psychological factors in childhood headaches

PK

Ibvflsa

CEwopab

mftrr

*†‡A

1d

sychological Factors in Childhood Headachesathleen Farmer, PsyD,* David Dunn, MD,† and Eric Scott, PhD‡

Recurrent headaches in children are most often migraines and are based in a geneticpredisposition with a low headache threshold. As with any pain experience, there is a largeemotional component associated with an attack of migraines that grows in amplitude as theheadaches become more frequent and resistant to medicine, sleep, or other agents thatused to work. Childhood headaches are especially complicated for 3 reasons: (1) theparents’ fear (communicated to the child that serious medical pathology underlies the headpain), (2) the lack of evidence-based pharmacologic treatment, and (3) the belief that theseheadaches are largely psychological. This article addresses the mystery surroundingchildhood headaches by delving into the influence of school, friends, and family; the impactof divorce; the coping skills required for a child to manage a migrainous nervous system;the potential secondary gain from headaches; psychiatric comorbidities and how to treatthem; and the role of psychological intervention.Semin Pediatr Neurol 17:93-99 © 2010 Elsevier Inc. All rights reserved.

tp

chdspvraaf

dcaahtbdtEf

SEnt

n children and adolescents, migraine headaches may beprecipitated by psychological factors, may be exacerbated

y psychosocial or environmental stressors, and may ad-ersely impact the quality of life of both the child and theamily. Migraines also may respond to therapeutic psycho-ogical interventions. In this article, we use 2 case reports tohow the effect of psychological factors on both the causationnd treatment of migraine in children and adolescents.

ase 1ric is a 10-year-old white male in the fifth grade. Since heas 5, he had on average 1 migraine a year that usuallyccurred during the summer when he was overheated whilelaying hard with his friends. The headache was treated withcetaminophen, but over the past 3 months, migraines haveeen occurring 2, 3, or 4 times a week.His mother reported that her husband lost his job 6onths ago, and she had taken on 2 jobs to support the

amily. Even though he is trying desperately to find work,here seems to be nothing for him. After his mother left theoom, Eric volunteered that the family has had to move to aental home, placing him in a different school. Being new to

Headache Care Center, Springfield, MO.Riley Child and Adolescent Psychiatry Clinic, Indianapolis, IN.Riley Pain Center, Indianapolis, IN.ddress reprint requests to Kathleen Farmer, PsyD, Headache Care Cen-

ter, 3805 South Kansas Expressway, Springfield, MO 65807. E-mail:
[email protected]
071-9091/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1016/j.spen.2010.04.002

he classroom, he has been bullied but has said nothing to hisarents because “They have enough to worry about.”Even though the psychological factors are obvious in this

ase, at the core of Eric’s attempts to cope with problems isis biology. As an infant, he was colicky; as a toddler, heisplayed “migrainous equivalents,” such as being a lightleeper and having motion sickness, episodic abdominalain, and intermittent vertigo.1 His genetically vigilant ner-ous system interacted with specific psychosocial and envi-onmental factors or triggers to produce migraines. Over timend as the migraines progressed, biological, psychological,nd social consequences occurred that interfered with hisunctioning optimally at home and school.2,3

When pain is recognized as a mind-body-spirit response,4

issecting the psychological from the other aspects is likeutting into a worm to discover how it functions. By elicitingnd listening to the child’s understanding of headaches, cluesre revealed that point to possible resolutions. In Eric’s case,e wants to know how to handle the bully at school5; how toell his parents that he too is taking on some of the responsi-ility for family turmoil; and, most importantly, what can heo about these headaches that are defeating him worse thanhe bully. Because migraine is a chronic disorder, teachingric coping skills to deal with a hyperexcitable brain is a tool

or health that lasts a lifetime.6

chool Absences and Secondary Gainric’s parents see him in pain and want to keep him home tourse and protect him. Yet, at the same time, they are afraidhat headaches are being used as an excuse to get out of
omething he does not want to do. There are 3 questions to
93

mailto:[email protected]

msatt

AYnh

INsprtphetwi

CEifo

WTtYt

CEfrhf

DWfdaatiw

esat

gd

SPifhtrHmfeb

fcbbatcllc

CTmchth

TAtikhwhHehsa

CGtt

ATc

94 K. Farmer, D. Dunn, and E. Scott

easure the influence of psychological factors in missingchool because of headaches: (1) Are headaches a way tovoid school? (2) Is the child a perfectionistic? and (3) Washere a perceived trauma that occurred when the frequency ofhe headaches increased?7

re Headaches a Way to Avoid School?es, Eric would be able to escape from the bully. Instead, heeeds to learn how to deal with the bully by standing up toim with friends. For Eric, staying in school is essential.

