Research Submissions

The Associations Between Headaches and Psychopathology:A Survey in School Childrenhead_1781 1537..1548

Isabelle Pitrou, MD, MSc; Taraneh Shojaei, MD; Christine Chan-Chee, MD; Ashley Wazana, MD, FRCP;Anders Boyd, MSc; Viviane Kovess-Masféty, MD, PhD

Background.—Headaches are common in childhood and significantly impact children’s quality of life. On the contrary tothe adolescent and adult population, there are few data on the associations between headaches and psychopathology in youngchildren.

Objective.—The aim of this study was to examine the relationships between child headaches, emotional and behavioraldifficulties in children aged 6-11 years old.

Methods.—A cross-sectional survey was conducted in 2004 in 100 primary schools from a large French region, with 2341children aged 6-11 years old randomly selected. Child headache status, comorbid physical conditions, and socioeconomiccharacteristics were collected in parent-administered questionnaires. Child psychopathology outcomes were assessed usingchild- and parent-reported standardized instruments: respectively, the Dominic Interactive and the Strengths and the Difficul-ties Questionnaire. Associations were estimated using logistic regression models.

Results.—Response rates to the parent questionnaire and the Dominic Interactive were 57.4% and 95.1%, respectively.The final sample size was 1308 children. Eleven percent of the children already experienced frequent headaches in their lifetime,with no difference by age or gender. Headaches were associated with parent-reported emotional problems (OR = 1.76; 95% CI:1.03-3.01) and self-reported general anxiety disorder (OR = 1.99; 1.13-3.52). Comorbid physical conditions �2 appeared as anindependent factor significantly associated with headaches (OR = 1.75; 95% CI: 1.13-2.73). Inversely, low parental punitivebehaviors were less frequently associated with headaches (OR = 0.41; 95% CI: 0.18-0.94).

Conclusion.—Our results suggest some associations between headaches, emotional disorders, and comorbid physicalconditions in young children aged 6-11 years old. Those results should be considered in the treatment approaches of childhoodheadaches and from the etiological aspect.

Key words: headaches, mental health, comorbidity, cross-sectional survey, primary school children

From the EA 4069 Paris Descartes University, Ecole des Hautes Etudes de Santé Publique (EHESP), Paris, France (I. Pitrou, A.Boyd, and V. Kovess-Masféty); Direction Médicale et Scientifique, Pôle Evaluation, Agence de la Biomédecine, Saint-Denis LaPlaine, France (T. Shojaei); French Institute for Public Health Surveillance, Saint Maurice, France C. Chan-Chee; Department ofPsychiatry, Jewish General Hospital, McGill University, Montreal, QC, Canada (A. Wazana); University Pierre et Marie Curie(UPMC), Inserm UMR-S 707 (A. Boyd).

Funding/financial support: The MGEN Foundation for Public Health (Mutuelle Générale de l’Education Nationale), MAE, MAIFFoundation, FNMF and the PACA Regional Directorate for Health and Social Affairs (DRASS Provence-Alpes Côte-d’Azur).

National Committee for Information and Liberty authorization number: no. 04-1112.

Address all correspondence to Viviane Kovess, EA 4069 Paris Descartes University, Ecole des Hautes Etudes de Santé Publique(EHESP), Hôtel Dieu, 1 place du parvis de Notre Dame, 75181 Paris Cedex 04, France.

Accepted for publication August 3, 2010.

Conflict of Interest: None.

ISSN 0017-8748doi: 10.1111/j.1526-4610.2010.01781.xPublished by Wiley Periodicals, Inc.

Headache© 2010 American Headache Society

1537

Abbreviations: ADHD attention deficit/hyperactivity disorder, CD conduct disorder, CI confidence interval, DI DominicInteractive, DSA Disadvantaged School Areas, DSM-IV Diagnostic and Statistical Manual – 4th revision, GADgeneralized anxiety disorder, OR odds ratio, PACA Provence-Alpes-Côte-d’Azur, SAD separation anxietydisorder, SD standard deviation, SDQ Strengths and Difficulties Questionnaire

(Headache 2010;50:1537-1548)

Primary headaches are the most frequent neuro-logical symptom and the most common manifestationof pain in childhood.1 They contribute to missedschool days, affect children’s peer and family relation-ships, and significantly impair children’s quality oflife.2-4 Headaches in children have a high risk of devel-oping into a chronic condition and tend to persist intoadulthood.5,6 The psychiatric comorbidity is an impor-tant risk factor for chronicization of headaches inadulthood.6,7

Previous studies that examined the associationsbetween psychopathology and headaches havereported associations between headaches and inter-nalizing disorders (particularly depression andanxiety) in the adult and adolescent population.7-13

Very few studies have examined those associations inyoung children aged 6-11 years, and the preexistingresearch is hampered by some methodological limi-tations. First, most studies have been conducted onclinical samples of children referred for headachesand this may not reflect what is seen in the generalpopulation (ie, differences in disease severity andtypes of headaches).6,7,10,11 Second, few studies haveassessed self-reported psychopathology in young chil-dren as most instruments available are designed forchildren aged �9 years.14 Studies that examined therelationship between headaches and mental health inyoung children frequently used instruments com-pleted by the parents only (eg, Child Behavior Cleck-list [CBCL], Strengths and Difficulties Questionnaire[SDQ]).7-12,15 Strine et al used the parent-ratedversion of the SDQ to screen a large sample of chil-dren (4-17 years) for psychological problems andfound significantly higher levels of psychological dif-ficulties in subjects with headaches compared withparticipants without headaches.15 Recently, Milde-Busch et al used the self-rated version of the SDQ toassess the impact of headache on psychopathologicalsymptoms in adolescents and confirmed the associa-

tion between headaches and psychological symp-toms.13 However, their results were limited toadolescents aged 13-17 years old, with no informationfor younger children.

