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Abstract

Aim

To investigate the prevalence, severity, and clinical correlates of obsessive-compulsive symptoms (OCS) in pediatric patients with primary headache disorders.

Methods

In this monocentric, observational, and retrospective study, we assessed 100 children and adolescents (mean age = 12.0 years; 63% female) diagnosed with migraine, tension-type headache (TTH) or coexisting migraine and TTH at a tertiary child neuropsychiatry outpatient clinic. OCS were evaluated using the Obsessive-Compulsive Inventory–Child Version (OCI-CV), with clinically significant symptoms defined as a total score ≥21. A multivariable logistic regression model examined associations with sex, age, and neurovegetative features. A post-hoc power analysis was also conducted.

Results

Clinically significant OCS were present in 17% of participants. Female sex (OR = 5.18, 95% CI = 1.24–36.32, p = .046) and the presence of neurovegetative symptoms (OR = 1.51, 95% CI = 1.11–2.08, p = .009) were significant predictors, whereas age showed no significant effect. The most elevated OCI-CV subscales were “Obsessing,” “Hoarding,” and “Ordering.”

Conclusion

OCS are relatively common in pediatric patients with primary headache, especially among females and those reporting autonomic symptoms. Routine psychopathological screening in this population may support early identification and targeted clinical management.

Graphical abstract

This is a visual representation of the abstract.

Keywords

pediatric headache migraine obsessive-compulsive symptoms OCI-CV psychiatric screening

Introduction

Headache is among the most prevalent neurological complaints in the pediatric population, affecting approximately 20%‒30% of school-aged children.^1,2 Primary headache disorders, particularly migraine and tension-type headache (TTH), represent the majority of cases³ and can significantly impair quality of life, school performance, and social functioning.⁴ Recurrent headaches in childhood have also been associated with an increased risk of chronic headache and long-term disability in adulthood.⁵

Diagnosing pediatric headache poses specific challenges, including age-related differences in symptom expression, communication difficulties, and the frequent presence of psychiatric comorbidities.⁶ These factors contribute to underdiagnosis or misdiagnosis and may delay effective treatment.

A growing body of research highlights the frequent co-occurrence of headache and psychiatric symptoms in youth. Psychiatric disorders such as anxiety and obsessive-compulsive traits have been proposed as potential risk factors for both the onset and persistence of primary headaches, while headaches themselves may exacerbate emotional dysregulation, resulting in greater functional impairment.^7,8 Although the relationship between anxiety and headache has been more widely investigated, recent studies have drawn attention to the association between headache and obsessive-compulsive symptoms (OCS), particularly during adolescence.⁹

It is important to distinguish between obsessive-compulsive disorder (OCD) and subclinical OCS, the latter of which may not meet full diagnostic criteria but still contribute to distress and impaired functioning.^10,11 Such symptoms may include intrusive thoughts, ritualistic behaviors, and cognitive rigidity—dimensions relevant to pain perception and emotional regulation.

Epidemiological estimates indicate that full-threshold OCD affects approximately 1–3% of children and adolescents in the general population,¹² while subclinical OCS have been reported in up to 14.7% of school-aged youth.¹³ Although pediatric data on headache populations are limited, one clinic-based study reported that 8.9% of children with migraine met criteria for OCD compared to 1.3% of those with TTH (p = .002).¹⁴ In adults, co-occurrence of refractory chronic migraine and OCD has also been documented.¹⁵ Together, these findings suggest a possible link between headache disorders and obsessive-compulsive symptomatology, yet systematic, dimensionally assessed data in pediatric clinical samples remain scarce.

Theoretical models suggest that headache and OCS may share underlying neurobiological vulnerabilities, including serotonergic dysregulation, heightened autonomic reactivity, and dysfunctional cortico-striato-thalamo-cortical circuits.^16,17 These overlapping mechanisms warrant closer investigation, particularly during sensitive developmental periods.

