONCLUSIONS

Children with recurrent headaches are often severely affected. A questionnaire-based classification appeared feasible to distinguish between migraine and tension-type headaches in children but leaving many children unclassified. A migraine-tension-type-index can be generated allowing to regard the traditional distinction as a continuum (including mixed headache), and potentially serving as an instrument to improve headache management. Trial registration ClinicalTrials.gov, identifier NCT02684916.

Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method

Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.

Total health insurance costs in children with a migraine diagnosis compared to a control group

Background

Health care costs of migraine constitute a major issue in health economics. Several publications analyzed health care costs for adult migraine patients, based on questionnaires or secondary (health insurance) data. Although migraine often starts already in primary school age, data on migraine related costs in children is scarce. In this paper we aimed to assess the migraine-related health care costs in 6 to 11 year old children in Germany.

Methods

Using claims data of a large German health insurer (BARMER), overall annual health care costs of 6 to 11 year old children with a diagnosis of migraine in 2017 (n = 2597) were compared to a control group of 6 to 11 year old children without a headache diagnosis between 2013 and 2017 (n = 306,926). The association of migraine and costs was modeled by generalized linear regression (Gamma regression) with adjustment for sex, age and comorbidities.

Results

Children with migraine caused considerably higher annual per capita health care costs than children without a headache diagnosis (migraine group: € 1018, control group: € 618). Excess costs directly related to migraine amounted to € 115. The remaining excess costs were related to comorbidities, which were more frequent in the migraine group. Mental and behavioural disorders constituted the most expensive comorbidity, accounting for € 105 of the € 400 annual excess costs in the migraine group.

Conclusion

6 to 11 year old children with a migraine diagnosis cause significant direct and comorbidity related excess costs in the German health care system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01349-w.

Migraine and Tension-Type Headache Among Children and Adolescents: Application of International Headache Society Criteria in a Clinical Setting

INTRODUCTION

The International Headache Society criteria were written in order to help physicians establish a headache diagnosis. However, sometimes children with headache do not seem to fit any diagnosis. The purpose of our study was to assess the application of the criteria in a clinical setting.

METHODS

Medical records of children referred for primary headache to the pediatric neurology clinic at Bnai Zion Medical Center from 2008 to 2017 were assessed.

RESULTS

A total of 989 patients (range 6-18 years; 53% female) were assessed at our neurology clinic. Twenty-four percent (n = 241) were diagnosed with tension-type headache, 26% (n = 256) with migraine, and 4.5% (45) with mixed headache. In 41.5% (410), we were unable to reach a specific diagnosis. No differences in gender or age were found between the groups. Children in the migraine group used more analgesic treatments to stop the headache attacks compared with the tension-type headache group (50% vs 38%, P = .001). Patients diagnosed with tension-type headache reported having more emotional difficulties (P = .001). No significant differences were found in headache characteristics (ie, location, sidedness, character), frequency, or intensity between the younger children (ages 6-11) and the adolescents (ages 12-18) within either the tension-type headache or migraine groups.

CONCLUSIONS

Retrospective application of International Headache Society criteria in a large cohort of children with headaches failed to diagnose a specific type of headache in 41.5% of children. Migraine and tension-type headache were equally prevalent, and both constituted a major burden on our patients' everyday lives. We found no major differences in frequency, intensity, and characteristics of pain between younger children and adolescents.

The clinical characteristics of primary headache and associated factors in children: A retrospective descriptive study

BACKGROUND

Headache is the most encountered manifestation of pain in childhood. The purpose of this study was to investigate the incidence and clinical characteristics of primary headaches. Further, the factors associated with primary headache were examined.

MATERIALS AND METHODS

A retrospective study was conducted among young children and adolescents over 3 years at a tertiary referral teaching hospital in North Jordan. Relevant patient information was obtained by reviewing patients' medical records.

RESULTS

This study included 194 children (95 males, 99 females). The incidence rate of primary headache in the current study was 2.815 per 1000 children visited pediatric clinic. The mean age of patients at the time of headache onset was 10 years, and about half of them were males (95/194; 49%). Approximately 30% (56/194) had a family history of headache. Migraine headaches were the most commonly reported types (87/194; 44.8%) and only 17/194; 8.7% suffered from tension type headaches. Approximately, 40% (84/194) of patients reported severe headache and a third of them (67/194; 34.5%) complained of daily headaches. Pain location was reported as bilateral in most patients (153/194; 78.9%). About one fifth (41/194; 21.1%) stated that their headache was precipitated by sleep deprivation. Abnormal serum level of vitamin D and family history of headache were significantly associated with primary headache (p < 0.001).

CONCLUSIONS

These findings highlight the importance of early detection and management of headaches among pediatric population. In addition, screening vitamin D status should be encouraged for children presented with primary headaches.

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.

Effectiveness of chiropractic manipulation versus sham manipulation for recurrent headaches in children aged 7-14 years - a randomised clinical trial

Background

To investigate the effectiveness of chiropractic spinal manipulation versus sham manipulation in children aged 7–14 with recurrent headaches.

Methods

Design: A two-arm, single-blind, superiority randomised controlled trial.

Setting: One chiropractic clinic and one paediatric specialty practice in Denmark, November 2015 to August 2020.

Participants: 199 children aged 7 to 14 years, with at least one episode of headache per week for the previous 6 months and at least one musculoskeletal dysfunction identified.

Interventions: All participants received standard oral and written advice to reduce headaches. In addition, children in the active treatment group received chiropractic spinal manipulation and children in the control group received sham manipulation for a period of 4 months. Number and frequency of treatments were based on the chiropractor’s individual evaluation in the active treatment group; the children in the control group received approximately eight visits during the treatment period.

