Obesity in Children With Headaches - Anak

8/13/2019 Obesity in Children With Headaches - Anak

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adjusted for age and gender.

For all comparisons and analyses, all Pvalues refer to 2-tailed tests. Pvalue of .05).

When adjusted for age and gender, the diagnosis of migraine but not of TTH was significantly associated with being

at risk for overweight (OR = 2.37, 95% CI 1.21 4.67, P= .01) or overweight (OR = 2.29, 95% CI 0.95 5.56, P= .04)

A significant independent risk for overweight was present in females with migraine (OR = 4.93, 1.46 8.61, P= .006)

compared with males (OR = 0.77, 0.41 4.28, P= .56) ().

Table 2. Prevalence Odds Ratios for Body Mass Index (BMI) in Relation to Headache Type


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At Risk for Overweight Overweight

Total samplea OR (CI) P OR (CI) P

Migraine 2.37 (1.214.67) .01 2.29 (0.955.56) .04

TTH 0.63 (0.321.22) .17 0.49 (0.191.22) .12

Girls

Migraine 3.01 (1.247.3) .012 4.93 (1.468.61) .006

TTH 0.50 (0.211.22) .13 0.25 (0.070.95) .06

Boys

Migraine 1.02 (0.373.32) .61 0.77 (0.414.28) .56

TTH 1.67 (0.515.41) .6 2.02 (0.376.04) .3

aAdjusted for age and gender.

BMI = body mass index; CI = confidence interval; OR = odds ratio; TTH = tension-type headache. Bold characters

highlight statistical significance.

BMI and Headache Frequency and Disability

Patients were subdivided into 3 groups according to attack frequency: (1) 4 or less attacks per month; (2) 5 15

attacks per month; and (3) more than 15 attacks per month. A high frequency of headaches was associated with

obesity. Frequent headaches (more than 15 attacks per month) were significantly more common in the obese

children compared with the normal-weight children, 23% vs 12%, P< .01. Headache duration was not significantly

different in the 2 groups, lasting less than 2 hours in 35% vs 38% of patients, 2 4 hours in 55% vs 49%, and longer

than 4 hours in 10% vs 13% (P= not significant). When asked, "How many days per month are you using

medications for acute headache?" 43% of the obese children vs 17% of the normal-weight children reported using

analgesic medications more than 15 days per month ().

Table 3. Headache Characteristics and Impact in Normal Weight and Obese Children

Body Mass Index (BMI) 85th Percentile 5th-85th Percentile P

Attack frequency (%)

4/month 37 63

15/month 23 12

Attack duration (%)

4 hours 10 13

Use of medications for acute treatment (%)

4/month 26 46

15/month 43 17

NS, not significant (P> .05). Bold characters highlight statistical significance.

A percentage of children with some level of disability (PedMIDAS grades II-IV) was assessed in relation to BMI and


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headache type, and adjusted for age and gender (). For the total study population, 14.7% of those with normal weight

had some level of disability compared with 20.3% of the at risk for overweight group (OR = 1.7; CI 1.4 2.2, P< .001)

and 33.3% in the overweight group (OR = 3.1; CI 1.9 5.8, P< .0001). Similar results were measured for both

migraine and TTH. For children with migraine, 12.5% of those with normal weight had some level of disability

compared with 17.8% of the at risk for overweight group (OR = 1.9; CI 1.5 2.4, P< .0001) and 30.7 in the overweight

group (OR = 3.7; CI 2.2 6.1, P< .0001). For children with TTH, 15.2% of those with normal weight had some level of

disability compared with 22.2% of the at risk for overweight group (OR = 1.6; CI 1.3 2.0, P< .0001) and 30% in the

overweight group (OR = 2.9; CI 1.7 4.9, P< .0001).

