ISSN 0017-8748 doi: 10.1111/head.12510 Published by Wiley Periodicals, Inc.

Headache © 2015 American Headache Society

Feature Article Psychosocial Adjustment of Children With Migraine and Tension-Type Headache – A Nationwide Study Marco A. Arruda, MD, PhD; Renato Arruda; Vincenzo Guidetti, MD; Marcelo E. Bigal, MD, PhD

Objective.—To describe patterns of psychosocial adjustment and psychological attributes in preadolescent children as a function of headache status in univariate and adjusted analyses. Methods.—Target sample of children (n = 8599) was representative of Brazil by demographics. Parents were interviewed using validated headache questionnaires and the “Strengths and Difficulties Questionnaire,” which measures behavior in 5 domains. One-year prevalence estimates of headaches were derived by demographics. Relative risk of abnormal Strengths and Difficulties Questionnaire scores were separately modeled in children with episodic migraine and episodic tension-type headache using logistic regression. Results.—Sample consisted of 5671 children (65.9% of the target sample), from 5 to 12 years old (49.3% girls). Prevalence estimates in children were 20.6% for “no headache,” 9% for episodic migraine, and 12.8% for episodic tension-type headache. Abnormal scores in psychosocial adjustment were significantly more likely in children with episodic migraine, relative to children without headaches and children with episodic tension-type headache, and was significantly influenced by frequency of headache attacks, nausea, school performance, prenatal exposure to tobacco, as well as by phonophobia and photophobia. Conclusions.—Children with migraine are at an increased risk of having impairment in psychosocial adjustment, and the factors associated with this impairment have been mapped. Future studies should address the directionality of the association and putative mechanisms to explain it. Key words: headache, migraine, tension-type headache, psychosocial adjustment, psychiatric comorbidity, children Abbreviations: ADHD attention deficit hyperactivity disorder, CBCL Child Behavior Checklist, EM episodic migraine, ETTH episodic tension-type headache, FSH frequent severe headache, ICHD-2 Second Edition of the International Classification of Headache Disorders, SDQ Strengths and Difficulties Questionnaire; TTH tensiontype headache (Headache 2015;55;S1:39-50)

4.5% of girls younger than 12 years old.1 The burden of migraine is well characterized as impacting the child’s quality of life,2 school attendance3,4 and school performance,4 and sometimes disrupting the family.5 Some determinants of the impact have been mapped, including headache severity, disease duration,

Migraine is frequent in the preadolescent pediatric population, affecting around 2.5% of boys and From the Glia Institute, Ribeirão Preto, SP, Brazil (M.A. Arruda); Medical Sciences Faculty, State University of Campinas, Campinas, SP, Brazil (R. Arruda); Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, Sapienza University of Rome, Rome, Italy (V. Guidetti); Vice President, Global Clinical Development, Migraine and Headaches, Teva, Frazer, PA, USA (M.E. Bigal). Address all correspondence to M.A. Arruda, Glia Institute, Av. Braz Olaia Acosta, 727, s. 310, Ribeirão Preto, SP CEP14026040, Brazil.

Conflict of Interest: Dr. Bigal is a full-time employee of Teva Pharmaceuticals. This study does not mention or discuss medications. Dr. Marco Arruda, Renato Arruda, and Prof. Vincenzo Guidetti report nothing to disclose.

Accepted for publication February 13, 2014.

Financial Support: This study was conducted without financial support.

39

40 frequency of migraine attacks, presence of nausea, as well as patterns of analgesic use.6 Clinical7-9 and population-based studies6,10,11 suggest that, relative to children without headaches, those with migraine are more likely to have symptoms suggestive of anxiety and depression, as well as to have psychological comorbidities. Limited findings also suggest that pediatric migraine is associated with impaired attention span11 and hyperactivity impulsivity,12 but not with fully developed attention deficit hyperactivity disorder (ADHD).12 Nonetheless, it is still a matter of controversy about whether children with migraine have specific psychological vulnerabilities or if they only cope differently with stressful situations. The debate is fueled by the relative lack of representative data and also by the fear that findings may contribute to stigmatize children with migraine. Psychosocial adjustment may be defined as the behavioral changes that are conducted in order to address conflicting needs. It largely reflects the process required to adapt to adverse conditions.13 Over the last decade, studies have suggested that children with chronic physical disorders, like obesity,14 renal transplantation,15 asthma,16 juvenile idiopathic arthritis,17 and idiopathic nephritic syndrome,18 are more likely to have psychosocial adjustment disorders, sometimes to a level that is similar to what is found in children from homeless families,19 with parents suffering from AIDS,20 or living in a war zone.21 Accordingly, studies focusing on patterns of psychosocial adjustment in children with migraine are of interest. Herein we take advantage of a nationwide epidemiological study (Attention Brazil Project) where children were identified at schools, and parents were interviewed in order to describe psychosocial adjustment (as assessed by the Strengths and Difficulties Questionnaire; SDQ) in children with migraine, relative to children with episodic tensiontype headache (ETTH) as well as with children with no headaches.

