Recurrent Headaches in Children:
An Epidemiological Survey of Two
Middle Schools in Inner City ChicagoThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Pain Pract. 2010 (May); 10 (3): 214—221 ~ FULL TEXT
Yaw A. Nyame MHSA, Andrew P. Ambrosy BS, Miguel Saps MD, Papa N. Adams BS,
Gati N. Dhroove MD, Santhanam Suresh MD
Department of Pediatric Anesthesiology Children's Memorial Hospital,
Northwestern University's Feinberg School of Medicine,
Chicago, Illinois 60614, USA.
OBJECTIVES: The aim of this study was to longitudinally evaluate the epidemiological characteristics of headaches in a school-based, community setting and to determine the impact of headache symptoms on the health of children.
METHODS: After institutional review board approval, a prospective cohort study was conducted at two Chicago public schools for a period of 6 months. Members of the research team surveyed both schools weekly for headache and other pain symptoms. The students rated each pain symptom on a 5-point scale from 0 ("not at all") to 4 ("a whole lot"). Demographic information was collected at the time of enrollment, and all participants were asked to complete age-appropriate and validated pediatric surveys to assess the severity of concurrent somatic complaints, anxiety symptoms, functional limitations, and quality of life issues.
RESULTS: Of the participating children, 89.5% reported at least one headache during the study period. Females experienced more frequent headaches compared with males (P < 0.05). Children reporting headaches had a significantly increased risk of experiencing other troubling somatic symptoms (P < 0.05). Headache severity showed a moderate correlation with increased feelings of anxiety, functional disability, and a diminished quality of life (P < 0.05).
CONCLUSIONS: School-aged children commonly experience headaches. Children experiencing headaches are more likely to report other somatic symptoms, feelings of anxiety, functional limitations, and quality of life impairments.
Key Words: headaches, prevalence, children, anxiety,functional disability, quality of life
From the FULL TEXT Article:
INTRODUCTION
Studies conducted worldwide have found headaches to be one of the primary complaints among children. [1–4] In the U.S., it is estimated that headaches are responsible for approximately 2.1 million emergency department visits each year for patients under the age of 18. [5] Research has demonstrated that the prevalence and severity of headaches varies among children by gender, [6] age, [7, 8] and socioeconomic status. [9, 10] In girls, the frequency and severity of headaches is greater following pubertal changes than boys. Conversely, boys typically experience more frequent headaches than girls before the onset of puberty. [7, 11–13] Prior studies have not provided conclusive evidence to support ethnic disparities in headache prevalence or severity. However, there are data showing that several other socioeconomic variables, such as parental income, marital status, and education level, may exert an effect on headache prevalence. [14] Moreover, headache severity is exacerbated by anxiety and/or stress [15–17] and chronic pain problems. [18, 19]
Understanding the instigating factors that increase headache frequency and severity is important due to the negative consequences that headache pain can have on children. Frequent headaches in children are associated with well-documented behavioral problems such as aggression, impulsivity, and inattention. [20] Additionally, there is strong evidence in the existing literature supporting the notion that chronic headaches pose the greatest physical, psychological, and social threat to children. [14, 17, 21, 22]
This study explored the dynamic attributes of headaches through a prospective cohort study of school-aged children. The research team aimed to determine the epidemiological characteristics of headaches in the cohort and to evaluate the impact of headaches on concurrent somatic symptoms, the state and trait of anxiety, functional limitations, and quality of life.
METHODS
After institutional review board (IRB) approval, a prospective cohort study was conducted at two ethnically and socioeconomically diverse Chicago Public Schools (WLNA and LMAS). All 3rd to 8th grade students and their parents/guardians received an invitation to participate in this prospective cohort study. Consent and assent (in children over 12) forms were obtained by one of the investigators. The study objectives were not revealed to the children or their parents, and there were no exclusion criteria for enrollment.
Data Collection
Between January and June of 2006, members of the research team visited each school in the middle of the week to administer a brief, confidential survey. The study questionnaire asked participants if they had experienced headaches, chest pain, stomach pain, or limb pain during the previous week. The students rated their pain on a 5-point scale, from 0 (“not at all”) to 4 (“a whole lot”) based on the Children’s Somatization Inventory (CSI). [23] It was explained to the students that “not at all” represented no pain and “a whole lot” was equivalent to maximum pain.
