Relaxation treatment administered by school nurses to adolescents with recurrent headaches

OBJECTIVE: To study the outcome of two different forms of relaxation training administered by school nurses to adolescents suffering from recurrent headaches in an effectiveness study. METHODS: A total of 11 school nurses were randomized to administer one of the two treatments to 63 adolescents. A post hoc group with 42 untreated subjects, matched for headache diagnosis, sex, and age were included as a control group. RESULTS: The results showed no pre-post differences in headache reduction between the treatment groups, however, subjects treated with either of the two relaxation approaches were significantly more improved than those in the post hoc group on total headache activity and headache-free days. Clinical improvement (at least 50% improvement) was attained among 19% of the treated subjects as compared to 7% for those in the post hoc group, a nonsignificant difference. Higher functional disability predicted a worse outcome, and positive self-statements predicted better outcome. Altogether, these variables accounted for 29% of the outcome variance in the total headache activity. CONCLUSIONS: In the present study, outcomes of relaxation training as administered by school nurses were not found to be as powerful as similar treatments provided for adolescents with migraine or tension-type headache in the previous controlled studies of clinic as well as school samples. It is likely that the school nurses need to be more thoroughly trained and informed to achieve cost-effective improvement. Presently, it is suggested that the relaxation training should not be used as a part of regular treatment in the school health care for adolescents with recurrent headaches until further evidence is provided.     

Swedish school nurses' view of school health care utilization,causes and management of recurrent headaches among school children

The present survey was addressed to a representative, nationwide sample of Swedish school nurses and 174 (69%) responded. They were asked about their views on: (i) the most usual problems for students that prompt attendance at school nurses' offices; (ii) the causes and management of school children's headaches and (iii) the school nurses' own education with respect to headaches. Headaches were reported to be one of the most common problems among adolescents visiting the school nurses' offices and tension-type headaches were regarded as a more serious school health problem, compared with migraine. Various stressors such as family and peer problems were regarded as important causes of recurrent headaches. In addition, the school nurses mentioned too little physical activity, sleep problems and poor eating habits as related factors, in particular among students with tension-type headaches. Common management approaches used by the school nurses were to provide information about headaches or supportive discussion, recommend follow-up visits, perform vision tests and refer students to a school physician. About one-fifth to one-third of the school nurses often gave analgesic medication to students because of headaches, most commonly used were paracetamol followed by various NSAIDs. Most of the school nurses regarded relaxation training as an "effective or very effective" treatment for both migraine and tension-type headaches, whereas palliative and prophylactic drug treatments were seen as more effective for migraine. It is suggested that school nurses, who often provide the first line of treatment for school children and adolescents with recurrent headaches, also should administer a cost-effective treatment such as relaxation training in school settings, where many of the headache episodes occur. However, school nurses also need to be properly trained to ensure quality in delivering such treatment approaches.     

The Psychological Treatment of Recurrent Headache in Adolescents Short-Term Outcome and Its Prediction

SYNOPSIS
The results from three separate treatment studies on adolescents (N = 108) aged 16-18 years with predominantly recurrent tension (n = 85), and migraine (n = 23) headaches are presented along with information on predictors of short-term outcome. A standardized therapist-or home-based relaxation training program was compared to attention-control approaches in which information or problem-discussion procedures were provided for the students. These treatment conditions were both contrasted with self-monitoring procedures. All students were assessed and treated in a school setting and may therefore, be regarded as representing a nonclinical replication series. The outcome results indicated that the majority (53%) of students, in particular those with tension headache, had improved after both forms of relaxation training, which were clearly superior to attention-placebo control and self-monitoring contrasts. Furthermore, it was found that treatment condition, baseline headache severity and students' satisfaction with their home life were the strongest predictors of overall outcome, accounting for 32% of the total variance. For students provided with relaxation training, a set of four parameters, again including baseline headache severity, in addition to students' level of somatic symptoms, school satisfaction and disease within their family, emerged as strong predictors of outcome, explaining 44% of the outcome variance. The results are discussed in view of similar outcome and prediction studies in the field of pediatric and adult recurrent headache.     

