Migraine and periodic limb movement disorders in sleep in children: a preliminary case-control study

Neuropsychological Functioning in Pediatric Primary Headache Disorders: A Meta-Analysis

OBJECTIVE

To evaluate whether neuropsychological functioning was impaired among individuals with pediatric primary headache disorders (PHD) compared with individuals without headaches. Adults with migraine appear to evidence deficits in neuropsychological performance, but few reviews have examined whether cognitive performance is impaired among children and adolescents with primary headache disorders.

METHODS

we considered studies using a validated clinical neuropsychological measure among pediatric samples (<20-y old) that included a phd and control sample. two authors independently reviewed candidate articles to determine inclusion and to extract data. data were pooled using random-effects models. data sources: pubmed, embase, proquest health & medical, proquest psychology database, and psycinfo were searched from inception to february 2024.

RESULTS

Analysis of 16 included studies indicated significantly worse overall neuropsychological performance among pediatric PHD (g = -0.31; 95% CI = -0.44 to -0.17), as well as significantly worse performance across the motor, executive function, learning/memory, language, processing speed, intelligence, and visuospatial/construction domains, as compared with nonheadache controls. Moderate heterogeneity was observed (I2 = 43.13%) but analyses of publication bias and moderators were not significant. Sensitivity analyses indicated that negative effects were driven by samples with migraine and not observed among tension-type headache (TTH) samples.

CONCLUSIONS

Relative to controls without headache, pediatric samples with migraine demonstrate worse neurocognitive performance both generally and across specific domains. A small number of studies among samples with TTH were included and moderator analyses were likely underpowered.

Rethinking pediatric "Periodic Limb Movement Disorder" (PLMD): A clinical review of pediatric PLMD and consensus criteria for an updated pediatric diagnostic category "Sleep Leg Movement Disorder of Childhood"

Pediatric Periodic Limb Movement Disorder (PLMD) is a sleep-related movement disorder characterized by repetitive limb movements, primarily in the legs, which disrupt sleep and potentially cause daytime functional impairments. This article reviews the clinical features, diagnostic challenges, and treatment approaches for pediatric PLMD, while emphasizing the importance of distinguishing it from simple periodic limb movements (PLMS). Although PLMD is associated with various conditions such as iron deficiency, attention-deficit/hyperactivity disorder (ADHD), and neurodevelopmental disorders, the exact prevalence and underlying mechanisms remain unclear. Diagnosis requires polysomnography, and adherence to standardized criteria, complicates the process. Treatment primarily involves iron supplementation, with behavioral interventions and off-label pharmacological options considered in more severe cases. Due to recent appreciation of non-periodic movements in many cases, this review proposes the introduction of a new diagnostic category, Sleep Leg Movement Disorder of Childhood (SLMDC), which would encompass a broader spectrum of pediatric limb movement disorders. This new category aims to improve clinical care by allowing for more tailored interventions and better communication between healthcare providers and families. SLMDC would facilitate long-term follow-up and offer a framework for understanding the continuum of these disorders from childhood to adulthood. The paper concludes by advocating for the retention of PLMD as a subset of SLMDC, emphasizing the need for updated diagnostic criteria and treatment strategies that reflect the unique characteristics of pediatric patients.

Exploring the associations of sleep bruxism and obstructive sleep apnea with migraine among patients with temporomandibular disorder: A polysomnographic study

BACKGROUND

Migraine is the most common disabling headache disorder in the world. Temporomandibular disorders (TMDs) are a group of conditions characterized by pain/dysfunction of masticatory muscles or their associated structures. There is a lack of studies concerning the association between sleep disorders such as sleep bruxism (SB), obstructive sleep apnea (OSA), migraine, and TMD, despite the increased prevalence of these conditions in TMD patients.

OBJECTIVE

Our case-control study assesses the potential relationship among SB, OSA, and migraine using polysomnography (PSG) among the group with TMD.

METHODS

One hundred nineteen patients with TMD were recruited and hospitalized in the Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension, and Clinical Oncology at Wroclaw Medical University. Their sleep parameters were assessed by PSG according to American Academy of Sleep Medicine guidelines. Migraine diagnosis was based on the third edition of the International Classification of Headache Disorders. The group of 30 patients with median age 35.0 years (interquartile range [IQR]: 26.0, 41.0) were diagnosed with migraine and this group consisted of 17 without aura (MwoA) and 13 with aura (MwA). Thirty patients with migraine were compared to 89 patients with TMD without migraine (controls) with median age 37.0 years (IQR: 26.0, 44.0).

RESULTS

Sleep bruxism was detected in 86% of the migraine group and 71.9% of control participants. The median bruxism episode index (BEI) among patients with migraine was 3.8 n/h (IQR: 2.7, 5.8) and 3.5 n/h (IQR: 1.8, 6.0) in the control group. SB and severe SB (respectively, BEI > 2 and BEI > 4) were not associated with migraine (odds ratio [OR] = 2.68, 95% confidence interval [CI]: 0.84-8.55, p = 0.095; OR = 0.98, 95% CI: 0.42-2.32, p = 0.966). However, mixed bruxism episodes were more frequent in the migraine group compared to study participants not experiencing migraine (median 0.7 n/h [IQR: 0.4, 1.6] vs. median 0.5 n/h [IQR: 0.2, 0.9], p = 0.044; OR = 1.96 with 95% CI: 1.16-3.32, p = 0.013). The median average duration of SB episodes in the migraine group was longer than in the controls (7.0 s [IQR: 5.5, 8.4] vs. 5.9 s [IQR: 5.1, 6.6], p = 0.005). The apnea-hypopnea index (AHI) value was not associated with migraine compared to controls (OR = 1.01, 95% CI: 0.96-1.06, p = 0.605), but MwoA had significantly increased AHI values compared to MwA (mean AHI = -0.1, standard deviation [SD] = 1.5 for MwA vs. mean AHI = 0.9 with SD = 1.3 for MwoA, p = 0.049).

CONCLUSION

Sleep bruxism may not be associated with migraine among patients with TMD; however, mixed bruxism episodes were more frequent in the migraine group. The increased duration of SB episodes in patients with migraine may suggest the common background of these conditions. OSA is also not associated with migraine; however, MwoA might increase the odds of OSA. There is a need to further explore sleep disturbances and migraine, especially in groups with their increased prevalence, such as patients with TMD.