In order to add evidence to the preexistingresearch, we examined the associations betweenheadaches and child psychopathology in a largepopulation-based survey of primary school childrenaged 6-11 years old. The objectives were (1) to esti-mate the lifetime prevalence rate of headaches; (2) toexamine the associations between headaches andchild psychopathology, using both parent- and child-reports of psychopathology, parent-reports of head-ache status, and adjusting on a large range of potentialconfounding factors (ie, sociodemographic charac-teristics and parental behaviors). Our main studyhypothesis is that childhood headaches might be asso-ciated with significant psychopathological symptomsin young children aged 6-11 years.

MATERIALS AND METHODSSample.—A cross-sectional survey was conducted

in 2004-2005 in the South of France, Provence-Alpes-Côte-d’Azur region (PACA). To ensure representa-tiveness across the 1856 schools of the area(approximately 296,257 pupils), a stratified 2-levelprobability sample was selected with randomizationof 100 primary schools and 25 children per school (5from each of grades 1 to 5). Randomization was strati-fied on the following school characteristics: public/private, rural/urban, and Disadvantaged School Areas(DSA)/no DSA. In France, DSA were defined in 1982by the Ministry of Education on the basis of lowsocioeconomic status, low educational level, and highunemployment rate. Of the 100 primary schoolsselected, 99 accepted to participate. Some schools,mostly in isolated rural zones, had less than 25 chil-dren. Contacts were achieved for 2341 children,among whom 2324 met the inclusion criteria for the

1538 November/December 2010

age range 6-11 years. Further details about the sam-pling method are available in previous reports.16,17

The research was approved by the ethics commit-tee of the National Committee for Information andLiberty (authorization number: 04-1112). Informa-tion letters about the objectives of the study andrefusal forms were delivered before the survey to allparents of the selected schools and anonymity wasguaranteed.The authors had full access to all the datain the study and take responsibility for the integrity ofthe data and the accuracy of the data analysis

Questionnaires.—The headache status of childrenwas assessed in the parent questionnaire by askingthe following “yes” or “no” question: “Since his/herbirth, did your child have frequent headaches, includ-ing migraines?,” together with the lifetime childcomorbid physical conditions (asthma, bronchitis, earnose throat infections, allergies, dermatitis). Thepotential confounders and mediators were obtainedfrom the parent questionnaires and included: (1)sociodemographic characteristics, ie, parental educa-tional level (highest level among parents), unemploy-ment (either parent), household monthly income,family structure (single- or 2-parent); (2) traumaticlife events (Life Events Checklist);18 (3) parentingstyle, ie, the frequency over the past 12 months ofcaring behaviors, punitive behaviors, autonomy-promoting attitudes (Parent Behaviors and AttitudesQuestionnaire),19 and an overprotective attitudesscale adapted from the Diagnostic and StatisticalManual – 4th revision (DSM-IV) criteria of separa-tion anxiety disorder (SAD).20 The parenting atti-tudes were rated on 5-point Likert scales. The childacademic achievement was reported by the teachers(by comparison of the child’s overall performance tothat of other classmates) and by the parents (reportsof grade repetition).

The parent questionnaires were mailed withpostage paid return envelopes and were to be com-pleted by the parent who spent the most importanttime with the child. The teacher questionnaires weredelivered at school by a research assistant.

Psychopathology Assessment.—The psychopathol-ogy outcomes were assessed using the validatedFrench version of the parent-reported SDQ,17 and thechild-reported Dominic Interactive (DI).16,21 Both

instruments have shown satisfactory psychometricproperties in our sample, with notably Cronbach’s acoefficients ranging from 0.62 to 0.89 for the DI and0.46 to 0.74 for the SDQ subscales.16,17

The parent-reported SDQ is a brief psycho-pathology screening questionnaire divided into 5subscales (emotional problems, hyperactivity-inattention, conduct problems, peer relationshipdifficulties, and prosocial behaviors).22 The SDQsubscales scores – except for the prosocial score – addup to a total difficulties score (range 0-40). Thescoring algorithms available on the SDQ website(http://www.sdqinfo.com/ScoreSheets/e1.pdf) wereused to classify subscale scores as “normal” (approxi-mately 80% of the distribution), “borderline” (10%)and “abnormal” (10%). As the subscale “emotionalproblems”of the SDQ included headaches (“I get a lotof headaches, stomachaches or sickness”), we treatedthis item as a missing value to avoid mixing betweenthe exposure and the outcome. This procedure hasbeen reported by Milde-Busch et al13 and was possiblebecause the SDQ can be analyzed even if 1 or 2 itemsof each scale are missing23 http://www.sdqinfo.org/. Inthis study, the SDQ was included in the parentquestionnaires.

The DI is a computer-based instrument (91cartoon-based questions) that generates probabilitydiagnoses for the most prevalent DSM-IV disorders,ie, specific phobia, major depressive disorder, SAD,generalized anxiety disorder (GAD), attentiondeficit/hyperactivity disorder (ADHD), oppositionaldefiant disorder, and conduct disorder (CD). It alsoincludes a strengths and competencies scale that dis-plays 10 positive situations. Validated cut-off pointswere used to determine 3 diagnostic probabilitycategories: “likely absent,” “possible,” and “likelypresent.”21 Children completed the DI on a computerstation at school under the supervision of a researchassistant.