Primary outcome measures: ‘Number of days with headache’, ‘pain intensity’ and ‘medication’ were reported weekly by text messages, and global perceived effect by text message after 4 months. A planned fixed sequence strategy based on an initial outcome data analysis was used to prioritize outcomes. ‘Number of days with headache’ and ‘pain intensity’ were chosen as equally important outcomes of highest priority, followed by global perceived effect and medication. The significance level for the first two outcomes was fixed to 0.025 to take multiplicity into account.

Results

Chiropractic spinal manipulation resulted in significantly fewer days with headaches (reduction of 0.81 vs. 0.41, p = 0.019, NNT = 7 for 20% improvement) and better global perceived effect (dichotomized into improved/not improved, OR = 2.8 (95% CI: 1.5–5.3), NNT = 5) compared with a sham manipulation procedure. There was no difference between groups for pain intensity during headache episodes. Due to methodological shortcomings, no conclusions could be drawn about medication use.

Conclusions

Chiropractic spinal manipulation resulted in fewer headaches and higher global perceived effect, with only minor side effects. It did not lower the intensity of the headaches.

Since the treatment is easily applicable, of low cost and minor side effects, chiropractic spinal manipulation might be considered as a valuable treatment option for children with recurrent headaches.

Trial registration

ClinicalTrials.gov, identifier NCT02684916, registered 02/18/2016 – retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-020-00360-3.

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.

Manifestation of migraine in adolescents: Does it change in puberty?

PURPOSE

To analyze the association between pubertal stage, menstrual cycle and migraine attacks in girls with migraine. In addition, headache frequency, accompanying symptoms, duration and onset in relation to the specific phase of the cycle were investigated.

METHODS

Girls between 7 and 18 years old, diagnosed with headaches that met "International Classification of Headache Disorders II" diagnostic criteria for migraine without aura, kept a daily headache and menstrual cycle diary over 8 weeks. Ovulatory cycles were identified by weekly progesterone saliva tests.

RESULTS

47 girls participated in the study and were divided into three groups according to Tanner stage and onset of regular menstruation: pre- (n = 16), peri- (n = 19) and post-pubertal (n = 12). A significant difference in migraine frequency was found between pre- and post-pubertal girls (p = 0.005). No significant differences with regard to headache characteristics were detected. Interestingly, a higher frequency of attacks in follicular phase occurred compared to luteal phase in peri- and post-pubertal girls (p = 0.030).

CONCLUSION

During puberty, migraine patterns in girls change to a typical adult pattern of migraine in a stepwise manner not clearly related to menarche. The first sign of this transition phase could be the higher frequency of migraine attacks in post-pubertal girls.

The relationship between personality traits and psychosomatic complaints in a sample of Iranian adults

BACKGROUND

It has been suggested that personality traits may be related to the psychological conditions of people. The current study aimed to explore the relationship between personality traits and psychosomatic complaints.

METHODS

This study was carried out on a sample of Iranian adults living in Isfahan province. The NEO Five- Factor Inventory questionnaire was used to assess personality traits. A 30-item comprehensive questionnaire was used to assess somatoform symptoms and factor analysis was performed to construct psychosomatic complaints profiles. Data was analyzed by Multiple Indicators Multiple Causes (MIMIC) model, using R software.

RESULTS

In total, 4763 participants were recruited 44.2% males and 55.8% females, with a mean age of 36.54 ± 8.04 years. The results of the MIMIC model showed that there is a significant association between the dimensions of personality (neuroticism, extroversion, openness, agreeableness and conscientiousness) and dimensions of psychosomatic complaints profiles (gastrointestinal, neuro-skeletal, pharyngeal-respiratory and psychological) (P < 0.05). In addition, we found that characteristics such as age, sex, marital status, education, physical activity, and body mass index are related to psychosomatic complaints (P < 0.05) and can affect the association between personality traits and psychosomatic complaints.

CONCLUSIONS

Given the relationship between personality traits and psychosomatic complaints, it is possible to provide preventive and therapeutic interventions for psychosomatic complaints based on personality traits specific to each individual.

Prevalence and burden of headache in children and adolescents in Austria - a nationwide study in a representative sample of pupils aged 10-18 years

BACKGROUND

Headache disorders are highly prevalent worldwide, but not so well investigated in children and adolescents as in adults: few studies have included representative nationwide samples. No data exist for Austria until now. In a representative sample of children and adolescents in Austria, we estimated the prevalence and attributable burden of headache disorders, including the new diagnostic category of "undifferentiated headache" (UdH) defined as mild headache lasting less than 1 hour.

METHODS

Within the context of a broader national mental health survey, children and adolescents aged 10-18 years were recruited from purposively selected schools. Mediated self-completed questionnaires included sociodemographic enquiry (gender, age, socioeconomic status, family constellation, residence [urban or rural] and migration background). Prevalence and attributable burden of all headache, UdH, migraine (definite plus probable), tension-type headache (TTH: definite plus probable) and headache on ≥15 days/month (H15+) were assessed using the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents. Health-related quality of life (HrQoL) was assessed using the KIDSCREEN questionnaire.

RESULTS

Of 7643 selected pupils, 3386 (44.3%) completed the questionnaires. The 1-year prevalence of headache was 75.7%, increasing with age and higher in girls (82.1%) than in boys (67.7%; p < 0.001). UdH, migraine, TTH and H15+ were reported by 26.1%, 24.2%, 21.6% and 3.0% of participants. Attributable burden was high, with 42% of those with headache experiencing restrictions in daily activities. Medication use (50% overall) was highest in H15+ (67%) and still considerable in UdH (29%). HrQoL was reduced for all headache types except UdH. Participants in single parent or patchwork families had a higher probability of migraine (respectively, OR 1.5, p < 0.001; OR 1.5, p < 0.01). Participants with a migration background had a lower probability of TTH (OR 0.7, p < 0.01).

CONCLUSIONS

Headache disorders are both very common and highly burdensome in children and adolescents in Austria. This study contributes to the global atlas of headache disorders in these age groups, and corroborates and adds knowledge of the new yet common and important diagnostic category of UdH. The findings call for action in national and international health policies, and for further epidemiological research.

