Psychological disorders

Anxiety and depression. In the adult headache population, several studies have shown associations with psychological disorders such as anxiety and depression. However, while in the pediatric population some associations with the symptoms related to anxiety and depression have been shown, studies have not been able to show specific associations with anxiety and depressive disorders. Criteria for Major Depressive Disorder and Generalized Anxiety Disorder as well as many other related conditions are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Common screening tools used in-office to help diagnose patients with anxiety and/or depression include the 7-item Generalized Anxiety Disorder Scale (GAD-7) and 9-Item Patient Health Questionnaire (PHQ-9). These are available for use, free of charge and can be accessed at: www.phqscreeners.com . The issue with these tools, specifically in trying to diagnose patients with headache, is that there is substantial overlap between the symptoms of anxiety and depression assessed during these inventories and the symptoms of headache. For example, the questions in the PHQ-9 that deal with poor appetite or poor concentration and in the GAD-7 that deal with being restless can all be seen independently in patients who have headaches, which may lead to false-positive comorbid diagnoses. As such, some research has looked into better overall assessments to use in patient with tension-type headache (TTH) and migraine, leading to the implementation of the Psychosocial Assessment Tool 2.0 (PAT) by some healthcare providers. Once patients are identified as needing further assessment and treatment based on these screening tools, they should be treated and/or referred for interventions such as Cognitive Behavioral Therapy (CBT) and Biofeedback, which have shown independent efficacy in pediatric headache patients, and/or medication treatment if needed.

Alexithymia. Alexithymia is characterized by a difficulty in emotional regulation and verbalizing emotional expression. Associations between children and adolescents with TTH and alexithymia have been shown in several studies. These findings are suggestive of some incomplete or immature cognitive and emotional development in this population that could point towards an underlying pathologic neurodevelopmental mechanism. In screening for alexithymia in these patients, the Toronto Alexithymia Scale, Symptom Checklist 90-R, and Alexithymia Questionnaire for Children have been utilized specifically in this population. Should this condition cause impairment in important aspects of social or academic functioning, referral for psychological interventions such as mentalization-based treatment, as well as other general cognitive behavioral, developmental, and educational therapies may be of benefit for management of alexithymia.

Functional disorders. Functional disorders represent a wide array of phenotypes and include such manifestations as movement disorders and gastrointestinal symptoms. Different types of functional disorders are associated with different types of headache. Specifically, functional movement disorders (especially nonepileptic spells, tremor, functional syncopal spells, and gait disorders), have been associated more with people having chronic migraine than those with episodic migraine. Functional gastrointestinal disorders such as functional constipation is associated with TTH whereas other functional gastrointestinal disorders like functional dyspepsia and IBS are associated more with migraine. Identification of functional gastrointestinal disorders can be achieved through use of the Rome IV criteria questionnaires (which require a fee for use) whereas functional movement disorders can be recognized utilizing the Fahn and Williams Criteria. The Functional Disability Inventory can be used in adolescents with chronic pain disorders to assess their physical and functional impairments and help identify the need for additional therapeutic options. Treatment involves mindfulness based stress reduction and avoidance of migraine triggers, and preventive medications if indicated.

Obesity

Several population- and clinic-based studies in children and adolescents, have shown some associations between being overweight/obese and having migraine. In addition, an elevated BMI has been shown to be correlated with an increase in both headache frequency and disability from headache. One possible etiology of this, as proposed by a study from Ray et al., is that obesogenic eating behaviors (including the consumption of high fat and sugary items) are correlated with migraine frequency and headache disability. Shared mechanisms of both obesity and migraine include involvement of the hypothalamus including the orexin system, serotonin system, the calcitonin gene-related protein (CGRP), and adipocytokines such as leptin and adiponectin. Many of these proposed shared mechanisms deal with satiety and food intake behaviors as well as pain and inflammation. In addition, both migraine and obesity have strong genetic predispositions. Assessment of obesity in these individuals includes more than just measurement of height, weight, and calculation of BMI, but also assessment of eating behaviors, food intake, and activity level. Management of nutrition as well as dietary behaviors and physical exercise has been showed to be beneficial for both treatment of obesity as well as headache. CBT has also been shown to be of value in this population. As diet is often dictated by the family, and parents specifically, it is imperative to involve the parents in this treatment plan. Without parental support and participation, it can be almost impossible to effect change in the child alone. Family therapy, group nutrition, counselling, group exercise plans, and/or physical therapy may benefit the entire family as well as the patient.