Statistical Analysis.—Prior to statistical analysis,weighted prevalence rates were calculated with eachsubject being assigned a weight computed as theproduct of the inverse probability of being selected inthe survey. Parent response rates were compared onschool characteristics, child age, and gender to assesspotential nonresponse bias. As reported by Bergeron

Headache 1539

et al, z-scores were computed for each parentingdimension and were transformed into categoricalvariables as followed: “high” (z-score > standarddeviation [SD]), “average,” and “low” (z-score < SD)behaviors. Monthly income was computed into a cat-egorical variable (“low,” “middle,” “high”) accordingto the 25th and 75th percentiles of their distributions.The number of comorbid physical conditions was cat-egorized into 0-1 and �2. Chi-square tests were usedto compare frequencies. Multivariate logistic regres-sions were used to examine the associations betweenchild headaches (the dependent variable) and psy-chopathology (SDQ and DI).Variables in the univari-ate analysis with P values of <.20 and the potentialconfounders and mediators (age, gender, socioeco-nomic status) were included in the adjusted logisticmodels. The odds ratios (OR) for associations andtheir 95% confidence intervals (95% CI) are reportedfor univariate comparisons and adjusted logisticmodels. We tested the potential interactions betweengender, age, and mental health psychopathologies inour logistic models and found no interaction. Theassociations between headaches, the SDQ, and the DIprobability diagnoses were reported in the same sta-tistical model; those associations were tested for theSDQ and the DI separately and the results weresimilar (data not shown). The estimates reported intables excluded missing data. All statistical analyseswere performed using Stata 9.2 (Stata Corporation,College Station, TX, USA).

RESULTSAmong the 2324 eligible children, the response

rates to the parent questionnaire and the DI were57.4% (n = 1334) and 95.1% (n = 2210), respectively.Parent-reports of headaches status were availablefor 1308 children (missing data = 26). The parentresponse rate was less elevated in DSA (47.8% vs59.0%; P < .001). There was no statistical differencebetween private/public, rural/urban school setting,child gender, and age.

Table 1 describes sociodemographic characteris-tics of children in the PACA regional sample. Mostresponding parents (85.0%) were mothers, and theirmean age was 38.3 years (SD = 5.7). The child male/female sex ratio was 1.00 (556/552). According to

parent-reports, approximately 10.9% (95% CI: 9.1-12.7) of children had experienced frequent headachesin their lifetime (Table 2). There was no statisticaldifference of headaches prevalence between boys andgirls (respectively 10.7% and 11.1%; P = .81) and

Table 1.—Sociodemographic Characteristics in a FrenchRegional Sample of Children Aged 6-11 Years (N = 1308)

N (%)

ChildrenAge (years)

6 225 (17.2)7 265 (20.2)8 269 (21.6)9 249 (18.0)10-11 300 (23.0)

GenderBoys 656 (50.7)Girls 652 (49.3)

Single child 237 (18.4)Already repeated 1 school grade 99 (8.3)Low academic achievement† 146 (11.7)Traumatic life events �1 (lifetime) 652 (51.1)

ParentsSingle-parent family 168 (13.1)Monthly income (per capita)

Median (IQR) 1249 (1125)<National poverty line‡ 202 (18.0)

Low education (<high school) 469 (37.1)Unemployment (either parent) 155 (12.5)Punitive behaviors

Low 199 (15.2)Average 899 (70.6)High 176 (14.2)

Caring behaviorsLow 221 (17.0)Average 847 (65.7)High 228 (17.3)

Autonomy-promoting attitudesLow 220 (16.9)Average 864 (67.1)High 214 (16.0)

Overprotective attitudesLow 272 (20.6)Average 852 (64.6)High 184 (14.8)

SchoolsDisadvantaged School Area 131 (10.0)Rural setting 209 (7.8)Public schools 1139 (89.0)

†Teacher-report.‡Compared with the national poverty standard of 646 Eurosper month per capita.IQR = interquartile range.

1540 November/December 2010

Table 2.—Prevalence of Childhood Headaches, Comorbid Physical Conditions, and Mental Health Problems by Gender in aFrench Regional Sample of Children Aged 6-11 Years (N = 1308)

Caseness

N (%)

P valueMale Female Total

Headaches 64 (10.7) 75 (11.1) 139 (10.9) 0.81Comorbid physical conditions �2 292 (45.4) 269 (39.5) 561 (42.5) 0.04Child-report (Dominic Interactive)

GAD Normal 530 (80.6) 499 (76.0) 1029 (78.3) 0.14Possible 64 (9.9) 84 (13.3) 148 (11.6)Likely present 62 (9.5) 69 (10.7) 131 (10.1)

SAD Normal 526 (80.1) 481 (73.4) 1007 (76.8) 0.002Possible 48 (7.4) 87 (13.6) 135 (10.4)Likely present 82 (12.5) 84 (13.0) 166 (12.8)

SPh Normal 482 (73.4) 368 (55.2) 850 (64.4) 0.001Possible 101 (15.9) 203 (32.1) 304 (23.9)Likely present 73 (10.8) 81 (12.7) 154 (11.7)

MDD Normal 541 (82.7) 540 (82.4) 1081 (82.6) 0.22Possible 53 (7.7) 62 (10.0) 115 (8.8)Likely present 62 (9.6) 50 (7.6) 112 (8.6)

ADHD Normal 513 (77.6) 550 (84.0) 1063 (80.8) 0.02Possible 72 (11.8) 56 (8.9) 128 (10.3)Likely present 71 (10.6) 46 (7.1) 117 (8.9)