Polysomnographic and clinical characteristics of sleep apnea headache patients

PURPOSE

Sleep apnea headache can be defined as a persistent, widespread, throbbing headache that occurs recurrently, is not accompanied by any additional symptoms after waking up, and usually resolves within four hours. Diagnosis of the condition requires confirmation through polysomnography with an apnea-hypopnea index of at least 5, indicating the presence of obstructive sleep apnea syndrome (OSAS). While sleep apnea headaches are common in 10-15% of individuals with OSAS, morning headaches are experienced by 5% of this population. The aim of this study is to examine both polysomnographic and clinical features associated with sleep apnea headache in individuals confirmed to have OSAS by polysomnography.

METHOD

The study was conducted in the sleep center of University of Health Science, Erenköy Mental and Nervous Disease Training and Research Hospital. We have examined the clinical and polysomnographic data of the patients with sleep apnea headache (SAH) diagnosed according to IHS-3 criteria retrospectively and grouped the patients as mild, moderate and severe OSAS. Patients with morning headache except sleep apnea headache and under PAP titration treatment were excluded. The differences between the sleep macro structures of patients with (WSAH) and without sleep apnea headache (WOSAH) were examined.

RESULTS

The WSAH group consisted of 384 participants and the control group (WOSAH) consisted of 294 participants The mean age was 46.29 ± 12.18 and 45.08 ± 12.62 years, respectively. Patients in the WSAH group had significantly higher scores on the Epworth Sleepiness Scale (ESS) (p = 0.004) and higher periodic limb movement index (PLMI) (p = 0.014) compared to the WOSAH group. WSAH patients exhibited shorter wake times after sleep onset (WASO) and lower scores on the sleep quality index, in contrast to WOSAH patients. Additionally, within the WSAH group, there was a negative correlation between age and several sleep parameters, including total sleep parameters. A positive correlation was observed between sleep duration (p = 0.009), waking up after sleep (p = 0.043), sleep efficiency (p = 0.001) and apnea-hypopnea index (AHI) (p = 0.018). Additionally, ESS scores were positively correlated with AHI and total awake time (p = 0.000 and p = 0.008, respectively), while negatively correlated with stage N3 sleep percentage and mean minimum oxygen level (p = 0.001 and p = 0.020, respectively) in the WSAH group.

CONCLUSION

The causes and possible mechanisms of sleep apnea headache are not fully clarified and the underlying processes are not fully understood. Sleep apnea headaches appear to be related to disturbances in nocturnal sleep. Dysregulation in regions that modulate sleep and nociception may be one possible mechanism.

The complexities of the sleep-pain relationship in adolescents: A critical review

Chronic pain is a common and disabling condition in adolescents. Disturbed sleep is associated with many detrimental effects in adolescents with acute and chronic pain. While sleep and pain are known to share a reciprocal relationship, the sleep-pain relationship in adolescence warrants further contextualization within normally occurring maturation of several biopsychological processes. Since sleep and pain disorders begin to emerge in early adolescence and are often comorbid, there is a need for a comprehensive picture of their interrelation especially related to temporal relationships and mechanistic drivers. While existing reviews provide a solid foundation for the interaction between disturbed sleep and pain in youth, we will extend this review by highlighting current methodological challenges for both sleep and pain assessments, exploring the recent evidence for directionality in the sleep-pain relationship, reviewing potential mechanisms and factors underlying the relationship, and providing direction for future investigations. We will also highlight the potential role of digital technologies in advancing the understanding of the sleep and pain relationship. Ultimately, we anticipate this information will facilitate further research and inform the management of pain and poor sleep, which will ultimately improve the quality of life in adolescents and reduce the risk of pain persisting into adulthood.

Headache in ADHD as comorbidity and a side effect of medications: a systematic review and meta-analysis

There is mixed evidence on the association between headache and attention-deficit/hyperactivity disorder (ADHD), as well as headache and ADHD medications. This systematic review and meta-analysis investigated the co-occurrence of headache in children with ADHD, and the effects of ADHD medications on headache. Embase, Medline and PsycInfo were searched for population-based and clinical studies comparing the prevalence of headache in ADHD and controls through January 26, 2021. In addition, we updated the search of a previous systematic review and network meta-analysis of double-blind randomized controlled trials (RCTs) on ADHD medications on June 16, 2020. Trials of amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with a placebo arm and reporting data on headache as an adverse event, were included. Thirteen epidemiological studies and 58 clinical trials were eligible for inclusion. In epidemiological studies, a significant association between headache and ADHD was found [odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.63-2.46], which remained significant when limited to studies reporting ORs adjusted for possible confounders. The pooled prevalence of headaches in children with ADHD was 26.6%. In RCTs, three ADHD medications were associated with increased headache during treatment periods, compared to placebo: atomoxetine (OR = 1.29, 95% CI = 1.06-1.56), guanfacine (OR = 1.43, 95% CI = 1.12-1.82), and methylphenidate (OR = 1.33, 95% CI = 1.09-1.63). The summarized evidence suggests that headache is common in children with ADHD, both as part of the clinical presentation as such and as a side effect of some standard medications. Monitoring and clinical management strategies of headache in ADHD, in general, and during pharmacological treatment are recommended.

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

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

Headache and Sleep Disturbances in the Pediatric Population

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

Subjective Sleep Quality and Sleep Architecture in Patients With Migraine: A Meta-analysis

BACKGROUND AND OBJECTIVES

Sleep disturbance is often associated with migraine. However, there is a paucity of research investigating objective and subjective measures of sleep in patients with migraine. This meta-analysis aims to determine whether there are differences in subjective sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI) and objective sleep architecture measured using polysomnography (PSG) between adult and pediatric patients and healthy controls.

METHODS

This review was preregistered on PROSPERO (CRD42020209325). A systematic search of 5 databases (Embase, MEDLINE, Global Health, APA PsycINFO, and APA PsycArticles, last searched on December 17, 2020) was conducted to find case-control studies that measured PSG or PSQI in patients with migraine. Pregnant participants and those with other headache disorders were excluded. Effect sizes (Hedges g) were entered into a random effects model meta-analysis. Study quality was evaluated with the Newcastle Ottawa Scale and publication bias with the Egger regression test.