[Headache, abdominal and back pain in children and adolescents in Germany : Results from KiGGS Wave 2 and trends]

BACKGROUND

Pain not only causes suffering in children and adolescents, but also leads to school absenteeism, medication intake, medical treatment, and an increased risk of recurrent pain in adulthood.

OBJECTIVES

Based on data from the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017), the 3‑month prevalence of recurrent headache, abdominal and back pain in girls and boys is reported, and is compared with the prevalence from the KiGGS baseline survey (2003-2006). The consequences of recurrent headache were also explored.

MATERIALS AND METHODS

Data from >11,000 participants (KiGGS Wave 2) and from >12,000 (KiGGS baseline) participants aged between 3 and 17 years were analyzed. For 3‑ to 10-year-olds, parents/guardians answered the questions, while 11- to 17-year-olds provided information themselves.

RESULTS

In 3‑ to 10-year-olds, recurrent abdominal pain was most prevalent, affecting one third of girls and one quarter of boys. Headache was the most frequent type of pain in 11- to 17-year-olds, affecting almost every second girl and about every third boy. The 3‑month prevalence of recurrent headache, abdominal and back pain has increased in girls and boys, especially in the age groups 7 to 10 years and 11 to 13 years. Among recurrent headache sufferers, adolescents take medication almost twice as often as children.

CONCLUSIONS

Headache, abdominal, and back pain are still and with increasing prevalence very common symptoms in children and adolescents in Germany. Their prevention requires a holistic view of children's health in the psychosocial living environment, and healthcare context.

Prevalence and Burden of Primary Headache Disorders in Kuwaiti Children and Adolescents: A Community Based Study

Background/Objective: Primary headaches are common in the pediatric and adolescent population and can be disabling for them and their families. We aimed to assess the prevalence and burden of primary headache disorders among children and adolescents in Kuwait.

Methods: A cross-sectional community-based study included Kuwaiti population aged 6–17 years. They were randomly recruited from all six governorates of Kuwait using stratified multistage cluster sampling. The Headache-Attributed Restriction, Disability, and Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents was used to collect the data.

Results: Data were collected from 3,423 subjects; 664 subjects were diagnosed as having primary headache disorders. The mean age was 12.61 ± 2.51 years and 64.2% were females. One year prevalence of headache was 19.4%. It was significantly prevalent in females compared to males (25.2% vs. 13.8%; P < 0.001). Primary headache disorder significantly increased in age group 12–17 when compared to age group 6–11 years (25.8% vs. 10.4 %; p < 0.001). One year primary headache prevalence showed non-significant differences in both males and females in age group 6–11 years (10.1% in males vs. 10.6% in females; P < 0.79), while it was significantly higher in female vs. males (38.1% vs. 15.8%; P < 0.001) in age group 12–17 years. Migraine prevalence was 10.9% followed by tension type headache (TTH) 6.2% and chronic headache 0.9%. Medical care utilization was reported in 67% of our cohort. The majority (95%) of the patients received symptomatic drugs for headache attacks and only 7.5% used preventive medication. The students with headache lost a mean of 1.29 ± 1.23 days of school, reported mean of 1.16 ± 1.50 days they could not do activities they had wanted to. Their parents lost a mean of 1.01 ± 1.02 days of work because of headaches of their children during the preceding 4 weeks of the study.

Conclusions: The estimated 1 year prevalence of headache was 19.4% overall. Primary headache prevalence increased with age and it was more prevalent in female adolescents compared to males of the same age. Headache disorders in children/adolescents affect school and social activities as well as their parents work. The awareness for early diagnosis and preventive medications for headache in this age group may reduce the headache burden.

The Role of School-Related Well-Being for Adolescent Subjective Health Complaints

BACKGROUND

This study aimed to explore the prevalence of chronic specific-site and multisite pain in adolescents and to investigate how it can possibly be determined by school-related factors.

METHODS

A population-based cross-sectional study was conducted in 2014 in Lithuania as a Health Behavior in School-Aged Children (HBSC) survey. The sample consisted of 5730 school children, aged 11, 13, and 15 years. The analyzed data focused on the school-related context (relations with family, peers, and teachers; school demand, satisfaction, and bullying) of adolescents and subjective health complaints. The relationships between social support and health complaint variables were estimated using multivariate analyses.

RESULTS

The most common subjective health complaint among respondents was a headache. Backache, headache, and stomachache were more common among girls than boys. All somatic complaints were expressed more in younger ages. Multisite complaints were more common among girls and were associated with age-older ones reported more complaints. School-related bullying, school demand, satisfaction, and social support were the most relevant and independent factors for multisite somatic complaints among adolescents.

Age- and sex-specific first health care use for migraine in 2016 in children and adolescents from prospectively collected health insurance data in Germany

BACKGROUND

Migraine in children and adolescents is associated with significant disability and a high risk of persistence into adulthood.

OBJECTIVE

Data on migraine incidence in children and adolescents are few and relatively coarse. To tailor interventions starting shortly after disease onset, detailed information on age- and sex-specific incidence of migraine in children and adolescents is needed.

METHODS

We used health care data prospectively collected by the BARMER statutory health insurance, representing ∼11% of the German population. The incidence of migraine diagnoses (International Classification of Diseases (ICD)-10 code G43) in the year 2016 was assessed in subjects aged 0-19 years, who had been continuously insured with the BARMER between 2005 and 2016 or during their entire lifespan.

RESULTS

Data from ∼1.2 million children and adolescents were available. The incidence of migraine diagnoses steadily increased with age, reaching ∼1% per year around the age of 10 for both sexes, and 3.49% per year in females and 1.72% per year in males at the age of 19. Incidences in males and females were similar up to the age of 13 and higher in females from there on. The proportion of incident migraine diagnoses specified as "definite" versus "probable" migraine increased with age.

