Psychosocial factors in children and adolescents with migraine and tension-type headache: a controlled study and review of the literature

We investigated 341 children and adolescents to evaluate the relevance of psychosocial factors in idiopathic headache. According to the criteria of the International Headache Society, 151 subjects had migraine and 94 had tension-type headache (TTH). Ninety-six subjects were headache-free controls. Psychosocial factors covered family and housing conditions, school problems, relations in the peer group, and several other items. We found that migraine patients did not differ from headache-free controls. Patients with TTH more often had divorced parents than the headache-free controls, and they had fewer peer relations than migraineurs and controls. In addition, migraine patients were significantly more often absent from school due to headache. All other psychosocial factors failed to discriminate between the three study groups. In conclusion, this controlled study in children and adolescents suggests that migraine is not related to family and housing conditions, school situation, or peer relations, whereas TTH is associated with a higher rate of divorced parents and fewer peer relations.     

Migrainous disorder and headache of the tension-type not fulfilling the criteria: a follow-up study in children and adolescents

In this follow-up study in children and adolescents with recurrent headaches classified as migrainous disorder (IHS 1.7) and headache of the tension-type not fulfilling the criteria (IHS 2.3), 28.6% were headache-free and 71.4% still had headaches 2-5 years after the first examination. The majority remained in the same one-digit IHS diagnosis, whereas 20% changed from migraine to tension-type headache or vice versa. The number of IHS criteria fulfilled increased significantly from the first to the second examination. The reason for diagnosing IHS 1.7 and IHS 2.3 most often was a short headache duration or headache characteristics not meeting the criteria. By reducing the minimum headache duration to 1 h, 11 of 58 patients could be diagnosed as migraine without aura. There was a remarkable overlap in the diagnostic criteria for migraine without aura and tension-type headache. In IHS 1.7 and IHS 2.3 this overlap exceeded 80%, with a trend to decrease at the second examination.     

Headache in schoolchildren: association with other pain, family history and psychosocial factors

Limited information exist about associations between different headache types and other pains, family history of pain, and psychosocial factors among children from the general population suffering from less severe headache. We interviewed 130 schoolchildren together with a parent to find out whether such factors differ between children with mainly infrequent and moderate migraine or tension-type headache as compared to those without primary headache. Children with headache, especially those with migraine reported other pains and physical symptoms more frequently than children without primary headache. Coherently, parents of children suffering from migraine reported their children to have significantly more somatic symptoms than parents of children without primary headache. In addition, first-degree relatives of children with headache suffered from more migraine, other pains, and physical symptoms compared with first-degree relatives of children without primary headache. Children with migraine visited the school nurse, used medication and were absent from school because of headache more often than those with tension-type headache. Few other differences in psychosocial factors were found between the three groups. Migraine among first-degree relatives and the total sum of physical symptoms in children were the strongest predictors of headache in logistic regression analysis. It is concluded that in schoolchildren with mainly infrequent and moderate headache, pain and physical symptoms cluster within individuals as well as their families, however, psychological and social problems are uncommon.     

The burden of illness associated with headache disorders among young adults in a representative cohort study

This study investigated the functional impairment (work and social functioning and general health status) associated with migraine and tension-type headache (TTH) among young adult members of the Dunedin Multidisciplinary Health and Development Study. Using criteria based on the International Headache Society classificatory system, the 1-year prevalence for migraine headache was 7.4%, TTH was 11.1%, and combined headache (coexisting migraine and TTH) was 4.3%. All comparisons were against a health control group (headache free) and a diagnostic control group (individuals without headache currently using medication for asthma). Although those suffering from migraine and combined headache had the most severe impairment in work- and social-related activities, those with TTH reported significantly poorer social and mental health functioning and poorer emotional and physical functioning while performing everyday roles than did headache-free controls. Study members with combined headache had the poorest self-reported health, with significantly lower ratings on physical, vitality, and mental health measures than asthmatics currently using medication. The pervasive impairment reported across multiple life domains among young headache sufferers illustrates the significant burden of illness associated with headache disorders.     