RESULTS

Thirty-two studies were eligible, of which 21 measured PSQI or Migraine Disability Assessment Test in adults, 6 measured PSG in adults, and 5 measured PSG in children. The overall mean study quality score was 5/9; this did not moderate any of the results and there was no risk of publication bias. Overall, adults with migraine had higher PSQI scores than healthy controls (g = 0.75, p < 0.001, 95% confidence interval [CI] 0.54-0.96). This effect was larger in those with a chronic rather than episodic condition (g = 1.03, p < 0.001, 95% CI 0.37-1.01; g = 0.63, p < 0.001, 95% CI 0.38-0.88, respectively). For polysomnographic studies, adults and children with migraine displayed a lower percentage of rapid eye movement sleep (g = -0.22, p = 0.017, 95% CI -0.41 to -0.04; g = -0.71, p = 0.025, 95% CI -1.34 to -0.10, respectively) than controls. Pediatric patients displayed less total sleep time (g = -1.37, p = 0.039, 95% CI -2.66 to -0.10), more wake (g = 0.52, p < 0.001, 95% CI 0.08-0.79), and shorter sleep onset latency (g = -0.37, p < 0.001, 95% CI -0.54 to -0.21) than controls.

DISCUSSION

People with migraine have significantly poorer subjective sleep quality and altered sleep architecture compared to healthy individuals. Further longitudinal empirical studies are required to enhance our understanding of this relationship.

Sleep Disorders in Pediatric Migraine: A Questionnaire-Based Study

There is a high comorbidity between migraine and sleep disorders (SD), with a mutual dependence between sleep and headache. This study aimed to analyze the relationship between headache features (migraine frequency and severity, migraine equivalents, use and efficacy of treatments) and sleep in pediatric migraine. Parents of children and adolescents with migraine completed the Children’s Sleep Habits Questionnaire (CSHQ) and the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD) and answered questions about headache characteristics. The presence of SD was defined according to CSHQ score. SD were detected in 72.9% of 140 subjects, but only 5.0% already received a diagnosis. Patients with SD presented statistically significant higher headache frequency (p = 0.031) and higher prevalence of migraine equivalents (p = 0.007). A higher CSHQ total score was associated with higher frequency of severe attacks (p = 0.012) and lower acute drug efficacy (p = 0.003). Significant positive correlations of sleep onset delay, sleep duration and nightwakings subscales with migraine frequency emerged. Our findings indicate that SD are highly prevalent in pediatric migraine and frequently associated with a higher headache severity and lower response to acute therapy, but often remain underdiagnosed. Improving sleep quality could help to reduce migraine intensity and disability and vice versa.

Sleep Deficiency and Pediatric Chronic Pain

Sleep deficiency in children is a public health concern, and it is highly comorbid in pediatric chronic pain conditions. Children may be particularly vulnerable to the deleterious effects of sleep deficiency, because comorbid sleep deficiency in chronic pain may further exacerbate already existent symptoms of pain, anxiety, depressions, daytime function, and increase health care use. Sleep deficiency is modifiable and integrating human-centered approaches into the development of sleep interventions is a pragmatic approach to partner with parents and children to provide them with the knowledge, motivation, and skills for setting and achieving goals, adapting to setbacks, and problem solving.

Changes in headache characteristics with oral appliance treatment for obstructive sleep apnea

Changes in headache characteristics in obstructive sleep apnea (OSA) patients following oral appliance treatment was investigated for the first time. Thirteen OSA patients with headaches treated with a mandibular advancement device were investigated. Level I polysomnography and Migraine Disability Assessment Questionnaire were completed before and after treatment. Various headache characteristics and concomitant conditions were analyzed. The patient was considered a headache responder when ≥ 30% reduction in headache frequency following treatment. Differences in headache and polysomnographic parameters were compared between headache responder groups. Eight patients (62%) were headache responders. Eleven patients (85%) before and 7 (54%) after treatment reported morning headaches. Significantly more patients had bilateral headache in the responder group before treatment (P = 0.035). The severest headache intensity (P = 0.018) at baseline showed a significant decrease in the headache responder group after treatment. The time spent in N2 (r = - 0.663, P = 0.014), REM sleep (r = 0.704, P = 0.007) and mean oxygen saturation (r = 0.566, P = 0.044) showed a significant correlation with post-treatment average headache intensity. Pre-treatment lower PLM index (r = - 0.632, P = 0.027) and higher mean oxygen saturation levels (r = 0.592, P = 0.043) were significantly correlated with higher post-treatment severest headache intensity. Treatment with an oral appliance is beneficial for many OSA patients with headaches. It should be considered as an alternative treatment in headache patients with mild to moderate OSA.

Migraine and Sleep in Children: A Bidirectional Relationship

Migraine and sleep disorders in children exhibit a bidirectional relationship. This relationship is based on shared pathophysiology. Migraine involves activation of the trigeminal vascular system. Nociceptive neurons that innervate the dura release various vasoactive peptides. Calcitonin gene-related peptide is the most active of these peptides. Neural pathways that are involved in sleep generation are divided into those responsible for circadian rhythm, wake promotion, non-rapid eye movement, and rapid eye movement sleep activation. Sleep state switches are a critical component of these systems. The cerebral structures, networks, and neurochemical systems that are involved in migraine align closely with those responsible for the regulation of sleep. Neurochemical systems that are involved with both the pathogenesis of migraine and regulation of sleep include adenosine, melatonin, orexin, and calcitonin gene-related peptide. Sleep disorders represent the most common comorbidity with migraine in childhood. The prevalence of parasomnias, obstructive sleep apnea, and sleep-related movement disorders is significantly greater in children migraineurs. Infantile colic is a precursor of childhood migraine. Treatment of comorbid sleep disorders is important for the appropriate management of children with migraine. Sleep-based behavioral interventions can be of substantial benefit. These interventions are particularly important in children due to limited evidence for effective migraine pharmacotherapy.