CONCLUSION

The present study provides a representative estimation of the first documented health care use for migraine in children and adolescents in Germany within 1-year age bins, separately for boys and girls. These data will be helpful for tailoring early healthcare interventions to reduce disability and prevent migraine chronification.

Primary headaches during lifespan

Primary headaches are one of the most prevalent neurological disorders and can occur during a wide range of lifespan. Primary headaches, especially migraine, are cyclic disorders with a complex sequence of symptoms within every headache attack. There is no systematic review of whether these symptoms changes during lifespan. Indeed, the clinical presentation of migraine shows an age-dependent change with a significantly shorter duration of the attacks and occurrence of different paroxysmal symptoms, such as vomiting, abdominal pain or vertigo, in childhood and, in contrast, largely an absence of autonomic signs and a more often bilateral headache in the elderly. The age-dependent differences in the clinical presentation are less distinct in cluster headache and, especially, in tension-type headache. The differences in the clinical presentation are in agreement with the idea that the connectivity of hypothalamic areas with different brainstem areas, especially the central parasympathetic areas, is important for the clinical manifestation of migraine, as well as, the change during lifespan.

The prevalence of headache in German pupils of different ages and school types

Background/objective

Headache in pupils is underestimated and has a negative impact on learning and life. The aim of this study was to investigate headache prevalence and its collateral effects, in pupils of different ages and school types in a German city.

Methods

Anonymized questionnaires were distributed to 5419 pupils attending primary and secondary schools. Demographics, headache frequency, analgesic use, school absence and, for secondary school children, data on lifestyle were collected.

Results

The questionnaire was returned by 2706 children (49%), 1362 (50.3%) girls, 1344 (49.7%) boys. Of these, 36.6% indicated a frequency of 1, and 31.5% a frequency of ≥ 2 headache days per month within the last 3 months. Headache prevalence increased with school grade, age and secondary school type: 63.6%, 67.2% and 79.5% for primary school children, pupils attending 8-year and pupils attending 6-year secondary schools, respectively. With secondary school level I certificates, pupils are prepared for general professional training in 6 years. Secondary school level II results, after 8 years of training, in university entrance level II certificates, which are the precondition for university studies. Girls reported significantly more headache than boys (73% vs. 63.1%). A significant relationship has been observed between headache frequency and school absence and between headache intensity and headache frequency. Of pupils with headache at least twice a month, 48.1% reported analgesic intake. Ibuprofen (49.1%) and paracetamol (32.8%) were the most frequently used analgesics. Of those pupils with headache ≥ 2 days/month, 68.3% did not have a specific headache diagnosis. Concomitant diseases and regular drug intake, analgesic intake for another reason than headache, caffeine consumption and lack of participation in sports were positively correlated with headache.

Conclusions

The majority of pupils suffer from headache at least once a month. Since frequent headache results in educational and social limitations, pupils at risk should be identified and referred to headache education programs. Efforts are needed to improve the management of juvenile headache patients.

Clinical manifestations of headache in children younger than 7 years

PURPOSE

Headache is a common symptom during childhood. It is usually persistent and requires special care. This study aimed to identify the characteristics of headache in children <7 years of age.

METHODS

We reviewed 3 years of clinical files on children <7 years of age with a chief complaint of headache.

RESULTS

This study included 146 children (66 males, 80 females; mean age, 5.5±1.0 years). Mean symptom duration was 5.8±7.9 months. Attack durations were longer than 2 hours in 31 patients, shorter than 2 hours in 70 patients, and unchecked in 45 patients. Attack frequency was 15.1±10.6 times per month. Pain locations and characteristics were also variable. Mean pain severity score was 5.1±2.2 on the visual analog scale. Of 38 patients who underwent electroencephalography, 9 showed positive findings. Of 41 who underwent brain magnetic resonance imaging, 20 showed positive findings. The diagnoses were migraine (including probable migraine) in 34, tension-type headache in 5, and congenital malformations in 3. Medications were used in 29 patients: acetaminophen in 17, ibuprofen in 8, naproxen sodium in 1, and topiramate or amitriptyline in 3.

CONCLUSION

In children aged <7 years, headache has a relatively benign course, but detailed history taking is needed for more accurate diagnosis.

Using Virtual Human Technology to Examine Weight Bias and the Role of Patient Weight on Student Assessment of Pediatric Pain

The purpose of the study was to investigate the influence of weight bias and demographic characteristics on the assessment of pediatric chronic pain. Weight status, race, and sex were manipulated in a series of virtual human (VH) digital images of children. Using a web-based platform, 96 undergraduate students with health care-related majors (e.g., Health Science, Nursing, Biology, and Pre-Medicine) read a clinical vignette and provided five ratings targeting the assessment of each VH child's pain. Students also answered a weight bias questionnaire. Group-based analyses were conducted to determine the influence of the VH child's weight and demographic cues, as well as greater weight bias on assessment ratings. Male and VH children with obesity were rated as more likely to avoid non-preferred activities due to pain compared to female and healthy weight children, respectively (both p < .001). The pain of VH children with obesity was rated as more likely to be influenced by psychological/behavioral issues compared to the pain of healthy weight VH children (p = .022). African American VH children were rated as experiencing significantly greater pain than Caucasian VH children (p = .037). As child weight increased, low weight bias participants felt more sympathy, while high weight bias participants felt less sympathy (p = .002). Also, low weight bias participants showed increased motivation to help, while high weight bias participants showed less motivation to help, as VH patient weight increased (p = .008). Child weight and evaluator weight bias may be influential in the assessment of pediatric pain. If supported by future research, results highlight the importance of training in evidence-based practice and education on weight bias for students majoring in health-care fields.

Primary headaches in children and adolescents - experiences at a single headache center in Korea

Background

Headache is a common complaint in children and adolescents. Recently, an increased prevalence of headache in children and adolescents has been reported.