Follow-up on Behavioral Treatment of Recurrent Headache in Adolescents

A sample of 108 adolescent students suffering from migraine and tension headaches, treated with relaxation training and attention-control approaches, were evaluated at 5-6 month and 3-4 year follow-ups. Data were obtained for 69% (75) of the original subjects at the second follow-up. The treatments administered within a school setting were contrasted with students' self-monitoring of headache. The results indicated that students treated with relaxation training showed a good maintenance of posttreatment headache reduction at the two follow-up evaluations, 80% and 85%, respectively. Although treatment condition and level of pretreatment headache were associated with a favorable outcome at the 5-6 month follow-up, only baseline headache severity emerged as a significant predictor at the final follow-up. Several variables from the psychological functioning and health behavioral domains found to predict posttreatment outcome for the adolescent headache sufferers in previous research, did not contribute significantly to outcome at the follow-ups.     

Multimodal Migraine Treatment: Does Thermal Feedback Add to the Outcome?

SYNOPSIS
This study was carried out to examine the therapeutic necessity of thermal feedback training in a multimodal treatment program for migraine headache. Twenty-one patients with frequent (at least two per month) migraine headaches or combined migraine-tension headaches were randomly assigned to one of two conditions: (1) autogenic relaxation training followed by stress-coping training; (2) the same treatment package supplemented with thermal feedback.
Results indicated the equivalent effectiveness of both treatments in ameliorating headache activity and reducing medication use. These outcomes were stable 7 months after treatment. Between-group comparisons on clinical improvement and on temperature performance with autogenic relaxation, as well as findings from post-treatment interviews, led to the conclusion that thermal feedback training can be excluded without weakening the program's therapeutic efficacy.
In general the results suggest that thermal feedback per sé does not add to the treatment outcomes obtainable with general relaxation training, and that for patients characterized by high achievement-motivation and sensitivity to initial failure a feedback regimen might even be counterproductive. Both findings need further experimental clarification.     

DreKiP – ein ambulantes Therapieprogramm für Kinder und Jugendliche mit Kopfschmerzen

Headaches are a frequent health problem among children and adolescents. The ocurrence of headaches and the resulting impairments in the quality of life and activities of daily living are modulated by biopsychosocial interactions, which necessitate a complex treatment program. The Dresden Childrens Headache Program (DreKiP) is a multidisciplinary therapy program consisting of eight modules for children and adolescents: education, stress relief, relaxation techniques, physical fitness, climbing therapy, art therapy and sensory training. In addition, there are six modules containing parallel workshops for parents. This outpatient program lasts 2–3 months and is performed parallel to the daily and school routine. Therapy groups consist of 6–8 patients in each age group. In total patients receive 15?h and the parents 7?h of therapy. Concomitant with the program, headache-associated data, such as headache frequency, medication use and school absence are documented. So far 32 children and adolescents in groups of 11, 14–15, 14–16, 17 and 17–18 years old completed the program. Of the 32 patients 19 presented with migraine and tension type headache, 6/32 with migraine and 7/32 with tension type headache only. The median number of headache days was 15 per month and 4 official school absence days per month. Preliminary results 6 months after the end of the therapy program showed reduced frequency of headaches in three quarters of our patients. The headache frequency was reduced from an initial median of 15 days per month to a median of 8 days per month after the program. The multidisciplinary program DreKiP improves the use of therapeutic means in children and adolescents with primary headaches. Children and adolescents with headache-related impairment in activities of daily life in school and leisure times constitute the target group of this therapy.     

Childhood headaches: Behavioral assessment and treatment

Many children experience chronic headaches, particularly migraine and tension headaches. These can be quite debilitating for the child and produce much concern from caregivers and health professionals. Following a discussion of pathophysiology and epidemiological findings, we emphasize the need for nonpharmacological interventions for chronic headaches. This review explores advances in the behavioral assessment and treatment of childhood headaches. We outline behavioral assessment procedures, including the behavioral interview, headache questionnaires, self-monitoring, caregiver observations, and psychophysiological recording. Treatment typically encompasses relaxation training, biofeedback, assertion training, and cognitive therapy. Parental involvement is also one emphasized component in behavioral approaches to treatment. Our review suggests that behavioral treatment strategies are effective in the management of childhood headaches, although most of the research support appears limited to relaxation training and biofeedback. Nonetheless, behavioral assessment and treatment of childhood headaches appears to be a promising clinical and research direction.     