Despite emerging evidence, data on OCS in pediatric headache populations remain limited, especially in clinical settings. Moreover, the influence of sex on the presentation of OCS in youth with headache has been insufficiently explored, despite robust epidemiological evidence pointing to a higher prevalence of internalizing symptoms in females.^18,19

Therefore, the objectives of this study were: (i) to characterize the symptomatic and clinical profile of pediatric patients with primary headache disorders; (ii) to determine the prevalence and severity of OCS using the OCI-CV; (iii) to explore potential predictors of clinically significant OCS, with a specific focus on sex and headache severity markers such as frequency and neurovegetative features; and (iv) to test the hypothesis that female sex and higher clinical burden are associated with an increased risk of OCS.

Materials and methods

Study design

This was a monocentric, observational, descriptive, and retrospective study conducted at the Child and Adolescent Neuropsychiatry outpatient clinic of the Azienda Ospedaliero-Universitaria di Parma. The study included a consecutive series of patients assessed between January 1, 2024, and December 31, 2024. The study was conducted in a public academic setting and designed to explore the clinical characteristics, etiopathogenetic factors, and psychopathological comorbidities in pediatric patients presenting with headache.

Ethical considerations

The study protocol was approved by the Ethics Committee of the Azienda Ospedaliero-Universitaria di Parma (Protocol Number: 630.2024). Written informed consent was obtained from parents or legal guardians, and assent was obtained from minors in accordance with their age and comprehension level. Data collection was conducted retrospectively by reviewing medical records and utilizing information collected for clinical purposes.

Participants

The primary headache group included 100 children and adolescents diagnosed with migraine, TTH, or coexisting migraine and TTH. All diagnoses were made by experienced child neuropsychiatrists according to ICHD-3 criteria.

Inclusion criteria

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Children and adolescents aged between 7 and 17 years.

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Diagnosis of primary headache according to the International Classification of Headache Disorders, Third Edition (ICHD-3).

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Access to the Neuropsychiatry Unit of the Azienda Ospedaliero-Universitaria di Parma between January 1, 2024, and December 31, 2024.

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Availability of signed informed consent from parents/legal guardians and assent from the minor.

Exclusion criteria

Presence of severe neuropsychiatric or medical conditions impairing the ability to provide informed consent/assent, complete the self-administered questionnaire, or ensure the reliability of results (e.g., intellectual disability, non-verbal autism).

Data collection

Headache characteristics (frequency, intensity, and neurovegetative symptoms) were collected using 30-day headache diaries reviewed during clinical intake. Neurovegetative symptoms were defined according to ICHD-3 criteria and included nausea, vomiting, photophobia, and phonophobia.

Psychopathological assessment

OCS were assessed using the Obsessive-Compulsive Inventory-Child Version (OCI-CV), a validated 21-item self-report questionnaire designed to evaluate specific symptom dimensions in children and adolescents aged 7 years and older. The Italian version of the OCI-CV has shown adequate psychometric properties in terms of internal consistency and factorial validity.²⁰ Each item is rated on a 3-point Likert scale (0 = never, 1 = sometimes, 2 = always), yielding a total score ranging from 0 to 42. Although the OCI-CV is primarily used as a dimensional measure, previous validation studies suggest a total score ≥21 as indicative of clinically relevant OCS.²¹

The questionnaire was administered in paper-and-pencil format in a quiet setting within the outpatient clinic. Average completion time was 10–15 min. Clinical staff were available to support children if needed, particularly younger patients or those reporting reading difficulties. The questionnaire was administered in a quiet outpatient setting as part of the routine clinical assessment conducted by trained staff. Although collected for clinical purposes, the OCI-CV data were retrospectively analyzed for research, with no additional burden for participants.

Statistical analysis

Data were analyzed using JASP. Descriptive statistics were calculated for all variables. Continuous variables were reported as means and standard deviations (SD), and categorical variables as frequencies and percentages. The primary analyses focused on predictors of clinically significant OCS (OCI-CV ≥21). A binary logistic regression model was conducted including age, sex and the presence of neurovegetative symptoms as independent variables. Odds ratios (ORs), 95% confidence intervals (CI), and p-values were reported. A p < .05 was considered statistically significant. A post-hoc power analysis was also conducted.

