The revised International Classification of Headache Disorders allows for the association of headaches and psychiatric diseases and includes, for the first time, a separate subdirectory titled "Headache attributed to psychiatric disorder" (IHS, 2004). However, the vast majority of headaches that occur in association with psychiatric disorders are not causally related to them, but rather they represent real comorbidity--most probably reflecting a common biological substrate. Headaches in adults are comorbid with depressive, dysthymic, panic, generalized anxiety and somatoform disorders, as well as with suicide attempts and drug overuse. Both migraine and depression, for example, may be associated with low levels of 5-hydroxytryptamine (Glover et al., 1993). The somatoform pain disorder may emerge from primary headaches and is characterized by repeated presentations of physical symptoms, accompanied by insistent demands for diagnostic procedures despite negative results and affirmations that no sufficient organic pathology is present. Usually there is great resistance to hypotheses that suggest a psychiatric origin. Thiscan put stress on the patient-doctor relationship and promote "doctor-shopping" behavior.
During childhood and adolescence, comorbidity occurs typically with sleep disorder, separation-anxiety disorder, school phobia and adjustment disorder, among others (IHS, 2004). In about 30% of patients with headaches, psychiatric problems are clinically relevant and require separate therapy (Just et al., 2003). In one clinical population (headache outpatient department), the comorbidity rate shown was even higher (up to 60%) (Guidetti et al., 1998). Due to comorbidity with psychiatric diseases, headache prevalence is also higher (approximately 30%) in patients of child psychiatry primary care than in the healthy population (Livingston et al., 1988).
Children with migraine lose more school days than healthy children. This might provide a model for "school avoiding" physical complaints. Therefore, many children who present with school fear or school phobia (often referred to as school refusal) may actually have a history of primary headache (Hockaday, 1988).
Headache is associated with other somatic complaints as well, and the combination of multiple physical complaints is a strong indicator for the presence of psychiatric disorders, especially anxiety and depression (Egger et al., 1999). The families of somatizing children are characterized by fear of loss (Campo and Fritsch, 1994), overprotection (Lehmkuhl et al., 1989), marital problems of the parents (Mullins and Olson, 1990), communication problems and lower levels of emotional expressiveness (Liakopoulou-Kairis et al., 2002). Parents of somatizing children report more somatic concerns, psychosomatic disorders and proneness to pain than controls and usually share several physical symptoms with their children (Apley, 1975). However, the transmission may be environmental rather than genetic, with somatization representing a kind of family "style" (Torgersen, 1986). Mothers of children with headache present high expressed emotions, especially criticism and emotional overinvolvement, more frequently than controls (Liakopoulou-Kairis et al., 2002).Treatment
Early diagnosis and adequate therapy are important not only for an acute relief of headache but also to foster functional coping strategies early in life, because these strategies will usually persist into adulthood. Although there is an increasing prevalence of childhood headache, there are very few clinical studies on available treatment. The treatment is often inappropriate in daily practice, although various options are available (including pharmacological and psychological therapy). The most efficacious acute treatments of pediatric migraine include the nonsteroidal anti-inflammatory drug ibuprofen(Drug information on ibuprofen), dosed at 7.5 mg/kg to 10 mg/kg or nasal sumatriptan(Drug information on sumatriptan) (Imitrex) (Lewis et al., 2002). Migraine attack treatments must be given early, at the beginning of the crisis. Nonpharmacological treatments (biofeedback, progressive muscle relaxation, multicomponent programs) have been shown effective and may be superior to pharmacological prophylaxis (Hermann et al., 1995). Cost- and resource-saving minimal therapeutic counseling interventions seem to be effective in a remarkable number of patients as well, especially when no psychiatric comorbidity is present.Conclusions
A headache diagnosis should heighten the clinician's index of suspicion for depressive and anxiety disorders, and vice versa. The presence of a comorbid psychiatric disorder tends to worsen the course of primary headache by increasing the frequency and severity of attacks, thus making the headaches less responsive to treatment and increasing the risk of chronification. Therefore, identification and treatment of any comorbid psychiatric condition is mandatory for proper headache management, especially in children and adolescents (IHS, 2004). Headache, especially when associated with other somatic complaints, is an important cue for depressive and anxiety disorders. Child psychiatrists and clinicians should look for these underlying issues and help these children with the expression and control of their feelings relevant to worry, separation anxiety, irritability and sadness.