When headache speaks about childhood psychiatric disorders

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1 When headache speaks about childhood psychiatric disorders CARMEN TRUŢESCU 1, IULIANA DOBRESCU 2 ABSTRACT: Headaches are the reason of numerous presentations of children and adolescents in both pediatric and child mental health services. Diagnosis involves first of all a detailed headache history, a thorough neurological evaluation, physical and ophthalmologic examinations which would certainly exclude possible organic etiology. Headaches occurred in children and adolescents can have multiple meanings, changes of clinical characteristics forcing clinicians to make further investigations and sometimes to reconsider the diagnosis. Key words: headache, migraine, child and adolescent. REZUMAT: Cefaleea constituie motivul a numeroase prezentări a copiilor şi adolescenţilor, atât în serviciile de pediatrie cât şi în serviciul de psihiatrie a copilului şi adolescentului. Diagnosticul implică o anamneza detaliată, o evaluare neurologică amănunţită, examinare fizică şi oftalmologică, pe baza cărora se poate exclude posibila etiologie organică. Cefaleea apărută la copil şi adolescent are valenţe multiple, schimbările caracteristicilor clinice obligând clinicianul să facă investigaţii suplimentare şi uneori să reconsidere diagnosticul. Cuvinte cheie: cefalee, migrenă, copil şi adolescent. Headaches are a common problem for children and adolescents and a cause of significant anxiety for parents and physicians. Children with headaches usually go to both pediatric and child 1 MD, resident in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Hospital of Psychiatry, Bucharest 2 MD, PhD, Primary doctor in Neuropsychiatry, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Psychiatry Hospital, Bucharest, Professor Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy Carol Davila Bucharest

2 mental health services. Chronic headaches are often comorbid with various psychiatric disorders, like anxiety and depressive disorders and associated with somatization and school problems. Headaches in infancy and early childhood are rare, and in children younger than 3 years are more likely to have an organic cause (Kaufman, 2007; Rutter et al., 2008). Studies of Swedish schoolchildren have indicated that 40% of children experience a headache by age 7, 75% experience a headache by age 15, and migraine (one of the most common causes of headache in childhood) occurs in 1% of children by age 7 and 5% of children by age 15. Studies in the United States have found that the highest incidence (246 per 100,000 person-years) of migraine headache occurs in boys ages 10 to 14. Approximately 20% of children in the US have chronic headaches (Rubin et al., 2006; Kaufman, 2007). Tension-type headaches and migraine are the two most common types of headache in children and adolescents. However, classification systems have difficulties in separating tensiontype headaches from migraine without aura in children. Although the smaller genetic effect on tension-type headaches than on migraine suggests that the two disorders are distinct, many believe that tension-type headaches and migraine represent the same pathophysiological spectrum (Rutter et al., 2008) Characteristics of headaches in children are less typical and more variable than in adults, and small children have more difficulties perceiving and describing headache characteristics in detail. Abdominal symptoms, such as cyclical vomiting or abdominal "migraine," are common precursors to migraines and occur especially in preschool children. While migraine is a well-recognized phenomenon in adults, it is often overlooked or minimized in children and adolescents. Headaches represent quite a common complaint in children, and migraine often has its onset in the first two decades of life. Recognition and appropriate treatment can have a significant impact on the quality of life for young sufferers as well as their caregivers, and may ultimately impact the course of the illness (Singer et al., 2005) The difference between a successful and an unsuccessful headache evaluation depends on the history. The headaches should be described as to frequency, duration, severity, location at onset, exacerbating or precipitating factors, and associated signs and symptoms. The patient s past medical history is important, as is a family history of migraine headaches. Using the history, one should attempt to classify the headaches as: (1) an acute single episode, 2