s the Child a Perfectionistic?o, Eric is not a perfectionistic in school, but with a very

ensitive nervous system, he is attuned to the expectations ofarents, siblings, and others close to them. He takes on theesponsibility of avoiding conflict before it occurs. With an-enna picking up possible clues to unrest, he may become aerfectionistic on the way to making his parents and othersappy with his performance. He expects to be liked by ev-ryone, as well as involved with many extracurricular activi-ies. In the process, the child’s nervous system becomes over-helmed under the stress of being unable to achieve the

mpossible.

oping Skill: “I Forgive Myself for Being Imperfect”ric needs to understand that being human means being

mperfect. It is alright to be imperfect, and mistakes are ef-ective ways to learn. Eric’s focus needs to shift from whatthers expect to what he wants.

as There a Traumahat Occurred Simultaneously Withhe Increased Frequency of Headaches?es, Eric’s family structure and interaction has changed dras-ically since his father lost his job.

oping Skill: Set Realistic Expectations for Selfric needs to become aware of his desire to take over for his

ather and solve the family crisis. As a 10-year old, he cannotescue his parents, but he can help ease the chaos in theousehold by once again becoming wrapped up in sports andriends.

ivorcehen a family appears to be falling apart and emotions are

rayed, children cannot help but worry about their parents’ivorcing. Children may absorb the tension, believing theyre being punished for misbehavior, and they cling or pushway. A child may attempt to parent the parents, modelinghe art of sharing and getting along, or he/she may transformnto a hellion on wheels, destroying everything in his/herake, including the rift between Mom and Dad.The distress children feel can also be physical. This may be

xpressed as stomach aches and nightmares. Under suchtress, the genetic predisposition to migraines may erupt intofirst or more frequent attacks. In fact, a child often becomes

he designated patient in the hope of holding the family to- c

ether by diverting attention to his/her health instead of theisintegrating relationship between parents.8

omatizing Stresshysical pain is easier to express than emotional pain. Phys-

cal pain is tangible, diagnosable, and understandable. Peopleeel sorry for a person in pain and reach out to soothe theurt. In the process, the person receives special attention andreatment, and it can alter family dynamics. Especially whenest is the best medicine, dependency becomes fostered.9

owever, the longer the physical problem continues, theore it becomes a component of the person as well as the

amily interaction. Eventually, it becomes a monkey on ev-ryone’s back. Even though it is unwanted, overtime painecomes a familiar companion.The need to be needed can be seductive to the parent who

eels wronged, betrayed, or abandoned by the divorce. Thisan lead to the development of a codependent relationshipetween child and parent in which the child’s pain or illnessrings the parent closer. Codependency, which is automaticnd unconscious, convinces the child and the parent thathey are doing the best they can, but, in reality, when thehild feels healthy, the parent’s role as caregiver diminishes,eading to a sense of being unwanted. This may result in aong-term codependent enmeshment between parent andhild.

oping Skill: Express Feelingshe pain of headaches needs to be associated in the child’sind with the pain of a possible divorce. By encouraging the

hild to identify and express feelings, the child sees that theeadache is an expression of his distress over the fear thathe family is breaking up. Tapping into the emotional painelps temper the physical pain.

he Helpers a migraineur, the child is highly sensitive to the feelings of

he family and may attempt to protect a parent by intercept-ng the barbs thrown by the other parent. He/she aims toeep his/her parents happy by doing everything right so theyave less to worry about. He/she has a hard time sleeping,orrying that he/she is shirking his/her duty by being inis/her own bed rather than looking after his/her parents.e/she has bad dreams about his/her home teetering on the

dge of a mountain, being swept around by a mud slide whilee/she stands by watching unable to rescue his parents in-ide. Trying to outparent his/her parents may trigger or ex-cerbate headaches.

oping Skill: Play Everydayive the child permission to be a kid. The message should be

he following: “You can’t fix this. Your parents need to workhings out. Your job is to enjoy childhood.”