Methods

We retrospectively reviewed the medical records of children and adolescents attending the Headache Clinic of Daejeon St. Mary’s Hospital during the period from January 2005 through December 2016.

Results

The study population consisted of 2466 children, aged between 3 and 18 years (mean age: 10.9). Our study showed an increase in the number of patients visiting the hospital with headaches during the past decade. Compared with 2005, the number of patients with headache increased three-fold in 2016. Interestingly, the proportion of boys, preschool children, and other primary headaches revealed a steady and statistically significant increase.

Conclusion

Due to a steady increase in pediatric headaches, the earlier the problem is recognized and properly diagnosed and a treatment plan is established, the greater the likelihood of a better lifelong outcome. Studies are needed to estimate recent trend in prevalence and to identify the demographic and socioeconomic factors predicting the occurrence of headache.

Obesity and Migraine in Childhood

PURPOSE OF REVIEW

The purpose of this work was to review the current literature on the epidemiology and pathophysiology of pediatric obesity and migraine, underlying pathogenic mechanisms that may explain the association between the two disorders, and the effects of treatment.

RECENT FINDINGS

In children and adolescents, the bulk of the available data support an association between obesity and headache disorders in general, though a small number of studies contradict these findings. Relative to the adult population, however, few studies have focused specifically on migraine, and no wide-ranging meta-analyses have been conducted to date. It seems that the pathophysiology of obesity and migraine in adults holds true for the pediatric population as well. The association between obesity and migraine in the pediatric population is likely to be multifactorial and to involve both central and peripheral mechanisms. More attention is currently being addressed to the role of the hypothalamus and the bioactive neurotransmitters and neuropeptides that modulate energy homeostasis, namely serotonin, orexin, and the adiponectins, in migraine. A few innovative studies have demonstrated some benefit for migraine from weight reduction treatments such as exercise and lifestyle management. Many open questions remain regarding the modifiable nature of the obesity-migraine relationship and its implications in clinical practice. Further studies of these issues are needed.

Clinical characteristics of headache in Italian adolescents aged 11-16 years: a cross-sectional questionnaire school-based study

Background

The purpose of this study was to determine headache characteristics, impact on daily activities and medication attitudes among a large sample of adolescents in Italy.

Methods

Secondary school classes were randomly selected from a national stratified multistage sampling. Data regarding socio-familial factors, headache characteristics, impact on daily activities and medication use were recorded with an anonymous multiple-choice questionnaire.

Results

The survey involved 2064 adolescents. 1950 questionnaires were considered for analysis. Study population included 944 males (48.4%) and 1006 females (51.6%), aged between 11 and 16 years (mean 13.5 ± 1.87). Headache prevalence was 65.9%. Mean age at headache onset was 8.33 years. 9.8% suffered from headache > 1/week, 14.3% > 1/month, 24.2% monthly and 17.7% less than monthly. The mean duration of a headache episode was less than 30 min in 32.9%, 1 hour in 28.1%, 2 hours in 19.3% and several hours in 19.5%. Pain intensity was moderate in 52.2% and severe in 9.5%. School represented the main trigger factor (67%). Impact on daily activities was noted in 57.5%. 69.2% of adolescents reported the use of pain relievers. Up to 5.7% declared self-medication, while only 20.6% followed a physician’s prescription. Female adolescents experienced headache more frequently (70.2% vs 60%) and more intensely than male peers. Girls had a higher family history of headache, could more frequently identify a trigger factor, and were more affected into their daily activities than boys.

Conclusions

Population-based studies of headache disorders are important, as they inform needs assessment and underpin service policy for a disease that is a public-health priority. Headache has a high prevalence among adolescents and carries a significant burden in terms of impact on daily activities and use of medication. Furthermore, underdiagnose is common, while trigger factors are often detectable. Special consideration should be given to female adolescents and self-medication attitudes.

Gender disparity in pediatrics: a review of the current literature

BACKGROUND

Gender-based medicine is an innovative branch of biomedical research and represents a new perspective for the future of health research. Many studies have been published on gender medicine in adults but very few data regarding children are available.

LITERATURE SEARCH AND RESULTS

A literature search covering articles published between 1stJuly, 2006 and 1st February, 2017 and concerning children only was conducted using multiple keywords and standardized terminology in Pubmed database. The search was limited to English-language publications. All relevant articles on endocrines, neurological, psychiatric, gastrointestinal, immunological, oncological, rheumatic, pneumological disorders, infectious diseases and analgesia were evaluated and pertinent articles were included in this review. Most of the available studies on gender disparity in childhood are about endocrine and neuro-psychiatric disorders, while there are few data in other areas of medicine.

CONCLUSIONS

Even if several studies on pediatric gender differences can be found on literature, few of them move forwards to analyze the reasons of the observed diversity. No data on pharmacokinetic and pharmacodynamic differences between boys and girls can be found. Hence, more efforts should be directed to investigate these topics in childhood.

Long term outcome of childhood onset headache: A prospective community study

Purpose

To examine prevalence, course, and long-term outcome of childhood migraine and other headaches.

Method

Using questionnaires, 1185 children were followed for recurrent headaches at ages seven, 14 and 32 years, respectively.

Results

At age seven years, 4.0% of the 1185 children (girls 3.7%, boys 4.3%) had migraine and 24% (25%/23%) had nonmigrainous headache. In adulthood, 16% (22%/8%) had migraine and 60% (64%/54%) nonmigrainous headache. Childhood migraine persisted into adulthood in 65% of females and 21% of males, and nonmigrainous headache in 62% and 59%, respectively. After childhood, 17% of females and 7% of males started to have episodes of migraine. No recurrent headache during the follow-up was reported by 11% (6%/16%). In a multivariate analysis, compared with no childhood headache, childhood migraine increased the risk of adulthood migraine by 3.36-fold (95% CI 1.94–5.82) and that of nonmigrainous headache by 1.72-fold (1.14–2.60).