METHODS Overview.—This study is part of a larger project designed to establish inception cohorts for studying disorders that may impact learning in preadolescent

February 2015 children (Attention Brazil Project). It was built from a non-for-profit academic virtual network of professionals founded in 2006 (“Aprender Criança” – Learning the Child).22 Questionnaires and methods were defined in a pilot study, reported elsewhere.23,24 Flow of the Study.—Members of the organization fulfilling the following criteria were invited to participate: (1) teaching in the public system, (2) teaching at the elementary school level, and (3) not teaching children with special learning needs (eg, with developmental problems). A total of 124 educators volunteered to participate. They were trained as interviewers, as described below. Of the 8599 children being educated by the participating teachers, parental consents were obtained from 6445 (75%), and analyzable data (complete demographic and headache information) from 5671 (65.9%). All were ages 5-12 years old (50.7% boys). They were enrolled from 87 cities in 18 Brazilian states, under the 5 national regions.25 All teachers completed a 4-hour online training provided by one of the authors (M.A.A.). During the training, they were instructed on how to apply the study questionnaires (see below). We emphasize that using teachers to obtain health information is a well-accepted method in assessing mental health in preadolescent children.26,27 Teachers were not selected based on special interest on headache disorders, although they certainly had interest in mental health since they voluntarily joined the community. The data collection phase happened at the end of October, close to the end of the school year in Brazil (which starts in February and extends until the end of November). First, teachers were asked to respond to questions about educational performance of the students (see assessments, below). At this point, teachers were unaware of headache information. After the information had been provided, parents were interviewed by the teachers using standardized questionnaires. After a period of 2 weeks, the questionnaires were collected and sent to the investigators. Diagnostic assignment (headache status and questionnaire coding) was made by one of the authors (M.A.A.). Assessments.—Information Obtained From the Teachers.—Before conducting parental interviews, teachers were asked to provide information on the

Headache performance of the students while at school, which consisted of the same information provided to the educational board, with measurements of the overall achievement of competencies (for the school year) in language, mathematics, science, and social studies. Children were ranked as below expectations (failed to achieve a minimal number of established milestones for the year), matching expectations, or above expectations (achieved milestones only expected to be achieved in the following school year) for the grade. Information Obtained From the Mothers.— Mothers were then interviewed by the teachers using a standardized questionnaire with 102 questions assessing (1) sociodemographic features, (2) relevant medical history for the child, (3) headaches, (4) parental perspective on school performance (not reported here); and (5) psychosocial adjustment. Details are described below. Headache.—The headache module of the questionnaire consisted of 14 structured questions, assessing the distinguishing features required for headache diagnosis, such as headache characteristics, frequency of pain, nausea, photophobia, phonophobia, duration of the episodes, consumption of analgesics, etc. The questionnaire followed the Second Edition of the International Classification of Headache Disorders (ICHD-2),28 but also assessed headache frequency over the past month and year, and other headache parameters. The questionnaire is the validated Portuguese version of the questionnaire used in the American Migraine Studies29 and has been extensively used in pediatric and adult populational studies in Brazil.30,31 Based on the response to the questionnaires, we identified children with migraine overall (including probable migraine) and strict episodic migraine (EM). We also identified children with tension-type headache overall (TTH) and ETTH, which included both infrequent and frequent ETTH. Children with headaches on 15 days or more were not included in order to avoid the interference of psychiatric disorders that are often associated with this condition.6,11 Finally, we defined a group with “no headaches” as children who did not endorse criteria for any primary headaches.

