Behavioral and emotional symptoms and primary headaches in children: A population-based study

Abstract

Objective:

To investigate behavioral and emotional symptoms in a community-based sample of children as a function of headache status and of headache frequency.

Methods:

Our sample consisted of 1,856 children (5–11 years). Primary headaches were assessed using a validated headache questionnaire. Emotional symptoms were assessed by the Child Behavior Checklist (CBCL). CBCL scores were modeled as a function of headache status after adjustments for demographics and headache frequency.

Results:

Relative to controls, children with migraine were significantly more likely to have abnormalities in the following CBCL domains: somatic, anxiety-depressive, social, attention, internalizing and total score. Children with tension-type headache (TTH) were significantly different from controls in the same domains but at a lower rate than migraine. In children with migraine, impairments significantly varied as a function of headache frequency, race, and income. In children with TTH, gender, age, and headache frequency were significantly associated with abnormal scores.

Conclusions:

Migraine and TTH are significantly associated with behavioral symptoms in several domains, and headache frequency affects the association. Internalizing symptoms are common in children with headaches, while externalizing symptoms (e.g. rule-breaking and aggressivity) are not significantly more common than in controls.

Keywords

Headache migraine tension-type headache psychiatric comorbidity children epidemiology

Introduction

Primary headaches are common in the pediatric population (1). When the International Headache Society criteria are strictly followed, prevalence of migraine in children ranges from 3.3% to 21.4%, increasing from early childhood to adolescence (1). The burden of pediatric headaches is best characterized for migraine, which impacts the child's quality of life and (2) school attendance (3), and sometimes disrupt the family (4). The impact associated with migraine seems to be influenced by several factors, including severity of pain and of associated symptoms, frequency of pain, anticipatory anxiety and adequacy of treatment (5,6).

Several conditions are comorbid with migraine (7,8). Comorbidities can alter the clinical course of diseases by affecting time to detection, prognosis, therapeutic selection and post-therapeutic outcomes (9). Nonetheless, the influence of established comorbidities or of psychological symptoms on the burden of primary headaches remains poorly studied in children. Clinical (10–13) and populational studies (14,15) suggest that, relative to children without headaches, those with migraine are more likely to have somatic, anxiety and depressive symptoms. Limited findings also suggest that pediatric migraine is associated with impaired attention span (15) and hyperactivity-impulsivity (16), but not with fully developed attention deficit and hyperactivity disorder (ADHD) (16). The subject is less studied for the other primary headaches.

Although the association between primary headaches and behavioral symptoms is well studied, significant gaps exist. First, most studies focused on migraine or tension-type headache (TTH) in isolation, and contrasts between migraine and TTH are less common. Second, most studies either excluded probable diagnosis (probable migraine or probable TTH) or pooled probable diagnoses together with full diagnoses. Third, studies assessed symptoms as a function of presence or absence of specific headache diagnoses without accounting for headache frequency, and this is a major data gap, since chronic pain is per se associated with psychological symptoms (17). Accordingly, herein we investigated behavior and emotional symptoms as a function of headache status and of headache frequency in children.

Methods

Overview

This study was conducted as part of a large ongoing population study aiming to investigate mental health and headaches in children and adolescents (Attention-Brazil Project) (18). We targeted all children from 5 to 12 years of age registered in the public school system of a city (Santa Cruz das Palmeiras, São Paulo) in the year 2009. Mothers/caregivers and teachers were directly interviewed. Children from both urban and rural areas were assessed, as long as they were enrolled in the school system (which is mandatory). Consent forms and analyzable data (complete demographic, mental health and headache information) were obtained from 1856 children (92.5%). The very high participation rate is explained by the active engagement of the city authorities in raising awareness about the study (see below).