The Impact of Sleep on Disability and School Functioning: Results From a Tertiary Pediatric Headache Center

Pediatric headache patients often experience significant sleep disturbance, which may be a risk factor for poor physical, academic, and emotional functioning, including increased anxiety/fear. The current retrospective cohort study of a clinical sample of youth with persistent headache aimed to examine the impact of sleep on functional outcomes and to explore pain-related fear as a mediator of the association between sleep problems and functioning. A total of 109 youth (aged 7-17 years) with persistent headache presenting to a tertiary pediatric headache center (and their parents) completed measures of sleep problems, fear of pain, functional disability, and school functioning at the time of an initial evaluation and 6 months later. After controlling for age and headache frequency and severity, linear regression analyses indicated that increased sleep problems at baseline were associated with increased functional disability and poorer school functioning at baseline (β = 0.28, P = .01; β = -0.42, P < .001, respectively). Poor sleep at baseline was associated with poorer school functioning (but not functional disability) at follow-up (β = -0.25, P = .02). Mediation models demonstrated an indirect mediating effect of pain-related fear on the association between baseline sleep problems and follow-up functional disability (β = 0.06, 95% confidence interval 0.01, 0.15) and between baseline sleep problems and follow-up school functioning (β = -0.06, 95% confidence interval -0.13, -0.004). Sleep disturbance in youth with headache may be a risk factor for poor functional outcomes, both concurrently and over time, and may be explained partially through pain-related fear. Given the frequency with which pediatric headache patients experience co-occurring sleep problems, sleep should be thoroughly assessed and considered as a potential early treatment target.

The Role of Polysomnography in Identifying Sleep Disorders in Children with Migraine

Migraine pathophysiology and sleep share common neural pathways, and there are clinical as well as paraclinical observations, which lead to the hypothesis of an association between migraine and sleep disorders. The objective of this study consisted of the evaluation of a possible correlation between migraine and sleep disorders in children, as reflected by sleep architecture and electroencephalographic patterns. Eighteen patients aged five to seventeen were recruited for the migraine group, and sixteen age-matched patients with no criteria for migraine or any underlying organic disorder, diagnosed with emotional disorders, were enrolled in the control group. All patients underwent inpatient full night polysomnographic recordings, the results of which were analyzed using appropriate statistical methods. Patients in the migraine group had decreased REM sleep (p = 0.049) and increased N1 sleep (p = 0.018) percentages, compared to the control group. Also, more arousals (p = 0.011) and lower sleep latency (p = 0.029) were noted in the migraine group. A statistically significant association was observed between migraine and sleep disorders when the latter was defined with respect to normal values of polysomnographic parameters published in studies conducted on healthy children. Polysomnography can be a useful tool for studying sleep in pediatric migraine patients. The results of this study can be regarded as a starting point for a better understanding of the complex role of sleep in the developing brain and of eventual intricacies with migraine pathophysiological mechanisms.

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

OBJECTIVE

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

The Interrelationship between Sleep and Chronic Pain in Adolescents

Over half of youth with chronic pain report sleep deficiency including difficulties falling asleep, maintaining sleep, feeling unrested, and experiencing short sleep duration. Sleep deficiency has been shown to play a causal role in the development or worsening of chronic pain, and is associated with a variety of negative consequences for youth with chronic pain. The purpose of this review is to provide a summary of the literature on the interrelationship of sleep and chronic pain in adolescents. We review the impact and prevalence of sleep disturbances, conceptual models of the interrelationship of sleep and pain, biobehavioral mechanisms and risk factors, sleep assessment, and treatment of sleep deficiency and chronic pain in adolescents. Our recommendations for future research include understanding biobehavioral mechanisms that underlie the link between chronic pain and sleep deficiency to help guide development and testing of treatments for co-occurring pain and sleep disturbance in adolescents.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A trial case of medical treatment for primary headache using telemedicine

RATIONALE

Video-based treatment in telemedicine is a potential alternative to face-to-face treatment. We describe our trial use of telemedicine to treat a patient with primary headache.

PATIENT CONCERNS

A 25-year-old woman visited our branch hospital with a chief complaint of recurrent headache. Our branch hospital had no headache specialist, so a headache specialist at our main hospital provided treatment remotely.

DIAGNOSES

She was diagnosed with migraine without aura by the headache specialist using telemedicine.

INTERVENTIONS

The branch hospital physician and the headache specialist used video conferencing to interview and examine the patient and share cranial magnetic resonance imaging (MRI). Audio and camera angle/zoom could be adjusted during interviews, and high-quality video was continuously displayed at both hospitals simultaneously without lag between audio and video. Temporal/spatial resolution was sufficient for proper neurological evaluation. MRI had sufficient image quality and resolution for detailed interpretation. A prescription for medication was issued by the branch hospital physician and confirmed by the headache specialist.

OUTCOMES

Zolmitriptan was effective in treating her migraine.

LESSONS

Telemedicine was useful for treating this primary headache patient and can contribute to regional health care. Future challenges in telemedicine include expanding its use to other areas within the purview of general physicians and headache specialists, covering implementation and maintenance costs, providing adequate explanations to patients and family members, ensuring security of video transmissions, maintaining patient medical records, and supervising treatment.

Altered Brain Functional Connectome in Migraine with and without Restless Legs Syndrome: A Resting-State Functional MRI Study

Background

Migraine is frequently comorbid with restless legs syndrome (RLS), both displaying functional connectivity (FC) alterations in multiple brain networks, although the neurological basis of this association is unknown.

Methods

We performed resting-state functional magnetic resonance imaging and network-wise analysis of FC in migraine patients with and without RLS and healthy controls (CRL). Network-based statistics (NBS) and composite FC matrix analyses were performed to identify the patterns of FC changes. Correlation analyses were performed to identify associations between alterations in FC and clinical profiles.

Results

NBS results revealed that both migraine patients with and without RLS exhibited lower FC than CRL in the dorsal attention, salience, default mode, cingulo-opercular, visual, frontoparietal, auditory, and sensory/somatomotor networks. Further composite FC matrix analyses revealed differences in FC of the salience, default mode to subcortical and frontoparietal, auditory to salience, and memory retrieval networks between migraine patients with and without RLS. There was a trend toward a negative association between RLS severity and cross-network abnormalities in the default mode to subcortical network.