3 (2) acute recurrent episodes, (3) subacute, and (4) chronic (Wright et al., 2006) Chronic nonprogressive headaches usually refer to "tension-type" headaches (TTH) - previously called tension or stress headaches; they are usually frequent, daily, and are mild to moderate in severity. This headache type is most often seen in adolescent girls. Mixed headaches have characteristics of tension-type and migraine headaches. Drug-rebound headaches are seen with the overuse of over the counter analgesics in patients with recurrent or chronic headaches (IHS, 2006). Childhood migraine is not simply migraine in short adults. Compared to migraine in adults, the headache component of childhood migraine is briefer (frequently less than 2 hours), more severe, and less likely to be unilateral (only one third of cases). As with migraine in adults, the non headache components may overshadow the headache. Childhood migraine can produce episodes of confusion, incoherence, or agitation. In addition, it often leaves children incapacitated by nausea or vomiting (Kaufman, 2007). There is also a variant with brief vertigo (Carey et al., 2009), lack of or excess sleep, sensorial stimulation (loud noise, bright light), or sympathetic stimulation (physical activity). Up to 30% of patients with migraines occasionally experience auras reversible focal neurological symptoms (typically visual and/or sensory and/or speech symptoms) that develop gradually over minutes and last for less than one hour. Frequency of migraine aura seems to be nearly as high in children as in adults, but the less typical symptoms are usually only reported on request rather than spontaneously (Oelkers et Resch, 2004). Typical characteristics are unilateral location (in young children commonly bilateral), pulsating quality, moderate or severe intensity, aggravation by physical activity, and association with nausea and/or photo and phonophobia (which may be inferred from particular behaviors in young children). Migraine episodes are frequently triggered by several factors such as emotional stress (school pressure, excitement) (Kaufman, 2007). Cyclical and lifetime fluctuations in hormones are common migraine triggers that warrant special attention because of their ubiquitous effects on women s migraine. Changes in hormonal status in addition to extrinsic sources of hormones (hormone replacement therapy) influence migraine frequency and severity. Increasing levels of plasma estrogen are correlated with increasing migraine frequency at puberty (Gupta et al., 2007). 3

4 Children are particularly susceptible to migraine variants, such as basilar-type migraine and hemiplegic migraine. In basilar-type migraine, the headache is accompanied or even overshadowed by ataxia, vertigo, dysarthria or diplopia symptoms that reflect brain dysfunction in the basilar artery distribution. In addition, when basilar migraine impairs the temporal lobes, located in the posterior cerebrum, patients may experience temporary generalized memory impairment, for example, transient global amnesia (Kaufman, 2007). There are clinical approaches to identify the different types of headache which include the use of drawing by the children. In a study, 226 children, aged 4 to 19 years, with a chief complaint of headache were asked, before any formal history: Please draw a picture of yourself having a headache. Where is the pain? Are there any other changes that come with your headache that you can show me in your picture? No leading questions were asked. Two pediatric neurologists, who were blinded to the clinical history, analyzed the drawings independently. Pictures were graded as either migrainous or nonmigrainous. Specific features of the drawings that were considered to represent migraine (included depiction of severe pain with a pounding/hammering quality, nausea or vomiting, sensitivity to light and/or sound, desire to sleep, headache exacerbation by exercise or movement, or clear-cut unilaterality), versus nonmigraine headaches (Stafstrom et al., 2002). These headache drawings were shown to be a simple inexpensive aid in the diagnosis of headache type, with a very high sensitivity, specificity and predictive value for migraine. Asking children to draw their headache is a simple and accurate adjunctive aid for headache differential diagnosis in the clinical setting. In children and adolescents, while headaches are commonly associated with various psychiatric disorders, whether this relationship is causal and, if so, the direction of the causation remains the object of study. The clinician should find the possible causal relationships between the psychiatric disorders and headache. In the vast majority of cases, headaches associated with these disorders most probably reflect common underlying risk factors or aetiologies. This should means that the headache is manifested only during times when the symptoms of the psychiatric disorder are also manifest. Thus, for example, in a child with separation anxiety disorder, the headache should be attributed to separation anxiety disorder only in those cases where it occurs solely in the context of actual or threatened separation (IHS, 2006). Sleep disorder, separation-anxiety disorder, schoolphobia, adjustment disorder and other disorders usually first diagnosed in infancy, childhood or adolescence (particularly attention- 4