cting Out Fearo every request, this child has the same response, “No! Youan’t make me!” He/she fights on the playground during re-
ess. He/she is sent to the principal’s office for talking back to

tathth

CTwahiHgthb

awcr

sBmicmlm

EBaPtoHioae2mprb

CMDcr

tce

pmsodtasplgdwsgoosfs

ECItasoIePacaabch

sadaihaabccs

Psychological factors in childhood headaches 95

he teacher. His/her grades are dropping. He/she has becomestranger to his/her parents. He/she is acting out his/her fear

hat his/her parents are about to leave him/her. He/she has aeadache everyday. He/she complains that he/she is too sicko go to school, but he/she feels just as bad when he/she staysome.

oping Skill: Activity Overcomes Fearhis child needs to be held and reassured that his/her parentsill always be there for him/her if not for each other. The

dults in his/her life need to understand that her “bad” be-aviors are his/her best attempts at beating back the fear that

s creeping up on him/her, threatening to overtake him/her.e/she needs an opportunity to act out his/her fear throughames or toys, drawing, or role playing in a safe place underhe supervision of an understanding, supportive adult, per-aps a therapist. As his/her fear lessens, her headaches willecome less frequent as well.Recurrent headaches in children are most often migraines

nd are generally precipitated by an environment that over-helms the child.10 Reassurance and encouragement that the

hild continues his/her routine are ways to focus on todayather the unknown of tomorrow.

One factor often neglected but potentially important in thetudy of stressors as triggers for migraines is family history.igal et al11 found that when there was a family history ofigraines, there was no difference in prevalence of migraine

n adolescents from high versus low socioeconomic status. Inontrast, when there was no family history, the prevalence ofigraine was significantly higher in those adolescents with a

ower socioeconomic status compared with adolescents fromore affluent families.

motional andehavioral Changes asComponent of Migraine

sychosocial stressors at home or school and disruptions inhe daily schedule, such as missing meals, inadequate sleep,r excessive sleep, are well-known triggers of headaches.owever, parents and children with migraines notice behav-

oral and emotional changes that occur in relation to attacksf migraines. These alterations in behavior are not caused bypsychiatric disorder but are components of migraines. Par-nts report changes in the child or adolescent’s behavior 1 todays before the onset of an attack. The behavioral changesay consist of excess energy, depression, or lethargy. Theresence of behavioral changes as a prodrome has not beeneported to be associated with persistent changes in behavioretween migraine attacks.

omorbidity:igraine and Psychopathology

o children and adolescents with migraines have an in-reased prevalence of depression, anxiety, or other psychiat-
ic conditions? If psychological stressors are major contribu- a
ors to the precipitation of migraine, does it follow that thehild or adolescent with migraines is more likely to have anmotional problems than other children?

Comorbidity is the occurrence of 2 separate disorders in 1atient. Both disorders may be caused by a common environ-ental or genetic risk factor, or 1 disorder may cause the

econd. There is substantial information on the comorbidityf migraine and depression, bipolar disorder, and anxietyisorders in adults, including studies that have used Interna-ional Headache Society (IHS) criteria for migraine and well-ccepted measures of psychopathology.12 Breslau et al13 havehown that there is a bidirectional association between de-ression and migraine. The presence of depression at base-

ine increases the risk for developing migraines, and mi-raines are associated with an increased risk of developingepression. Breslau14 also found that patients with migraineith an aura and comorbid depression had a greater risk of

uicide attempt and ideation than patients with either mi-raines or depression. In contrast, there was no increased riskf suicide attempt or ideation in patients with migraine with-ut an aura. Although the association was not as strong aseen between depression and migraines, Breslau et al15 haveound an association of panic disorder and both migraine andevere headaches.