Discussion

Migraine patients with and without RLS exhibit disruptions of brain FC. Such findings suggest that these disorders are associated with differential neuropathological mechanisms and may aid in the future development of neuroimaging-driven biomarkers for these conditions.

The Rorschach Test Evaluation in Chronic Childhood Migraine: A Preliminary Multicenter Case-Control Study

OBJECT

About 1.2-3.2% of children at 7 years of age with increasing age up to 4-19% in adolescents are suffering from migraine without aura (MwA). The aim of the present study is investigating the personality style associated with children and adolescents affected by MwA, administrating the Rorschach test, and comparing with typical developing healthy controls (TD).

METHODS

137 patients (74 males), aged 7.3-17.4 years (mean age 11.4, SD 3.02 years), affected by MwA according to the IHs-3 criteria. The Rorschach variables were treated as numerical variables and statistically tested with t-Student's analysis.

RESULTS

No statistical differences were found between the MwA and TD for age (p = 0.55), and gender (p = 0.804). From the comparison between the two samples, MwA group shows lower W responses (p < 0.001), good quality W responses (p < 0.001), high frequency of detailed responses (p < 0.001), the presence of even minor form of good quality responses (p < 0.001), increased presence of animals answers (A%) (p < 0.001), more frequent trivial answers (Ban%) (p < 0.001).

DISCUSSION

Rorschach interpretation pinpointed many interesting and, perhaps, peculiar aspects in our MwA population such as a trend predisposition for: analytical reasoning rather than synthetic, ease/practicality rather than creativity, oppositionality rather than external adaptation to the environment that may be interpreted as effect of general maladaptivity.

Restless legs syndrome/Willis-Ekbom disease prevalence in beta thalassemia patients

PURPOSE

Both beta thalassemia and restless legs syndrome (RLS) patients share some common pathophysiological characteristics related to iron handling. In the present study, the aim was to explore the prevalence of RLS as well as to explore potential association between the syndrome and various quality of life-related parameters in a sample of beta thalassemia patients.

METHODS

One hundred fourteen (age 40 ± 11 yr, 59 M/55F) beta thalassemia patients participated in this cross-sectional descriptive study. Patients were screened for RLS based on the international RLS study group diagnostic criteria as well as a battery of validated questionnaires.

RESULTS

The prevalence of RLS in this sample of beta thalassemia patients was zero. The quality of life score was low (78 ± 18). Iron levels were within normal range (191 ± 66 mcg/dL) while ferritin levels were high as expected (1836 ± 225 ng/dL).

CONCLUSIONS

Our sample of patients comes from central Greece where the prevalence of RLS in the general population is 4% while in renal failure patients is 27%. To our surprise, there was no presence of RLS among this sample of beta thalassemia patients. The adequate levels of iron and ferritin often seen in these patients could be the reason of the absence of RLS symptoms.

Periodic limb movements in sleep are followed by increases in EEG activity, blood pressure, and heart rate during sleep

Purpose

Periodic limb movements in sleep (PLMS) are related to arousal, sympathetic activation, and increases in blood pressure (BP), but whether they are part of the arousal process or causative of it is unclear. Our objective was to assess the temporal distribution of arousal-related measures around PLMS.

Methods

Polysomnographic recordings of six patients with restless legs syndrome were analyzed. We analyzed 15 PLMS, plus three 5-s epochs before and after each movement, for every patient. Mean values per epoch of blood pressure (BP), heart rate (HR), and electroencephalographic (EEG) power were calculated. For each patient, six 5-s epochs of undisturbed sleep were analyzed as controls.

Results

Alpha + beta EEG power, systolic BP, and HR were significantly increased following PLMS. The EEG power and HR increases were noticed in the first epoch after PLMS, whereas that of systolic BP was observed in the second and third epochs following a PLMS. No significant changes occurred in the epochs of undisturbed sleep.

Conclusions

The results suggest that PLMS are followed by arousal-related nervous system events. Given the high frequency of PLMS throughout the night, they could be a potential risk factor for nocturnal arrhythmias and hypertension, in addition to causing sleep deprivation.

Visual-spatial training efficacy in children affected by migraine without aura: a multicenter study

Routinely in the clinical practice, children affected by migraine without aura (MwA) tend to exhibit severe and persistent difficulties within cognitive processes such as attention, memory, and visual-motor integration (VMI) skills. The aim of this study was to assess the visual-spatial and visual-motor abilities among a sample of children with MwA and the effects of a specific computerized training. The study population was composed of 84 patients affected by MwA (39 girls and 45 boys; mean age: 8.91±2.46 years), and they were randomly divided into two groups (group A and group B) comparable for age (P=0.581), gender (P=0.826), socioeconomic status (SES), migraine frequency (P=0.415), and intensity (P=0.323). At baseline (T0), the two groups were comparable for movement assessment battery for children (M-ABC) and VMI performances. After 6 months of treatment (T1), group A showed lower scores in the dexterity item of M-ABC test (P<0.001) and higher scores in M-ABC global performance centile (P<0.001) and total (P<0.001), visual (P=0.017), and motor (P<0.001) tasks of VMI test than group B. Moreover, at T1, group A showed higher scores in total (P<0.001) and motor (P<0.001) tasks of VMI test and in M-ABC global performance centile (P<0.001) and lower scores in the dexterity item of M-ABC test (P<0.001) than at T0. Group B showed, at T1, performances comparable to T0 for all evaluations. As reported by recent studies about alteration MwA among children in motor abilities, our study confirmed these difficulties and the efficacy of a specific software training, suggesting a new rehabilitative proposal in childhood.

Sleep and Pain in Pediatric Illness: A Conceptual Review

BACKGROUND

Sleep disruption is a common comorbidity of pediatric pain. Consequences of pain and disrupted sleep, evidence for the pain-sleep relation, and how aspects of illness, treatment, and pharmacological pain management may contribute to or exacerbate these issues are presented.