Overview of tension-type headache

Tension-type headache (TTH) is the most prevalent form of headache. Although it is not the most severe form of headache, it has a significant impact on society. In spite of this, little is known about its pathophysiology. Current International Headache Society classification has been called into question, and new classification approaches have been suggested. With reference to chronic TTH, the issue of analgesic rebound may confound the diagnosis. Transformed migraine and new persistent daily headaches are clarified and differentiated from chronic TTHs (CTTHs). The best documented abnormality found in TTHs is the presence of pericranial tenderness. It is generally believed that pain is initiated by a peripheral mechanism, most likely increased input from the myofascial nociceptors. In CTTH, there may be an impaired supraspinal modulation of the incoming stimuli. Whether there is an overlap in the continuum between TTH and migraine is controversial. Abortive and prophylactic treatments are discussed and wellness and adjunct therapy are also emphasized. Lastly, special attention is paid to the doctor-patient relationship in patients with difficult headaches.     

Does Relaxation Treatment Have Differential Effects on Migraine and Tension-type Headache in Adolescents?

The present study evaluated the effects of relaxation treatment in 36 adolescents aged 13 to 18 years (mean +/- SD, 15.4 +/- 1.55 years) suffering from migraine or migraine and tension-type headache as compared with a waiting-list condition group. The subjects rated various characteristics of migraine and tension-type headache in a diary. Significant reductions were found for total headache sum (P <.05) and intensity scores of total headache activity (P <.05) as well as for migraine intensity (P <.05) for subjects treated with relaxation as compared with those in the waiting-list condition group. However, no significant differences between the two groups were found for tension-type headache. Fifty percent of the adolescents treated with relaxation training attained a clinically significant improvement, compared with 12% of those in the waiting-list condition. It is suggested that treatment goals for migraine and migraine occurring with tension-type headache might be different and that relaxation training also might benefit from focusing on specific aspects of the two headache types.     

Chronic headaches in adolescents: treatment in a school setting with relaxation training as compared with information-contact and self-registration

An experimental study was conducted on 33 adolescent students with various types of chronic headaches (tension and combined tension and migraine headaches), all treated in a school setting. After a 4-week baseline period during which the subjects rated their headache activity, they were randomly assigned to a 9-session relaxation training programme or to an information-contact condition, both contrasted with an untreated self-registration group. Relaxation therapy alone led to significant improvement in headache activity, particularly in reduction of the frequency of complaints which still was significantly reduced at a 6-month follow-up evaluation. The effects obtained in the information-contact condition were comparable to those in the self-registration group, both achieving only minor improvements after treatment or at the follow-up assessment. The majority of students in the relaxation treatment, however, was much improved, attaining more than 50% reduction in headache activity. The findings in the present study are consistent with results from similar treatment outcome studies, reported on adult populations with chronic headaches, and demonstrate that relaxation training programmes can be of substantial help in a school setting.     

The Efficacy and Cost-effectiveness of Minimal-therapist-contact, Non-drug Treatments of Chronic Migraine and Tension Headache

SYNOPSIS
Two studies, one involving 53 tension headache patients and the other involving 87 vascular (both migraine and combined migraine and tension headaches) headache patients, are presented in which a largely home-based, self-administered non-drug treatment for headache was compared to a comparable clinic-based, therapist-administered treatment regimen. The home-based treatment programs were equal in effectiveness to the clinic-based programs and significantly more cost effective for both types of headache patients.     

