Headache is a frequent somatic complaint in childhood and adolescence, and its prevalence has increased over the last few decades. The presence of a comorbid psychiatric disorder tends to worsen the course of headache by increasing attack frequency and severity, making the headaches less responsive to treatment, and increasing the risk of chronification. Identification and treatment of comorbid psychiatric conditions is, therefore, important for the proper management of headache, especially in children and adolescents.
Recurrent primary headache is the most frequent manifestation of pain in childhood (Eggers, 1984) and is present in up to 8% of 6-year-old children (Haffner et al., 1998; Sillanp and Anttila, 1996). After the first year of school, headache prevalence doubles; therefore, school is an important influencing factor. Prevalence of recurrent primary headache during childhood has increased over the last few decades to 10.6% (Abu-Arafeh and Russell, 1994). Childhood headache has a high risk of chronification and persists into adulthood at about a 60% rate of recurrence (Bille, 1981). And in adults, chronic headache, especially migraine, causes high socioeconomic health care costs, mainly due to high indirect costs (e.g., absenteeism, reduced work efficiency) (Fishman and Black, 1999).
Characteristics of headache in children are less typical and more variable than in adults, and small children have more difficulties perceiving and describing headache characteristics in detail. Abdominal symptoms, such as cyclical vomiting or abdominal "migraine," are common precursors to migraines and occur especially in preschool children.
Most often, primary headache can be classified as migraine or tension-type headache. Diagnosis is made according to the (recently modified) criteria of the International Headache Society (IHS) (2004) and includes duration, quality and intensity of the headache, and vegetative or neurological symptoms (Table). Parents often underestimate intensity and frequency of their child's headaches; therefore, diagnosis should be based on four to eight weeks of prospective monitoring using a headache diary, to record headache characteristics, drug intake, probable trigger factors and impact on daily life in a standardized way. Self-monitoring and documentation of symptoms may even lead to a reduction of pain.
A thorough history, as well as a physical and neurological examination, is essential for ruling out underlying diseases or situations that can cause secondary headaches, such as head trauma, infection, organic lesion or sinus disorders (IHS, 2004). Psychotropic drugs can be another source of headaches. Laboratory tests, including electroencephalogram and imaging studies, should not be undertaken routinely, but they should be performed when warranted by any specific clinical evidence. Headache in children younger than 3 and occipital headache in children always call for diagnostic caution.
Migraines manifest in attacks lasting four to 72 hours in adults and one to 72 hours in children (IHS, 2004). Typical characteristics are unilateral location (in young children commonly bilateral), pulsating quality, moderate or severe intensity, aggravation by physical activity, and association with nausea and/or photo- and phonophobia (which may be inferred from particular behaviors in young children). Migraine episodes are frequently triggered by several factors such as emotional stress (school pressure, excitement), lack of or excess sleep, sensorial stimulation (loud noise, bright light), or sympathetic stimulation (physical activity). Up to 30% of patients with migraines occasionally experience auras--reversible focal neurological symptoms--(typically visual and/or sensory and/or speech symptoms--that develop gradually over minutes and last for less than one hour. Frequency of migraine aura seems to be nearly as high in children as in adults, but the less typical symptoms are usually only reported on request rather than spontaneously.
Tension-type headaches manifest in episodes lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality, and of mild or moderate intensity. Vegetative symptoms are negligible, and the headache does not worsen with routine physical activity. Chronic (>180 days/year) childhood headache (tension-type or migraine) is nearly always associated with psychiatric comorbidity (Guidetti et al., 1998) and may represent a correlate of a psychiatric problem.
There are only a few investigations of long-term outcomes of headache in children. Chronification rates of 60% for migraine and 45% for tension-type headache have been reported (Guidetti and Galli, 1998). Before puberty, the gender ratio is balanced, but young boys experience a two- to threefold greater rate of spontaneous remission of headaches. Chronification risk of childhood headaches increases enormously when psychiatric comorbidity is present. A follow-up study by Guidetti et al. (1998) reported headache in 85% of children with psychiatric comorbidity, but only in 60% of patients without psychopathology. None of the children in the study who experienced spontaneous remission of headache had clinically relevant psychiatric problems. On the other hand, children with frequent headache recurrence had an increased risk of multiple physical symptoms and psychiatric disorders in adulthood.
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).
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, dosed at 7.5 mg/kg to 10 mg/kg or nasal 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.
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.
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