pidemiologic Surveys inhildren and Adolescents

n contrast to the data on adults, there is less information onhe association between childhood and adolescent migrainesnd depression or anxiety. Four epidemiologic studies havehown an association between headaches and psychopathol-gy in children and adolescents. These studies did not useHS criteria for headache diagnosis. Pine et al16 completed anpidemiologic assessment of 776 youths 9 to 18 years of age.sychopathology was diagnosed with structured interviews,nd youths were asked if they had a history of migraines orhronic headaches preventing usual functioning. They foundn association between depression and incapacitating head-ches. Depression predicted later development of headaches,ut headaches did not predict subsequent depression. Afterontrolling for depression, there was no association betweeneadache and anxiety disorders.Aromaa et al17 noted that symptoms of depression and

leep disruption present at 3 years of age predicted headachest 6 years of age. Egger et al18 used prospective epidemiologicata from the Great Smoky Mountains Study and found anssociation between headaches and both depression and anx-ety in girls but not boys. Girls with depression had 4 timesigher prevalence of headaches than girls without depressionnd girls with anxiety had 3 times higher prevalence of head-ches than girls without anxiety. There was an associationetween conduct disorder and headaches in boys. Boys withonduct disorder had twice the prevalence of headachesompared with boys without conduct disorder. Strine et al19

howed an association between frequent or severe headaches
nd emotional, conduct, inattention-hyperactivity, and peer

pQmc

cshIiihicsawctha

CoPCCbnmeha1ssstw

sgiahsa

ticodpsc

va

PICPSoppieasabspitwAuawrswIbb

DScebhsay

MSdtuMtmtdcA


roblems as measured by the Strengths and Difficultiesuestionnaire. Children with headaches were 3.2 timesore likely to have behavioral or emotional problems than

hildren without headaches.Two recent studies of comorbidity in children and adoles-

ents have used IHS criteria for migraine and validated mea-ures of psychopathology. Anttila et al20 used the Child Be-avior Checklist for the diagnosis of psychopathology andHS criteria for headache diagnosis. They found that childrenn the sixth grade who experienced migraines had more total,nternalizing, and somatic symptoms than children withouteadaches. Internalizing scores above the cutoff were found

n 28.8% of children with headaches compared with 8.8% ofhildren without headaches. Wang et al21 described the as-ociation between migraine and depression and suicidal ide-tion in adolescents 13 to 15 years of age. Suicidal ideationas more common in those with a migraine with aura. After

ontrolling for depression, there was still an association be-ween suicidal ideation and migraine with aura and higheadache frequency but not migraines without aura or prob-ble migraine.

linical Studiesf Migraine andsychopathology inhildren and Adolescents

linical studies have helped with defining the emotional andehavioral comorbidities of migraine. Cooper et al22 foundo difference between children 6 to 16 years of age withigraines and controls on measures of anxiety or stressful life

vents. They did find that the children with migraines whoad more symptoms of anxiety experienced more frequentnd severe migraines. Pakalnis et al23 studied 47 children 6 to7 years of age with migraines and 30 controls. There was notatistically significant difference in the prevalence of depres-ion or anxiety, but the children with migraines had moreymptoms of oppositional defiant disorder. They found thathe scores on their measure of anxiety were higher in childrenith migraines than controls.Heng and Wirrell24 compared sleep and behavioral mea-

ures in children with migraine with siblings without mi-raines. The children with migraines had elevated internaliz-ng scores compared with siblings, but no difference on thenxiety and depression subscales. Children with migrainesad more total sleep problems, sleep delay, and daytimeleepiness than siblings, and the sleep problems were associ-ted with more behavioral problems.

In summary, the association between migraines and emo-ional or behavioral problems is stronger in adults, suggest-ng possible developmental differences. Children and adoles-ents with migraines may have certain symptoms suggestivef depression or anxiety without being diagnosable as disor-ers of mood or anxiety. However, when symptoms areresent, mood and anxiety problems may contribute to theeverity and frequency of migraines in children and adoles-
ents. Clinicians should explore the relationship between en- p
ironmental and emotional stresses and the onset of migrainettacks in children and adolescents.

sychologicalnterventions to Treat Migrainease 2ain Symptomsam is a 14-year-old girl with prominent headaches that haveccurred daily for the last 2 months. She describes bilateralain most days, but there are times when she has unilateralain with no clear predominance of location for pain. She

ndicates that her headaches feel as though someone is tight-ning a band around her forehead and squeezing it, creatingthrobbing sensation. Each daily headache follows a fairly

teady course. She wakes up each morning with pain thatbates during the early afternoon immediately after lunch,ut during the late afternoon and early evening, there is ateady increase in pain intensity. She frequently has photo-hobia but no phonophobia and some nausea but no vomit-

ng. Her sleep onset is delayed by up to 1.5 hours secondaryo her pain. She suffers from middle insomnia twice a weekhen she awakens to a feeling of tension within her head.lthough she has not been diagnosed with temporomandib-lar joint disorder (TMJ), she has a history of teeth grindingt night, which predated the onset of her headaches. Medicalorkup, including magnetic resonance imaging of her head,

evealed nothing remarkable. She has not started her men-trual period and denied any significant medical problemsith the exception of occasional sinus problems and asthma.