Headache Disability Among Adolescents: A Student Population‐Based Study

(Headache 2010;50:210‐218) Objective.— To examine the extent and to identify the relevant predictors of headache disabilities in adolescents. Background.— Headaches are common in adolescents but their impact and related factors have not been extensively studied in adolescent communities. Method.— We recruited and surveyed 3963 students aged 13‐15 from 3 middle schools using self‐administered questionnaires. The questionnaires were used to make 3 assessments: (1) headaches were diagnosed using a validated headache questionnaire; (2) headache disabilities were valuated using the 6‐question Pediatric Migraine Disability Assessment; (3) depression was measured using the Adolescent Depression Inventory. Results.— The student response rate was 93%. In total, 484 students (12.2%) had migraines with or without auras, 444 (11.2%) had probable migraines, and 1092 (27.6%) had tension‐type headaches. The students with migraine had the highest Pediatric Migraine Disability Assessment scores (10.7 ± 20.0); whereas, the students with tension‐type headaches had the lowest scores (2.0 ± 4.4). Logistic regression analyses indicated that there were a number of independent predictors for moderate to severe headache‐related disability (Pediatric Migraine Disability Assessment score ≥31), including a migraine or probable migraine diagnosis, a higher depression score, severe headache intensity, and frequent headaches. Conclusions.— The Pediatric Migraine Disability Assessment provides a simple tool to measure the impact of headaches in adolescents. Adolescents with migraine headaches suffered the greatest level of disability. Higher depression scores were associated with more severe headache‐related disabilities in adolescents, independent of headache frequency and severity.     

Recurrent headache in adolescents: nonreferred versus clinic population

OBJECTIVE: To compare headache activity, psychosocial measures, and cold pressor response between referred and nonreferred adolescents with frequent headache. DESIGN: Thirteen boys and 19 girls with a mean age of 13.4 +/- 0.9 years who had been referred to a hospital-based behavioral treatment program for recurrent headache were compared with an age- and sex-matched school-based population of nonreferred students consisting of 31 adolescents with frequent headaches and 32 adolescents with infrequent or no headaches. All subjects completed the Spielberger State-Trait Anxiety Inventory/Trait form, the Children's Depression Inventory, the Childhood Somatization Inventory, and measures of headache activity and related functional disability. Additionally, all subjects reported interval discomfort scores on a 40-second cold pressor test with arm immersion in a 10 degrees +/- 1 degree C cold water bath. RESULTS: Subjects from both headache groups reported significantly more anxiety than those with infrequent or no headaches. The school-based nonreferred adolescents reported more depressive symptoms than the clinic-based referred subjects. In addition, the latter group reported headaches of longer duration and more school days missed due to headaches than both other groups. Whereas school-based subjects and those with infrequent or no headaches reported relatively low initial cold pressor test scores and gradually reported increasing scores with time, clinic-based subjects rated their discomfort as high at the initial interval report and maintained high levels throughout the test. No differences in somatization were found among groups. CONCLUSION: Although adolescents who seek behavioral treatment for recurrent headache do not report more psychological symptoms than nonreferred adolescents with frequent headaches, they report headaches of longer duration, miss more school days due to headache, and report higher initial sustained discomfort scores to a standardized noxious stimulus.     

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children’s drug-taking should be checked.     

Cognitive and relaxation treatment of paediatric migraine

The present study compared the efficacy of two active treatments, relaxation training and cognitive coping, with a non-specific placebo control in the treatment of 42 children and adolescents with migraine. The first treatment is a simplified version of progressive deep muscle relaxation; the second, a form of cognitive restructuring involving the alteration of dysfunctional thought processes. The results demonstrated that each active treatment was superior to the non-specific intervention in reducing overall headache activity and frequency but not duration or intensity. There were no differences between the experimental groups, and both continued to improve through a 16-week follow-up period, but the control group did not. Initial level of headache severity was an important factor in treatment outcome, with children with severe headaches responding better than those with milder headaches. Possible reasons for the differential treatment effects are discussed, and the implications for future research are considered.     

Psychosocial Functioning in Schoolchildren With Recurrent Headaches

The psychosocial functioning of 113 schoolchildren (8 to 15 years old) reporting headaches at least once a month was compared to a group of headache-free control subjects matched for sex and age. Thirteen percent of the headache sufferers had migraine headaches, 28% had episodic tension-type headaches, 30% had chronic tension-type headaches, and 29% had migraine coexisting with tension-type headaches.
Overall, the headache sufferers experienced more somatic complaints, stress, and psychological symptoms, in addition to being absent from school (due to illness), more often and reported fewer caring persons as compared to headache-free controls. Although few differences between the four headache groups emerged in the children's psychosocial functioning levels, children with migraine coexisting with tension-type headaches had significantly more frequent somatic complaints than those having episodic tension-type headaches. In addition, children with migraine or migraine coexisting with tension-type headaches were more often absent from school than those having tension-type headaches only. A significant but weak relationship between children's headache severity and their somatic complaints was noted.     