Headache type was not included in the main model due to the high proportion of patients with coexisting migraine and TTH, which limited interpretability. Exploratory comparisons by headache type are reported in the Supplementary Material for completeness only.

Missing data handling

The dataset was reviewed for completeness prior to analysis. All participants had complete data for the primary outcome (OCI-CV score) and the main predictors (sex, age, and neurovegetative symptoms). Cases with missing data on other clinical variables were excluded listwise from relevant subgroup analyses. The overall proportion of missing data was low (<5%), and no imputation was performed.

This observational cross-sectional study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Results

Sample characteristics

The total sample consisted of 100 children and adolescents, of whom 63% were female. The mean age was 12.0 years (SD = 2.7). Participants were grouped by headache type: migraine (n = 47), tension-type (n = 13), and coexisting migraine and TTH (n = 40).

Demographic and clinical characteristics by headache presentation are summarized in Table 1 . Given the overlap between categories, no inferential comparisons among headache subtypes were performed in the main analysis; descriptive statistics are reported only.

Table 1.

Sociodemographic and clinical characteristics of the sample.

Variable	Migraine (n = 47)	Tension-type headache (TTH) (n = 13)	Coexisting TTH and migraine (n = 40)	Total sample (n = 100)	p
Female, n (%)	29 (61.7)	8 (61.5)	14 (35)	63 (63)	.03
Male, n (%)	18 (38.3)	5 (38.5)	26 (65)	37 (37)	.03
Age, M (SD)	12.9 (2.6)	11.1 (2.1)	11.2 (2.6)	11.9 (2.6)	<.001
Age at headache onset, M (SD)	12 (4.8)	9 (2.6)	10 (3.1)	11 (4.1)	.155

p <.05 was considered statistically significant.

Acute medication use

Acute medication use was described across the three headache groups. Paracetamol was the most commonly used medication overall (36.7%), especially in the coexisting migraine and TTH (57.1%) and TTH (50.0%) groups. The use of non-steroidal anti-inflammatory drugs (NSAIDs) alone was more frequent among patients with migraine (27.9%), who also showed the highest use of combination therapy with paracetamol and NSAIDs (25.6%). A total of 22.2% of the sample did not require acute medication. Full details are presented in Table 2.

Table 2.

Acute medication use on an as-needed basis across headache groups.

Acute medication use (as-needed basis), n (%)	Migraine (n = 47)	Tension-type headache (TTH) (n = 13)	Coexisting migraine and TTH (n = 40)	Total sample (n = 100)	p
Not necessary	10 (21)	2 (15)	8 (20)	20 (20)	.01
Paracetamol	7 (14)	6 (46)	20 (50)	33 (33)
NSAIDs	12 (25)	2 (15)	5 (12)	19 (19)
Both paracetamol and NSAIDs	11 (23)	2 (15)	2 (5)	15 (15)

Obsessive-Compulsive symptoms

OCS were assessed using the OCI-CV. The total sample showed a mean total score of 13.9 (SD = 6.3). The most elevated subscales were “Obsessing” (M = 1.1, SD = 0.6), followed by “Hoarding” (M = 0.8, SD = 0.5) and “Ordering” (M = 0.7, SD = 0.7). Clinically significant OCS (OCI-CV total score ≥21) were observed in 17 patients, corresponding to 17% of the total sample. Descriptive data by headache subtype are provided in Supplementary Table S1, but were not included in the main inferential analyses due to the high proportion of patients with coexisting migraine and TTH.

Predictors of clinically significant OC symptoms

A multivariable logistic regression model was conducted to identify predictors of clinically significant OCS (OCI-CV ≥ 21). Independent variables included sex, age and the presence of neurovegetative symptoms (Table 3).

Female sex was significantly associated with higher odds of clinically significant OCS (OR = 5.18, 95% CI = 1.24–36.32, p = .046).

Presence of neurovegetative symptoms was also a significant predictor (OR = 1.51, 95% CI = 1.11–2.08, p = .009).

Age showed a non-significant trend (OR = 1.22, 95% CI = 0.97–1.57, p = .097).

Table 3.