ndeed, her only other history of headaches was a 2-weekout of daily headaches during a sinus infection. Once anti-iotics were initiated, the headaches stopped.

isabilityam missed approximately 15 days of school her fall semesterompared with no absences the previous school year while inlementary school. She believes she has lost some friendsecause she does not feel well enough to go to the movies,ang out with friends, or join in extracurricular activities thathe enjoyed in elementary school. She is rarely physicallyctive now and has gained 20 lb since the end of last schoolear.

ood Symptoms/Emotional Regulationamantha was diagnosed with attention-deficit hyperactivityisorder 3 years ago and started taking stimulant medica-ions. After several trials of different medications, she nowses the Daytrana patch (Noven Pharmaceuticals, Inc.,iami, FL) with good relief. Further complicating her symp-

omatology was a comorbid oppositional defiant disorderaking self-regulation of emotion difficult. Compounding

he difficulty with concentration brought on by the attention-eficit hyperactivity disorder, Samantha complains of pooroncentration on days when her headaches are more severe.nxiety has been a part of her life for sometime but never as
rominently as now.

wzsrhtmaih

PScnasactwc

FAhchdwBhccapf

TPcbe

SShcpiauwtibmwg

wcGcaa

CTgmsIf

etasgsjipaethsnmaiabaiab

bcmtdtm

ptiatutm


Her failing health and the recent death of a grandmother asell as several close family members have made her cogni-

ant of the brevity of life. Even though angry outbursts haveubsided, Sam now suffers from tearful bouts and anxiousuminations, not previously seen from her. A welcome changeas also been her mild anxiety related to fear of getting intorouble at school. She also fears getting sick and is afraid that herother too may become ill. Because self-regulation of emotion

nd behavior play important roles in controlling anger, anx-ety, and pain, they will likely be essential issues to address iner treatment plan.

sychosocial Stressorshe has experienced multiple stressors within the last yearontributing to her daily headaches. About 6 months ago, aeighbor boy bullied her, and now he and his friends teasend verbally harass her at home and during daily bus rides tochool. Moving from elementary school to the sixth gradecademy has proven a disappointment academically and so-ially. She was set to have her “best year yet” but because ofhe teasing, the headaches, and continual trouble completingork in a timely fashion, she has found school to be signifi-

antly challenging and a constant source of stress.

ormulation/Conceptualizationnxiety and depression may be comorbid with disablingeadaches in children and adolescents. Samantha meets theriteria for generalized anxiety disorder and attention-deficityperactivity disorder along with oppositional defiant disor-er. Additionally, she would also qualify for a pain disorderith both medical as well as psychological characteristics.ecause of her anxiety, she is likely to focus her attention oner pain and somatic complaints yet may not use approachoping strategies (orient to threat but then use avoidanceoping strategies to deal with it). This lack of coping puts hert risk for continued anxiety, social isolation, and later de-ression. Screening for these disorders along with timely re-errals to mental health professionals is often necessary.

reatmentsychological interventions for Samantha could include aombination of cognitive behavioral therapy (CBT), biofeed-ack, problem-solving skills, and intervention with school tonsure that she is provided with adequate accommodations.

chool Interventionamantha, like other children and adolescents with frequenteadaches, consider school as significantly stressful. Becausehildren have headaches at school, coordination with schoolersonnel is often vital. Ideally, the child will have either an

ndividual education plan under the Individuals with Dis-bilities Education Improvement Act of 2004 or a 504 Plannder the Rehabilitation Act of 1973. These are services inhich children can be provided accommodations to aid in

heir learning despite having a chronic illness. These couldnclude the use of a quiet room like a nurse’s office to useiofeedback or relaxation techniques, go to the office to takeedications, or have additional time for tests/assignmentshen having a headache. Careful consideration should be
iven to communicate expectations of school attendance, s
ork performance while having a headache, and what thehild is expected to do with a headache while at school.etting child agreement of this plan is essential. Ideally, alear plan for medication administration, school attendance,nd work performance will be shared across the home, clinic,nd school environment.