5 deficit/hyperactivity disorder [ADHD]), conduct disorder, learning disorder, enuresis, encopresis, tic) should be carefully looked for and treated if found, considering their negative burden in disability and prognosis of pediatric headache. (IHS, 2006). When depression is comorbid with migraine, the conditions seem reciprocal. Major depression increases the risk of migraine but not of other severe headaches. Similarly, unlike other headache disorders, migraine increases the risk of major depression (Kaufman, 2007). There were gender-, illness- and complaint-specific associations between somatic complaints and psychopathology. It appears likely that there are differences in the psychobiological processes underlying these associations in boys and girls. Headaches are associated with other somatic complaints as well, and the combination of multiple physical complaints is a strong indicator for the presence of psychiatric disorders, especially anxiety and depression. Overall, somatic complaints were strongly associated with emotional disorders in girls and with disruptive behaviour disorders in boys. For girls, stomach aches together with headaches and musculoskeletal pains alone were associated with anxiety disorders. For boys, stomach aches were associated with oppositional defiant disorder and attention-deficit hyperactivity disorder (Egger et al., 1999). The families of these children are often characterized by the tendency to experience many somatic symptoms, limited verbal communication about emotional issues, including conflict, and parental history of somatoform illness or anxiety/depression. Conscientiousness, emotional liability or low self-esteem serves as predisposing factors in the children themselves. Stressful life events, an episode of physical illness, peer group problems or academic pressures often precipitate the onset, and chronically stressful family situations or school related problems may contribute to symptom maintenance (Rutter et al., 2008). There has been a growing interest in the relationship of childhood maltreatment and a variety of pain disorders related to migraine. Overall, studies suggest an association between maltreatment and painful disorders (Raphael, 2005; Davis et al., 2005). Graham-Bermann and Seng also documented the association between child trauma and increased prevalence of many common health problems such as asthma, allergy, headaches, and gastrointestinal tract disturbance (Graham et Seng, 2005). Headaches in abused children is more disabling and frequent, including being more likely to be continuous and to transform from episodic to chronic (Fuller-Thomson et al., 2010). Maltreatment is associated with many factors with the 5

6 same risk for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity (Tietjen et al., 2010). Some of these children may not show initial symptoms or may have symptoms but be reticent to accept an initial referral to mental health services. Children with headache, especially migraine, lose more school days than healthy children. A 2-years follow-up study showed that recurrent headache ranked third among illness related causes of school absenteeism (Brna et al., 2005). This might provide a model for "school avoiding" physical complaints. Therefore, many children who present with school fear or school phobia (often referred to as school refusal) may actually have a history of primary headache (Hockaday, 1988). Mothers of children with headaches present high expressed emotions, especially criticism and emotional over-involvement more frequently than children without headaches (Liakopoulou-Kairis et al., 2002). Child psychiatrists and clinicians should look for these underlying issues and help these children with the expression and control of their feelings relevant to worry, separation anxiety, irritability and sadness. Parents are often concerned about the possibility of underlying brain pathology, but most can be reassured on the basis of history and examination. On history-taking the high-risk group are those headaches that have been present less than 6 months and have one other predictor from a list that includes sleep disturbing headaches, vomiting, abnormal neurological examination, seizures and a total absence of any family history of headaches or migraines (Rutter et al., 2008). The use of instrumental examinations in headache patients varies widely. The routine use of any diagnostic studies for headaches, including neuroimaging, is therefore not indicated when the clinical history is without associated risk factors and the child s examination is normal (Rutter et al., 2008). EEG is indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). A CT scan is used to check for conditions that may cause headaches or to determine if a structural problem is causing chronic sinusitis. In patients with atypical headache patterns, a history of seizures and/or focal neurological signs or symptoms, magnetic resonance imaging (MRI) may be indicated. CONCLUSIONS Headaches may be a primary disorder, such as migraine, tension type, or cluster, or they may be secondary to a systemic illness or primary central nervous system disorder. The vast 6