Study flow

During the planning period for the 2009 school year (month of February), all teachers in the public school system were trained by one of us (MAA). They were given information about the study and educated about how to teach the parents to complete the headache questionnaire (see below). This was seen as a mandatory step, since many mothers had little or no formal education. The teachers received information on how to explain specific questions in lay terms and received a glossary of lay definitions. They were trained about being neutral and non-judgmental. Parents were then invited to attend a meeting at school (during the first week of the school year) and, under the supervision of the teachers, completed the questionnaire. Meanwhile, children remained with monitors, practicing physical activities.

Questionnaires

Mothers were requested to complete the questionnaire on demographic, mental health and headache information about the children, as well as headache information about themselves.

Headache diagnosis

The headache module of the questionnaire consisted of 14 questions assessing the distinguishing features required for headache diagnosis in the children according to the classification criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) (19). The headache module is the validated Portuguese version (19) of the questionnaire used in the American Migraine Prevalence and Prevention Studies (20), which has been extensively used in the adult and pediatric population (16,21,22), although not for children younger than 10 years of age (see discussion regarding limitations). The logic used to assign a diagnosis followed two basic rules: (1) a full diagnosis (migraine and TTH) trumped a probable diagnosis (probable migraine and probable TTH) and (2) only one diagnosis was assigned (since questions were asked about the most severe headache type only). Accordingly, TTH refers to children endorsing TTH but not migraine criteria. “No headaches” refers to children without primary headaches (23).

The following primary headaches of interest were considered: migraine overall (migraine with and without aura plus probable migraine plus chronic migraine), episodic migraine (episodic migraine with and without aura), TTH overall (frequent and infrequent episodic TTH plus probable TTH plus chronic TTH) and episodic TTH (frequent and infrequent episodic TTH).

Behavior and emotional symptoms

The Child Behavior Checklist (CBCL) was developed for the assessment of competencies and psychopathological symptoms in children (20). The CBCL has been translated into more than 60 languages and has been validated in numerous cross-cultural studies (21).

The validated Brazilian version of the CCCL (CBCL/4–18) (22) was applied. The competency score of the CBCL consists of 20 questions concerning school achievement, social and activity scores. From these three scales, a total competency score is obtained. The behavior and emotional symptoms score consists of 112 questions focusing on the previous six months, which determine eight symptom scales: “Withdrawn,” “Somatic complaints,” “Anxious/Depressed,” “Social problems,” “Thought problems,” “Attention problems,” “Rule-breaking behavior” and “Aggressive behavior.” A ninth scale focusing on “Sexual problems” was not included. Two composite scales, Internalizing and Externalizing, were determined. The Internalizing scale comprises the “Withdrawn,” “Somatic complaints” and “Anxious/Depressed” scales. The Externalizing scale is composed by the “Rule-breaking” and “Aggressive” behaviors scales. The sum of scores of all scales defines the Total Problem Score. For each scale, cut-scores establish “clinically relevant” symptoms. The cut-scores were determined in the validation process of the CBCL by age and gender, and were adopted by us as recommended in the CBCL manual. For the Total Problem Score, the cut-score is 70 (20).

Analyses

Race and income were categorized according to the definitions proposed by the Brazilian Institute of Geography and Statistics (IBGE), which are adopted by the National Census. Race was dichotomized into white and non-white, which included black and brown. The five income classes were defined based on total family income, and do not reflect quintiles. They are 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. Classes A and B represent the upper economic classes, D and E describe different levels of poverty, and C is the middle class.

The sample was stratified by age, gender, race, income class and headache status, and 95% confidence intervals (CIs) compared specific categories (e.g. age categories or race) with the reference category. Relative risks (RR) was used to contrast children with migraine and TTH relative to controls on the different CBCL scales. The overall CBCL score and the scores for the individual scales were dichotomized (normal or abnormal, based on the pre-defined CBCL cut-off). They were independently modeled in binary logistic regression as a function of headache status, adjusted by age, gender, race and income. A second model also included headache frequency, categorized as low frequency (1–4 headache days per month), intermediate frequency (5–9) and high frequency (10 or more), as per previous studies (23). The headache questionnaire asked about headache frequency using the same categories (not as a continuous variable).