Epidemiological Analysis
Based on the weekly questionnaires, the prevalence and severity of headaches was determined. The proportions of children experiencing headaches for 4, 8, and 12 consecutive weeks were calculated as a proxy for headache chronicity. To minimize the effect of school absenteeism, consecutive weeks were defined as time periods in which study participants completed 75% or more of the total number of surveys administered.
For each student enrolled in the study, the total number of headaches and a pain score were determined for the entire study period. The pain score was simply the average of all headache scores reported during the study period. The Pearson correlation coefficient was calculated to define the relationship between the pain score and the number of headaches reported for the entire duration of the study.
Demographic data, including age, gender, and ethnicity, were recorded for all willing study participants. The effects of age, sex, and ethnicity on headache frequency and severity were determined using an unpaired, twotailed Student’s t-test. Site-related differences between the two schools participating in the study were also analyzed using an unpaired, two-tailed Student’s t-test. This and all subsequent statistical analysis was completed using JMP—Version 7, SAS system (Cary, NC, U.S.A.).
Measures of Concurrent Pain Symptoms, Psychological Impact, and Quality of Life
All study subjects completed the CSI, [23] the State-Trait Anxiety Inventory for Children (STAIC), [24] the Pediatric Functional Disability Inventory (PFDI), [25]and the Pediatric Quality of Life Inventory (PEDSQL) [26] version 4 at the time of enrollment.
CSI. CSI is designed to assess the severity of somatic symptoms (ie, “faintness or dizziness,” “sore muscles,” etc.) that do not require an organic disease etiology. Study participants rated each of 31 symptoms on a scale ranging from 0 (“not at all”) to 4 (“a whole lot”). The number of reported somatic symptoms irrespective of the severity (range 0 to 31) and a total score taking into account both the number and the severity of symptoms (range 0 to 124) were calculated. The Pearson correlation coefficients between both objective measures and headache pain were determined. Positive correlations signified a direct relationship between headache pain scores and concurrent somatic symptoms.
State-Trait Anxiety Inventory for Children. The survey consists of two scales: the S-anxiety scale and the T-anxiety scale, each of which is comprised of 20 statements designed to measure the Diagnostic and Statistical Manual of Mental Disorders defined symptoms of anxiety. [24] The S-anxiety scale is designed to measure transitory anxiety states that fluctuate over time, while the T-anxiety scale is intended to measure stable differences in anxiety that are fixed over time. For both scales, each statement was rated from 1 to 4, with higher scores indicating higher levels of anxiety. The responses were summed for total values for both scales for each participant. The Pearson correlation coefficient between the S-anxiety and T-anxiety scales and headache pain scores was calculated. Positive values indicated a direct correlation between headache severity and anxiety.
Pediatric Functional Disability Inventory. The PFDI assesses health-related difficulties in physical and psychosocial functioning in children. The survey consists of 15 potential activity limitations rated on a scale of 0 to 4. Total scores were calculated by summing the rating for each item. The total score had a potential range of 0 to 60 with higher values indicating greater functional disability. The Pearson correlation coefficient between the total scores and headache pain scores was determined. Positive correlations corresponded to a direct relationship between headache severity and functional limitations.
Pediatric Quality of Life Inventory. The PEDSQL is a modular survey that measures physical, emotional, social, and school functioning. A total of 23 items are rated on a scale of 0 to 4 and converted to a reverse score of 0 to 100 where 0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0. On the 100-point scale, higher numbers correspond to a greater quality of life. The total scale score was computed by averaging the rating for each survey item. The relationship between the average PEDSQL scale values and headache pain scores was assessed using the Pearson correlation coefficient. For consistency and comprehensibility, the inverse of the correlation coefficient was reported. Using this convention, a positive correlation denoted a direct relationship between headache pain score and decreases in quality of life.
RESULTS
Four hundred and ninety-five students were eligible to participate in the study. Two hundred and thirty-seven children, representing 48% of the eligible subjects, were enrolled in the study. An average of 208 students (88%) completed the survey each week, and all enrolled participants completed the study.
The average age of the students was 11.75 years (SD ± 1.59 years, range of 8 to 15 years of age). The gender composition of the cohort was 131 females and 105 males. One student did not provide any demographic information. The self-reported ethnicities of the cohort were 33% Black, 22% Hispanic, 21% Caucasian, 8% Asian, 13% other, and 3% not recorded.