ODD Normal 500 (77.0) 540 (82.0) 1040 (79.5) 0.09Possible 88 (12.5) 58 (9.1) 146 (10.8)Likely present 68 (10.5) 54 (8.9) 122 (9.7)

CD Normal 485 (73.7) 547 (83.3) 1032 (78.4) 0.001Possible 91 (14.4) 66 (10.8) 157 (12.6)Likely present 80 (11.9) 39 (5.9) 119 (9.0)

Strengths and competencies Normal 557 (84.1) 572 (86.9) 1129 (85.4) 0.40Possible 55 (8.9) 43 (7.1) 98 (8.0)Likely present 44 (7.0) 37 (6.0) 81 (6.5)

Parent-report (SDQ)Emotional problems Normal 564 (86.4) 555 (85.9) 1119 (86.2) 0.80

Borderline – – –Abnormal 88 (13.6) 92 (14.1) 180 (13.8)

CD Normal 475 (71.8) 518 (79.8) 993 (75.7) 0.001Borderline 81 (12.6) 73 (11.3) 154 (12.0)Abnormal 98 (15.6) 56 (8.9) 154 (12.3)

Peer relationship difficulties Normal 462 (70.3) 469 (72.3) 931 (71.3) 0.43Borderline 87 (13.3) 91 (14.0) 178 (13.6)Abnormal 105 (16.4) 87 (13.7) 192 (15.1)

Hyperactivity-inattention Normal 486 (74.8) 547 (85.1) 1033 (79.9) 0.001Borderline 62 (9.7) 46 (7.1) 108 (8.4)Abnormal 106 (15.4) 53 (7.8) 159 (11.7)

Prosocial behaviors Normal 422 (64.3) 484 (74.2) 906 (69.2) 0.001Borderline 109 (16.8) 87 (14.0) 196 (15.4)Abnormal 122 (18.9) 73 (11.8) 195 (15.4)

Total difficulties Normal 512 (78.9) 564 (87.0) 1076 (82.9) 0.001Borderline 55 (8.3) 40 (6.4) 95 (7.4)Abnormal 85 (12.8) 42 (6.6) 127 (9.8)

ADHD = attention deficit/hyperactivity disorder; CD = conduct disorder; GAD = generalized anxiety disorder; MDD = majordepressive disorder; ODD = oppositional defiant disorder; SAD = separation anxiety disorder; SDQ = Strengths and DifficultiesQuestionnaire; SPh = specific phobia.

Headache 1541

between 6- to 8- and 9- to 11-year-old children(respectively 10.4% vs 11.7%; P = .47). The meannumber of comorbid physical conditions was 1.51(SD = 1.37) and the lifetime prevalence of childrenwith �2 comorbid physical conditions was 42.5%.Theprevalence for the mental health problems accordingto child-reports (DI) and parent-reports (SDQ) arereported by gender in Table 2.

Headaches Correlates.—In univariate analysis,headaches were significantly associated with childcomorbid physical conditions �2 (OR=1.92; 95% CI:1.32-2.79), low parental education (OR = 1.56; 95%CI: 1.08-2.27), low monthly income (OR = 2.17; 95%CI: 1.39-3.38), and high parental overprotectivebehaviors (OR = 2.03; 95% CI: 1.29-3.18) (Table 3).Inversely, headaches were less frequently associated

with low parental punitive behaviors (OR = 0.41;95% CI: 0.20-0.84). Although not statistically signifi-cant, rural setting was less frequently associated withheadaches (OR = 0.56; 95% CI: 0.30-1.03) andinversely, parental unemployment was more fre-quently associated with headaches (OR = 1.62; 95%CI: 0.97-2.69). The association between headachesand the SDQ total difficulties was statistically signifi-cant for the borderline and the abnormal categories(respectively OR = 2.46; 95% CI: 1.38-4.40 andOR = 2.47; 95% CI: 1.43-4.28) (Table 4). The follow-ing parent-reported problems were statistically sig-nificant: emotional problems (OR[abnormal] = 2.46;95% CI: 1.59-3.83) and peer relationship difficul-ties (OR[borderline] = 1.71; 95% CI: 1.05-2.79 andOR[abnormal] = 1.63; 95% CI: 1.00-2.66). Headaches

Table 3.—Correlates of Childhood Headaches in a French Regional Sample of Children Aged 6-11 Years Old (N = 1308)

Crude OR (95% CI) Adjusted OR (95% CI)

Child6-8 years old (vs 9-11 years) 0.87 (0.60-1.27) 0.87 (0.55-1.36)Female (vs male) 1.04 (0.72-1.51) 0.93 (0.59-1.45)Single child 0.67 (0.40-1.13) 0.56 (0.30-1.03)Grade repetition 1.44 (0.78-2.66) –Low academic achievement 0.89 (0.48-1.64) –Traumatic life events �1 (lifetime) 1.11 (0.76-1.63) –Comorbid physical conditions �2 1.92 (1.32-2.79)*** 1.75 (1.13-2.73)**

ParentsSingle-parent 1.14 (0.68-1.91) –Low monthly income 2.17 (1.39-3.38)*** 1.49 (0.84-2.63)Low education (<high school) 1.56 (1.08-2.27)* 1.20 (0.73-1.96)Unemployment (either parent) 1.62 (0.97-2.69) 1.27 (0.66-2.45)Punitive behaviors (vs average)

Low 0.41 (0.20-0.84)** 0.41 (0.18-0.94)*High 1.29 (0.79-2.12) 0.86 (0.45-1.63)

Caring behaviorsLow 1.45 (0.90-2.34) 1.39 (0.78-2.48)High 1.20 (0.73-1.96) 1.25 (0.70-2.21)

Autonomy promoting attitudesLow 1.27 (0.79-2.04) –High 1.07 (0.63-1.81) –

Overprotective behaviorsLow 0.66 (0.37-1.18) 0.87 (0.46-1.65)High 2.03 (1.29-3.18)*** 1.49 (0.82-2.73)

SchoolsDSA 1.41 (0.79-2.52) –Rural setting 0.56 (0.30-1.03) 0.56 (0.28-1.10)Public schools 0.88 (0.52-1.50) –

*P < .05; **P < .01; ***P < .001.Univariate and multivariate analyses: crude OR, adjusted OR, and their 95% CI.DSA = Disadvantaged School Area.