The level of significance adopted was p < 0.05. 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 the Human Research Committee (São José do Rio Preto Medical School, São Paulo, Brazil). Written informed consent was obtained from the mothers.

Results

Overview

Table 1 displays the demographics of the participating sample and also of those without complete data. Around 52% of respondents were boys and most were from the middle class (income class C). Participation rates were very high for all the categories, although they decreased as a function of decreased family income.

Table 1.

Demographic of the sample and response rates.

	Respondents		Non-respondents		Response rate
Age	N	%	N	%	%
5	90	4.8	13	8.6	87.4
6	350	18.9	18	11.9	95.1
7	310	16.7	39	25.8	88.8
8	370	19.9	33	21.9	91.8
9	465	25.1	27	17.9	94.5
10+	271	14.6	21	13.9	92.8
Gender
Girls	897	48.3	65	43.0	93.2
Boys	959	51.7	86	57.0	91.8
Race
White	1082	58.3	64	42.4	94.4
Non-white	699	37.7	62	41.1	91.9
Not stated	75	4.0	25	16.6	75.0
Income class
A, B	329	17.7	16	10.6	95.4
C	976	52.6	56	37.1	94.6
D, E	551	29.7	79	52.3	87.5
Total	1856		151		92.5

Prevalence of headaches

Detailed description of headache prevalence has been described elsewhere (24) and is summarized in Table 2 since the information is of relevance for this study. Among participating children, 18.6% had no headache (Table 2). Episodic migraine occurred in 6.4%. Any migraine occurred in 23% (17.3% under the age of six and 27.6% in children older than nine years old). TTH overall occurred in 28.9% of the sample, while episodic TTH was the diagnosis of 5.1%. Most TTH cases endorsed probable TTH diagnosis.

Table 2.

Prevalence of headache, migraine and tension-type headache by age, gender, race and income.

	No headache			Migraine overall^a			Episodic migraine			TTH overall^b			Episodic TTH
Age	N	%	RR (95% CI)	N	%	RR (95% CI)	N	%	RR (95% CI)	N	%	RR (95% CI)	N	%	RR (95% CI)
5, 6	109	24.8	Reference	76	17.3	Reference	14	3.2	Reference	114	25.9	Reference	18	4.1	Reference
7, 8	127	18.7	0.7 (0.6–0.9)	148	21.8	1.3 (1.0–1.6)	42	6.2	1.9 (1.1–3.5)	196	28.8	1.1 (0.9–1.4)	34	5.0	1.2 (0.7–2.1)
9, 10+	109	14.8	0.6 (0.5–0.8)	203	27.6	1.6 (1.3–2.0)	62	8.4	2.6 (1.5–4.7)	227	30.8	1.2 (1.0–1.4)	43	5.8	1.4 (0.8–2.4)
Gender
Female	159	17.7	Reference	213	23.7	Reference	55	6.1	Reference	264	29.4	Reference	51	5.7	Reference
Male	186	19.4	1.1 (0.9–1.3)	214	22.3	0.9 (0.8–1.1)	63	6.6	1.1 (0.7–1.5)	273	28.5	1.0 (0.8–1.1)	44	4.6	0.8 (0.5–1.2)
Race
White	201	18.6	Reference	241	22.3	Reference	65	6.0	Reference	335	31.0	Reference	62	5.7	Reference
Non-white	126	18.0	1.0 (0.8–1.2)	172	24.6	1.1 (0.9–1.3)	51	7.3	1.2 (0.8–1.7)	183	26.2	0.8 (0.7–1.0)	28	4.0	0.7 (0.4–1.1)
Not stated	18	24.0	1.3 (0.8–2.0)	14	18.7	0.8 (0.5–1.4)	2	2.7	0.4 (0.1–1.8)	19	25.3	0.8 (0.5–1.2)	5	6.7	1.2 (0.5–2.8)
Income
A, B	49	14.9	Reference	72	21.9	Reference	13	3.9	Reference	92	28.0	Reference	15	4.6	Reference
C	178	18.2	1.2 (0.9–1.6)	229	23.5	1.1 (0.8–1.3)	66	6.8	1.7 (1.0–3.1)	301	30.8	1.1 (0.9–1.3)	61	6.2	1.4 (0.8–2.4)
D,E	118	21.4	1.4 (1.1–1.9)	126	22.9	1.0 (0.8–1.3)	39	7.1	1.8 (1.0–3.3)	144	26.1	0.9 (0.7–1.2)	19	3.4	0.8 (0.4–1.5)
Total	345	18.6		427	23.0		118	6.4		537	28.9		95	5.1

