Abstract: Pediatric migraine and chronic fatigue

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Headache. 2004 Jun;44(6):627-628. [No authors listed]

Just U, Oelkers R, Bender S, Parzer P, Ebinger F, Weisbrod M, Resch F.

Emotional and behavioral problems in children and adolescents with primary headache. Cephalalgia. 2003;23:206-213.

Psychiatric co-morbidity is an important risk factor for chronification of primary headache into adulthood. The aim of this study was to investigate the extent and clinical relevance of emotional and behavioral problems in children and adolescents with primary headache.

Children and adolescents (n = 128) with primary headache (International Headache Society, codes 1.1, 1.2, 2.1) and 83 matched controls aged 6-18 years were examined by standardized dimensional psychometric tests (Child Behavior Checklist, Depression Inventory for Children and Adolescents, Anxiety Questionnaire for Pupils). Children and adolescents with primary headache suffer more often from internalizing problems (depression, anxiety, and somatization) than healthy controls. The detected emotional and behavioral problems are clinically relevant and require particular therapy in every third child suffering from headache. Two out of three children and adolescents with primary headache do not show clinically relevant psychopathology and may benefit from minimal therapeutic intervention. One of three examined headache patients needs additional psychiatric therapy.

Smith MS, Martin-Herz SP, Womack WM, Marsigan JL.

Comparative study of anxiety, depression, somatization, functional disability, and illness attribution in adolescents with chronic fatigue or migraine. Pediatrics. 2003;111(4 Pt 1):e376-e381.

Objective: To compare adolescents with migraine, unexplained profound chronic fatigue of >6 months duration, and normal school controls on measures of anxiety, depression, somatization, functional disability, and illness attribution.

Methods: Adolescents referred to Children's Hospital and Regional Medical Center for behavioral treatment of migraine (n = 179) or evaluation of chronic fatigue (n = 97) were compared with a group of healthy controls of similar age and sex from a middle school (n = 32). Subjects completed the Spielberger State-Trait Anxiety Inventory-Trait Form, the Children's Depression Inventory, the Childhood Somatization Inventory, and estimated the number of school days missed in the past 6 months because of illness. Migraine and fatigued subjects completed an illness attribution questionnaire.

Results: Subjects in the 3 groups were 56% to 70% female and ranged from 11 to 18 years old with a mean age of 14.0 +/- 2.0. Forty-six of the 97 chronically fatigued adolescents met 1994 Centers for Disease Control and Prevention (CDC) criteria for chronic fatigue syndrome (CDC-CFS), while 51 had idiopathic chronic fatigue syndrome (I-CFS) that did not meet full CDC criteria. Adolescents with migraine had significantly higher anxiety scores than those with I-CFS or controls and higher somatization scores than controls. Adolescents with CDC-CFS had significantly higher anxiety scores than those with I-CFS or controls, and higher depression and somatization scores than all other groups. There were significant differences between all groups for school days missed with CDC-CFS more than I-CFS more than migraine more than controls. Parents of adolescents with unexplained I-CFS had significantly lower attribution scores relating illness to possible psychological or stress factors than parents of adolescents with CDC-CFS or migraine.

Conclusions: Adolescents referred to an academic center for evaluation of unexplained chronic fatigue had greater rates of school absenteeism than adolescents with migraine or healthy controls. Those meeting CDC-CFS criteria had higher anxiety scores than controls and higher depression and somatization scores than migraineurs or controls. Parents of adolescents with I-CFS were less likely to endorse psychological factors as possibly contributing to their symptoms than parents of adolescents with CDC-CFS or migraine.

Comment: I included these two studies because of the comorbidity of migraine, depression, and anxiety. Note that migraine alone was assty. Note that migraine alone was associated with less school absenteeism than in fatigue patients, while teens with fatigue had higher anxiety scores than migraine patients. However, the migraine patients had more “internalizing problems (depression, anxiety, and somatization) than healthy controls,” with one-third meriting psychiatric intervention.

Stewart J. Tepper

Migraine studies in children often have a high-placebo response rate, which makes it difficult to demonstrate the therapeutic benefit or gain for a new therapy over and above placebo. The high prevalence of psychiatric comorbidity may explain the high-placebo response rate and confounding therapeutic benefits of specific therapies such as the triptans which have little or no known direct effects on depression, anxiety or somatization. This is in contrast to the use of SSRIs as prophylactic treatments which have may many nonspecific effects on the serotonerigc systems.

David S. Millson Hershey AD.

Chronic daily headaches in children. Expert Opin Pharmacother. 2003;4:485-491.

Chronic daily headache (CDH) or highly frequent headaches are being recognized as an increasing problem. In adults it is estimated that up to 4% of the population has CDH, however, this number appears to be lower in children. The actual prevalence of CDH in children, however, has not been determined. The simplest definition of CDH is >15 headache days per month. In the international headache society (IHS) criteria, only chronic tension-type headaches and chronic cluster headaches are recognized as CDH. Criteria for CDH have been suggested for adults that mirror the IHS criteria. In children, the majority of CDH appear to be migraine-related. The next revision of the IHS criteria has been proposed to include chronic migraine as one of the CDH. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Treatment and management involves a multitiered approach, which includes abortive therapy when the headache becomes more severe. With the precaution of avoiding overuse of analgesic medication, prophylactic therapy is used to help reduce the characteristics of the headache as well as the frequency and mild behavioral therapy. Comment: What is the prevalence of CDH in children? We do not have the data on this group, unlike the 4% found in the general population in both the studies by Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of Frequent Headache in a Poulation Sample. Headache. 1998;38:497-506 and by Castillo J, Munoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache. 1999;38:190-196. Stewart J. Tepper PMID: 15186313 [PubMed – as supplied by publisher]