41 Psychosocial Adjustment.—Psychosocial adjustment was evaluated by the validated Brazilian version of the SDQ.32,33 The SDQ asks about 25 psychological attributes in order to assess emotional and behavioral problems from the view of the self (if adolescents or adults), or from the parents or teachers.34,35 It consists of 5 scales, each of them with 5 items assessing emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, and prosocial behaviors problems. The total difficulties score is the sum of the individual subscales.36 The parental version was used in the present study, as well as an extended version assessing the impact of any adjustment symptom in terms of chronicity, resultant distress, social impairment, or burden for others.37 The SDQ impact supplement consists of 8 questions exploring whether the informant thinks the child has a problem, the chronicity of the problem, social impairment, and burden for others. According to these questions, 3 domains are defined – perception of difficulties, impact to the children, and a burden rating.37 Criteria for abnormality have been standardized.32,33 Cut-offs are individually defined as per the studied population. The distribution of scores is analyzed, and the 10% with the highest scores are considered to be abnormal for the population in question. The impact score is reported as a categorical variable (normal vs abnormal). The SDQ has been translated into more than 30 different languages38 and was recently included by the National Institute of Mental Health as its epidemiological screener in the National Health Interview Survey.39,40 The briefness and user-friendliness of the SDQ, plus the strategy to focus on both positive and negative attributes of child behavior, may be the reasons for its good acceptability by parents and teachers, resulting in higher response rates.40,41 A recent review of 48 studies on the SDQ psychometric properties has shown its satisfactory internal consistency, test–retest reliability, interrater agreement, and construct validity.41 Analyses.—Data were described using summary tables and descriptive statistics. Participants were stratified as a function of headache status and described as a function of demographics. Race and income were defined following the definitions of the Brazilian Institute of Geography and

42 Statistics (IBGE), which are adopted by the National Census. Race was dichotomized as white vs nonwhite. The 5 income classes were determined based on the buying power for a basket of products and services that is defined by the institute and that correlates with socioeconomic characteristics. Based on the teachers’ assessments, school performance was stratified as being average, below average, and above average (achieving competencies only expected to be achieved in the subsequent year), following the regular procedure for assessing school competencies in the public school system. The variable was then dichotomized as below average vs average or above. The relative risk of having an abnormal SDQ scale was calculated as a function of headache subtype, using the no headache group as a reference. We used the same procedure to calculate the risk in children with EM compared with children with ETTH. Adjusted Analysis.—The adjusted relative risk was estimated by logistic regression in 2 separated models (1 for EM and the other for ETTH). The dependent variable was abnormal SDQ total difficulties score with identifiable impact (based on the SDQ and its impact supplement). Two independent models were constructed. For the EM model, variables included headache frequency, nausea during attacks, photophobia, phonophobia, prenatal exposure to tobacco, and below-average school performance, as well as age, gender, race, income class, parents’ marital status, analgesic overuse, and prenatal exposure to alcohol. As for the ETTH model, variables included school performance, age, gender, race, income class, parents’ marital status, headache characteristics (mean duration, frequency, and severity of the attacks), analgesic overuse, and prenatal exposure to tobacco and alcohol. The level of significance adopted was 5%. Statistical analysis was performed with the aid of SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Investigation Review Board Approval.—This study and surveys received full approval from a universitybased ethics review committee (São José do Rio Preto Medical School, São Paulo, Brazil). Written informed consents were obtained from all of the parents.

February 2015

RESULTS Overview.—Complete interviews were obtained from 5671 mothers.Table 1 displays the demographics of the participating sample and also of those without complete data. Overall participation rate was approximately 75%, and complete data were obtained from 66% of the target sample (and 88% of those who consented). Participation was strikingly uniform as a function of demographics and of school year. Participation was similar across region of the country, but the proportion of participants with analyzable data varied, being higher in the most developed regions of the country, likely reflecting educational status of the mothers. Psychological Attributes as a Function of Headache Diagnosis.—Table 2 displays the prevalence of different psychological attributes assessed by the SDQ as a function of headache status. Although the questionnaire was not developed to allow item comparisons, some of the findings are worth noticing. As contrasted to controls, children with EM were more likely to have several attributes, such as being restless, being solitary, looking worried, being involved in bullying situations, looking unhappy, being distracted or nervous, and getting better with adults than with other children. Full description is provided in the table. They were less likely than controls to endorse the following questions: “Generally obedient, usually does what adults request,” “Thinks things out before acting,” and “Sees tasks through to the end, good attention span.” As contrasted to controls, children with ETTH were more likely to have the following attributes: “Shares readily with other children,” “Often has temper tantrums or hot tempers,” “Helpful if someone is hurt, upset or feeling ill,” “Constantly fidgeting or squirming,” “Kind to younger children,” “Often volunteers to help others (parents, teachers, other children),” “Many fears, easily scared,” and “Sees tasks through to the end, good attention span.” Psychological Adjustment as a Function of Headache Diagnosis.—Table 3 contrasts the prevalence of abnormal scores in the different scales of the SDQ as a function of headache status. Significant differences were seen for the following scales (relative risk and confidence intervals are displayed in the table