Migraine overall: migraine with and without aura plus probable migraine (all features required for diagnosis but one) plus chronic migraine.

TTH overall: infrequent and frequent TTH plus probable TTH (all features required for diagnosis but one) plus chronic TTH.

CI: confidence interval; TTH: tension-type headache; RR: response rate.

Behavior and emotional symptoms as a function of headache diagnosis

Table 3 displays the prevalence of abnormal scores in different domains of the CBCL as a function of headache status. As contrasted to controls (no headache), children with migraine overall were more likely to have symptoms on the following domains (RR and CIs are displayed in the table only for ease of reading): somatic (21.8% vs. 2.9%, p < 0.001), anxious-depressed (15.0% vs. 3.5%, p < 0.01), social (9.4% vs. 5.2%, p < 0.05), attention (17.1% vs. 6.4% p < 0.01), internalizing (51.3% vs. 19.1%, p < 0.001) and total score (32.8% vs. 14.5%, p < 0.01). Relative to controls, children with episodic migraine had significant differences in the same domains: somatic (26.3% vs. 2.9, p < 0.01), anxious-depressed (20.3% vs. 3.5%, p < 0.01), social (11.9% vs. 5.2%, p < 0.05), attention (17.8% vs. 6.4%, p < 0.05), internalizing (56.8% vs. 19.1%, p < 0.01)) and total score (36.4% vs. 14.5%, p < 0.05).

Table 3.

Prevalence of clinical impairment in different CBCL symptoms scales between children with migraine, TTH and controls.

	No headache		Migraine overall^a			Episodic migraine			TTH overall^b			Episodic TTH
	N	%	N	%	RR (95% CI)	N	%	RR (95% CI)	N	%	RR (95% CI)	N	%	RR (95% CI)
Withdrawn	22	6.4	29	6.8	1.1 (0.6–1.8)	6	5.1	0.8 (0.3–1.9)	40	7.4	1.2 (0.7–1.9)	7	7.4	1.2 (0.5–2.6)
Somatic	10	2.9	93	21.8	7.5 (4.0–14.2)	31	26.3	9.1 (4.6–18.0)	47	8.8	3.0 (1.5–5.9)	10	10.5	3.6 (1.6–8.5)
Anxious-depressed	12	3.5	64	15.0	4.3 (2.4–7.8)	24	20.3	5.8 (3.0–11.3)	40	7.4	2.1 (1.1–4.0)	10	10.5	3.0 (1.4–6.8)
Social	18	5.2	40	9.4	1.8 (1.0–3.1)	14	11.9	2.3 (1.2–4.4)	36	6.7	1.3 (0.7–2.2)	9	9.5	1.8 (0.8–3.9)
Thought	9	2.6	16	3.7	1.4 (0.6–3.2)	3	2.5	1.0 (0.3–3.5)	25	4.7	1.7 (0.8–3.8)	2	2.1	0.8 (0.2–3.7)
Attention	22	6.4	73	17.1	2.6 (1.7–4.2)	21	17.8	2.8 (1.6–4.9)	55	10.2	1.6 (1.0–2.6)	14	14.7	2.3 (1.2–4.3)
Rule-breaking	17	4.9	29	6.8	1.4 (0.8–2.5)	6	5.1	1.0 (0.4–2.6)	28	5.2	1.1 (0.6–1.9)	3	3.2	0.6 (0.2–2.1)
Aggressive	12	3.5	15	3.5	1.0 (0.5–2.1)	2	1.7	0.5 (0.1–2.1)	23	4.3	1.2 (0.6–2.4)	4	4.2	1.2 (0.4–3.7)
Internalizing	66	19.1	219	51.3	2.7 (2.1–3.4)	67	56.8	3.0 (2.3–3.9)	200	37.2	1.9 (1.5–2.5)	38	40.0	2.1 (1.5–2.9)
Externalizing	53	15.4	73	17.1	1.1 (0.8–1.5)	15	12.7	0.8 (0.5–1.4)	89	16.6	1.1 (0.8–1.5)	19	20.0	1.3 (0.8–2.1)
Total	50	14.5	140	32.8	2.3 (1.7–3.0)	43	36.4	2.5 (1.8–3.6)	126	23.5	1.6 (1.2–2.1)	25	26.3	1.8 (1.2–2.8)