Logistic regression model predicting clinically significant obsessive-compulsive symptoms (OCI-CV ≥21).

Predictor	β (SE)	OR [95% CI]	p
Age (years)	0.08 (0.09)	1.22 [0.97, 1.57]	.097
Female (vs. male)	1.61 (0.77)	5.18 [1.2, 36.3]	.046
Neurovegetative symptoms	0.41 (0.54)	1.51 [1.11, 2.08]	.009

p < .05 was considered statistically significant.

Headache type was not included in the primary model due to potential bias from diagnostic overlap.

Correlations among clinical variables

To further explore the relationships among clinical and psychopathological dimensions, we computed a Pearson correlation matrix including age, age of headache onset, presence of neurovegetative symptoms, headache frequency, intensity, and OCI-CV total score (Figure 1). The analysis revealed a moderate positive correlation between age and age of onset (r = .51), as expected. Weak positive correlations emerged between neurovegetative symptoms and both intensity (r = .17) and OCI-CV total score (r = .14). All remaining correlations were weak (r < .26), suggesting a relative independence among core headache-related features and limited overlap with overall symptom burden.

Figure 1.

Pearson’s correlation matrix among clinical and psychopathological variables in the pediatric headache cohort. The matrix displays pairwise Pearson correlation coefficients (r) between age, age of headache onset, neurovegetative symptoms, headache frequency, intensity, and total clinical score. Color intensity represents the strength and direction of the correlation, with red indicating positive and blue negative values. The strongest correlation was observed between age and age of onset (r = .51), indicating a moderate association. All other correlations were weak (r < .26), suggesting limited interdependence among core headache-related clinical features.

Discussion

This study explored the association between primary headache disorders and OCS in a pediatric clinical population. Descriptive data suggested higher OCI-CV scores in the migraine and coexisting groups; however, given the potential bias related to diagnostic overlap, headache type was not included in the main analyses. Instead, we focused on transdiagnostic predictors such as sex and neurovegetative symptoms.

In our clinical cohort, clinically significant OCS (OCI-CV ≥21) were present in 17% of participants, a rate substantially higher than population-based estimates for full-threshold OCD in youth (1–3%)¹² and also exceeding reported frequencies of subclinical OCS in community samples (14.7%).¹³ This prevalence is consistent with the higher occurrence of OCD observed in pediatric migraine compared to TTH reported by Pavone et al.¹⁴ and aligns with adult case descriptions linking chronic migraine and OCD.¹⁵ These converging data reinforce the clinical relevance of screening for obsessive-compulsive symptomatology in pediatric headache populations, particularly in tertiary care settings, where symptom burden and comorbidity rates may be elevated. This finding supports previous work showing that OCS are dimensional and impactful, rather than being strictly categorical.^22,23

Among predictors, female sex emerged as the strongest correlate, with a fivefold increase in the odds of clinically relevant symptoms. This aligns with established developmental patterns of internalizing psychopathology and may reflect a combination of biological vulnerability, gendered stress exposure, and emotion-focused coping styles.²⁴ The presence of neurovegetative symptoms also significantly predicted higher OCS burden, potentially reflecting heightened autonomic arousal or interoceptive sensitivity—mechanisms that warrant further investigation.^25,26 Interestingly, while migraine patients reported higher OCS scores at the group level, this did not translate into predictive significance in the multivariable model, suggesting that the relationship is not purely phenotype-driven but may depend on shared vulnerabilities, such as serotonergic dysregulation or altered pain perception.²² Future research should investigate whether dysregulated cortico-striatal circuitry, implicated in both migraine and OCD, could represent a neurobiological bridge between the two.^27,28 Although no patients met criteria for medication-overuse headache, the pattern of frequent and combination analgesic use, particularly in the migraine group, may reflect low distress tolerance or rigid pain management expectations.²⁹ While this interpretation remains speculative, it highlights the potential overlap between coping styles and compulsive symptomatology, a hypothesis that could be tested in future prospective studies.