Headache

43 Table 1.—Target Sample, Consented, and the Final Sample According to Demographic Features

Participation Rates (%)

Target Sample

Age group 5-8 9-12 Gender Female Male School year 1o. 2o. 3o. 4o. 5o. Race White Non-white Non-respondents Income class A, B C D, E Region North Northeast Mid-West Southeast South Population density 500,000 Total

Consented

Completed Interviews

Relative to Target Sample

Relative to Consented

n 4801 3798

n 3657 2788

% 76.2 73.4

n 3111 2560

% 64.8 67.4

% 85.1 91.8

4259 4340

3186 3259

74.8 75.1

2794 2877

65.6 66.3

87.7 88.3

1538 2384 1716 2053 908

1160 1884 1252 1490 659

75.4 79.0 73.0 72.6 72.6

1044 1674 1105 1272 576

67.9 70.2 64.4 62.0 63.4

90.0 88.9 88.3 85.4 87.4

5856 2743 –

4198 1964 283

71.7 71.6 –

3769 1672 230

64.4 61.0 –

89.8 85.1 81.3

3034 4347 1218

2332 3234 879

76.9 74.4 72.2

2069 2856 746

68.2 65.7 61.2

88.7 88.3 84.9

278 1245 405 3778 2893

172 912 298 2837 2226

61.9 73.3 73.6 75.1 76.9

134 712 188 2542 2095

48.2 57.2 46.4 67.3 72.4

77.9 78.1 63.1 89.6 94.1

3245 3546 1808

2567 2589 1289

79.1 73.0 71.3

2220 2365 1086

68.4 66.7 60.1

86.5 91.3 84.3

8599

6445

75.0

5671

65.9

88.0

only for ease of reading): emotional symptoms (controls = 20.6%; ETTH = 27.5%, P < .0001; EM = 62.4%, P < .0001 vs controls and P < .0001 vs ETTH), conduct problems (controls = 23.2%; ETTH = 25.3%; EM = 43.5%, P < .0001 vs controls and P < .0001 vs ETTH), hyperactivity (controls = 14.0%; ETTH = 14.7%; EM = 29.2%, P < .0001 vs controls and P < .0001 vs ETTH), peer problems (controls = 23.7%; ETTH = 19.8%, P = .053; EM = 32.7%, P < .0001 vs controls and P < .0001 vs ETTH), total difficulties (controls = 20.9%; ETTH = 22.6%; EM = 47.8%, P < .0001 vs controls and P < .0001 vs ETTH), and total difficulties causing impact (controls = 3.4%; ETTH = 5.5%, P < .05; EM = 16.9%, P < .0001 vs con-

trols and P < .0001 vs ETTH). No significant differences were seen between the 3 groups comparing prosocial behavior problem score (Table 3). Regression Analysis.—Table 4 displays variables that significantly influenced the SDQ scores for children with EM and ETTH. For ease of reading, we only present the variables retained in the full model. In children with EM, an abnormal total difficulties score causing impact was most significantly influenced by headache frequency (P < .001), nausea during attacks (P < .001), photophobia (P < .05), phonophobia (P < .05), prenatal exposure to tobacco (P < .05), and below-average school performance (P < .01). Age, gender, race, income class, parents’

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February 2015

Table 2.—Prevalence of SDQ Discriminant Items Between Children With Episodic Migraine, Episodic Tension-Type Headache, and Controls (No Headache)