BThe evidence for using CBT with children and adolescents isrowing and includes 2 recent meta-analyses25,26 showingoderate to large effect sizes. There is also growing empiric

upport for providing cost-effective CBT interventions via thenternet,27-29 which could effectively reach those individualsar from specialty headache clinics.

The basic elements of CBT interventions for pain includeducation, relaxation training, reducing the impact of cogni-ive distortions, and behavioral changes. The goal is to usepproach instead of avoidance coping strategies. Thorn’stress-appraisal coping model of pain conceptualization is aood example of a comprehensive model specifically de-igned for pain populations.30 It conceptualizes stress as audgment by an individual that the pain he/she is experienc-ng exceeds innate resources. If one makes a primary ap-raisal that pain threatens identity or survival, then anxietybout future pain increases. This severely limits activity lev-ls, increases reluctance to take risks, and curtails social ac-ivities out of fear of exacerbating pain. This is particularlyarmful if an individual misinterprets headache pain as aignal that there are larger medical problems looming despiteegative medical workups. A second problematic appraisalade by individuals with pain is seeing pain as the cause forloss in life or being flawed or damaged. For Samantha, pain

s the cause of social and academic loss, making her vulner-ble to depression. One goal in CBT is to help individualsecome effective agents of change (internal locus of control)nd interpret pain as a challenge to be overcome. This redef-nition of “I’m a well person with pain” gives hope, direction,nd self-confidence and frees the person from the misery ofeing sick or disabled.Additional targets of intervention can be an individual’s

elief about the cause of pain, level of control over the pain,atastrophizing thoughts about the future, negative self-state-ents about coping ability, and negative thoughts about in-

eractions with others. High degrees of negativity, as seen inepressed individuals, can be highly demoralizing and leado hopelessness and despair. Paradoxically, the first step inanaging pain is to overcome this despair.Biofeedback is essential for treatment in this case.31-33 The

rimary goals for using biofeedback include specific symp-om relief and control, alleviation of anxiety, depression, andncreased self-efficacy. Trautmann et al,25 in a recent meta-nalysis, showed reductions in frequency, duration, and in-ensity of tension type and migraine headaches when childrensed biofeedback. Moderate to large effect sizes characterizehese interventions for symptom relief, which lasted up to 17onths (longest longitudinal follow-up reported). Results also

howed improvements in the overall quality of life through

rb

tfcghoibrsswo

CaACrihpcaumcterchw

chcrtaficicdtvtfpis

sehdtan

CCrObirtcfmbclEttgSiptia

R

1


eductions in anxiety and depression. The range of the num-er of sessions used was 4 to 10 sessions.There is support for several different biofeedback modali-

ies for migraines and tension headaches. The most commonorms include thermal biofeedback in which an individualhanges vasodilatations via relaxation. Surface electromyo-raphy (in comparison with invasive electromyography)elps individuals learn to relax chronically tense frontalis,ccipital, or trapeziums muscles. Blood-volume pulse helpsndividuals change the blood perfusion and vasodilatation oflood vessels in the hands and the surface of the temporalegion of the head. Although the adult literature32 showsome emerging evidence that blood-volume pulse may belightly more efficacious than other modalities, especiallyhen treating migraines, this has not been shown in childrenr adolescents.25

ombining Medicationnd Behavioral Treatmentslthough many children and adolescents will respond toBT, biofeedback, and psychosocial interventions, some may

equire additional pharmacotherapy. Pharmacologic therapys covered elsewhere in this issue and will not be repeatedere. Only minimal modifications need to be made in theharmacologic treatment of migraine in the child with a psy-hiatric disorder. Nonsteroidal anti-inflammatory agents,cetaminophen, sumatriptan, and oral triptans have beensed for the acute treatment of childhood and adolescentigraine.34,35 In general, these drugs can be used safely in

hildren and adolescents with comorbid psychiatric condi-ions. Nonsteroidal anti-inflammatory drugs can cause anlevation of lithium serum levels. Although there is a theo-etic concern about a serotonin syndrome if sumatriptan isombined with serotonin reuptake inhibitors, sumatiptanas been used by patients on serotonin reuptake inhibitorsithout adverse effect.Antiepileptic drugs, antidepressants, antihistamines, cal-

