The prevalence rate of headache increases with age in children, with female predominance, after the age of 13 years (Russell et al. 2006). It ranged from 37 to 51 % in those who were at least seven years of age and gradually rose to 57 to 82 % by age 15 (Karli et al. 2006). Frequent episodic tension-type headache was the most common (25.9 %) headache followed by migraine (14.5 %) (Karli et al. 2006). The prevalence of adolescent migraine varies from 3 to 22 % in different populations (Laurell et al. 2006).

In India, Gupta et al. (2009) found 57.5 % adolescents to be suffering from recurrent headaches. Migraine was the most prevalent (17.2 %) followed by unspecified (14.9 %) and tension headache (11 %). Average age of headache onset was 11 years.

Migraine causes significantly reduced school attendance. Collin et al. (1985) reported that over a time span of twelve weeks, the prevalence of school absence due to headache for children 5 to 19 years of age was 3.7 %.

Caring for a child with a physical disease puts a strain on the child’s family. School absence and frequent somatic complaints due to frequent headache or migraine may lead to ‘perceived role restriction’ in the parents which is defined as ‘the extent to which a person feels unable to pursue one’s own personal interests due to the responsibilities involved with raising a child with a chronic physical condition’ (Breslau et al. 1982). Thus, though tension headache and migraine are not regarded as disabling physical diseases, these disorders may lead to a perceived role restriction in the family to the same degree as a disabling disease.

According to The International Classification of Headache Disorders–2nd Edition (ICHD–II) (IHS 2004), primary headache disorders in adolescence are often comorbid with psychiatric disorders. Girls with anxiety disorder had a significantly greater prevalence of headaches than girls without an internalizing disorder (Egger et al. 1998). Cross-sectional investigations of psychiatric disorder prevalence in migraine samples found an increased risk of anxiety disorders, particularly panic disorder and phobias (IHS 1998). Breslau et al. (1991) found an association between migraine and obsessive–compulsive disorder as well as generalized anxiety disorder. Thirty-five percent of youths with chronic headaches had anxiety disorders (Liakopoulous-Kairis et al. 2002). Emiroglu et al. (2004) found 94 % adolescents suffering from unexplained neurological symptoms (such as headache) to be suffering from at least one mental disorder, most frequent being depressive disorders (40 %). High rates of anxiety and depressive symptoms among adolescents with headaches have been found by Fritz et al. (1997). For more information on anxiety or depression, refer to Chaps. 11 and 12.

The CBT model for headache is based on the belief that thoughts influence feelings which influence our behaviors/experience (including pain). CBT has been successfully applied to pediatric headaches (Palermo et al. 2009, 2010; Trautmann and Kroner-Herwig 2010). There is increasing evidence for the short- and long-term efficacy of CBT for anxiety-related difficulties in childhood and adolescence (Silverman et al. 2008). Cognitive behavior therapies represent a range of empirically supported psychotherapy for adolescents with depression (Kazdin and Weisz 1998).

Transdiagnostic treatments are those that apply to the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses (McEvoy et al. 2009 ). According to Mansell et al. (2009), less time is spent on selecting the right therapy, there is no problem with comorbidity in an individual, the stigma attached to a diagnostic label can be avoided and it fosters a more idiographic approach to treatment. It helps the continued generalization of knowledge from established models of psychological disorders to new disorders that are yet to be fully investigated. It further leads to development of treatment components that are effective across a wide range of disorders (Mansell 2008).

Headache frequency is significantly associated with externalizing and internalizing problem behaviors (Virtanen 2008). Comorbidity of headache with other disorders renders it suitable for application of TCBT as TCBT focuses on all aspects of problem behavior.

Master N is a 13-year-old male studying in class IX belonging to middle socioeconomic status and urban domicile presented with complaints of frequent, recurring headache and feeling anxious in social situations. N had always been a shy child, but the situation had intensified in the last six months after he changed school owing to a change in residence. He had been in the previous school since kindergarten, every teacher knew him, and thus, his anxiety symptoms went unnoticed to some extent. With the new school, he had to start all over again. This was distressing for him. Unable to hold a conversation, he could not make friends, and even when he tried, he stammered. This lead to his being made fun of by classmates and further drew him away from everyone. These situations at school distressed him, and he was unable to concentrate on studies resulting in poor performance. He began feeling sadness of mood, lost interest in earlier pleasurable activities, and had low self-esteem. It was also at this time that the headaches started and gradually increased in intensity and duration. He reported significant physiological (e.g., sweating excessively, having a dry mouth, heart racing), cognitive (e.g., ‘I will say something wrong and embarrass myself’), and behavioral (e.g., blushing, stammering) symptoms of anxiety when forced to face social situations. At best, he liked to avoid all social interactions. He reported ‘freezing up’ when talking to others and often felt that he was not able to respond despite wanting to, which he found very distressing. His mind went ‘blank’ and he stopped trying to talk. Even while narrating these symptoms, N was seen struggling with anxiety and it was difficult for him to talk. He used compensatory behaviors to communicate across settings by asking others to do things for him (e.g., parents ordering food at restaurants). Further, recurring headache episodes made it difficult for N to concentrate on anything. School being a consistent stressor due to its social demands led N to refuse to go to school leading to several absences each week. His ‘silent’ instances in the class (not asking questions in class, not answering when asked of, not talking to peers, or remaining silent during group work) prompted teachers to complain to his parents. N’s concerned parents brought him to a psychiatrist for identification and management of the problem. He was diagnosed as having tension headache (IHS classification), social phobia, and mild depressive episode (ICD-10 classification). He was given medication and sent to psychologist for further management.

Before initiating intervention, an in-depth assessment is an integral part of the treatment process and helps in deciding the treatment module to be followed. Assessment involves a detailed case history focusing on current problems, factors leading to and maintaining current problems, family history, and any comorbid conditions. Further assessment includes the application of inventories, rating scales, and self-report questionnaires to assess degree and severity of headache, anxiety, and other comorbid disorders. Some of the important tools to measure headache and anxiety are listed in Table 14.2. For information on tools to measure depression, refer to Chap. 11.

Parents, teachers, and peers are important sources of assessment apart from adolescent himself. Assessment is an ongoing process and continues into therapy where tools such as ABC chart (see Appendix) and self-monitoring form (see Appendix) will be used.

Intervention includes therapy sessions for headache and comorbid disorders such as depression and anxiety.

The total number of sessions range from 10 to 16 weekly sessions (minimum). The average duration of a session is 45–50 min. The sessions may either be with the adolescent alone or parents or a single session involving a separate time for both. A brief look at the various therapy phases is given in Table 14.3.