No Headache

SDQ Items

Restless, overactive, cannot stay still for long Often complains of headaches, stomachaches, or sickness Shares readily with other children (treats, toys, pencils, etc) Often has temper tantrums or hot tempers Rather solitary, tends to play alone Generally obedient, usually does what adults request Many worries, often seems worried Helpful if someone is hurt, upset, or feeling ill Constantly fidgeting or squirming Often fights with other children or bullies them Often unhappy, downhearted, or tearful Generally liked by other children Easily distracted, concentration wanders Nervous or clingy in new situations, easily loses confidence Kind to younger children Often lies or cheats Picked on or bullied by other children Often volunteers to help others Thinks things out before acting Gets on better with adults than with other children Many fears, easily scared Sees tasks through to the end, good attention span

ETTH

Episodic Migraine

n

%

n

%

n

%

183 91 712 223 101 604 218 715 256 106 106 925 265 274 881 110 212 717 413 198 237 531

16.0 7.9 61.5 19.3 8.7 52.1 18.9 62.0 22.1 9.2 9.2 79.6 23.0 23.8 76.1 9.6 18.4 62.1 35.9 17.2 20.5 45.8

131 97 492 167 55 371 138 502 188 74 52 604 171 169 587 73 121 481 241 128 187 366

18.2 13.6 68.6 23.4 7.7 51.5 19.4 70.1 26.3 10.3 7.2 83.9 23.8 23.6 81.2 10.3 16.9 67.2 33.8 17.8 26.2 51.0

137 292 317 198 71 216 168 347 186 95 108 390 219 209 386 78 166 323 149 150 185 193

27.2 57.9 62.5 39.4 14.0 42.9 33.1 69.0 36.8 18.8 21.3 77.5 43.4 41.5 76.9 15.5 32.9 64.5 30.1 29.8 36.8 38.1

ETTH = episodic tension-type headache; SDQ = Strengths and Difficulties Questionnaire.

marital status, vomiting, duration and severity of the attacks, and prenatal exposure to alcohol did not contribute to the model. In children with ETTH, an abnormal total difficulties score causing impact was most significantly influenced by below-average school performance (P < .01). The remaining variables did not influence the model.

DISCUSSION To the best of our knowledge, the present study is the first to examine psychosocial adjustment and psychological attributes in preadolescent children with EM and ETTH using the ICHD-2 criteria and the SDQ in a large population-based study. Our findings can be summarized as follows: (1) Relative to controls, children with EM are more likely to present emotional symptoms, conduct problems, hyperactivity, peer problems, and total difficulties in psychosocial adjustment, as well as to be impacted because of these

difficulties. (2) Children with ETTH, in turn, were significantly more likely to have emotional symptoms and total difficulties causing impact in their psychosocial adjustment compared with controls. (3) Compared with children with ETTH, children with EM were significantly more likely to have abnormal score in all but one SDQ scale (prosocial behavior problems score). (4) Determinants of the impact among children with migraine, as seen in multivariate analyses, include headache frequency, associated symptoms (nausea, photophobia, and phonophobia), prenatal exposure to tobacco, and below-average school performance. In children with ETTH, only belowaverage school performance was seen as a predictor. Psychosocial adjustment problems in childhood are common, affecting up to 18% of all children,41 although they are often not recognized, diagnosed, and treated.42 Given the fact that psychosocial problems in young children show relative stability over

Headache

45

Table 3.—Prevalence of Abnormal Scores of Psychological Adjustment Between Children With Episodic Migraine, Episodic Tension-Type Headache, and Controls

ETTH No Headache

SDQ Scales

Episodic Migraine (RR vs No Headache) [RR vs ETTH]

(RR vs No Headache)

n

%

RR (95% CI)

n

%

RR (95% CI)

n

%

RR (95% CI)

Emotional symptoms

241

20.6

Reference

200

27.5

1.34 (1.14-1.57)

318

62.4

Conduct problems

271

23.2

Reference

184

25.3

1.09 (0.93-1.29)

222

43.5

Hyperactivity

164

14.0

Reference

107

14.7

1.05 (0.84-1.32)

149

29.2

Peer problems

277

23.7

Reference

144

19.8

0.84 (0.70-1.00)

167

32.7

84

7.2

Reference

40

5.5

0.77 (0.53-1.11)

32

6.3

244

20.9

Reference

164

22.6

1.08 (0.91-1.29)

244

47.8

40

3.4

Reference

40

5.5

1.61 (1.05-2.47)