Migraine overall: migraine with and without aura plus probable migraine (all features required for diagnosis but one) plus chronic migraine.

TTH overall: infrequent and frequent TTH plus probable TTH (all features required for diagnosis but one) plus chronic TTH.

CI: confidence interval; TTH: tension-type headache; RR: response rate.

Children with TTH overall were significantly more likely to have abnormal clinical scores in the following domains: somatic (8.8% vs. 2.9%, p < 0.05), anxious-depressed (7.4% vs. 3.5%, p < 0.05), attention (10.2% vs. 6.4%, p < 0.05), internalizing (37.2% vs. 19.1%, p < 0.05) and total score (23.5% vs. 14.5%, p < 0.05), and a similar pattern was seen for episodic TTH (Table 3).

Relative to children with episodic TTH, children with episodic migraine were significantly more likely to have abnormalities in the following domains: somatic (26.3% vs. 10.5%, p < 0.05), anxiety-depressive (20.3% vs. 10.5%, p < 0.05) and internalizing symptoms (56.8% vs. 40.0%, p < 0.05).

Multivariate analyses

In children with migraine, white race was significantly associated with abnormal scores on the anxiety-depression (p < 0.05) and internalizing (p < 0.05) scales; lower income was associated with abnormal social (p < 0.05), attention (p < 0.05), externalizing (p < 0.05) and total (p < 0.05) scores (Table 4). Male gender was significantly associated only with abnormal externalizing score (p < 0.05). Age did not contribute to the model. In children with TTH, male gender was significantly associated with abnormal somatic (p < 0.05), anxious-depressed (p < 0.05), rule-breaking (p < 0.05), aggressive (p < 0.05), internalizing (p < 0.05) and externalizing (p < 0.05) scores, and age was associated with abnormal somatic (p < 0.05) and social (p < 0.05) scores. White race was significantly associated only with the abnormal thought score (p < 0.05). Income did not contribute to the model (Table 4).

Table 4.

Multivariate analyses of determinants of CBCL symptoms scales in children with migraine and in children with TTH.