Discussion and conclusions

Headaches are generally as common in preschool girls as boys. From early school years, headaches steadily increase up to young adulthood, but among boys the prevalence levels off after adolescence. About two thirds of children experienced changes in their headache status during a 25-year follow-up. Any kind of recurrent headache at school entry predicts an increased risk of headache in young adulthood. Special attention should be paid to girls and particularly those girls who have recurrent headache when they start school.

Population Pharmacokinetic Analysis of Zolmitriptan and Its Metabolite in Adults and Adolescents to Support Dose Selection in Children With Migraine

Zolmitriptan is a serotonin (5-HT) _1B/1D receptor agonist effective for the treatment of migraine. This analysis aimed to develop a population pharmacokinetic (PK) model for zolmitriptan and its active metabolite in adults and adolescents and provide appropriate dosing regimens to be used in clinical trials for children 6-11 years old. The data from a single-dose clinical study of 5.0-mg zolmitriptan nasal spray (ZNS) conducted in adult and adolescent patients with migraine between migraine attacks was applied. Similar plasma concentration profiles of zolmitriptan and its metabolite, 183C91, were observed in adults and adolescents. A 1-compartment model with first-order absorption and first-order elimination reasonably described the zolmitriptan PK. With a portion of elimination of zolmitriptan being treated as the conversion from zolmitriptan to 183C91, the disposition of 183C91 was described by a 1-compartment model with first-order elimination. The estimated typical apparent volume of distribution and clearance of zolmitriptan were 136 L and 121 L/h, respectively, with 56.5% and 42.6% between-subject variability, respectively. Based on the simulation results with the final population PK model, a body weight-based dosing scheme of 5.0 and 2.5 mg ZNS in children greater than and less than 50 kg is recommended to achieve exposures similar to those of the adult and adolescent population administered 5.0 mg ZNS. The recommended doses for children to achieve exposure similar to that observed in adults given 2.5 mg ZNS are 2.5 mg (≥50 kg) and 1.0 mg (15-50 kg). These dosing regimens could be used in future clinical trials.

[Peppermint oil in the acute treatment of tension-type headache]

Tension-type headache is the most frequent form of headache. The local topical treatment with peppermint oil (oleum menthae piperitae) has proven to be significantly more effective than placebo in controlled studies. Peppermint oil targets headache pathophysiology in multiple ways. The efficacy is comparable to that of acetylsalicylic acid or paracetamol. Solutions of 10 % peppermint oil in ethanol are licensed for the treatment of tension-type headache in adults and children above 6 years. It is included in treatment recommendations and guidelines by the respective professional societies and is regarded as a standard treatment for the acute therapy of tension-type headaches.

Predicting the occurrence of headache and back pain in young adults by biopsychological characteristics assessed at childhood or adolescence

The aim of the current study was to identify predictors of recurrent headache and back pain in young adults (aged 18–27 years) from data assessed in childhood or adolescence, i.e., 9 years before the final survey. Our interest was whether psychological characteristics contribute to the risk of pain prevalence in adult age when controlling for already empirically supported risk factors such as parental pain, pediatric pain and sex. The study was part of a five-wave epidemiological investigation of >5000 families with children aged between 7 and 14 years when addressed first. In a multiple hierarchical regression analysis, the abovementioned three variables (Block-I variables) were entered first followed by five psychological trait variables (Block-II variables: internalizing, anxiety sensitivity, somatosensory amplification, catastrophizing and dysfunctional stress coping) to find out the extent of model improvement. The multivariable hierarchical regression analysis confirmed the hypothesis that the Block-I variables significantly enhance the risk of future pain at young adult age. None of the psychological variables did so. Thus, the hypothesis of a significant surplus predictive effect was not confirmed. The amount of total explained variance differed strongly between headache and back pain. In particular, a valid prediction of back pain was not possible. When analyzed separately in simple regression analysis, psychological variables turned out to be significant predictors, however, of very low effect size. The inclusion of Block-I variables in the model clearly reduced the impact of the psychological variables. This risk profile is discussed in the context of the different trajectories of headache and back pain from childhood to adult age, which were proposed by various studies. We propose that a biopsychological characteristic denoted as emotional negativity, especially regarding self-reference, might be a common factor behind all selected variables. Risk research in recurrent pain is a field where much more multidisciplinary research is needed before progress can be expected.

A thicker intima-media carotid wall was found in a cohort of children with recent onset migraine

AIM

Migraine affects approximately 10-20% of the general population, including children and adolescents, and an association between migraine and increased risks for cardiovascular disease and stroke have been reported in adult patients. This study aimed to address the lack of data on children with migraine.

METHODS

This study comprised 30 children and adolescents (16 male) with migraine. We evaluated their biochemical profile, glucose homeostasis, vascular function by flow-mediated dilatation and arterial structure by carotid intima-media thickness (cIMT). A group of 32 age, sex and auxologically matched children (17 male) served as controls.

RESULTS

The group of children with migraine had a normal biochemical profile and glucose homeostasis, but presented with significantly thicker cIMT than the control group (0.48 ± 0.07 mm versus 0.45 ± 0.04, p < 0.05).

CONCLUSION

We observed a significantly thicker cIMT in children with migraine compared with the controls. The brief time interval between the onset of the disease and the time of the study makes it unlikely that repetitive migraine attacks could be responsible for the thickening of the cIMT. Thus, it may be speculated that primitive vascular function abnormalities were wholly or partly responsible for the development of migraine in this paediatric cohort.

Magnetic stimulation of the upper trapezius muscles in patients with migraine - A pilot study

BACKGROUND

Repetitive peripheral magnetic stimulation (rPMS) has been applied to musculoskeletal pain conditions. Since recent data show that migraine and tension-type headache (TTH) might be closely related to peripheral muscular pain in the neck and shoulder region (supporting the concept of the trigemino-cervical complex (TCC)), this pilot study explores the acceptance of rPMS to the upper trapezius muscles in migraine (partly in combination with TTH).