86

16.9

3.03 (2.66-3.45) 2.26 [1.98-2.59] 1.88 (1.63-2.17) 1.72 [1.47-2.01] 2.08 (1.71-2.54) 1.98 [1.59-2.47] 1.38 (1.18-1.63) 1.65 [1.36-2.00] 0.87 (0.59-1.30) 1.14 [0.73-1.79] 2.29 (1.99-2.65) 2.12 [1.80-2.49] 4.93 (3.44-7.07) 3.06 [2.14-4.38]

Prosocial behavior problems score Total difficulties Impact score

Italicized and bold values are statistically significant. CI = confidence interval; ETTH = episodic tension-type headache; RR = relative risk; SDQ = Strengths and Difficulties Questionnaire.

time and can predict psychiatric disorders in adulthood,43 screening preadolescent children for psychosocial problems in order to allow preventative interventions is of great importance.44 The SDQ is designed to measure psychosocial adjustment in children and adolescents.36 Psychometric evaluations of the instrument have shown satisfactory convergent and discriminant validity.41 Compared with other similar instruments, such as the Child Behavior Checklist (CBCL),45 the SDQ has been validated for clinical and research applications, is much shorter in format, and can be used free of charge (available online at www.sdqinfo.com).41 The CBCL, in turn, seems to be more appropriate for the investigation of a broader range of psychopathological conditions. Validation and factor analyses revealed that the SDQ properly identifies emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, and prosocial behavior.35 The parent-rated SDQ also shows a good correlation

with measures of ADHD,46 conduct disorder,47 depression, and anxiety.48 The traditional 2-dimensional taxonomy of childhood psychopathology contrasts the presence of withdrawal, sadness, anxiety, and the sometimes referred to as “intropunitive” behaviors (internalizing disorders) vs salient, disrupting, and socially negative behaviors (externalizing disorders).49 The comorbidity between childhood migraine with depression and anxiety, prototypes of the internalizing disorders, has been reported in clinical7-9 and populational studies.6,10,11,50,51 However, few studies have found an association between primary headaches and externalizing behaviors in children. In a cross-sectional study, Strine et al found a higher prevalence of emotional, conduct, hyperactivity, and peer problems in children with frequent severe headache (FSH) compared with controls (without FSH). The authors also found that children with FSH were significantly more likely than controls

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February 2015

Table 4.—Multivariate Analyses of Determinants of an Abnormal SDQ Total Difficulties Score Causing Impact in the Life of Children With Episodic Migraine and Episodic Tension-Type Headache

95% CI

Episodic migraine Frequency of attacks 0-4 vs 5-9 attacks/month 0-4 vs 10-14 attacks/month Nausea Photophobia Phonophobia Prenatal exposure to tobacco School performance Below vs above average Constant Episodic tension-type headache School performance Below vs above average Constant

Wald Chi-Square Value

P value

Odds Ratio for Predictors

Lower

Upper

20.622 18.484 4.758 30.212 4.049 4.303 4.533 12.744 8.092 154,156

.000 .000 .029 .000 .044 .038 .033 .002 .004 .000

– 4.263 3.261 9.584 1.809 1.980 1.957 – 2.683 .030

– 2.201 1.127 4.281 1.016 1.038 1.055 – 1.359 –

– 8.255 9.432 21.457 3.222 3.776 3.631 – 5.297 –

30.528 15.671 400.109

.000 .000 .000

– 18.130 .004

– 4.319 –

– 76.111 –

For episodic migraine, the following did not contribute to the model: age, gender, race, income class, parents’ marital status, duration of attacks (1-12 hours vs 12-24 hours, 1-12 hours vs 24-72 hours), severity of headaches, vomiting, analgesic overuse, and prenatal exposure to alcohol. For episodic tension-type headache, the following did not contribute to the model: age, gender, race, income class, parents’ marital status, frequency of attacks (0-4 vs 5-9 attacks/month; 0-4 vs 10-14 attacks/month), duration of attacks (30-60 minutes vs 1-12 hours; 30-60 minutes vs 12-24 hours; 30-60 minutes vs >24 hours), severity of headaches, nausea, vomiting, photoand phonophobia, analgesic overuse, and prenatal exposure to tobacco and alcohol. CI = confidence interval; SDQ = Strengths and Difficulties Questionnaire.

to be upset or distressed by their difficulties, and to have their difficulties interfere with home life, friendships, classroom learning, and leisure activities.52 Virtanen et al in a prospective follow-up study of adolescent Finnish twins demonstrated that headache frequency among 11- and 14-year-old twins was associated with externalizing and internalizing problem and adaptive behaviors reported by parents and teachers, and the headache frequency of adolescents at age 14 was predicted by psychological factors, especially by externalizing problem behaviors.11 In another cross-sectional populational study, we found a significant association between hyperactivity impulsivity symptoms with any headache, ETTH, and migraine (P = .001).12 The present study corroborates some of previous findings, suggesting that children with migraine are more likely not only to have internalizing problems, as previously reported, but also of externalizing behaviors.