The prevalence of migraine and tension-type headaches among adolescents in Norway. The Nord-Trøndelag Health Study (Head-HUNT-Youth), a large population-based epidemiological study

The aim of this study was to examine the prevalence of headache and primary headache disorders like migraine and tension-type headaches among adolescents, and to explore the differences in headache prevalence and frequency by gender and age. This cross-sectional study was conducted in Nord-Tr?ndelag county, Norway, during the years 1995-97. In total, 8984 (88%) out of 10 202 invited adolescents aged 12-19 years participated in the youth part of the Nord-Tr?ndelag Health Study [Helseunders?kelsen i Nord-Tr?ndelag (HUNT)]. The total study population in this study consisted of 8255 individuals after exclusion of invalid questionnaires and students outside the target range of 13-18 years of age. The students completed a comprehensive questionnaire, and one of the questions was whether the students had experienced any headaches during the last 12 months. In addition, 5847 of these students were also subject to an interview in which they were asked whether they had experienced recurring headaches during the last year and, if so, were they classified as migraine (MI), tension-type headache (TTH) or non-classifiable headache. In the total questionnaire-based population, 76.8% reported having had headaches during the last 12 months (69.4% boys and 84.2% girls). Among those who also were interviewed, 29.1% reported having recurrent headaches (21.0% boys and 36.5% girls). The overall 1-year prevalence of migraine was 7%, of tension-type headache 18%, and of non-classifiable headache 4.8%. Higher prevalence rates were found for girls in all age groups and for all headache categories. The overall frequency of recurrent headaches did not vary significantly with age, but girls had significantly more frequent headaches than boys. We concluded that headache in general, and recurrent primary headache disorders like migraine and tension-type headaches, are common somatic complaints among Norwegian adolescents, especially among girls.     

Determinants of tension-type headache in children

The objective of this study was to study the prevalence, characteristics and predisposing factors of tension-type headache in children. An unselected population-based questionnaire study was carried out in 1409 Finnish schoolchildren aged 12 years. Of them, 1135 (81%) returned an acceptably completed questionnaire. The prevalence of episodic tension-type headache in children was 12% (138 of 1135). Children with episodic tension-type headache also often reported characteristics of pain typical for migraine. Children with frequent and persistent episodic tension-type headache reported stabbing and severe occipital pain, phonophobia and abdominal pain significantly more often than children with infrequent episodic tension-type headache. Neck-shoulder symptoms, symptoms of depression and oromandibular dysfunction were each independently associated with episodic tension-type headache. The father's occupation of a lower-level white-collar worker put the child at a four-fold risk for episodic tension-type headache. We conclude that episodic tension-type headache is as common as migraine in children. It can be associated with depression, oromandibular dysfunction and muscular stress. Especially children with frequent and persistent episodic tension-type headache report characteristics of pain typical for migraine.     

Outcome of juvenile headache in outpatients attending 23 Italian headache clinics. Italian Collaborative Study Group on Juvenile Headache (Società Italiana Neuropsichiatria Infantile [SINPI])

A multicenter 3-year follow-up study was carried out on young patients with headache referred to tertiary headache centers or pediatric clinics. Three years after the first examination in 1993, 442 (of an original sample of 719) young outpatients with headache (226 females and 216 males) were re-examined. The diagnostic criteria of the International Headache Society (IHS) and those modified for migraine without aura by Winner et al were applied at both the baseline evaluation and the 3-year re-examination. At the follow-up, 290 children still had headache, 101 were in clinical remission, and 51 had dropped out. Using the current diagnostic criteria, only 46.2% of patients having migraine without aura, 50% of those having migraine with aura, and 35.3% of those suffering from migraine disorders which do not fulfill IHS criteria for migraine received the same diagnosis at the time of follow-up. The percentage of patients receiving a diagnosis of migraine without aura rose significantly when new modified criteria were used (60.5%), whereas a drop in the frequency of migraine disorders not fulfilling IHS criteria was observed at follow-up, both in patients with the diagnosis of migraine without aura at the first examination (4.6%) and in patients with migraine not always fulfilling IHS criteria at the first examination (6.2%). Among all patients who received this latter diagnosis at the first examination, it was possible to make a diagnosis of migraine with aura at the follow-up in 8.8% of cases and that of migraine without aura in 26.5%. No significant variations in the frequency of either episodic tension-type headache or chronic tension-type headache were found, with the exception of a slight decrease in the percentage of tension-type headache which did not fulfill IHS criteria, but the difference between the first examination and the follow-up values does not reach the level of statistical significance (5% versus 12%). As far as the evolution of migraine is concerned, 17.4% of patients with migraine were headache-free at the 3-year follow-up. In tension-type headache, the percentage of patients who were headache-free was particularly high in those with the episodic form (32.9%) and in those suffering from tension-type headache not fulfilling IHS criteria (29.1%). The majority of patients who had been diagnosed as having unclassifiable headache at the first examination received a correct diagnosis at the follow-up with the exception of one patient. As observed in adult patients, variations in the headache characteristics were also observed in children and adolescents (that is, migraine with aura can change to migraine without aura, or the latter can transform into episodic tension-type headache or chronic tension-type headache can change into the episodic form). This follow-up study was aimed at reaching a better understanding of headache disturbances in children and adolescents, examining, in particular, variations of headache with time in this stage of life.     