ium channel blockers, and antihypertensive medicationsave been used as preventive therapies for migraines. A re-ent practice parameter from the American Academy of Neu-ology and the Child Neurology Society34 concluded thathere was good evidence for the effectiveness for flunarizine,drug not currently available in the United States, and insuf-cient evidence for the other agents presently in use. For thehild or adolescent with migraine and psychiatric comorbid-ty, the best option may be a combination of CBT and psy-hopharmacology. SSRIs may be effective for anxiety andepression but have not been effective for migraine preven-ion. Tricyclic antidepressants may help with migraine pre-ention and possibly anxiety but have been ineffective in thereatment of depression in children and adolescents. The dataor the use of propranolol in migraine are contradictory. Pro-ranolol may help with the physiological symptoms of anx-

ety but has minimal efficacy for reduction of emotional
ymptoms.
Several drugs that may help with migraine preventionhould be used cautiously in children and adolescents withmotional and behavioral problems. Propranolol and cypro-eptadine can result in symptoms of depression. Moodisturbance has been associated with topiramate and leve-iracetam. Also, levetiracetam has caused irritability andggression, whereas topiramate sometimes produces cog-itive problems.

onclusionshildhood headaches that become a medical problem dis-

upt families and create a dark cloud over the child’s life.nce the child’s headaches are recognized and validated asiological events in response to environmental stressors, fam-

ly issues can be addressed. After secondary headaches areuled out, the focus of successful treatment is the dynamics ofhe situation in which the child functions. Often, there ishaos instead of structure; there are many activities withoutree time, and there is a sense of urgency without sharingeals or highlights of the day. In most cases, brief biofeed-

ack training for the child (3 or fewer sessions) and 1 or 2ognitive behavioral consultations with the parents begin theifelong process of managing migraine. The 2 case studies,ric (age 10 years) and Samantha (age 14 years), represent

he spectrum of childhood headaches. Eric’s headaches areransforming from episodic to chronic, but intervention be-an early enough to use biofeedback and OTCs, whereasamantha has multiple problems that exacerbate headachesnto a chronic pattern. She requires more intensive treatmentsychologically and pharmacologically. She is an example ofhe value of preventing such chronicity in a child by screen-ng for and managing migraine and emotional factors thatffect the child’s health.

eferences1. Al-Twaijri W, Shevell MI: Pediatric migraine equivalents: Occurrence

and clinical features in practice. Pediatr Neurol 26:365-368, 20022. Lewandowski AS, Palermo TM, Peterson CC: Age-dependent relation-

ships among pain, depressive symptoms, and functional disability inyouth with recurrent headaches. Headache 46:656-662, 2006

3. Kernick D, Campbell J: Measuring the impact of headache in children.Cephalalgia 29:3-16, 2008

4. Price DD: Psychological and neural mechanisms of the affective dimen-sion of pain. Science 288:1769-1772, 2000

5. Odegaard G, Lindbladh E, Hovelius B: Children who suffer from head-aches-a narrative of insecurity in school and family. Br J Gen Pract53:210-215, 2003

6. Powers SW, Patton SR, Hommel KA, et al: Quality of life in childhoodmigraines; Clinical impact and comparison to other chronic illnesses.Pediatrics 112:e1-e5, 2003

7. Tietjen GE, Brandes JL, Peterlin BL, et al: Childhood maltreatment andmigraine (part II). Emotional abuse as a risk factor for headache chroni-fication. Headache 50:32-41, 2009

8. Vannatta K, Getzoff EA, Powers SW, et al: Multiple perspectives on thepsychological functioning of children with and without migraine.Headache 48:994-1004, 2008

9. Garralda ME: Somatisation in children. J Child Psychol Psychiatry1:13-33, 1996

0. Kroner-Herwig B, Morris L, Heinrich M: Biopsychosocial correlates ofheadache: What predicts pediatric headache occurrence? Headache
48:529-544, 2008

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3


1. Bigal ME, Lipton RB, Winner P, et al: Migraine in adolescents: Associ-ation with socioeconomic status and family history. Neurology 69:16-25, 2007