METHODS

We used rPMS to stimulate active myofascial trigger points (aTrPs) of the upper trapezius muscles in 20 young adults suffering from migraine. Acceptance was assessed by a standardized questionnaire, whereas self-rated effectiveness was evaluated by headache calendars and the Migraine Disability Assessment (MIDAS). Algometry was performed to explore the local effect of rPMS on the muscles.

RESULTS

Acceptance of rPMS was shown in all subjects without any adverse events, and rPMS had a statistically significant impact on almost every parameter of the headache calendar and MIDAS. Among others, the number of migraine attacks (p < 0.001) and migraine intensity (p = 0.001) significantly decreased regarding pre- and post-stimulation assessments. Accordingly, 100.0% of subjects would repeat the stimulation, while 90.0% would recommend rPMS as a treatment option for migraine.

CONCLUSIONS

rPMS might represent a promising tool to alleviate migraine symptoms within the context of myofascial pain. This might be due to stimulation-dependent modulation of the peripheral sensory effect within the TCC in migraine. However, sham-controlled studies with larger and more homogeneous cohorts are needed to prove a potential beneficial effect. Ethics Committee Registration Numbers: 356-14 and 447/14.

Migraine in childhood: biobehavioural or psychosomatic disorder?

It is well documented that headache is a multifactorial disorder which includes not only genetic, biological, medical and neuropsychological factor but also psychological and personality traits. The close relationship between stress and migraine attacks and the significant psychiatric comorbidities in migraine provide evidence of a “paradigm” of tight interaction between somatic and psychological aspects in paediatric migraine. In particular in younger children, an uncomfortable situation, a psychological problem or an emotional distress is rarely expressed directly but usually through physical symptoms. So migraine may be considered as a disorder of psychobiological adaptation in which genetic predisposition interplays with internal and/or external environmental influences such as psycho-emotional, climatic, hormonal, dietary or other factors.

Comparison of comorbidities of migraine and tension headache in a pediatric headache clinic

Objective To compare comorbidities between migraine and tension headache in patients treated in a tertiary pediatric headache clinic. Methods Files of patients with migraine or tension headache attending a pediatric headache clinic were retrospectively reviewed for the presence of organic comorbidities. Additionally, patients were screened with the self-report Strengths and Difficulties Questionnaire to identify nonorganic comorbidities. If necessary, patients were referred to a pediatric psychiatrist, psychologist or social worker for further evaluation. Results The study cohort comprised 401 patients: 200 with migraine and 201 with tension headache. The main organic comorbidities were atopic disease, asthma, and first-reported iron-deficiency anemia; all occurred with statistical significance more often with migraine than with tension headache (Familial Mediterranean fever was six times more frequent in the migraine group than in the tension headache group, but the difference was not statistically significant. Nonorganic comorbidities (psychiatric, social stressors) were associated significantly more often with tension headache than with migraine (48.3% versus 33%; p = 0.03). Conclusions Children and adolescents with migraine or tension headache treated in a dedicated clinic have high rates of organic and nonorganic comorbidities. In this setting, patients with migraine have significantly more organic comorbidities, and patients with tension headache, significantly more nonorganic comorbidities.

Psychological predictors of headache remission in children and adolescents

OBJECTIVE

Longitudinal studies on headaches often focus on the identification of risk factors for headache occurrence or "chronification". This study in particular examines psychological variables as potential predictors of headache remission in children and adolescents.

METHODS

Data on biological, social, and psychological variables were gathered by questionnaire as part of a large population-based study (N=5,474). Children aged 9 to 15 years who suffered from weekly headaches were selected for this study sample, N=509. A logistic regression analysis was conducted with remission as the dependent variable. In the first step sex, age, headache type, and parental headache history were entered as the control variables as some data already existed showing their predictive power. Psychological factors (dysfunctional coping strategies, internalizing symptoms, externalizing symptoms, anxiety sensitivity, somatosensory amplification) were entered in the second step to evaluate their additional predictive value.

RESULTS

Highly dysfunctional coping strategies reduced the relative probability of headache remission. All other selected psychological variables reached no significance, ie, did not contribute additionally to the explanation of variance of the basic model containing sex and headache type. Surprisingly, parental headache and age were not predictive. The model explained only a small proportion of the variance regarding headache remission (R(2) =0.09 [Nagelkerke]).

CONCLUSION

Successful coping with stress in general contributed to remission of pediatric headache after 2 years in children aged between 9 and 15 years. Psychological characteristics in general had only small predictive value. The issue of remission definitely needs more scientific attention in empirical studies.

Developmental trajectories of paediatric headache - sex-specific analyses and predictors

BACKGROUND

Headache is the most common pain disorder in children and adolescents and is associated with diverse dysfunctions and psychological symptoms. Several studies evidenced sex-specific differences in headache frequency. Until now no study exists that examined sex-specific patterns of change in paediatric headache across time and included pain-related somatic and (socio-)psychological predictors.

METHOD

Latent Class Growth Analysis (LCGA) was used in order to identify different trajectory classes of headache across four annual time points in a population-based sample (n = 3 227; mean age 11.34 years; 51.2 % girls). In multinomial logistic regression analyses the influence of several predictors on the class membership was examined.

RESULTS

For girls, a four-class model was identified as the best fitting model. While the majority of girls reported no (30.5 %) or moderate headache frequencies (32.5 %) across time, one class with a high level of headache days (20.8 %) and a class with an increasing headache frequency across time (16.2 %) were identified. For boys a two class model with a 'no headache class' (48.6 %) and 'moderate headache class' (51.4 %) showed the best model fit. Regarding logistic regression analyses, migraine and parental headache proved to be stable predictors across sexes. Depression/anxiety was a significant predictor for all pain classes in girls. Life events, dysfunctional stress coping and school burden were also able to differentiate at least between some classes in both sexes.