1542 November/December 2010

Table 4.—Mental Health Correlates of Childhood Headaches in a French Regional Sample of Children Aged 6-11 Years Old(N = 1308)

Caseness Crude OR (95% CI) Adjusted OR (95% CI)

Child-report (Dominic Interactive)GAD Normal Referent Referent

Possible 2.13 (1.30-3.50)** 1.99 (1.13-3.52)*Likely present 1.84 (1.07-3.18)* 1.43 (0.50-4.09)

SAD Normal Referent ReferentPossible 1.79 (1.06-3.04)* 1.60 (0.87-2.97)Likely present 2.15 (1.33-3.48)** 1.41 (0.64-3.11)

SPh Normal Referent ReferentPossible 1.24 (0.80-1.91) 1.06 (0.62-1.81)Likely present 1.47 (0.85-2.55) 0.68 (0.30-1.52)

MDD Normal Referent ReferentPossible 1.63 (0.92-2.90) 1.43 (0.69-2.99)Likely present 1.62 (0.90-2.92) 0.50 (0.16-1.54)

ADHD Normal Referent ReferentPossible 1.19 (0.64-2.22) 1.00 (0.45-2.24)Likely present 2.02 (1.16-3.51)* 2.43 (0.86-6.85)

ODD Normal Referent ReferentPossible 1.12 (0.63-1.98) 1.15 (0.53-2.46)Likely present 1.64 (0.93-2.87) 1.03 (0.33-3.24)

CD Normal Referent ReferentPossible 0.85 (0.46-1.59) 0.51 (0.26-1.01)Likely present 1.56 (0.88-2.77) 1.15 (0.33-4.02)

Strengths and competencies Normal Referent –Possible 0.77 (0.37-1.63) –Likely present 0.74 (0.31-1.78) –

Parent-report (SDQ)

Emotional problems Normal Referent ReferentBorderline – –Abnormal 2.46 (1.59-3.83)*** 1.76 (1.03-3.01)*

CD Normal Referent ReferentBorderline 1.63 (0.97-2.74) 1.42 (0.80-2.51)Abnormal 1.49 (0.88-2.52) 1.48 (0.75-2.90)

Peer relationship difficulties Normal Referent ReferentBorderline 1.71 (1.05-2.79)* 1.68 (0.93-3.04)Abnormal 1.63 (1.00-2.66)* 1.04 (0.57-1.89)

Hyperactivity-inattention Normal Referent ReferentBorderline 1.62 (0.91-2.90) 1.39 (0.70-2.76)Abnormal 1.01 (0.57-1.79) 0.71 (0.35-1.41)

Prosocial behaviors Normal Referent –Borderline 0.76 (0.43-1.34) –Abnormal 0.99 (0.59-1.67) –

Total difficulties Normal Referent ReferentBorderline 2.46 (1.38-4.40)** 1.90 (0.94-3.87)Abnormal 2.26 (1.34-3.82)** 2.65 (1.47-4.75)***

*P < .05; **P < .01; ***P < .001.Univariate and multivariate analyses: crude OR, adjusted OR, and their 95% CI.One Model with SDQ and DI was adjusted on the following variables: age, gender, family structure (single child or not),sociodemographic characteristics (income, educational level, and unemployment), parental attitudes (overprotection, caring, andpunitive behaviors), school setting (rural or urban), and comorbid physical conditions.ADHD = attention deficit/hyperactivity disorder; CD = conduct disorder; GAD = generalized anxiety disorder; MDD = majordepressive disorder; ODD = oppositional defiant disorder; SAD = separation anxiety disorder; SDQ = Strengths and DifficultiesQuestionnaire; SPh = specific phobia.

Headache 1543

were not statistically associated with parent-reportedCD, hyperactivity, and prosocial behaviors. Thefollowing self-reported disorders through the DIwere significantly associated with headaches:GAD (OR[possible] = 2.13; 1.30-3.50; OR[likely present] =1.84; 1.07-3.18), SAD (OR[possible] = 1.79; 1.06-3.04;OR[likely present] = 2.15; 1.33-3.48), and ADHD(OR[likely present] = 2.02; 1.16-3.51).

In multivariate analysis, children with comorbidphysical conditions �2 were 1.75 times (95% CI: 1.13-2.73) more likely to suffer from headaches comparedwith children with 0 or 1 comorbid condition. Lowparental education did not remain statistically associ-ated with headaches (OR = 1.20; 95% CI: 0.73-1.96)after adjustment. There was no statistical associationbetween headaches and parental behaviors, exceptfor low punitive behaviors (OR = 0.41; 95% CI: 0.18-0.94). After adjustment, the association betweenheadaches and the SDQ total difficulties remainedstatistically significant for the abnormal category(OR = 2.65; 95% CI: 1.47-4.75). Children with parent-reported emotional problems were nearly 2 timesmore likely to have headaches (OR[abnormal] = 1.76;95% CI: 1.03-3.01). Children with self-reported pos-sible GAD were 1.99 (95% CI: 1.13-3.52) more likelyto suffer from headaches. The association betweenheadaches, the likely present category of GAD, andself-reported SAD was no more significant afteradjustment.