	Migraine overall		TTH overall
Model 1^a	Model 2^b	Model 1^a	Model 2^b
Withdrawn	NS	NS	NS	NS
Somatic	NS	Frequency (p = 0.000)	Gender (p = 0.027) Age (p = 0.014)	Gender (p = 0.017) Age (p = 0.014) Frequency (p = 0.005)
Anxious-depressed	Race (p = 0.034)	Frequency (p = 0.000) Race (p = 0.044)	Gender (p = 0.022)	Gender (p = 0.018) Frequency (p = 0.025)
Social	Income (p = 0.048)	Frequency (p = 0.000)	Age (p = 0.028)	Age (p = 0.028)
Thought	NS	Ns	Race (p = 0.04)	Race (p = 0.04)
Attention	Income (p = 0.03)	Frequency (p = 0.002) Income (p = 0.22)	NS	NS
Rule-breaking	NS	NS	Gender (p = 0.007)	Gender (p = 0.007)
Aggressive	NS	Frequency (p = 0.000)	Gender (p = 0.047)	Gender (p = 0.047)
Internalizing	Race (p = 0.034)	Frequency (p = 0.000)	Gender (p = 0.029)	Gender (p = 0.020) Frequency (p = 0.024)
Externalizing	Gender (p = 0.012)	Income (p = 0.047) Gender (p = 0.021) Frequency (p = 0.001)	Gender (p = 0.031)	Gender (p = 0.031)
Total	NS	Income (p = 0.03) Frequency (p = 0.000)	NS	NS

Model 1: gender, race, age and, income class.

Model 2: gender, race, age, income class, and headache frequency.

NS: non-significant.

Frequency had a clear influence on CBCL scores of migraineurs (Table 4). After adjustments for headache frequency, children with migraine were more likely than controls to have a clinically relevant abnormal total CBCL score, as well as abnormalities in somatic, anxious-depressed, social, attention, aggressive, internalizing (p < 0.001 for all comparisons) and externalizing (p < 0.05) domains. Children with TTH, in turn, were more likely than controls to have clinically relevant abnormal scores in somatic (p < 0.01), anxious-depressed (p < 0.05) and internalizing symptoms (p < 0.05).

Discussion

Pediatric headaches impact quality of life (2) and school attendance (3,25), and seem to be associated with behavioral, emotional, and social problems and competencies (13,14). To the best of our knowledge, the present study is the first study to examine the behavior and emotional correlates of migraine and TTH in young children using the ICHD-II criteria and the CBCL questionnaire and accounting for headache frequency in a large community-based study. Our findings can be summarized as follows: (1) relative to controls, children with migraine are more likely to have symptoms in several domains and to have clinically abnormal total CBCL scores; (2) children with TTH have impairments in the same domains seen in those with migraine, but with lower magnitude; (3) in children with migraine and with TTH, impairments significantly vary as a function of headache frequency.

Our findings corroborate the higher prevalence of somatic and anxiety-depressive symptoms in children with migraine and TTH compared to those without headache. Previous populational studies have also showed the higher prevalence of somatic (14,26) and anxiety-depressive symptoms (15,27) in children and adolescents with migraine compared to children without chronic headaches, although controversial findings are reported concerning children with TTH (14,26).

As previously reported by others (14), we found that migraine was associated with social problems but not with “rule-breaking” and/or “aggressive’ symptoms (externalizing behavior problems). The “social” domain identifies difficulties in social engagement as well as infantilized behavior for the age and this may be associated with an important impact on personal and social life. Social isolation is, in turn, associated with anxiety and depression, with the potential for a self-perpetuating association. Providers should be aware of this possibility in children with migraine, in order to properly address the problem. We found no evidence of differences in withdrawn (shy behavior), thought (delusions and obsessive–compulsive behavior) and externalizing (“rule-breaking” and “aggressive” behaviors) scales.

Two previous population studies suggest that migraine (but not TTH) and chronic daily headaches are associated with inattention (15,28), hyperactivity (28) and other behavioral problems. Here we found abnormal scores in the CBCL attention domain. However, in a separate study using the Swanson, Nolan, and Pelham scale version IV (MTA SNAP-IV), which is DSM-IV-based and validated to identify specific symptoms of ADHD, we found that, in multivariate analyses, ADHD or inattention symptoms were not predicted by headache subtypes or headache frequency, but hyperactivity-impulsivity symptoms were significantly associated with any headache (p < 0.01), tension-type headache (p < 0.01) or migraine headaches (p < 0.001) (16).