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%.     

Lifetime prevalence and characteristics of recurrent primary headaches in a population-based sample of Swedish twins

OBJECTIVE: To examine the lifetime prevalence and other characteristics of recurrent primary headaches in twins. BACKGROUND: The twin model may provide insights into the role of genetic and environmental influences in headache disorders. However, assumptions as to whether twins are representative of the general population, and whether monozygotic and dizygotic twins are similar have rarely been addressed. METHODS: The study population consisted of a random sample of 17- to 82-year-old twins from the Swedish Twin Registry (n = 1329). Structured interviews on the telephone by lay personnel and the International Headache Society criteria were used for assessment and diagnosis of recurrent primary headaches. Prevalence data of the general population for migraine and tension-type headache was obtained from various published reports. RESULTS: A total of 372 subjects (29%) had ever had recurrent headaches. In total, 241 recurrent headache sufferers fulfilled the criteria for migraine or tension-type headache, and the lifetime prevalence was 7.1% for migraine without aura, 1.4% for migraine always with aura, 1.9% for migraine occasionally with aura, 9.4% for episodic tension-type headache, and 1.3% for chronic tension-type headache. The lifetime prevalence of all migraine and all tension-type headache, including another 84 subjects fulfilling all but one of the criteria for migraine or tension-type headache, was 13.8% and 13.5%, respectively. The corresponding prevalence risk for women was 2.4 (95% confidence interval [CI] 1.7, 3.4) and 1.5 (95% CI 1.1, 2.1), respectively. Zygosity was not a significant predictor for migraine. In tension-type headache, the prevalence risk for dizygotic twins and unlike-sexed twins as compared with monozygotic twins was 1.9 (95% CI: 1.2, 3.1) and 1.8 (95% CI: 1.1, 2.9), respectively. CONCLUSION: There is no twin-singleton or monozygotic-dizygotic difference for the risk of migraine. In tension-type headache, twins seem to have a lower risk than singletons, and this is especially true for monozygotic twins.     

Osmophobia in juvenile primary headaches

This study was planned to investigate the prevalence of osmophobia in juvenile headache sufferers and to analyse the diagnostic utility of osmophobia in order to distinguish migraine without aura from episodic tension-type headache. We examined 305 consecutive patients presenting at our Paediatric Headache Centre. A semistructured questionnaire was given to 275 selected patients affected by migraine or tension-type headache. The prevalence of osmophobia during attacks was 18.5%, mainly in migraine patients (25.1%) vs. those with tension-type headache (8.3%). Osmophobia showed more specificity than phonophobia or photophobia in the differential diagnosis between migraine and tension-type headache. In conclusion, this study demonstrates that osmophobia resulted in a symptom with poor sensitivity (27.1%) but high specificity (92%) that could become a supportive diagnostic criterion even in children for the differential diagnosis between migraine without aura and tension-type headache.     

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.     

