Why are headaches becoming more common in children?

Abstract

Headache is a symptom, not a disease or disorder itself. There are many causes of headaches in children, the most common of which are: migraine, tension-type headaches, headaches as a symptom of viral infections, or upper respiratory tract infections (ear, sinus, throat infections, colds, allergies) or as a result of mild to moderate head injury. A small number of children with headaches have a serious underlying cause, such as a brain tumor or life-threatening infection. They are recognized by symptoms of increased intracranial pressure (ICP) and progressive neurological dysfunction. These children report that the pain is becoming more intense and frequent, wakes them up at night or occurs immediately upon waking, and is accompanied by vomiting. They often describe it as “the worst headache ever” and then require hospital treatment and brain imaging.

Chronic daily headaches (CDH) are increasingly common in children today. According to the International Classification of Headache Disorders (ICHD-3), these are recurrent headaches that last longer than 2 hours a day, more than 15 days a month, for longer than 3 months in total, and include five headache subtypes: transformed (chronic) migraine, chronic tension-type headache, new persistent daily headache, hemicrania continua, and comorbid/mixed headache (migraine and tension-type). In our experience, chronic tension-type headaches are the most common, but we are increasingly seeing children with mixed comorbid migraine and tension-type headaches. Of course, chronic pain interferes with children's daily activities and causes frequent absences from school, extracurricular sports, and other activities, and causes disruption of interpersonal relationships, personal and family relationships, as well as the "child-teacher" relationship, which often requires psychological treatment and support. About 75 % of children with KDG have chronic tension-type headaches, and about 7 - 10 % have migraine. It is believed that they are dealing with "sickness behavior" in which a headache, as a physical symptom, is an expression of some internal conflict or fear.

Children with KDG have significant comorbidities: impaired functional ability and quality of life, which is a risk for psychiatric disorders and depression. Research by various authors has shown that 29 - 47 % of children with KDG have one or more psychiatric disorders: most often anxiety, mood disorders, juvenile bipolar disorder, and an increase in suicides.

Another comorbidity is a sleep disorder. About 30 - 55 % of children with KDG have a sleep disorder, difficulty falling asleep, insufficient sleep, sleep-related anxiety, restless sleep parasomnias (sleepwalking, nightmares), and consequent daytime fatigue. The headache can cause a sleep disorder when headache episodes occur during sleep (migraine, cluster, and chronic paroxysmal hemicrania occur in REM sleep, while migraine occurs in slow-wave sleep). On the other hand, sleep deprivation or prolonged sleep can trigger headaches, and we know that sleep is important for migraine recovery.

The association between KDG and epilepsy has been described. The prevalence of epilepsy in children with migraine is 1 %, and the prevalence of migraine in children with epilepsy is 12 %. The risk of unprovoked seizures is increased in children who have migraine with aura (M/A) but is not present in children with migraine without aura (M/O). The risk of migraine is twice as high in children with epilepsy compared to those without epilepsy. About 62 % of children with epilepsy have postictal headaches, 57.6 % have interictal headaches, and 30 % have preictal headaches. (DeSimone et al., 2007.). Pathophysiologically, it is assumed that migraine causes cerebral ischemia or cerebral damage and the resulting epilepsy or seizures trigger a headache episode, often with migraine characteristics, by activating the trigeminovascular system.

Other comorbidities in children with headache (CHD) include: ADHD, learning disabilities, stuttering, anemia, asthma, and other atopic and intestinal diseases, as well as obesity. The pathophysiology of migraine has been linked to central and peripheral pathways that regulate feeding. It is believed that the neurotransmitter serotonin and the adipocytokines adiponectin and leptin play a role in the feeding process and migraine. There is a known positive relationship between migraine and body mass index (BMI), and weight loss reduces the frequency of migraine.

School is an important part of a child's life and world. School functioning is one of the most important life domains in children affected by chronic pain. Chronic headache represents a great burden for children, limiting them in academic, social, and recreational activities, more than children with other chronic diseases: tumors, diabetes, or cardiomyopathy.

Several studies have examined the impact of headaches (especially migraines) on school performance. The results indicate lower long-term and short-term memory, lower performance in selective and alternative attention, and dysfunction in information processing. Cognitive impairment in the group of children with headaches is associated with an earlier onset of headaches and a higher frequency of pain attacks. Most studies have shown that learning difficulties were much more common in the group of children with migraine compared to tension-type headaches, and in the group of children with longer headache duration and higher frequency of headache episodes (more than 10x per month). Studies have also shown that the prevalence of headaches increases with the age of the child. The prevalence is higher in girls compared to boys, but no difference in prevalence was found among industrialized countries. This is a consequence of earlier brain maturation and various external factors, the most commonly mentioned of which are: increased school stress, little rest and relaxation (free time for yourself, without obligations), high parental expectations, changes in lifestyle and habits: increased consumption of alcohol, coffee, tobacco and narcotics that trigger headaches, long-term listening to music, loss of pleasure and happiness, lack of physical activity, obesity, changes in social interaction at school and negative attitudes and treatment by teachers. Namely, studies have shown that 25 % of children who feel that their teachers do not accept them will develop recurrent headaches, and if they feel loved by their teachers, they will reduce the risk of recurrent headaches by >40 %. Family stress, conflicts, or parental divorce also increase the risk of headaches. We are witnessing an increasing incidence of physical, emotional, sexual, or online violence at school, which has been identified as one of the important risk factors for the occurrence of headaches. These differences in stressful lifestyles, which are the reason for the increase in headache frequency, are most pronounced in the United States, then in Europe, and least in Asia.

Frequent headaches in children increase the risk of chronic headaches in adulthood. Given such a negative impact of headaches on children, on the WHO scale of causes of disability, headaches are ranked among the top ten in both sexes and among the top five causes of disability in women.

According to our experience and the examples that I will present in the lecture, headaches in children, especially chronic daily headaches, are a great diagnostic and therapeutic challenge and require a lot of patience and time, a detailed history, clinical and neurological examination, headache diary, psychological assessment and support, and, if necessary, brain imaging studies. Encouraging parents and a non-punitive attitude, as well as understanding teachers and educators, reduce the risk and frequency of headaches, which implies an interdisciplinary approach to the treatment of headaches in children.