DISCUSSIONOur results highlight that according to their

parents, 10.9% of children aged 6-11 years experi-enced headaches in their lifetime. Estimates of head-ache prevalence in children vary widely in literature,depending on the setting, the methodology, the timeframe, and diagnostic criteria applied. Previousstudies involving school children have reportedannual prevalence rates varying from 3% to 11% formigraine and from 10% to 24% for tension-typeheadache.4,24-26 Our results are consistent with thoseprevious data, although the time frame is differentand hampers a precise comparison. In this study, wedid not find independent associations between head-aches, age, gender, and socioeconomic characteristics.Results in the literature on the associations between

headaches and sociodemographic characteristics areconflicting. Several studies reported no gender differ-ence9 while a number found relevant gender differ-ences.4,27 Similarly, some studies have reported someassociations of childhood headaches and low socio-economic status;8,28,29 others reported no or little asso-ciations.30,31 We found that headaches were lessfrequently associated with low punitive parentalbehaviors compared with the average category ofpunitive behaviors. The bidirectional relation has tobe considered as a low level of punitive behaviorsmay conduct to less frequent headaches, andinversely, parents might be less punitive when theirchildren are complaining from headaches. Previousstudies have shown that 1 common psychological pre-dictor of headaches among children was stress withinthe family (eg, marital problems, family bereavement,poor relationships with parents, illness in thefamily).32-38 Low punitive behaviors might be associ-ated with less stress within the family as well.

Our results highlight that children with head-aches were 2.65 times more likely than childrenwithout headaches to have a high level of total diffi-culties according to their parents. More specifically,headaches were significantly associated with emo-tional problems on both self- and parent-reports.Those results are consistent with previous research,where internalizing disorders (depression andanxiety) were frequently associated with head-aches.13,15,39 Our results strengthen those previousreports of associations and suggest the existence of anassociation in children as young as 6 to 10 years.Moreover, the results from parent- and child-reportsappeared concordant, both instruments (DI andSDQ) revealing an association of headaches withemotional disorders. Several hypotheses are availablein the literature to explain the associations of head-aches and psychopathology, with some controversies.First, the relation might be causal with 1 disorderpredisposing the other. In a longitudinal study, Pineet al reported that depression in adolescents prospec-tively predicted the new onset of headaches in adult-hood.39 Merikangas et al suggested a syndromicrelationship between migraine and psychiatric disor-ders with anxiety in childhood and adolescence, fol-lowed by chronic headaches and then by depression.40

1544 November/December 2010

Other authors, notably Breslau et al reported in alongitudinal study a bidirectional influence betweenmigraines and affective disorders, where each disor-der increased the risk of the other disorder 3-fold.41

The causal relation might also not be linear as sug-gested by Costello et al, their findings being moresuggestive of a spectrum of associations betweenheadaches and emotional difficulties with a distinctgender difference. Finally, some authors have evokedthe possibility of an underlying etiologic factorcommon in both headaches and psychopathology.Notably, a genetic or environmental factor may causea dysregulation in serotoninergic and noradrenergicsystems, the common neurotransmitter involved inmigraine, depression, and anxiety.39

We found that children with comorbid conditions�2 were 1.75 times more likely to suffer from head-aches. This is consistent with preexisting data report-ing strong associations between headaches in youngchildren and other health problems.27,42 Sillanpaa et alshowed that the risk of stomach ache was 14-fold inchildren with headaches compared with children withno headache.43 Among hypotheses, those physicalconditions might present similarities in trigger andcomorbid factors, with risks of chronicization overtime. Moreover, Galli et al reported a very similarpsychological profile between headaches and recur-rent abdominal pain, with a statistically significanttendency to show problems in the internalizing scaleof the CBCL (ie, anxiety, mood, and somatic com-plaints) and no problems in the externalizing scale (ie,behavioral).44 This co-occurrence of multiple comor-bid physical conditions and complaints might berelated to the beginning of a process of somatizationin children, which in adults develops into a somatiza-tion disorder. DSM-IV criteria mention headache andother pain conditions as symptoms of somatoformdisorders, stressing indirectly the reciprocal link andthe involvement of psychological factors.20

Clinical implications.—The associations we foundbetween headaches and emotional difficulties high-light the importance of considering childhood head-aches from a biopsychosocial perspective. Thosefindings should be considered for diagnostic andtherapeutic purposes of childhood headaches.Healthcare providers should warrant a periodic

assessment of possible psychosocial issues and anappropriate mental health referral.The results shouldalso be considered from the etiological aspect as theassociations between headaches, comorbid physicalconditions, and emotional disorders might reflect thebeginning of a process of somatization in children.Finally, finding out more about the relationshipsbetween headaches, comorbid physical conditions,and psychopathology may help identify those chil-dren in need of psychological support and highlightthe types of psychological support that should form acritical part of the care of children with headaches.