Behavioral medicine for migraine and medication overuse headache

Primary headaches, including migraine and medication overuse headache (MOH), can be conceptualized as biobehavioral disorders based on the interaction of biological, psychological, and environmental factors. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of headaches in general, with an emphasis on migraine and MOH from a biopsychosocial perspective. Evidence-based behavioral medicine treatments for migraine and MOH are reviewed, including patient education, cognitive behavioral therapy, and biobehavioral training (biofeedback, relaxation training, and stress management). Information regarding psychological comorbidities and risk factors for progression of migraine and the development of MOH is also reviewed. Strategies are provided for enhancing adherence and motivation, as well as facilitating medical communication.     

Chronic Daily Headache in Children and Adolescents

SYNOPSIS
Recurrent headache is a relatively frequent problem in children and adolescents, with the majority of the research attention focused on pediatric migraine. This study assessed differences in consequences to headaches, coping with headaches, and associated disability in children and adolescents attending a headache clinic who were diagnosed with migraine, chronic daily headache, or carried both diagnoses. Results, generally indicated higher levels of impairment for patient's with chronic daily headaches. These patients were also more likely to use blaming others and wishful thinking as coping mechanisms. Gender and racial status interacted with headache diagnosis to predict parent response patterns and disability outcomes. The results provide initial support for the applicability of Martin's functional model of chronic headaches to a pediatric population.     

Psychosocial impact of headache and comorbidity with other pains among Swedish school adolescents

BACKGROUND: The psychosocial impact of headache combined with other pains has previously been insufficiently investigated. OBJECTIVE: The present study examined the prevalence of headache, its comorbidity with other pains and psychosocial impact among adolescents. METHODS: 793 adolescents in a sample recruited from 8 schools in the middle of Sweden were assessed. RESULTS: Forty-five percent of the adolescents reported ongoing pain during assessment and more than half of the adolescents reported at least one frequent pain during the previous 6 months. The most common pain among girls was headache (42%), but for boys muscle pain (32%) was most prevalent. Number of pains and perceived pain disability were also higher among girls than boys. One-third of the headache sufferers had headache only, while one-third reported one other frequent pain and the others had at least two other frequent pains. Overall, adolescents with frequent headaches had higher levels of anxiety or depressive symptoms, in addition to functional disability and usage of analgesic medication. Frequent headache sufferers reported more problems in everyday life areas than those with infrequent headaches. CONCLUSIONS: It is recommended that adolescents suffering from recurrent headaches routinely should be asked about the presence of other pains, anxiety and depressive symptoms, medication usage, in addition to psychosocial consequences in their everyday life activities. Longitudinal research is also needed to delineate causal relationships between psychosocial factors and recurrent pains, in particular regarding possible sex differences.     

Acute and interictal allodynia in patients with different headache forms: an Italian pilot study

OBJECTIVE: To investigate allodynia in patients with different primary headaches. BACKGROUND: Many migraineurs have allodynia during headache attacks; some may have allodynia outside attacks; allodynia may also be associated with other primary headaches. METHODS: A total of 260 consecutive primary headache patients presenting for the first time at a headache center, and 23 nonheadache controls answered written questions (subsequently repeated verbally) to determine the presence of acute and interictal allodynia. RESULTS: We divided the patients into: episodic migraine (N = 177), subdivided into only migraine without aura (N = 114) and those sometimes or always reporting migraine with aura (N = 63); episodic tension-type headache (N = 28); chronic headaches (headache > or = 15 days/month, N = 52), including chronic migraine, chronic tension-type headache, and medication-overuse headache; and other headache forms (N = 3). Acute allodynia was present in 132 (50.7%), significantly more often in patients sometimes or always suffering migraine with aura, and those with chronic headache forms, compared to patients with migraine without aura and episodic tension-type headache. Interictal allodynia was present in 63 (24.2%) patients, with significantly higher frequency in those having migraine with aura attacks than controls and common migraine patients. CONCLUSIONS: Allodynia is not specific to migraine but is frequent in all headache patients: acute allodynia was reported in half those interviewed and in over a third of patients in each headache category; interictal allodynia was reported by nearly 25%.