Epilepsy

Studies have shown that although headache and epilepsy co-occur infrequently, there is a higher incidence of migraine in children and adolescents with epilepsy and vice versa. However, this same pattern does not hold true with TTH. In patients with epilepsy, headaches can be a phenomenon preictally, interictally, or postictally, which can sometimes lead to diagnostic confusion. Also complicating matters, occipital lobe seizures can present similarly to migraine aura. Shared mechanisms have been postulated to include that epileptic discharges lead to activation of the trigeminovascular systems with subsequent migraine development and/or lead to the cortical spreading depression associated with migraine. Evaluation of patients with both epilepsy and migraine requires a thorough history to try and distinguish features of both migraine and epilepsy, an electroencephalogram to provide further data about epileptiform activity, and possible genetic testing. Some genetic polymorphisms have been identified as possible contributing factors in these patients. Imaging, specifically Magnetic Resonance Imaging (MRI), can be useful at identifying possible seizure foci, however its utility in headache evaluation is usually in patients with abnormal neurologic exams or worrisome symptomatology. While acute treatments for migraine and epilepsy differ, prophylactic regimens for both disorders may include antiepileptic medications such as topiramate and valproic acid as well as some limited data to support the ketogenic diet/modified Atkins diet as adjunctive therapy. While there is not specific data in children to suggest whether behavioral therapies might be helpful in epilepsy treatment, there have been studies showing that cognitive behavioral therapy and relaxation therapies using progressive muscle relaxation can be beneficial in headache reduction as well as the management of epilepsy among adults. An adult multicenter randomized control trial has shown that behavioral therapies such as progressive muscle relaxation and control focused-attention activity with extremity movements can significantly reduce seizure frequency. Thus, there could likely be benefit to behavioral therapies for pediatric patients with both migraine and epilepsy, but currently there are not enough data to support this recommendation.

Atopic disorders

Atopic disorders are those disorders that involve genetic predisposition for Immunoglobulin E production after allergen exposure and includes allergic conjunctivitis, allergic rhinitis, atopic dermatitis, and asthma. In patients with migraine headache, associations with higher incidence and co-occurrence of atopic disease exist. In patients with allergic conjunctivitis and allergic rhinitis there is a higher incidence of migraine without aura. Atopic dermatitis and asthma also both co-occur more frequently in patients with migraine over other types of headache. In addition, patients with persistent asthma were more likely to have a higher number of monthly migraine episodes compared to those with intermittent asthma. The significance of these disorders co-occurring gives insight into the possible role of inflammation mediated by mast cells. Atopic disorders are usually symptomatic, yet the Global Initiative for Asthma (GINA) guidelines exist to help both with diagnosis and asthma management. Treatment for atopic disorders usually involves inhaled or nasal corticosteroids, however, there is some data to suggest that this may also decrease risk of migraine in children and adolescents. Because of this, screening for atopic disorders may be helpful for treatment planning in patients with migraine. Conversely, in patients presenting with atopic disorders, screening for migraine may aid overall disease management.

Neurodevelopmental and neurobehavioral issues

Attention deficit hyperactivity disorder ( ADHD ). Both primary headache subtypes and ADHD are common pediatric diagnoses that can impact a child’s learning and social interactions. Research into the possible associations between the two has shown mixed results; some studies have shown that there is some association between ADHD and primary headaches (specifically migraine, although others show specific associations with TTH as well), however other studies have shown no association or that some of the primary symptoms of ADHD like hyperactivity/impulsivity and impaired attentiveness (but not formal ADHD diagnosis) are associated with headache. In the studies showing associations between headache and ADHD, increased ADHD risk is associated with increased headache frequency. However, some of the research has been limited by the screening tools such as the Childhood and Behavioral Checklist (CBCL), which asks limited questions on inattentive symptoms, for example. Criteria for ADHD are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Other assessment tools used for diagnosis of ADHD include the Multimodal Treatment Study of Children with ADHD-Swanson, Nola, and Pelham IV Scale (MTA-SNAP-IV scale). Targeted treatments towards patients with both ADHD and headache still require further research.