Limitations.—There are some limitations to ourstudy. The first limit is the low parent response rate.The nonresponder analysis did not highlight differ-ences in parent response rates, except for DSA wherethe response rate was lower. Children attendingschools in DSA might be underrepresented in ourstudy sample. However, as DSA was not associatedwith the prevalence of headache, ascertainment biasrelated to the DSA school characteristic appearsunlikely. Moreover, the association between punitivebehaviors and DSA was not significant (P = .07).Second, the headache status and the number ofcomorbid conditions were reported by the parents.This may lead to misestimating the prevalence ratesas the parents might perceive childrens’ health con-ditions differently from the children themselves (inthe sense of underreport).45 The period of assessmentof headaches and mental health problems differed aswe assessed the lifetime prevalence of headaches andthe current prevalence of psychopathologies.The life-time prevalence of headaches did not inform aboutthe onset of the last episode of headaches. Thisepisode might be ancient and the parents may haveforgotten those older episodes. Among other limits,we do not have information about the frequency andperiodicity, the types according to the IHS criteria46

(eg, migraine, tension-type headaches, cluster head-aches) and the severity of headaches, the parentalhistory of headaches. This survey was regional andcaution is needed in generalizing our results for thePACA region to a national range as to other Westerncountries. Despite some possible geographical varia-tions, we believe though our sample was representa-tive of primary school children aged 6-11 years. Other

Headache 1545

limits are related to the cross-sectional design. Ourresults draw the following question about causalordering: do headaches increase the risk of emotionaldifficulties or do emotional difficulties increase therisk of headaches? Further data from longitudinalstudies investigating the sequence of events are nec-essary to conclude about the causal direction.

Conclusion.—We report some associationsbetween headaches and psychopathologies in youngchildren aged 6-11 years, particularly in the field ofemotional disorders. Children with comorbid physi-cal conditions �2 were independently associatedwith headaches. Inversely, parental low punitivebehaviors were less frequently associated with head-aches. Those results should be considered in thetreatment approaches of childhood headaches. Thehealthcare providers should be informed of thosepossible mental health issues in children with head-aches and warrantee periodic assessment of thosepsychological issues. The associations between head-aches, comorbid physical conditions, and emotionaldisorders should be considered from the etiologicalaspect, as they might reflect the beginning of aprocess of somatization in children. Further datafrom longitudinal studies are needed to explore thecausal relationship.

Acknowledgments: We are indebted to Drs. Robert

Goodman and Jean-Pierre Valla, the French Ministry of

Health and Social Affairs, the French Ministry of Educa-

tion, the PACA Regional Directorate for Health and

Social Affairs, the Aix-Marseille and Nice Educational

Authorities, as well as the children, parents, teachers, and

principals of participating schools.

REFERENCES

1. Goodman JE, McGrath PJ. The epidemiology ofpain in children and adolescents: A review. Pain.1991;46:247-264.

2. Frare M, Axia G, Battistella PA. Quality of life,coping strategies, and family routines in childrenwith headache. Headache. 2002;42:953-962.

3. Powers SW, Patton SR, Hommel KA, Hershey AD.Quality of life in childhood migraines: Clinicalimpact and comparison to other chronic illnesses.Pediatrics. 2003;112:e1-e5.

4. Abu-Arefeh I, Russell G. Prevalence of headacheand migraine in schoolchildren. BMJ. 1994;309:765-769.

5. Fearon P, Hotopf M. Relation between headache inchildhood and physical and psychiatric symptoms inadulthood: National birth cohort study. BMJ.2001;322:1145.

6. Guidetti V, Galli F, Fabrizi P, et al. Headacheand psychiatric comorbidity: Clinical aspects andoutcome in an 8-year follow-up study. Cephalalgia.1998;18:455-462.

7. Just U, Oelkers R, Bender S, et al. Emotional andbehavioural problems in children and adolescentswith primary headache. Cephalalgia. 2003;23:206-213.

8. Anttila P, Sourander A, Metsahonkala L, AromaaM, Helenius H, Sillanpaa M. Psychiatric symptomsin children with primary headache. J Am Acad ChildAdolesc Psychiatry. 2004;43:412-419.

9. Egger HL, Angold A, Costello EJ. Headaches andpsychopathology in children and adolescents.J Am Acad Child Adolesc Psychiatry. 1998;37:951-958.

10. Mazzone L, Vitiello B, Incorpora G, Mazzone D.Behavioural and temperamental characteristics ofchildren and adolescents suffering from primaryheadache. Cephalalgia. 2006;26:194-201.

11. Karwautz A, Wober C, Lang T, et al. Psychosocialfactors in children and adolescents with migraineand tension-type headache: A controlled study andreview of the literature. Cephalalgia. 1999;19:32-43.

12. Balottin U, Termine C, Nicoli F, Quadrelli M,Ferrari-Ginevra O, Lanzi G. Idiopathic headache inchildren under six years of age: A follow-up study.Headache. 2005;45:705-715.

13. Milde-Busch A, Boneberger A, Heinrich S, et al.Higher prevalence of psychopathological symptomsin adolescents with headache. a population-basedcross-sectional study. Headache. 2010;50:738-748.

14. Costello EJ, Egger H, Angold A. 10-year researchupdate review: The epidemiology of child and ado-lescent psychiatric disorders: I. Methods and publichealth burden. J Am Acad Child Adolesc Psychiatry.2005;44:972-986.

15. Strine TW, Okoro CA, McGuire LC, Balluz LS. Theassociations among childhood headaches, emotionaland behavioral difficulties, and health care use. Pedi-atrics. 2006;117:1728-1735.

1546 November/December 2010

16. Shojaei T, Wazana A, Pitrou I, et al. Psychometricproperties of the dominic interactive in a largeFrench sample. Can J Psychiatry. 2009;54:767-776.