AIMS

This conceptual review explored the relation between pain and sleep in children diagnosed with chronic medical or developmental conditions. The goal of this review is to expand upon the literature by examining common themes in sleep disturbances associated with painful conditions across multiple pediatric illnesses. Populations reviewed include youth with intellectual and developmental disabilities (IDD), migraines, cystic fibrosis (CF), sickle cell disease (SCD), cancer, juvenile idiopathic arthritis (JIA), juvenile fibromyalgia (JFM), and functional gastrointestinal disorders (FGIDs).

RESULTS

Consistent evidence demonstrates that children with medical or developmental conditions are more vulnerable to experiencing pain and subjective sleep complaints than healthy peers. Objective sleep concerns are common but often under-studied. Evidence of the pain-sleep relationship exists, particularly in pediatric SCD, IDD, and JIA, with a dearth of studies directly examining this relation in pediatric cancer, JFM, CF, and FGIDs. Findings suggest that assessing and treating pain and sleep disruption is important when optimizing functional outcomes.

CONCLUSION

It is essential that research further examine objective sleep, elucidate the pain-sleep relationship, consider physiological and psychosocial mechanisms of this relationship, and investigate nonpharmacological interventions aimed at improving pain and sleep in vulnerable pediatric populations.

Sleep bruxism: challenges and restorative solutions

Bruxism is a parafunctional activity related to clenching or grinding the teeth and tooth wear can be a consequence of sleep bruxism (SB). Management of severe tooth wear due to SB is a challenging situation because of the common reduced amount of remaining dental structure and loss of vertical dimension of occlusion. Rationale for the planning of oral rehabilitation of patients with SB presenting severe tooth wear should rely on evidence-based approaches; however, few studies have discussed properties of dental materials for SB rehabilitation and how to cosmetically manage severe tooth wear. This review aimed to provide an overview into bruxism cosmetic rehabilitation and how this can be implemented with good outcomes for the patient.

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

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

Headache and ADHD in Pediatric Age: Possible Physiopathological Links

Primary headache and attention-deficit/hyperactivity disorder (ADHD) are common disorders in children and adolescences, frequently associated to severe cognitive, emotional, and behavioral impairments. They both are a disabling condition with consequences on family and child's quality of life. Literature data on their association are contrasting. Dopaminergic system dysfunction, brain iron deficiency, and sleep disturbance should be considered to better understand headache and ADHD overlap. In this review, we analyze the complex association between these two diseases and the potential impact on child neurodevelopment.

Medical Comorbidities in Pediatric Headache

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

Sleep and Headache

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

Tension-type headache associated with obstructive sleep apnea: a nationwide population-based study

BACKGROUND

There is still controversy regarding the association between primary headaches and obstructive sleep apnea. We explored the relationship between tension-type headache (TTH) and obstructive sleep apnea (OSA) using a large nationwide population-based data set in Taiwan.

METHODS

We identified 4759 patients diagnosed with OSA from the Taiwan Longitudinal Health Insurance Database, based on polysomnography, as the OSA group. We then randomly selected 19036 subjects without OSA, matched by sex and age, to serve as the non-OSA group. The multivariate Cox proportional hazards model with matching for age and sex was used to assess the possible associations between TTH and OSA among the patients.

RESULTS

The prevalence of TTH was 10.2% among OSA patients and 7.7% among non-OSA patients (p < 0.001). The multivariate Cox proportional hazards model revealed patients with OSA were more likely to have TTH (hazard ratio, 1.18; 95% CI, 1.06-1.31) (p = 0.003) than patients in the non-OSA group.

CONCLUSION

Patients with OSA had a higher likelihood of developing TTH than patients in the non-OSA group. Further studies of physiological patterns between OSA and TTH are needed to confirm the study findings.

Forehead carbuncle with intractable headache

Although carbuncles are commonly seen and may heal on their own or respond well to treatment, in rare conditions, bacteria from carbuncles can spread into the bloodstream and migrate to other areas of the body. Herein, we report on an elderly female who suffered from forehead carbuncle with intractable headache, later confirmed as having subgaleal abscess. Physicians should pay special attention to elderly and immune-compromised patients with carbuncles located on the middle of the face, especially when accompanied by intractable headache, to avoid poor outcome.

Risk factors for migraine and tension-type headache in 11 year old children

BACKGROUND

Though migraine and tension type headache are both commonly diagnosed in childhood, little is known about their determinants when diagnosed prior to puberty onset. Our aim was to determine psychosocial- and health-related risk factors of migraine and tension-type headache in 11 year old children.

METHODS

871 New Zealand European children were enrolled in a longitudinal study at birth and data were collected at birth, 1, 3.5, 7, and 11 years of age. Primary headache was determined at age 11 years based on the International Headache Society. Perinatal factors assessed were small for gestational age status, sex, maternal smoking during pregnancy, maternal perceived stress, and maternal school leaving age. Childhood factors assessed were sleep duration, percent body fat, television watching, parent and self-reported total problem behaviour, being bullied, and depression.

RESULTS

Prevalence of migraine and tension-type headache was 10.5% and 18.6%, respectively. Both migraine and TTH were significantly associated with self-reported problem behaviour in univariable logistic regression analyses. Additionally, migraine was associated with reduced sleep duration, and both sleep and behaviour problems remained significant after multivariable analyses. TTH was also significantly associated with antenatal maternal smoking, higher body fat, and being bullied. For TTH, problem behaviour measured at ages 3.5 and 11 years both remained significant after multivariable analysis. Being born small for gestational age was not associated with either headache group.

CONCLUSIONS

Although they share some commonality, migraine and tension-type headache are separate entities in childhood with different developmental characteristics. The association between primary headache and problem behaviour requires further investigation.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Headache and attention deficit and hyperactivity disorder in children: common condition with complex relation and disabling consequences

The aim of this review was to analyze literature data on the complex association between headache and attention deficit and hyperactivity disorder (ADHD) in children, in order to explore its possible consequences on child neurological development. Headache and ADHD are two common conditions in the pediatric population. They both are disabling diseases that impact the child's quality of life and are associated with severe cognitive, emotional, and behavioral impairments. To assess and analyze literature data about the association of ADHD and headache in children and possible physiopathogenesis relationships, we searched for the following terms: headache, migraine, tension-type headache, ADHD, and children (MESH or text words). We found different studies that assess the clinical, epidemiological, and physiopathogenetic overlap between these two diseases, with contrasting results and unresolved questions. Structural and functional abnormalities in brain networks have been found to be central in both headache and ADHD pathophysiology. It will be crucial to gain a better understanding of how subcortical-cortical and corticocortical network development is altered during the onset of the disorders.

