Children and adolescents with recurrent headache often present with a wide array of psychological and social issues. These have been hypothesized to contribute to the onset and maintenance of their pain as well as to be a product of the chronicity of their symptoms. Early investigations into the personality features of individuals with migraine suggested that they were ambitious, perfectionistic, and efficient people who loved orderliness and often appeared reserved and distant in interpersonal relationships.1 Children and adolescents with migraine reported more anxiety, tension, and nervousness than peers without migraine. In addition, they were described by their parents as less enduring physically and more tidy, sensitive, and worried.2 In recent years, the elaboration of psychological factors commonly associated with recurrent headache has been the focus of much research, and our understanding of the interrelationship of psychosocial issues and recurrent headache has grown substantially.1-7
This article discusses the psychological factors commonly associated with recurrent pediatric head' ache. The literature on the treatment of recurrent pediatric headache is extensive, but investigation of psychosocial correlates has been more limited. It is therefore often necessary to draw on the adult headache literature for elaboration. In the comprehensive evaluation of both organic disorders and psychosocial problems in recurrent pediatric headache, the primary care clinician must investigate the degree to which psychosocial issues are influencing symptoms and determine whether referral for psychological intervention is warranted.
Recurrent pediatric headache has been proposed as a marker for depression in children and adolescents8 as well as adults.9 However, most children and adolescents with migraine and other forms of recurrent headache are not likely to show clinically significant levels of depression. Clinical interviews have revealed elevated rates of dysthymia and adjustment disorder with depressed mood among adolescents with recurrent pediatric headache,5 but not the incidence of major depression more commonly reported in adults with migraine.9'11 It has been suggested that pediatric migraine12 and recurrent headache4,6 patients may have increased levels of depressive symptoms compared to peers without headache, but this relationship has not been found consistently.5,13 The contradicting reports may be the result of differences in methodology used by the researchers. Table 1 summarizes controlled studies of depression in pediatric headache.
Controlled Studies of Depression
The high rates of comorbid migraine and depression reported in adults,10,11 along with the inconclusive results in the pediatric literature, indicate that an evaluation for depressive symptoms is warranted in patients with recurrent pediatric headache. Either a clinical interview designed to elicit symptoms of depression or a self-report questionnaire should provide the necessary screening information. Symptoms associated with depression include feelings of sadness, decreased interest or pleasure in previously enjoyed activities, changes in weight or appetite, sleep disturbances, psychomotor agitation or retardation, fatigue, feelings of worthlessness, decreased ability to concentrate or make decisions, recurrent thoughts of death, suicidal ideation, and a suicide attempt or plan.14 It is important to be aware that depressed children and adolescents also may present as irritable and acting out rather than sad and fatigued as is common in adults with depression. One self-report measure, the Children's Depression Inventory,15 has been shown to be effective in screening for depression in an adolescent clinical population.16
An association between migraine with aura, suicidal ideation, and suicide attempts has been reported in the adult literature.17 However, there is currently no epidemiological or clinical evidence to suggest that children and adolescents with migraine are at increased risk for suicide attempt or suicidal ideation.
Although early investigations suggested that recurrent pediatric headache was associated with increased levels of anxiety,2 more recent work has not supported this relationship.3,5,12,13 There is reason to believe, however, that the level of anxiety in individuals with recurrent pediatric headache may increase as they mature through adolescence. Adolescents over the age of 12 were found to report higher levels of trait anxiety (how they feel in general) but not state anxiety (how they feel right now).12 Older adolescents with recurrent pediatric headache (age 16 to 18) reported higher anxiety levels, more nervous problems, and greater perceived stress than peers without headache.6 The coexistence of anxiety disorders and migraine in adults is well documented.11 Although there are no published longitudinal pediatric data, it is possible that adolescents with recurrent pediatric headache will develop more pronounced anxiety symptoms as they approach adulthood.
In general, the frequency and severity of headache in children and adolescents with recurrent pediatric headache appear to be closely related to anxiety level.3,5,12 Children and adolescents with elevated anxiety symptoms are likely to experience more frequent and severe headaches.3,5 In addition, the severity of headache has been found to increase as anxiety level increases.5 As with depression, anxiety symptoms may be evaluated through clinical interview or with a standardized measure such as the State-Trait Anxiety Inventory.18 Symptoms associated with anxiety include restlessness, easy fatiguability, difficulty concentrating, irritability, muscle tension, and sleep disturbance.14 Table 2 summarizes controlled studies investigating anxiety in pediatric headache patients.
Controlled Studies of Anxiety
Predisposing conditions that often are referred to as "stress* are commonly considered as contributing factors in recurrent pediatric headache and other somatic complaints.19 Stress is the most frequently mentioned precipitating factor in epidemiological studies with adult headache sufferers and often is mentioned as a headache trigger in children as well.7 Individuals with recurrent pediatric headache have been found to report more stress in their daily lives than those without headache,6 and those reporting stress as a cause of their headaches are reported to have more frequent and problematic ones.7
It is important in practice to be aware that what is considered stressful by one individual may seem trivial to another. An individual's subjective interpretation of an event may determine how stressful it is and whether a stress reduction intervention would be effective. Although many environmental fee tors can act as precipitants, recurrent pediatric headache often appears related to a physiological response to stress. The degree of response may be influenced by a genetic predisposition as well as one's cognitive appraisal of the situation. Some children and adolescents may have lower stress thresholds at which a physiological reaction, in this case precipitating headache, is elicited.5
Major life changes, negative life events in particular, have been presumed to increase stress level and may exacerbate recurrent pediatric headache. Adolescents who have recurrent somatic symptoms with no identifiable organic etiology were found to have experienced more frequent negative life events within the past year than those being seen for routine checkups, those with acute minor illnesses, or those who had somatic symptoms with identified etiology.19 Investigations have revealed no differences in the frequency of life events experienced by children and adolescents with migraine3,12 or recurrent headache.5 It has been reported, however, that children with recurrent pediatric headache are significantly more likely to have divorced parents.6 This relationship appeared regardless of the length of time that had passed since the divorce took place. It has been suggested that adults experience more significant life change in the year prior to the onset of recurrent headache than headache-free controls.20 While there are no data to support a relationship between the frequency of life events and recurrent pediatric headache, an evaluation of psychosocial changes in the past year remains an important part of a comprehensive evaluation.