17. Shojaei T, Wazana A, Pitrou I, Kovess V. Thestrengths and difficulties questionnaire: Validationstudy in French school-aged children and cross-cultural comparisons. Soc Psychiatry Psychiatr Epi-demiol. 2009;44:740-747.

18. Johnson JH, McCutcheon SM. Assessing life stressin older children and adolescents: Preliminary find-ings with the Life Event Checklist. In: Sarason IG,Spielberger CD, eds. Stress and Anxiety. Washing-ton, DC: Hemisphere, 1980;111-125.

19. Bergeron L, Valla JP, Breton JJ. Pilot study for theQuebec Child Mental Health Survey: Part II. Corre-lates of DSM-III-R criteria among six to 14 yearolds. Can J Psychiatry. 1992;37:381-386.

20. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders, 4th edn.Washington: American Psychiatric Association;2005.

21. Valla JP, Bergeron L, Smolla N. The Dominic-R: Apictorial interview for 6- to 11-year-old children. JAm Acad Child Adolesc Psychiatry. 2000;39:85-93.

22. Goodman R. The Strengths and Difficulties Ques-tionnaire: A research note. J Child Psychol Psychia-try. 1997;38:581-586.

23. Youth in Mind.SDQ information for researchers andprofessionals about the Strenghts and DifficultiesQuestionnaire.Available at:http://www.sdqinfo.org/.

24. Bille BS. Migraine in school children. A study of theincidence and short-term prognosis, and a clinical,psychological and electroencephalographic com-parison between children with migraine andmatched controls. Acta Paediatr Suppl. 1962;136:1-151.

25. Laurell K, Larsson B, Eeg-Olofsson O. Prevalenceof headache in Swedish schoolchildren, with a focuson tension-type headache. Cephalalgia. 2004;24:380-388.

26. Zwart JA, Dyb G, Holmen TL, Stovner LJ, Sand T.The prevalence of migraine and tension-type head-aches among adolescents in Norway. The Nord-Trondelag Health Study (Head-HUNT-Youth), alarge population-based epidemiological study.Cephalalgia. 2004;24:373-379.

27. Kroner-Herwig B, Heinrich M, Morris L. Headachein German children and adolescents: A population-based epidemiological study. Cephalalgia. 2007;27:519-527.

28. Isik U, Topuzoglu A, Ay P, et al. The prevalence ofheadache and its association with socioeconomicstatus among schoolchildren in Istanbul, Turkey.Headache. 2009;49:697-703.

29. Ostberg V, Alfven G, Hjern A. Living conditionsand psychosomatic complaints in Swedish school-children. Acta Paediatr. 2006;95:929-934.

30. Bakoula C, Kapi A, Veltsista A, Kavadias G, KolaitisG. Prevalence of recurrent complaints of painamong Greek schoolchildren and associated factors:A population-based study. Acta Paediatr. 2006;95:947-951.

31. Zuckerman B, Stevenson J, Bailey V. Stomachachesand headaches in a community sample of preschoolchildren. Pediatrics. 1987;79:677-682.

32. Carlsson J, Larsson B, Mark A. Psychosocial func-tioning in schoolchildren with recurrent headaches.Headache. 1996;36:77-82.

33. Abu-Arafeh I. Chronic tension-type headache inchildren and adolescents. Cephalalgia. 2001;21:830-836.

34. Carlsson J. Prevalence of headache in schoolchil-dren: Relation to family and school factors. ActaPaediatr. 1996;85:692-696.

35. Larsson B. The role of psychological, health-behaviour and medical factors in adolescent head-ache. Dev Med Child Neurol. 1988;30:616-625.

36. Odegaard G, Lindbladh E, Hovelius B. Childrenwho suffer from headaches – A narrative of inse-curity in school and family. Br J Gen Pract.2003;53:210-213.

37. Rhee H. Risk factors for and sequelae of headachesin schoolchildren with clinical implications from apsychosocial perspective. J Pediatr Nurs. 2001;16:392-401.

38. van der Wouden JC, van der Pas P, Bruijnzeels MA,Brienen JA, van Suijlekom-Smit LW. Headache inchildren in Dutch general practice. Cephalalgia.1999;19:147-150.

39. Pine DS, Cohen P, Brook J. The association betweenmajor depression and headache: Results of a longi-tudinal epidemiologic study in youth. J ChildAdolesc Psychopharmacol. 1996;6:153-164.

40. Merikangas KR, Angst J, Isler H. Migraine and psy-chopathology. Results of the Zurich cohort study ofyoung adults. Arch Gen Psychiatry. 1990;47:849-853.

41. Breslau N, Davis GC. Migraine, major depressionand panic disorder: A prospective epidemiologicstudy of young adults. Cephalalgia. 1992;12:85-90.

Headache 1547

42. Petersen S, Brulin C, Bergstrom E. Recurrent painsymptoms in young schoolchildren are often mul-tiple. Pain. 2006;121:145-150.

43. Sillanpaa M, Piekkala P, Kero P. Prevalence of head-ache at preschool age in an unselected child popu-lation. Cephalalgia. 1991;11:239-242.

44. Galli F, D’Antuono G, Tarantino S, et al. Headacheand recurrent abdominal pain: A controlled studyby the means of the Child Behaviour Checklist(CBCL). Cephalalgia. 2007;27:211-219.

45. Sundblad GM, Saartok T, Engstrom LM. Child-parent agreement on reports of disease, injury andpain. BMC Public Health. 2006;6:276.

46. Headache Classification. Subcommitee of the Inter-national Headache Society. The international classi-fication of headache disorders: 2nd edition.Cephalalgia. 2004;24(Suppl. 1):9-160.

1548 November/December 2010