7 majority of headaches in children and adolescents are not due to serious underlying problems. When evaluating a youngster with headaches, both physical factors and emotional factors must be considered in order to arrive at the correct diagnosis and to initiate appropriate treatment. Headaches, especially when associated with other somatic complaints, are an important clue for depressive and anxiety disorders. Child psychiatrists and clinicians should look for these underlying issues and help these children with the expression and control of their feelings relevant to worry, separation anxiety, irritability and sadness. The presence of a comorbid psychiatric disorder tends to worsen the course of primary headache by increasing the frequency and severity of attacks, thus making the headaches less responsive to treatment and increasing the risk of chronification. References: Brna, P., Dooley, J.,Gordon, K., Dewan, T. (2005) The prognosis of Childhood Headache, Archives of Pediatrics & Adolescent Medicine, 159: Carey., W. B., Crocker, A. C., Coleman, W. L., Elias, E., Feldman, H. M. (2009) Developmental Behavioral Pediatrics, Saunders Elsevier, Philadelphia, pp , Davis DA, Luecken LJ, Zautra AJ. (2005) Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature. Clinical Journal of Pain.;21: Egger HL, Costello EJ, Erkanli A, Angold A (1999) Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches, Journal of American Academy - Child and Adolescent Psychiatry 38(7): Fuller-Thomson E, Baker TM, Brennenstuhl S. (2010) Investigating the association between childhood physical abuse and migraine., Headache, vol50, pp Graham-Bermann SA, Seng J. (2005) - Violence exposure and traumatic stress symptoms as additional predictors of health problems in high-risk children, The Journal of Pediatrics; 146(3): Gupta S, Mehrotra S, Villalo n CM, (2007) Potential role of female sex hormones in the pathophysiology of migraine, Journal of Pharmacology and Experimental Therapeutics, 113(2):

8 Hockaday J.M. (1988) Migraine in Childhood and Other Non-Epileptic Paroxysmal Disorders, Butterworths. London. International Headache Society (IHS), Headache Classification Subcommittee (2006) The international classification of headache disorders (Cephalalgia), Retrieved May 17, from Kaufman, D. M. (2007) Clinical Neurology for Psychiatrists -6th edition, Saunders Elsevier, Philadelphia, pp Liakopoulou-Kairis M, Alifieraki T, Protagora D et al. (2002) Recurrent abdominal pain and headache-psychopathology, life events and family functioning, European Child and Adolescent Psychiatry 11(3): Oelkers, R., Resch, F. (2004) Headache in Children and Psychiatric Problems, Psychiatric Times. Vol. 21 No. 5 Raphael KG. (2005) Childhood abuse and pain in adulthood: More than a modest relationship? Clinical Journal of Pain, vol 21, pp Rubin D, Suecoff S, Knupp K. (2006) Headaches in children, Pediatric Annals., 35(5): Rutter, M., Bishop, D. V. M., Piine, D. S. (2008) Rutter s Child and Adolescent Psychiatry, Blackwell Publishing Limited, pp Singer, H. S., Kossoff, E.H., Hartman,A.L., Crawford,T.O.(2005) Treatment of Pediatric Neurologic Disorders, Taylor &Francis Group, pp Stafstrom, C.E., Rostasy, K., Minister, A. (2002) The usefulness of children's drawings in the diagnosis of headache, Journal of Neuro-Ophthalmology, Volume 22 - Issue 3 - p 253 Tietjen GE, Brandes JL, Peterlin BL, Eloff A, Dafer RM, Stein MR, Drexler E, Martin VT, Hutchinson S, Aurora SK, Recober A, Herial NA, Utley C, White L, Khuder SA. (2010) Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification, Headache, Jan; 50(1): Wright, K.W., Spiegel, P.H., Thompson, L. S. (2006) Handbook of Pediatric Neuro- Ophthalmology, Springer Science+Business Media, Inc., CA,. U.S.A., pp Wilne, S. H., Ferris R. C., Nathwani, A and Kennedy, C. R. (2006) The presenting features of brain tumors: a review of 200 cases, Published online at BMJ Publishing Group & Royal College of Pediatrics and Child Health. 8

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