Headache Epidemiology
Table 1
Figure 1 89.5% of children reported experiencing at least one headache during the study period. The overall weekly prevalence of headaches among the students was 38.2%. Fifty-four percent of the participants experienced headaches for 4 consecutive weeks, 30.4% for 8 consecutive weeks of headaches, and 22.8% for 12 consecutive weeks (Table 1).
In general, children reported low headache pain scores. The mean of headache scores for the cohort was 0.6 (SD ± 0.73, range of 0 to 4). Statistical analysis showed a strong correlation (R = 0.80) between the headache pain score and the total number of headaches reported (Figure 1).
Demographic Differences in Headache Epidemiology
There was not a significant difference between the two schools (WLNA and LMAS) in the total number of headaches or headache pain scores reported. Furthermore, with one exception, there were no age or ethnicity-related differences in the total number of headaches or the pain scores reported by study participants. There was a significant difference between Blacks and Hispanics (P < 0.05), with Blacks reporting 37% fewer headaches than Hispanics. Interestingly, female study participants reported more headaches than males (P < 0.05). The girls also reported greater pain scores than boys; however, the difference was not statistically significant.
Concurrent Somatic Symptoms
Table 2 The average number of somatic symptoms reported was 8.97 (SD ± 6.77, range 0 to 31) for the study population (Table 2). There was a statistically significant correlation (R = 0.44, 95% CI: 0.31 to 0.54) between headache pain scores and the number of concurrent somatic symptoms reported. There were no statistically significant gender differences in the correlations. Similarly, the average total score for the CSI, reflecting number and severity, was 13.73 (SD ± 15.31, range 0 to 104) for the cohort. Total score and headache pain score were also directly related (R = 0.50, 95% CI: 0.38 to 0.60) and the magnitude of the correlation was comparable for boys and girls.
Headache-Related Anxiety
The data revealed a weak association between the headache pain score and a state of anxiety as measured by the S-anxiety scale (R = 0.23, P <0.05). Interestingly, there was a stronger association between headache pain scores and trait anxiety as calculated by the T-anxiety scale (R = 0.45, P < 0.05).
Quality of Life and Headaches
Table 3
Table 4
Table 5
Table 6 The PFDI mean sum total for the cohort was 7.00 (SD ± 7.61, range 0 to 41) (Tables 3 and 4). There was a moderate correlation (R = 0.53, 95% CI: 0.42 to 0.63) between headache pain scores and the presence of functional disability, which was consistent across girls and boys. Study participants also reported an average total score of 85.17 (SD ± 13.37, range 26.09 to 100) for the PEDSQL (Tables 5 and 6). Similarly, there was a moderate correlation (R = 0.48, 95% CI: 0.36 to 0.59) between headache pain scores and decreases in quality of life. This finding was also independent of gender.
DISCUSSION
The primary objective of this study was to characterize the epidemiology and the social impact of headaches on school-aged children through a large, prospective, community-based cohort study. Eighty-nine percent of the students surveyed reported experiencing at least one headache during the 6-month study period. Current research protocols for children and adults define chronic headaches as 5 or more days with headache symptoms each week. [27] It was not possible to quantify headache chronicity in this study based on this criterion because the data were not collected on a daily basis. However, it is important to note that 30% of study participants experienced headaches for 8 or more consecutive weeks. These findings are consistent with prior research and indicate that headaches are one of the principle chronic pain symptoms experienced by children. [28, 29]
The data also showed that girls reported experiencing headaches more frequently than their male peers. Previously conducted studies have found that headaches tend to occur more frequently in boys than in girls prior to puberty, while the opposite is true during and following pubertal changes. Unfortunately, the research team did not collect data on the pubertal status of study participants and therefore could not definitively assess the relationship between puberty and gender-related differences in headache frequency. However, based on the average age of study subjects (11.75 years, range 8 to 15 years, SD ± 1.59 years), it is probable that this relationship existed in our study population as well, explaining the fact that girls reported a greater total number of headaches for the entire duration of the study.