Achievement Motivation and Fear of Failure
Many clinicians have the impression that children and adolescents with recurrent pediatric headache frequently demonstrate personality characteristics associated with a drive to perfection, time urgency, and overcommitment to academic excellence and extracurricular activities. One may encounter a middle school student who consistently receives A's in advanced courses, plays in the band, swims on the school swim team, and is running for student council. On weekends, she takes riding lessons and plays in the community soccer league. This commitment to more activities than can reasonably be completed in the time available has been reported in adult recurrent headache patients.21
It has been hypothesized that children and adolescents with recurrent pediatric headache have higher levels of achievement motivation and fear of failure than headache-free peers. Those with recurrent pediatric headache have been reported to spend more time on their homework than peers without headache.6 In a school-based investigation, the frequency and intensity of recurrent pediatric headache were found to be related to fear of failure. The possible consequences of headache, including missed activities, school absence, procrastination related to homework, and health-care use, also were associated with these headache variables. No relationship was found between the frequency and intensity of headache and the level of achievement motivation in individuals with recurrent pediatric headache.7 The accuracy of these particular results has been questioned, however, since the participating schools deemphasized academic pressure at the time and achievement scores were reportedly low. Because no pain-free control group was involved in the project, further investigation of this theory was not possible.
The achievement orientation found in parents of children and adolescents with recurrent pediatric headache also has been investigated. It was hypothesized that parents of individuals with recurrent pediatric headache would maintain higher expectations for their children's behavior and performance. In fact, the opposite was found to be true. Parents of children with headache were found to focus less on achievement and have fewer expectations than parents of children without recurrent pediatric headache.5 Studies of adults with recurrent headache have revealed higher levels of achievement motivation, more fear of failure, and increased levels of related anxiety that interfere with task completion.22 Although information related to achievement motivation is inconclusive, children and adolescents with recurrent pediatric headache may have more fear of failure contributing to their symptoms. It appears that these feelings may be internally based rather than externally imposed through parental demands.
It is possible that recurrent pediatric headache occurs as one symptom of a generalized tendency to report multiple somatic symptoms when under stress. It is well documented that children and adolescents with migraine12,13 and recurrent headache5,6 show significantly higher levels of somatic complaints (most often on parent report measures) than peers without headache. Unfortunately, the questionnairesjtypically used to investigate somatization often include items that are known to frequently co-occur with migraine. Items such as nausea, vomiting, and abdominal pain are likely to be reported more frequently by individuals with recurrent pediatric headache than by others. Until analysis of the particular symptoms is available, the reason for the high levels of reported somatic symptoms in recurrent pediatric headache will remain unclear.
Behavioral characteristics of individuals with recurrent headache have long been a topic of interest. In children and adolescents with recurrent pediatric headache, behavior has been investigated primarily through the use of questionnaires completed by parents and teachers. Based on parent report, children and adolescents with recurrent pediatric headache have been found to be less socially competent, to participate less in interpersonal interactions, and to be more shy and sensitive than children without headache.5,13 In general, they are reported to exhibit more internalizing behaviors, such as being self-conscious, withdrawn, fearful, and underactive.12,13 Boys with recurrent pediatric headache also were found to show significantly more externalizing (aggressive and destructive) behaviors than either girls with recurrent pediatric headache or boys and girls without headache.12 Teachers, unlike parents, did not report observing significantly more internalizing behaviors in students with recurrent pediatric headache than in those without headache. They did indicate, however, that the students with recurrent pediatric headache appeared less happy.13
Children may learn pain-related behaviors from frequent exposure to people with chronic pain, commonly referred to as "pain models." Investigations in this area indicate that adults with migraine and tension headache have had significantly more exposure to pain models than those without headache.23 The relationship may be genetically based, particularly in the case of migraine. Alternatively, individuals may learn that somatic symptoms, such as headache, are appropriate means of expressing emotional distress.23 Finally, they simply may be learning maladaptive ways of coping with pain.
Compared to headache-free controls, children and adolescents with recurrent headache:
* endorse more symptoms of depression, but typically do not meet clinical criteria for depressive disorders,
* report increasing anxiety levels with advancing age during adolescence,
* do not report a higher frequency of negative life events,
* may work longer on homework and have increased fear of academic failure but do not appear to have higher levels of achievement motivation (nor do their parents have higher expectations of them),
* report more somatic symptoms, and
* exhibit more internalizing behaviors, although boys may additionally exhibit more externalizing behaviors.
It is probable that many but not all children and adolescents who present with symptoms of recurrent pediatric headache to their primary health-care provider have significant psychosocial factors that contribute to the frequency and intensity of headache and associated functional disability. In some cases, the severity of the underlying psychosocial problems (eg, major depression and abuse) may require intervention by a mental health professional. At other times, mild to moderate difficulties can be managed appropriately by the primary clinician. It is therefore essential in the initial evaluation of recurrent pediatric headache to screen carefully for possible psychosocial fee tors and to place particular emphasis on depression, anxiety, and predictable stressors.
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Controlled Studies of Depression
Controlled Studies of Anxiety