Consulting behaviour in migraine and tension-type headache sufferers: a population survey in Santiago, Chile

Migraine and tension-type headaches are the most frequent types of headaches in Santiago. The purpose of this paper is to describe the patterns of health care utilization in migraine and compare them with tension-type headache sufferers in a community-based study of the prevalence of headache in Santiago, Chile. A two-step questionnaire was administered to an age- and gender-representative sample of 1540 eligible subjects who were aged 15 years or older. Of these, 1385 (89.9%) responded. Cases were defined according to the most frequent type of headache experienced in the last year. Migraine and tension-type headaches were diagnosed according to a questionnaire-based algorithm constructed using the IHS criteria. Consultation rates in migraneurs were significantly (P < 0.01) higher (63%) than in tension-type headache suffers (39%). Migraneurs were more likely to be female, younger and less educated, and had more severe attacks than those with tension-type headache. Female sex, younger age, fewer years of education in migraneurs and younger age and moderate or severe headache in tension-type headache sufferers were found to be independently associated with the likelihood of ever consulting, respectively. Migraneurs are more likely to consult than tension-type headache suffers in this population.     

Outcome of early school-age migraine

We studied the outcome of migraine from early school-age to prepuberty in a group of 84 children. The children belonged to a population-based, unselected follow-up sample of a 1-year age cohort. At the age of 8 to 9 years, 95 (2.7%) children of this age cohort had migraine according to a postal questionnaire. At age 11 to 12 years, 84 of them were traced and interviewed face-to-face. Only four (4.8%) of these children no longer had headache. Fifty-three (63.1%) children had migraine. Seventeen (20.2%) had migraine-type headache which did not completely fulfil the International Headache Society criteria for migraine, seven (8.3%) children had episodic tension-type headache and three (3.6%) had other headache. Among the children who had migraine at age 11 to 12, boys had significantly more frequent migraine attacks than girls (mean 2.7/month versus 1.8/month; p =0.016). They also used more drugs and were more frequently absent from school because of headache than girls, but these differences were not significant. Problems in the relationships between parents seemed to be another factor associated with frequent migraine.     

Prevalence of frequent headache in a population sample

PURPOSE: Patients with daily or near-daily headaches are commonly seen in neurology practices and in headache subspecialty centers, but there is little information on the prevalence of this condition in the general population. We present the first US-based study describing the prevalence and characteristics of frequent headache in the general population. METHODS: In Baltimore County, Maryland, 13 343 individuals 18 to 65 years of age were selected by random-digit dialing and interviewed by telephone about their headaches. Subjects reporting 180 or more headaches per year were classified as having frequent headache. Three mutually exclusive subtypes of frequent headache were identified: frequent headache with migrainous features, chronic tension-type headache, and unclassified frequent headache. RESULTS: The overall prevalence of frequent headache was 4.1% (5.0% female, 2.8% male; 1.8:1 female to male ratio). Frequent headache was 33% more common in Caucasians (4.4%) than in African Americans (3.3%). In both males and females, prevalence was highest in the lowest educational category. Among frequent headache sufferers, more than half (52% female, 56% male) met criteria for chronic tension-type headache, almost one third (33% female, 25% male) met criteria for frequent headache with migrainous features, and the remainder (15% female, 19% male) were unclassified. Overall, 30% of female and 25% of male frequent headache sufferers met International Headache Society (IHS) criteria for migraine (with or without aura). CONCLUSIONS: Frequent headache is common in the general population and is more prevalent in Caucasians and in those with less than a high school education. Chronic tension-type headache is more common than frequent headache with migrainous features, though the latter is more disabling. Although more common in females than males, the female preponderance of frequent headache is less marked than in migraine. The sex ratio varies by frequent headache subtype.     

Transcranial Doppler ultrasonic features in episodic tension-type headache

In a pilot study we used transcranial Doppler ultrasound (TCD) to measure cerebral blood flow velocities in 21 headache-free episodic tension-type headache sufferers and in the same number of age- and sex-matched control subjects. We found increased blood flow velocities in the anterior, middle and posterior cerebral arteries and a decreased pulsality index in the middle and posterior cerebral arteries in tension-type headache sufferers compared to controls. Vascular bruits were significantly more frequent in the basal cerebral arteries of the patients compared to controls. There were no significant asymmetries of blood flow velocities in corresponding arteries. The findings suggest a multifactorial pathogenesis in episodic tension-type headache including vascular abnormalities.     