CONCLUSIONS

The identified trajectories reflect sex-specific differences in paediatric headache, as seen in the number and type of classes extracted. The documented risk factors can deliver ideas for preventive actions and considerations for treatment programmes.

Headache in school children: is the prevalence increasing?

The objectives of this systematic review were to examine age dependency of headache prevalence in school age children and to assess secular trends of headache prevalence in the last decade, gender and regional differences. A literature search was performed in MEDLINE to identify all prevalence studies in children and adolescents. Five hundred seventy studies were found, of which 37 studies could be included for this review. Headache prevalence in school children increases with their age as demonstrated in cohorts of identical children and cross-sectional surveys covering different age groups of children in one population. Regarding a potential general increase in the prevalence of headache in children and adolescents in the last decade, there are four studies which all show some increase of headache prevalence; however, the degree of increase is varying. Prevalence of headache in girls appears to be higher than in boys. There were no clear regional differences in the prevalence of headache.

[Headache in children and adolescents. Epidemiology, biopsychosocial correlates, and psychological treatment approaches]

EPIDEMIOLOGY

An abundance of studies have consistently shown that headache is the most prevalent pain in children and adolescents. Weekly headache is experienced by more than 10 % and is distinctly more frequent in girls. The number of headache-affected youths with high disability is lower than expected (~ 4 %).

THE ASSOCIATION WITH BIOPSYCHOSOCIAL FACTORS

Headache is associated with pain in other body sites, thus multiple pain is experienced more often than isolated headache. Various somatic symptoms and even chronic diseases are also correlated with headache. Headache in parents carries a high risk of also occurring in their children. Various other psychosocial factors such as dysfunctional psychological traits are closely linked with headache, the most prominent being internalizing symptoms. However, externalizing symptoms also correlate with headache. Pain catastrophizing, as well as somatosensory amplification and anxiety sensitivity, have been shown to characterize individuals with headache. Features of the social environment, such as life events, school, as well as family stressors and socioeconomic parameters, are among the risk factors.

PSYCHOLOGICAL INTERVENTIONS

Psychological interventions such as biofeedback, relaxation, and cognitive-behavioral training have proved their efficacy in headache treatment according to several meta-analyses. The latter has also been conducted in group settings and more recently in self-management focused trainings using electronic media. They mainly aim at the prevention of further headache episodes. The goal of this training is the strengthening of self-efficacy beliefs and active coping strategies. It is proposed that these competencies could contribute to the successful long-term prevention of an adverse course of headache into adulthood.

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

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

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.

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.

Pediatric migraine and episodic syndromes that may be associated with migraine

Importance

Migraine is a common disorder and a frequent cause of medical consultation in children. Many childhood episodic syndromes have been described as common precursors of migraine.

Objective

To review current knowledge on migraine and childhood episodic syndromes, and to discuss future directions for research and clinical practice.

Findings

For most children it is difficult to describe a headache and fully verbalize symptoms such as photophobia and phonophobia that must be inferred from behaviour. Classical migraine features are rare before the age of 6 years, but some migraine-related syndromes have been described. Benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of childhood, cyclic vomiting syndrome and abdominal migraine are currently classified as childhood episodic syndromes, and therefore common precursors of migraine. A strong association between infantile colic and migraine has recently been reported. There are similarities between children with episodic syndromes and children with migraine, regarding social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurologic, and vasomotor features. The real pathophysiological mechanisms of migraine are not fully understood. Current data obtained through molecular and functional studies provide a complex model in which vascular and neurologic events cooperate in the pathogenesis of migraine attacks. Genetic factors causing disturbances in neuronal ion channels, make a migraineur more sensitive to multiple trigger factors that activate the nociception cascade. The expanding knowledge on migraine genetics and pathophysiology may be applicable to childhood episodic syndromes. Migraine preventive strategies are particularly important in children, and could be beneficial in childhood episodic syndromes. Nonspecific analgesics like ibuprofen and acetaminophen are widely used in pediatrics to control pain and have been found to be effective also in the treatment of acute migraine attacks. Triptans are the specific fist-line drugs for acute migraine treatment.

Conclusions and relevance

Migraine phenotype differs somewhat in the developing brain, and childhood episodic syndromes may arise before typical migraine headache. Diagnosing pediatric migraine may be difficult because of children’s language and cognitive abilities. The risk of underestimating migraine in pediatric age is high. An adequate diagnosis is important to maintain a good quality of life and to avoid inappropriate therapy.

Headache prevalence and related symptoms, family history, and treatment habits in a representative population of children in Alba, Italy

BACKGROUND

Headache is a widespread disorder in children, but little is known about the headache prevalence in northwest Italy, on less frequent migraine equivalents, family history, and treatment habits in children.

METHOD

This is an epidemiologic population-based study of a representative sample of children aged 3 to 11 years, conducted in Alba, Italy. We used a self-administered questionnaire to acquire information on gender, age, headache, possible migraine equivalents, family history for various diseases, and treatment habits.

RESULTS

We distributed the questionnaire to 1152 children, and a total of 649 questionnaires were successfully completed. In the preschool age, 10.3% (seven boys and nine girls) of children suffered from headache. In school-age children, the prevalence of headache was 31.4% (75 boys and 80 girls; 27% in 6 year olds and 41% at age 9 years). We found a significant correlation between headache and abdominal pain in the entire sample and with cyclic vomiting syndrome and dizziness in school-age children only. Headache correlated significantly with a family history of headache, thyroid diseases, diabetes, hypertension, and vascular diseases. Headache was treated with drugs, primarily paracetamol, in 60 of the 171 (35%) children who reported headache and in 61% of the children with migraine; no subjects were treated with triptans.

CONCLUSIONS

Headache is widespread in children, with a high prevalence of associated symptoms and family history for many other headache-related disorders.