To explain this discrepancy, we highlight that of the 11 questions that encompass the CBCL domain for attention, only three indeed capture this domain, and only one seems to truly focus on attention. The remaining questions focus on hyperactivity, impulsivity, executive dysfunctions and lack of coordination (20). The specificity of the scale to measure attention can therefore be questioned, since it seems to be a composite metric.

The influence of headache frequency on the behavior of children with migraine and other primary headaches is still poorly understood. In a recent study we explored the influence of maternal headache frequency on the CBCL scores of their children (29). In multivariate analyses, we found that, in children with migraine, maternal migraine status and maternal headache frequency did not predict CBCL scores in children with migraine but did predict them in children without migraine (p < 0.01). Our current results add to the picture by suggesting the relevance of probands headache frequency, and highlighting that the burden of migraine on the family is complex. Taken together it seems that children with migraine are more likely to have behavioral and emotional symptoms than children without migraine, and that this is influenced by their headache frequency but not by their mother's headache status or headache frequency. Children with TTH follow the same pattern of children with migraine, but are less severely impacted. Children without migraine may be affected, in turn, by frequent headaches experienced by their mothers (29).

The strengths and limitations of our study deserve comment. Among the strengths we list the relatively large sample size of young children, the use of validated questionnaires, the help of trained facilitators (teachers) and the strict following of standardized criteria for diagnosis, as well as the very high participation rate.

Among the limitations, we first highlight that headache diagnosis was determined by the information provided by the mother; and that no direct interviews were conducted with the children, raising the potential for unavoidable biases. Mothers could fail to report existent migraine symptoms from their children or could, alternatively, have a distorted perception (reporting them as more severe than they were) of the symptoms. However, it was necessary to obtain the information from the mothers, as the patient group was too young to properly understand the questions. 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 (30). Second, we underestimated the prevalence of TTH, as we classified only the most severe type of headache presented by patients. This is a standard method in the field (31), but because we did not assess more than one type of headache, we cannot adjust for whether one headache (TTH) influences the association of headache/CBCL in children with another (migraine).

Finally, our most important limitation involved the questionnaire used, which has been validated for children 10 years or older, not for younger children. This is a limitation not only of our study, but to virtually all studies in the field where medical diagnosis has been done. Nonetheless, a random sample of 100 children was seen by one of us (MAA) and sensitivity was above 90%, with specificity above 75% for the four diagnoses of interest. The process of validation is currently being written for publication. Nonetheless, because the questionnaire basically presents the ICHD diagnostic criteria, and because we interviewed the mothers, we are confident that major biases are excluded.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement

This study was conducted without commercial financial support. Dr Bigal is a full-time employee of Merck Inc. He owns Merck stocks and stock options. Merck did not sponsor this study. Dr Arruda reports no disclosures.

References

Abu-Arafeh

Razak

Sivaraman

Graham

. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol 2010; 52: 1088–1097.

Powers

Patton

Hommel

Hershey

. Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics 2003; 112: e1–e5.

Abu-Arefeh

Russell

. Prevalence of headache and migraine in schoolchildren. BMJ 1994; 309: 765–769.

Galli

Canzano

Scalisi

Guidetti

. Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents. J Headache Pain 2009; 10: 187–197.

Lipton

Silberstein

. Why study the comorbidity of migraine?. Neurology 1994; 44: S4–S5.

Bigal

Krymchantowski

Lipton

. Barriers to satisfactory migraine outcomes. What have we learned, where do we stand?. Headache 2009; 49: 1028–1041.

Breslau

. Psychiatric comorbidity in migraine. Cephalalgia 1998; 1(Suppl 22): 56–58discussion 8–61.

Scher

Stewart

Lipton

. The comorbidity of headache with other pain syndromes. Headache 2006; 46: 1416–1423.

