Chronic daily headaches are an increasingly recognized neurologic issue in children. Frequent headaches can be a source of significant disability and family discord with work/school absenteeism. Medication overuse and emotional disorder would significantly impact treatment and progression. This study examined the frequency of emotional and behavioral problems in children and adolescents with chronic daily headache compared with age-related healthy controls. Prevalence of medication overuse in this chronic daily headache group was evaluated. Otherwise healthy children and adolescents with chronic daily headache (according to International Classification of Headache Disorders-II criteria) were enrolled from the Headache Clinic. Healthy controls were prospectively enrolled from physician offices. Multiple psychological rating scales, headache diaries, presence of medication overuse, and disability surveys (Pediatric Migraine Disability Assessment Survey) were completed. A total of 57 healthy controls and 70 patients were studied. The sample consisted largely of females, many of whom (60%) had medication overuse before medical treatment. Headache patients had significantly more symptoms of anxiety, depression, and somatization compared with controls. Patients with chronic daily headache were at higher risk for emotional disorders, and medication overuse was a significant occurrence, suggesting a need for multisystem treatment approach.

Objective.-To determine whether behavioral and psychiatric disorders occur more frequently in school-age children with migraine headache. To also elucidate treatment response related to comorbid psychiatric or behavioral diagnosis.Background.-Recurrent migraine headaches are common in school-age children. Concurrent behavioral or psychiatric diagnoses could significantly impact headache frequency, severity, and response to treatment.Methods.-Healthy children from 6 to 17 years of age presenting to our headache clinic with migraine headache according to International Headache Society (IHS) criteria were identified. Parents/guardians were asked to complete the Child Symptom Inventory, 4th edition (CSI-4) after written informed consent. Children with positive rating scales underwent psychological interviews for confirmatory diagnosis. Results were compared to controls. Headache patients were assigned our usual treatment paradigm. Response regarding headache frequency was assessed at 3 months.Results.-A total of 47 patients were diagnosed with migraine headaches. The mean age was 10.55 years. Thirty controls were identified. After completing the CSI-4 and confirmatory psychological interview, 14 of 47 headache patients fulfilled Diagnostic and Statistical Manual (DSM-4) criteria for a psychiatric or behavioral disorder. Oppositional defiant disorder (ODD) was significantly represented among children with migraine compared to the control group of children. Headache patients improved significantly post-treatment regarding their headache frequencies regardless of comorbid psychiatric or behavioral disorder. No significant differences were noted between boys and girls regarding diagnoses or treatment outcome.Conclusion.-ODD was a significant comorbidity in our headache population. Although families complained of significant behavioral symptomatology in their children, most of these symptoms did not qualify their children for a psychiatric diagnosis and may be related to the stressors of headache on social/school disruption.

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Levetiracetam had some efficacy in reducing migraine frequency and disability. Further larger studies are warranted, possibly utilizing a placebo-controlled design.

Obesity and headaches are common in children and adults. Adult studies suggest obesity is a risk factor for chronic daily headache and increased migraine frequency and severity. Pediatric studies have suggested a relationship between obesity, increasing headache frequency, and disability. The authors retrospectively evaluated 925 children from their Pediatric Headache Clinic between July 2004 and July 2008, assessing headache frequency, medication overuse, and body mass index compared to population-based norms. The pediatric headache group as a whole had a greater percentage of overweight than the general population. This was also true with the subgroup of patients with chronic tension-type headache, although the numbers were small. Data did not show increased incidence of overweight in children with medication overuse or chronic migraine. This contrasts with adult data, which have suggested a closer link between chronic migraine and obesity and have not supported a link with chronic tension-type headache.

The pathophysiology of migraine and its associated perceptual symptoms remains controversial. We recorded long-latency auditory event related potentials (AEPs) in 30 unmedicated patients with common migraine, and compared them to 20 controls. 1,000 and 3,000 Hz tones were presented in an 80:20 ratio at 75 dB SL. 200 responses were recorded and replicated from Cz-A1 + A2, with filter band-pass of 1-100 Hz, analysis time of 1,000 ms., and interstimulus interval of 1.1 second. N100, P200, and N200 ERP components did not differ in latency or amplitude between migraine patients and controls. P300 was longer in latency among those with common migraine, and P300 amplitude was significantly reduced (P greater than 0.05). These findings suggest that migraine may have a central mechanism, and that migraineurs may have a difference in task involvement or perception which may influence their clinical course and response to therapy.

Many headache patients complain of poor sleep, and sleep disturbance has been shown to play a role in chronic pain. We recorded nocturnal sleep with a 4-channel cassette EEG monitoring device in 10 common migraine patients, 10 individuals with muscle contraction (tension) headache, and 10 chronic tension-vascular headache sufferers. Migraine patients had essentially normal sleep, although rapid eye movement (REM) sleep and REM latency were increased. Patients with tension headache had reduced sleep time and sleep efficiency, decreased sleep latency but frequent awakenings, increased nocturnal movements, and marked reduction in slow wave sleep, without change in REM sleep or latency. Mixed-element headaches with both tension and vascular features were associated with reduced sleep, increased awakening, diminished slow wave sleep, and REM sleep that was decreased in amount and reduced in latency. The findings suggest that patients with intermittent migraine may have minimal sleep disturbance, while chronic headache may be worsened by chronically poor sleep. Muscle contraction headache may be associated with frequent awakenings and decreased slow wave sleep similar to the sleep changes of fibrositis, while chronic tension-vascular headache may have a depressive substrate. Four-channel sleep recording may miss contributory sleep apnea, but nonetheless cassette EEG may facilitate outpatient evaluation of refractory headaches.

Background Our aim was to describe the relationship between risk factors, such as stress, depression, and anxiety and potentially protective factors against pediatric headache-related disability, such as mindfulness, resilience, and self-compassion, and to determine teens’ interest in mind-body skills training to help reduce headache-related disability. Methods This was a cross-sectional survey among adolescents seen in an academic neurology clinic reporting four or more headaches monthly using standardized instruments to determine the relationship between putative risk and protective factors as well as physiologic markers of inflammation and vagal tone and headache-related disability. Results Among the 29 participants, 31% were male, the average age was 14.8 years, average headache frequency was 11.6 per month, and the most commonly reported trigger was stress (86%). The only risk or protective factor significantly associated with headache-related disability was depression (r=0.52, P=0.004). Depression was negatively correlated with mindfulness, resilience, and self-compassion (P<0.01 each) and positively correlated with stress, sleep disturbance, and anxiety (P<0.01 each). Biomarkers of vagal tone and inflammation were correlated with each other, but not with headache-related disability or depression. There was strong interest in learning skills like slow, deep breathing practices supported by a smart phone app to reduce stress and the negative impact of headaches on daily life. Discussion Among teens with frequent migraine headaches, depression is the strongest risk factor for headache-related disability. Stress is viewed as a headache trigger, and teens reported wanting to learn simple stress management strategies supported by a smart phone application to help reduce headache-related disability.