2. Low NCP, Merikangas KR: The comorbidity of migraine. CNS Spectr8:433-444, 2003

3. Breslau N, Lipton RB, Stewart WF, et al: Comorbidity of migraine anddepression. Investigating potential etiology and prognosis. Neurology60:1308-1312, 2003

4. Breslau N: Migraine: Suicidal ideation, and suicide attempts. Neurol-ogy 42:392-395, 1992

5. Breslau N, Schultz LR, Stewart WF, et al: Headache types and panicdisorder. Directionality and specificity. Neurology 56:350-354, 2001

6. Pine DS, Cohen P, Brook J: The association between major depressionand headache: Results of a longitudinal epidemiological study in youth.J Child Adolesc Psychopharmacol 6:153-164, 1996

7. Aromaa M, Rautava P, Helenius H, et al: Factors of early life as predic-tors of headache in children at school entry. Headache 38:23-30, 1998

8. Egger HL, Angold A, Costello EJ: Headaches and psychopathology inchildren and adolescents. J Am Acad Child Adolesc Psychiatry 37:951-958, 1998

9. Strine TW, Okoro CA, McGuire LC, et al: The association among child-hood headaches, emotional and behavioral difficulties, and health careuse. Pediatrics 117:1728-1735, 2006

0. Anttila P, Sourander A, Metsähonkala L, et al: Psychiatric symptoms inchildren with primary headache. J Am Acad Child Adolesc Psychiatry43:412-419, 2004

1. Wang S-J, Fuh J-L, Juang K-D, et al: Migraine and suicidal ideation inadolescents aged 13 to 15 years. Neurology 72:1146-1152, 2009

2. Cooper PJ, Bawden HN, Camfield PR, et al: Anxiety and life events inchildhood migraine. Pediatrics 79:999-1004, 1987

3. Pakalnis A, Gibson J, Colvin A: Comorbidity of psychiatric and behav-ioral disorders in pediatric migraine. Headache 45:590-596, 2005

4. Heng K, Wirrell E: Sleep disturbance in children with migraine. J Child
Neurol 21:761-766, 2006
5. Trautmann E, Lackschewitz H, Kroner-Herwig B: Psychological treat-ment of recurrent headache in children and adolescents—A meta-anal-ysis. Cephalalgia 26:1411-1426, 2006

6. Eccleston C, Morley S, Williams A, et al: Systematic review of random-ized controlled trials of psychological therapy for chronic pain in chil-dren and adolescents, with a subset meta-analysis of pain relief. Pain99:157-165, 2002

7. Strom L, Pettersson R, Andersson G: A controlled trial of self-helptreatment of recurrent headache conducted via the internet. J ConsultClin Psychol 68:722-727, 2000

8. Palermo T, Wilson A, Peters M, et al: Randomized controlled trial of aninternet-delivered family cognitive-behavioral therapy intervention forchildren and adolescents with chronic pain. Pain 146:205-213, 2009

9. Trautmann E, Kroner-Herwig B: Internet-based self-help for childrenand adolescents with recurrent headache: A pilot study. Behav CognitPsychother 36:241-245, 2008

0. Thorn BE: Cognitive therapy for chronic pain: a step-by-step guide.New York, NY, Guilford Press, 2004

1. Goslin R, Gray R, McCrory D, et al: Behavioral and physical treatmentsfor migraine headache (technical review 2.2): Prepared for the Agencyfor Health Care Policy and Research under Contract No, 1999, p29094-2025. (NTIS Accession No. 127946)

2. Nestoriuc Y, Martin A: Efficacy of biofeedback for migraine: A meta-analysis. Pain 128:111-127, 2007

3. Nestoriuc Y, Martin A, Rief W, et al: Biofeedback treatment for head-ache disorders: A comprehensive efficacy review. Appl PsychophysiolBiofeedback 33:125-140, 2008

4. Lewis D, Ashwal S, Hershey A, et al: Practice parameter: Pharmacolog-ical treatment of migraine headache in children and adolescents. Reportof the American Academy of Neurology Quality Standards Subcommit-tee and the Practice Committee of the Child Neurology Society. Neu-rology 63:2215-2224, 2004

5. Pakalnis A: Current therapies in childhood and adolescent migraine.
J Child Neurol 22:1288-1292, 2007

psychological factors in childhood headaches

Documents