Visual attention. Selective and alternate attention as well as visual motor integration are skills involved with visual processing and attention. Children and adolescents with migraine have shown more difficulty in these tasks than have age-matched peers from the general population, suggestive of at least partial disturbance of visual processing in migraine. This disturbance may, in part, lead to a disturbance in academic performance. An array of assessments in these patients can be performed to assess visual attention and processing including Trail Making Test A and B, the Letter Cancellation Test, Test of Visual Attention (3rd edition), and Visual Evoked Potentials. Interestingly, treatment of migraine with prophylactic medications has been shown to improve children’s ability to perform visual attention tasks to a level comparable to their healthy peers. Visual attention-specific treatment may include various neuropsychological therapeutic approaches including specialized Visuospatial Software training.

Auditory processing. Deficits in auditory processing in a noisy background (selective auditory attention) as well as temporal processing impairments are seen specifically in children with migraine although some studies show no difference in performance between children and adolescents with migraine and TTH. Specialized screening tools performed to assess for impairments in auditory processing include the Duration Pattern Test (DPT), Synthetic Sentence Identification Test (SSI), Nonverbal Dichotic Test (NVDT) . Unlike with visual attention, little research exists to suggest specific treatment options to improve auditory processing in patients with migraine/headache although we suggest avoidance of noisy backgrounds, for these patients.

Nocturnal/sleep disorders

Narcolepsy. Narcolepsy is a rare disorder that normally develops by mid-adolescence that involves disruption of the control of the sleep-wake cycle. According to some research, migraine represents an independent risk factor for the development of narcolepsy. Given the relationship between migraine and narcolepsy, the latter is mediated by destruction of orexin-producing neurons in the hypothalamus, some additional light can be shed on the pathogenesis of migraine. Diagnosing narcolepsy can be achieved by using Mean Sleep Latency Testing (MSLT) as well as criteria from the International Classification of Sleep Disorders, Third Edition (ICSD-3). In treating patients with both narcolepsy and headache, some common treatment themes exist including sleep hygiene (such as trying to maintain regular sleep-wake cycles). However, some treatments for narcolepsy include stimulants, which can result in headache independently, so avoiding these medications when possible may be a specific consideration for this population.

Bruxism. Involuntary nocturnal teeth grinding and jaw clenching, also known as bruxism, has been researched in the context of headache in children and adolescents. Some studies have shown that there is an association between episodic migraine as well as TTH and bruxism. However, the rates that have been reported in these studies are within the typical frequency range seen in the general population. On the other hand, one study has shown that children with bruxism may be more likely to report headaches. Assessing for nocturnal bruxism can be achieved through completing the Children’s Sleep Habits Questionnaire or by using polysomnography. Once a diagnosis of bruxism has been made, management includes biofeedback, stress management techniques, sleep hygiene, and behavioral therapies which have also shown efficacy in patients with headache.

Restless leg syndrome ( RLS ). RLS is characterized by an almost uncontrollable urge to move the legs that can also be connected to abnormal or unpleasant sensations such as tingling or “ants crawling” on the skin. While studying this disorder in the context of children and adolescents with headache, it was found that in both migraine and TTH, there is a higher frequency of RLS than in the general population. However, no difference was found between people with migraine and those with TTH. Diagnostic criteria have been compiled by the Pediatric International RLS Study Group and can be used along with serum ferritin to aid in diagnosis. In children and adolescents with low serum ferritin, iron supplementation may be helpful whereas sleep hygiene, CBT, and distraction techniques can be useful for all patients with this comorbidity.

Celiac disease

Celiac disease occurs when the body produces antibodies to gluten which subsequently results in damage to the small intestine. In people with headache, the comorbidity of these conditions has been studied and although some studies do show an association between celiac disease and headache, while others do not. In those that do, headache subtypes such as migraine, TTH, and chronic headache all seem to share in this association with celiac disease. Aside from symptom assessment in these patients, blood testing including serum antibodies to tissue transglutaminase as well a total levels of immunoglobulin A helps with the diagnosis. In addition to this, duodenal biopsies are used to help confirm the diagnosis. Given the mixed research, there are no strict recommendations about screening every headache patient for celiac disease. However, in those that do, studies have shown that initiation of the gluten-free diet leads to both celiac disease symptom reduction as well as improvement in headaches. The concept of gluten being a migraine trigger is popular among people with migraine, in the lay press, and on social media. There is no empirical evidence for or against this belief; however, youth with migraine should be encouraged to eat a healthy, balanced diet, and stay on a regular, routine eating schedule.