We also found that EM was associated with peer problems but with no evidence of “rule-breaking” and/or “aggressive” symptoms. The peer problem score of the SDQ identifies difficulties in social engagement as well as infantilized behavior for the age, and this may be associated with important impact on the personal and social life. On the other hand, no significant differences were seen among groups (EM, TTH, and controls) comparing prosocial behavior problem score that measures the altruistic dimension of the child’s social interaction and are characterized by behaviors with the purpose of helping others. Adjusted analyses identified the expected influence of a high headache frequency and the presence of associated symptoms (nausea, photophobia, and phonophobia) on the psychosocial adjustment problems in children with migraine. Interestingly, the same correlation was found for prenatal exposure to tobacco and below-average school performance.

Headache Among these predictors, only below average school performance was significantly correlated in children with ETTH. Headache, nausea, and vomiting are considered among the most frequent functional-somatic symptoms in children and adolescents associated with young adult psychopathology,53 and the association between prenatal exposure to tobacco with mental health problems,54 ADHD,55 and poor school achievement56 has been reported in literature. In 2 previous populational studies in the pilot phase of the Attention Brazil Project, we have demonstrated by multivariate analyses a correlation between (1) headache frequency and behavioral and emotional symptoms in children with migraine,6 and (2) prenatal exposure to tobacco and alcohol and chronic daily headache at childhood.57 These novel findings must be confirmed by long-term longitudinal studies. In a work now considered as classical, Bille suggested that children with migraine were “more sensitive,” “less physically enduring,” and “more vulnerable to frustration” than those without migraine.58 The concept of a “migrainous personality” was later proposed by Saper, who described migraine patients as being “compulsive, perfectionistic, rigid, and achievement driven elements, often accompanied by internalized anger and excessive self-control.”59 Other studies also suggested the possible association between migraine and specific psychological attributes in children and adolescents, such as shyness, emotional rigidity, tendency to repress anger and aggression, and a poorest overall level of adjustment.60-62 Some of these characteristics were also identified in the present study and must be considered as major psychological attributes of children with migraine and ETTH, a potential area for further qualitative and long-term researches. The strengths and limitations of our study deserve comment. Among the strengths, we list the population nature of our study, the relatively large sample size of preadolescents, the use of validated questionnaires, the strict following of standardized criteria for headache diagnosis, and the multivariate adjustments. Among the limitations, we highlight that headache diagnosis was determined by the information

47 given by the mother; no direct interview was conducted with the child. Nonetheless, this is not different from what is often seen in medical practice for young children, and potential biases of our method need to be explored.31 Second, we underestimated the prevalence of the ETTH, since we only classified the most severe type of headache presented by patients. This is a standard method in the field,63 but by not assessing more than one type of headache, we cannot adjust for whether one headache (ETTH) influences the association of headache/SDQ in children with another (EM). Furthermore, the ICHD-2 may be of limited value in separating migraine and TTH in young children, and diagnostic inaccuracies exist, justifying our decision to run 2 independent models instead of having both diagnoses included in a single model.31 Finally, as mentioned in the methods, the items of the SDQ were not constructed to allow individual comparisons. Nonetheless, we found that the information offers value and decided to present it in Table 2, while not conducting formal comparisons and warning the reader about this caveat. Migraine and TTH are significantly associated with psychosocial adjustment problems in preadolescent children by means of SDQ. The association of these psychosocial adjustment problems with the burden caused by migraine itself may perpetuate both conditions. Providers should address this possibility in order to properly evaluate, diagnose, and treat children with chronic headache.

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Psychosocial adjustment of children with migraine and tension-type headache - a nationwide study.

To describe patterns of psychosocial adjustment and psychological attributes in preadolescent children as a function of headache status in univariate ...
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