Low

Merikangas

. The comorbidity of migraine. CNS Spectr 2003; 8: 433–4–437–44.

10.

Guidetti

Galli

Fabrizi

. Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia 1998; 18: 455–462.

11.

Galli

D'Antuono

Tarantino

. Headache and recurrent abdominal pain: a controlled study by the means of the Child Behaviour Checklist (CBCL). Cephalalgia 2007; 27: 211–219.

12.

Vannatta

Getzoff

Powers

. Multiple perspectives on the psychological functioning of children with and without migraine. Headache 2008; 48: 994–1004.

13.

Bruijn

Locher

Passchier

. Psychopathology in children and adolescents with migraine in clinical studies: a systematic review. Pediatrics 2010; 126: 323–332.

14.

Anttila

Sourander

Metsahonkala

. Psychiatric symptoms in children with primary headache. J Am Acad Child Adolesc Psychiatry 2004; 43: 412–419.

15.

Virtanen

Aromaa

Koskenvuo

. Externalizing problem behaviors and headache: a follow-up study of adolescent Finnish twins. Pediatrics 2004; 114: 981–987.

16.

Arruda

Guidetti

Galli

. Migraine, tension-type headache, and attention-deficit/hyperactivity disorder in childhood: a population-based study. Postgrad Med 2010; 122: 18–26.

17.

Tunks

Crook

Weir

. Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis. Can J Psychiatry 2008; 53: 224–234.

18.

Arruda M. Projeto Atenção Brasil, http://www.aprendercrianca.com.br/aprender-crianca-2010-dp17 (2009. accessed 22 June 2012).

19.

Headache Classification Committee of the International Headache SocietyThe international classification of headache disorders. 2nd edn. Cephalalgia 2004; 24(Suppl. 1): 9–160.

20.

Achenbach

Manual for the CBCL/4-18 and profile Burlington, VT: Department of Psychiatry, University of Vermont, 1991.

21.

Schmeck

Poustka

Dopfner

. Discriminant validity of the child behaviour checklist CBCL-4/18 in German samples. Eur Child Adolesc Psychiatry 2001; 10: 240–247.

22.

Bordin

Mari

Caieiro

. Validation of the Brazilian version of the Child Behavior Checklist (CBCL). Rev ABP APAL 1995; 17: 55–66.

23.

Bigal

Lipton

. Clinical course in migraine: conceptualizing migraine transformation. Neurology 2008; 71: 848–855.

24.

Arruda

Guidetti

Galli

. Primary headaches in childhood—a population-based study. Cephalalgia 2010; 30: 1056–1064.

25.

Hunfeld

Passchier

Perquin

. Quality of life in adolescents with chronic pain in the head or at other locations. Cephalalgia 2001; 21: 201–206.

26.

Laurell

Larsson

Eeg-Olofsson

. Headache in schoolchildren: association with other pain, family history and psychosocial factors. Pain 2005; 119: 150–158.

27.

Fichtel

Larsson

. Psychosocial impact of headache and comorbidity with other pains among Swedish school adolescents. Headache 2002; 42: 766–775.

28.

Strine

Okoro

McGuire

Balluz

. The associations among childhood headaches, emotional and behavioral difficulties, and health care use. Pediatrics 2006; 117: 1728–1735.

29.

Arruda MA and Bigal ME. Migraine and behavior in children: influence of maternal headache frequency. J Headache Pain. Epub ahead of print 30 March 2012. DOI 10.1007/s10194-012-0441-x.

30.

Arruda

Bordini

Ciciarelli

Speciali

. Decreasing the minimal duration of the attack to 1 hour: is this sufficient to increase the sensitivity of the ICHD-II diagnostic criteria for migraine in childhood?. J Headache Pain 2004; 5: 131–136.

31.

Lipton

Stewart

Simon

. Medical consultation for migraine: results from the American Migraine Study. Headache 1998; 38: 87–96.