In contrast to gender, the research team did not find any age-related differences in the total number of headaches or the average headache pain score. The absence of an age effect is not surprising because the age distribution of study participants was narrow. Similarly, with one exception, the research team did not find significant differences between ethnic groups in headache epidemiology. In contrast, a previous study investigating racial and ethnic differences in the physical pain symptoms reported by adolescents found the prevalence of recurrent headaches to be highest in Caucasians and lowest in Asians. [9] However, the impact of race and ethnicity on headache epidemiology is difficult to assess and is likely complicated by confounding socioeconomic factors such as family income and parental education level.
It is noteworthy that this study found that experiencing headache symptoms moderately correlated with experiencing additional undesirable somatic symptoms as measured by the CSI. This finding has important implications and demonstrates that headache symptoms rarely occur in isolation and are more often found to be part of a constellation of distressing somatic symptoms. Interestingly, there was a moderate and statistically significant association between anxiety and headache pain in the cohort. This finding is consistent with the outcome of a previous study measuring the impact of headache pain on anxiety using the Spielberg STAIC questionnaire. [30] A final important outcome of this study is the finding that headaches showed a modest correlation with alterations in quality of life. It is possible that this correlation would have been stronger if the PFDI and PEDSQL had been administered each week for the entire duration of the study. Nonetheless, this confirms earlier studies utilizing the PFDI and PEDSQL surveys, which have found frequent and severe headaches to be associated with significantly increased functional disability and decreased quality of life. [31–33] It is interesting to note that although girls reported experiencing a statistically significant greater total number of headaches, this study found that the functional limitations and quality of life impairments resulting from severe headaches is a relatively genderindependent phenomenon.
There are several methodological strengths of this study including its prospective design and community setting. In addition, the data were collected from two socioeconomically diverse Chicago public schools, which are exemplary of the social, racial, and economic variability of other inner-city populations. There were no statistically significant differences between the two study sites in the total number of headaches or the average headache pain score reported. This observation further substantiates the notion that the findings in this cohort are somewhat representative of other populations of inner-city school children in the U.S.
The research group recognized the possibility for recall bias and put several measures in place to increase the accuracy and reliability of the answers provided by the students. First, the students were only asked to retain information for the previous week. Second, instructions were provided to the participants before and during the completion of each weekly questionnaire. Third, members of the research team were available on-site to answer questions while students filled out the surveys. The research personnel were also able to check the questionnaires as students completed them, allowing members of the research team to immediately address any incomplete surveys. These precautions were integral to obtaining a high percentage (88%) of completed data throughout the study.
In addition, approximately 50% of eligible students enrolled in the study. Although incomplete participation presented the possibility of selection bias, concealing the objectives of the study from the students and their parents minimized this potential concern. Prior to study enrollment, families were informed that the research team was interested in collecting epidemiologic data on general childhood symptoms, including headache and other pain symptoms. Nonetheless, the research team recognizes that families with sicker children or healthconscious parents could have enrolled their children in the study with greater frequency. Similarly, it is also possible that sicker children may have missed the opportunity to enroll in the study due to school absenteeism. The research team attempted to compensate for this potential bias by allowing children who missed the first week of the study to enroll in the study during subsequent weeks.
A potential limitation of the data is the absence of diagnoses, such as the International Classification of Headache Disorders published by the International Headache Society. Collecting accurate and reliable headache diagnoses directly from study participants and/or their parents would have necessitated assuming an adequate level of health literacy in the cohort. In fact, a recent critical review of the literature focusing on the impact of headaches on quality of life in children found that less than half of the 33 studies reviewed included headache diagnoses. [34] Furthermore, the majority of the studies offering diagnostic categories did not provide defined diagnostic criteria. It is our opinion that assigning formal headache diagnoses is at best not desirable and at worst not reliable. In a community setting, children and adolescents are affected by the burden of headache and somatic symptoms. In contrast, formal diagnoses are best made in a clinical setting where they take on meaning with respect to prognosis and treatment.
In conclusion, this study demonstrates that headaches are a common complaint among children. A significant subset of the cohort reported experiencing headaches in successive weeks, suggesting that headache symptoms were a chronic problem for many study participants. Finally, this study found headaches to be associated with concurrent somatic symptoms, feelings of anxiety, functional restrictions, and a discernibly diminished quality of life. Consequently, early headache recognition and treatment may represent an important means for improving the physical and psychosocial health of children and adolescents.
ACKNOWLEDGMENTS
This research was funded in part by a FAER-MSARF grant, American Society of Anesthesiology, 2008.
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