Pediatric neurofibromatosis 1 and parental stress: a multicenter study

BACKGROUND

Neurofibromatosis 1 (NF1) is a complex and multifaceted neurocutaneous syndrome with many and varied comorbidities. The literature about the prevalence and degree of maternal stress and the impact of NF1 in the parent-child interaction is still scant. The aim of this study was to evaluate the prevalence of maternal stress in a large pediatric sample of individuals affected by NF1.

METHODS

Thirty-seven children (19 boys, 18 girls) of mean age 7.86±2.94 (range 5-11) years affected by typical NF1 and a control group comprising 405 typically developing children (207 boys, 198 girls; mean age 8.54±2.47 years) were included in this study. To assess parental stress, the mothers of all individuals (NF1 and comparisons) filled out the Parenting Stress Index-Short Form test.

RESULTS

The two study groups were comparable for age (P=0.116), gender (P=0.886), and body mass index adjusted for age (P=0.305). Mothers of children affected by NF1 reported higher mean Parenting Stress Index-Short Form scores on the Parental Distress domain (P<0.001), Difficult Child domain (P<0.001), and Total Stress domain than the mothers of typically developing children (controls) (P<0.001). No significant differences between the two groups were found for the Parent-Child Dysfunctional Interaction domain (P=0.566) or Defensive Responding domain scores (P=0.160).

CONCLUSION

NF1 is considered a multisystemic and complex disease, with many still unrecognized features in pediatric patients and in their families. In this light, our findings about the higher levels of maternal stress highlight the importance of considering the environmental aspects of NF1 management in developmental age.

Anxiety and depression levels in prepubertal obese children: a case-control study

INTRODUCTION

Childhood obesity has become a worldwide epidemic in Western and in developing countries and has been accompanied by many serious and severe comorbidities, such as diabetes, hypertension, sleep apnea syndrome, depression, dyslipidemia, impaired glucose homeostasis, steatohepatitis, and intracranial hypertension, as well as medical concerns unique to youth, such as accelerated pubertal and skeletal development and orthopedic disorders. To date, no specific studies about the psychological assessment in pediatric obesity are present. Therefore, the aim of this study was to evaluate the putative relationship between psychological troubles and obesity in a sample of school-aged children.

MATERIALS AND METHODS

The study population consists of 148 obese subjects (body mass index [BMI] >95th percentile) (69 males, mean age 8.9±1.23 years) consecutively referred from clinical pediatricians to the Child and Adolescent Neuropsychiatry department at the Second University of Naples. In all subjects, weight, height, and BMI z-score were evaluated. In order to assess the anxiety levels and the presence of depressive symptoms, the Children Depression Inventory (CDI) and the Italian Self-Administered Psychiatric Scales for Children and Adolescents (SAFA) were administered. The control group consisted of 273 healthy children (129 males and 144 females) (mean age 9.1±1.8 years), enrolled in schools within the Campania region of Italy.

RESULTS

No significant differences between the two study groups were found for age (8.9±1.23 years in the obese sample and 9.1±1.8 years in the control group) (P=0.228) or sex (ratio male/female: 69/79 in the obese group versus 129/144 in the control group) (P=0.983). Obviously, significant difference was found for the BMI z-score (2.46±0.31 in the obese group vs 0.73±0.51 in the control group) (P<0.001). The obese subjects showed significant higher level of depressive symptoms (CDI total score) (16.82±7.73 vs 8.2±2.9) (P<0.001) and anxiety (SAFA - Anxiety [SAFA-A]) scale score (58.71±11.84 vs 27.75±11.5) (P<0.001) compared with the control group. Moreover, the Pearson's correlation analysis showed a significantly positive relationship between the BMI z-score and both the CDI (r=0.677; P<0.001) and SAFA-A scores (r=0.591; P<0.001).

CONCLUSION

Our findings highlighted the importance of assessing the presence of internalizing problems, such as anxiety and depression, in the common management of childhood obesity.

Headache and comorbidity in children and adolescents

Headache is one of the most common neurological symptom reported in childhood and adolescence, leading to high levels of school absences and being associated with several comorbid conditions, particularly in neurological, psychiatric and cardiovascular systems. Neurological and psychiatric disorders, that are associated with migraine, are mainly depression, anxiety disorders, epilepsy and sleep disorders, ADHD and Tourette syndrome. It also has been shown an association with atopic disease and cardiovascular disease, especially ischemic stroke and patent foramen ovale (PFO).

Maternal personality profile of children affected by migraine

BACKGROUND

Empirical evidence of the important role of the family in primary pediatric headache has grown significantly in the last few years, although the interconnections between the dysfunctional process and the family interaction are still unclear. Even though the role of parenting in childhood migraine is well known, no studies about the personality of parents of migraine children have been conducted. The aim of the present study was to assess, using an objective measure, the personality profile of mothers of children affected by migraine without aura (MoA).

MATERIALS AND METHODS

A total of 269 mothers of MoA children (153 male, 116 female, aged between 6 and 12 years; mean 8.93 ± 3.57 years) were compared with the findings obtained from a sample of mothers of 587 healthy children (316 male, 271 female, mean age 8.74 ± 3.57 years) randomly selected from schools in the Campania, Umbria, Calabria, and Sicily regions. Each mother filled out the Minnesota Multiphasic Personality Inventory - second edition (MMPI-2), widely used to diagnose personality and psychological disorders. The t-test was used to compare age and MMPI-2 clinical basic and content scales between mothers of MoA and typical developing children, and Pearson's correlation test was used to evaluate the relation between MMPI-2 scores of mothers of MoA children and frequency, intensity, and duration of migraine attacks of their children.