Frequent migraine and migraine status without tension-type headaches: an unusual presentation of rebound headaches

Rebound headaches usually present as daily or almost daily, prolonged, generalized tension-type headaches with superimposed migraine-like attacks. The latter are more frequent, more intense, and longer than any episodic migraine that the patient might have experienced prior to the development of the chronic daily headaches. Rebound presenting as migraine without tension-type pain has been mentioned in a few previous articles on chronic daily headache, but there have been no previous articles stressing that frequent migraine might relate to the analgesics that are being used. These case histories are presented to illustrate that frequent migraine and migraine status without tension-type headaches may be manifestations of rebound and improve when the offending analgesic agents are stopped. If the clinician fails to recognize this unusual presentation of rebound headache, the patient might be placed on unnecessary and often ineffective medications for prophylaxis instead of stopping the offending pain relief medications.     

Specificity and Sensitivity of Temporalis ES2 Measurements in the Diagnosis of Chronic Primary Headaches

We have evaluated the specificity and sensitivity of temporalis ES2 measurements for the diagnosis of primary headaches. Ninety-four outpatients diagnosed according to IHS criteria were prospectively included: 25 had chronic tension-type headache (code 2.2.), 15 episodic tension-type headache (code 2.1.), 20 migraine without aura (code 1.1.) and 34 chronic daily headaches with daily analgesics/ergotamine abuse (code 8.2.). In chronic tension-type, the sensitivity of the ES2 test was 84% at the 0.1 and the 0.5 Hz, but only 56% at the 2Hz stimulation rates. Its specificity was 100% at 0.1Hz, 90% at 0.5Hz and 95% at 2Hz compared to migraine; positive predictive values were at similar levels. Sensitivity of ES2 at 0.1 Hz was 67% in episodic tension-type headache, but its positive predictive value versus migraine was excellent. Comparing chronic tension-type headache and analgesic abusers, the specificity and positive predictive value of the ES2 test for diagnosing chronic tension-type headache were less satisfactory (60%) while the negative predictive values, however, remained good (83% at 0.1Hz).
The results confirm that the temporalis ES2 test has a higher diagnostic sensitivity in chronic and episodic tension-type headache, but that it has a high negative predictive value for both types of tension-type headache compared to other primary headaches. For diagnostic purposes, the 0.1Hz stimulation rate seems optimal. The 2Hz stimulation rate is the least sensitive, although it may induce total disappearance of ES2 in up to 40% of patients. ES2 is of limited usefulness for separating chronic tension-type headache and chronic drug-abuse headache, possibly because the latter group comprises both tension-type headache and migraine patients.     

Electromyographic biofeedback-assisted relaxation training in juvenile episodic tension-type headache: clinical outcome at three-year follow-up

Although tension-type headaches are more common than migraine in children and adolescents, the limited studies that have been conducted with juveniles have focused chiefly on migraine treatment and its course. This report describes the clinical benefits for an electromyographic biofeedback-assisted relaxation treatment program for a group of children and adolescents experiencing episodic tension-type headache and examines whether the clinical presentation changed for headaches that remained. Of the 54 consecutive juveniles who began treatment, 38 completed and were available to participate in the 3-year follow-up. Headaches improved measurably immediately following treatment, with further gains being evident through 3 years. The few headaches that did occur at 3 years were nearly identical symptom-for-symptom to those that were experienced prior to treatment. This report suggests that behavioural treatment is a viable and durable intervention for juvenile episodic tension-type headache, but more definitive claims cannot be made due to the uncontrolled nature of the study. Further investigation is warranted.     

Overlap of migraine and tension-type headache in the International Headache Society classification

Using questionnaire data from two recent surveys, headache sufferers were classified as having either migraine, episodic, or chronic tension-type headache using the International Headache Society criteria. Of 410 subjects with a headache history of 2 years or more, 147 or 35.9% were assigned Code 1.7 (migrainous disorder not fulfilling the above criteria) or Code 2.3 (headache of the tension-type not fulfilling above criteria). In 79 of these 147 subjects (53.7%), either of the above codes would have been equally valid. Separate scores for "migraine" and "tension" symptoms may provide a way to handle this overlap and aid in choosing optimal therapy.