From a clinical perspective, the mean OCI-CV scores in this cohort often exceeded screening thresholds. This suggests that routine use of brief, validated tools such as the OCI-CV could enhance the early detection of internalizing traits in pediatric headache populations. Incorporating such tools into standard headache assessment protocols may allow clinicians to identify emotional vulnerabilities earlier and tailor management accordingly.

Finally, longitudinal studies are warranted to explore whether pediatric OCS in the context of headache represents a risk factor for psychiatric disorders, a coping mechanism, or an epiphenomenon. Understanding this trajectory could inform preventive strategies and integrated care pathways. We acknowledge several limitations. First, the cross-sectional and monocentric design limits causal inference and generalizability. Second, while the OCI-CV is a validated screening tool, it does not replace clinical diagnosis. Third, some potential confounding factors (e.g., family history, psychiatric comorbidities) were not assessed. Despite these constraints, our findings contribute novel data to an underexplored area and support the inclusion of brief, validated psychopathological tools—such as the OCI-CV—into routine pediatric headache evaluation protocols.

Limitations and bias management

This study has several limitations. To minimize selection bias, we enrolled a consecutive series of patients from a tertiary outpatient neuropsychiatric clinic over a defined 12-month period, and diagnostic criteria were consistently applied by trained child neuropsychiatrists. Information bias was reduced through the use of validated instruments (e.g., OCI-CV) administered under standardized conditions. However, as this was a retrospective, single-center study, residual confounding or unmeasured biases (e.g., reporting bias, diagnostic overshadowing) cannot be completely excluded. In addition, the relatively high proportion of patients with coexisting migraine and TTH (40%) limited the interpretability of analyses by headache subtype. For this reason, headache type was not included as a predictor in the main models, and exploratory subgroup analyses are presented only in the Supplementary Material.

Conclusion

This study shows that OCS are relatively common in pediatric headache, particularly in females and those with neurovegetative features. Although migraine was associated with higher OCI-CV scores, headache type did not independently predict clinically significant symptoms. Routine screening for obsessive-compulsive traits may help identify emotional vulnerabilities and support personalized care. Longitudinal studies are warranted to clarify causal pathways and prognostic implications.

Clinical Implications

In a pediatric sample with primary headache disorders, over 40% of participants reported OCS.

Migraine-like headaches and female sex were significantly associated with a higher severity of OCS.

The Doubt/Perfectionism and Ordering dimensions were the most frequently endorsed OCS domains.

These results support a possible neurobiological link between pediatric migraine and obsessive-compulsive traits.

Supplemental Material

sj-docx-1-rep-10.1177_25158163251391144 - Supplemental material for When pain meets obsession: Investigating the association between headache and obsessive-compulsive symptoms in a pediatric cohort

Supplemental material, sj-docx-1-rep-10.1177_25158163251391144 for When pain meets obsession: Investigating the association between headache and obsessive-compulsive symptoms in a pediatric cohort by Valentina Baldini, Giulia Pisanò, Martina Gnazzo, Serena Bacchetta, Jessica Maria Angelini, Diletta Ziveri, Beatrice Campana, Benedetta Piccolo, Emanuela Claudia Turco, Susanna Esposito and Maria Carmela Pera in Cephalalgia Reports

Footnotes

ORCID iDs

Martina Gnazzo

Jessica Maria Angelini

Consent to participate

Approved by the Ethics Committee (Protocol 630.2024). Written informed consent and assent were obtained as appropriate.

Consent for publishing

Yes

Author contributions

All authors read and approved the final manuscript. Valentina Baldini and Giulia Pisanò contributed equally to data collection, analysis, and manuscript drafting. Martina Gnazzo conceptualized the study, supervised the data analysis, and finalized the manuscript. Serena Bacchetta, Jessica Maria Angelini, Diletta Ziveri, and Beatrice Campana contributed to patient recruitment, clinical assessment, and database curation. Benedetta Piccolo, Emanuela Claudia Turco, and Susanna Esposito provided methodological input and critical manuscript revision. Maria Carmela Pera contributed to study design, interpretation of findings, and overall supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated and analyzed during the current study are not publicly available due to patient privacy restrictions but are available from the corresponding authors upon reasonable request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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