RESULTS

Mothers of MoA children showed significantly higher scores in the paranoia and social introversion clinical basic subscales, and in the anxiety, obsessiveness, depression, health concerns, bizarre mentation, cynicism, type A, low self-esteem, work interference, and negative treatment indicator clinical content subscales (P < 0.001 for all variables). Moreover, Pearson's correlation analysis showed a significant relationship between MoA frequency of children and anxiety (r = 0.4903, P = 0.024) and low self-esteem (r = 0.5130, P = 0.017), while the MoA duration of children was related with hypochondriasis (r = 0.6155, P = 0.003), hysteria (r = 0.6235, P = 0.003), paranoia (r = 0.5102, P = 0.018), psychasthenia (r = 0.4806, P = 0.027), schizophrenia (r = 0.4350, P = 0.049), anxiety (r = 0.4332, P = 0.050), and health concerns (r = 0.7039, P < 0.001) MMPI-2 scores of their mothers.

CONCLUSION

This could be considered a preliminary study that indicates the potential value of maternal personality assessment for better comprehension and clinical management of children affected by migraine, though further studies on the other primary headaches are necessary.

Temperamental characteristics in childhood migraine without aura: a multicenter study

BACKGROUND

Children with migraine seem to be more anxious, sensitive, deliberate, cautious, fearful, vulnerable to frustration, tidy, and less physically enduring than comparisons. To the best our knowledge no studies about the temperamental and the characterial dimension aspects in childhood migraine was conducted. Therefore, the aim of the present study was to describe the temperamental and character aspects in a sample of children affected by migraine without aura (MoA) and their relationship with clinical aspects of MoA such as frequency, duration, and severity of attacks.

MATERIALS AND METHODS

In our study, 486 children affected by MoA (239 male, 247 female) aged 7-12 years, (mean 10.04 ± 2.53 years) and 518 typical developing children comparable for age (P = 0.227) and sex (P = 0.892) were enrolled to assess their temperamental characteristics. The mothers of all subjects filled out the Junior Temperament and Character Inventory: Parent Version.

RESULTS

Children affected by migraine show a higher prevalence of harm avoidance and persistence temperamental domains (P < 0.001) and significantly lower prevalence of the self-directedness character trait (P = 0.023) with respect to the comparisons, according to Cloninger's model. The Spearman rank correlation analysis shows a significant relationship between migraine characteristics and temperamental domains.

CONCLUSION

The present study first identified differences in temperamental characteristics in children affected by MoA with respect to the comparisons, suggesting the need for this evaluation in order for better psychological pediatric management of children with migraine, with possible consequences and impact on the future outcomes of these subjects.

Psychomotor approach in children affected by nonretentive fecal soiling (FNRFS): a new rehabilitative purpose

BACKGROUND

According to the Rome III criteria, encopresis without constipation was defined as nonretentive fecal soiling (FNRFS) with not yet well understood etiology. Treatment approaches reported in the literature with varying results include biofeedback, hypnosis, reflexology, and Internet-based educational programs. In developmental age, another behavioral treatment could be identified in the psychomotor approach, which is called psychomotricity in the European countries, or is also known as play therapy. The aim of the present study was to verify the safety and efficacy of play therapy plus toilet training in a small sample of prepubertal children affected by FNRFS.

MATERIALS AND METHODS

Twenty-six patients (group 1; 16 males, mean age of 5.92 ± 0.84 years) underwent a psychomotor approach therapy program in association with toilet training for 6 months, and the other 26 subjects (group 2; 17 males, mean age of 5.76 ± 0.69) underwent the sole toilet training program for 6 months. During the observational time period (T0) and after 6 months (T1) of both treatments, the patients were evaluated for FNRFS frequency and for the behavioral assessment.

RESULTS

At T0, the FNRFS mean frequency per month for group 1 was 20.115 episodes/month (standard deviation [SD] ± 3.024) and for group 2 was 20.423 (SD ± 1.879) (P = 0.661). At T1 the mean frequency per month was 6.461 (SD ± 1.333) episodes/month and 12.038 (SD ± 1.341), respectively (P < 0.001). Moreover, the delta percent average of the frequency between T0 and T1 was 67.121 ± 8.527 for group 1 and 40.518 ± 9.259 for group 2 (P < 0.001). At T1, a significant improvement in scores on the behavioral scale was identified.

CONCLUSION

Our preliminary results show the importance of a multidisciplinary approach, and suggest the positive effect of an additional psychomotor approach, as this holds a new and interesting rehabilitative purpose for children in a toilet training program, even if further research is necessary.

Attachment styles in children affected by migraine without aura

BACKGROUND

In recent years, great attention has been given to the presence of psychological problems and psychiatric comorbidity that are also present in children affected by primary headaches. The relationship between pain and attachment has been identified, and it may be that pain perception may change in relation with specific attachment styles. The aim of the present study was to assess the prevalent attachment style and verify its putative relationship and correlation with the main characteristics of migraine attacks, in school-aged children affected by migraine without aura (MoA).

MATERIALS AND METHODS

The study population consisted of 219 children (103 males, 116 females) aged between 6 and 11 years (mean 8.96 ± 2.14 years), consecutively referred for MoA compared with 381 healthy controls (174 males, 207 females; mean age 9.01 ± 1.75 years) randomly selected from schools. All the children were classified according to the attachment typologies of the Italian modified version of the Separation Anxiety Test; monthly headache frequency and mean headache duration were assessed from daily headache diaries kept by all the children. Headache intensity was assessed on a visual analog scale. The chi-square test and t-test, where appropriate, were applied, and the Spearman rank correlation test was applied to explore the relationship between the types of attachment style and clinical aspects of MoA.

RESULTS

The MoA group showed a significantly higher prevalence of type A (avoidant) attachment (P<0.001) and a significantly lower prevalence of type B (secure) attachment (P<0.001) compared with the control group. Moreover, the Spearman rank correlation analysis showed a significant relationship between MoA characteristics and the attachment style of MoA children.

CONCLUSION

The main findings of the present study were the higher prevalence among MoA children of the avoidant attachment style (type A) and the significantly lower prevalence of the secure style attachment (type B) compared with the normal controls, suggesting that the study of psychiatric comorbidity in pediatric headache may be enriched by this new aspect of analysis.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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