Table 4. Children With Some Level of Disability, as Measured by the PedMIDAS Scale,ain Relation to Headache Type and

BMI Category

Total Migraine TTH

% With Disability ORb(CI) % With Disability ORb(CI) % With Disability ORb(CI)

Normal weight 14.7 1 (ref) 12.5 1 (ref) 15.2 1 (ref)

At risk for overweight 20.3 1.7 (1.42.2) 17.8 1.9 (1.52.4) 22.2 1.6 (1.32)

Overweight 33.3 3.1 (1.95.8) 30.7 3.7 (2.26.1) 30 2.9 (1.74.7)

P for trend


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migraine headache.[28, 29]In a recent study of 273 children and adolescents, 50% of obese patients suffered from

migraine compared with only 25% in the normal-weight group.[18]

Several possible mechanisms that may account for the association between obesity and frequent migraine have been

suggested.[30]Obesity is recognized as a pro-inflammatory state. Markers of inflammation, including leukocyte

count, tumor necrosis factor-, and interleukin-6, increase in obesity and may be associated with neurovascular

inflammation in patients with migraine.[31]Plasma calcitonin gene-related peptide levels, an important post-synaptic

mediator of trigeminovascular inflammation in migraine, are elevated in obese individuals, particularly in women. [32]

Finally, recent data suggest that dismodulation in hypothalamic neuropeptides orexin in obese persons may beassociated with increased susceptibility to neurogenic inflammation causing migraine attacks.[30, 33]

Information regarding the association between obesity and headache-related disability in children is limited. In his

study on 913 children with headache, Hershey et al found a significantly positive correlation between BMI percentile

and headache frequency and headache-related disability scores. At follow up, a reduction in BMI was associated with

a reduction in headache frequency, but not with headache-related disability. [16]In another recent study on 124

children with migraine, obesity was associated with frequency, but not severity of migraine attacks. [28]

Headache frequency, duration, and disability were considered in trying to assess the headache-related burden in our

study. Obese children in our study had a significantly higher rate of very frequent headaches (more than 15 attacks

per month) as well as higher disability grades compared with normal-weight children. The association between BMIpercentile and higher disability grades was similar for both migraine and TTH. There was no significant difference in

duration of attacks between obese and normal-weight children. Additionally, we found a significantly higher rate of

acute drug treatment in our patients with obesity compared with normal-weight children, similar for both migraineurs

and children with TTH. This may also reflect the more frequent and disabling attacks among the obese children.

These results are compatible with prior results in adult studies.[15, 23]In their population study of adults with CDH,

Bigal and Lipton found that obese patients not only had a higher rate of headache, but also suffered from increased

severity of headaches and missed more school and work days than non-obese patients. [13]It was hypothesized that

increased attack frequency may cause neuronal sensitization that reduces response to therapy and that obesity

contributed toward the development of this sensitivity. In adults with episodic headaches, obesity was associated

with higher disability grades only in patients with migraine, but not in those with other types of episodic headaches.[41]

Some caution is required in assessing the type of relationship between obesity and headache frequency and

disability in children. Current data are not sufficient to establish a significant causal relation, and both physiological

and environmental factors are probably playing a role. Obesity was found to be associated with increased prevalence

and severity of other chronic pain disorders besides headache, such as musculoskeletal and abdominal pain. [35, 36]

Both conditions are associated with psychiatric comorbidities, such as depression and anxiety, [10, 37]that can furthe

increase headache frequency and disability.[38]Lifestyle may have an impact on both weight and headache. In a

population-based study by Molarius et al,[39]physical inactivity was strongly associated with headache disorders

independent of economic and psychosocial factors. On the other hand, recurrent headaches were found to be

associated with low physical activity[40]that can further contribute to overweight and further increase headache

frequency.[17]Sleep problems such as short sleep duration and poor sleep quality may also play a role in bothobesity and recurrent headaches.[41, 42]

No matter what the leading explanations for the correlation between obesity and headaches are, given our evidence

as well as others, weight is a modifiable risk factor for recurrent headaches in children. Weight and BMI should be

measured and calculated in all children presenting with headache, and weight control should be part of the treatment

of chronic headache in children.

Some limitations should be considered in the present study. First, our sample cannot be considered as

representative of pediatric headache patients because of selection bias. Subjects who are referred to a hospital clinic

might have more health-related problems compared with children with headaches treated within the community.


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Second, stratification of data according to headache diagnosis and gender resulted in relatively small groups that

could underpower the analyses. Finally, as mentioned before, we cannot infer causality between obesity and

headache frequency and disability.

In summary, our data show a high rate of obesity in children with primary headaches compared with the general

population. The strongest association with obesity was found for females and for children with migraine headaches. In

all the children with primary headaches, a high BMI percentile was associated with increased headache frequency

and disability. Although we were unable to adequately address the question of causal relationship, we believe in and

emphasize the importance of obesity prevention and treatment in children with headaches.

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Obesity in Children With Headaches - Anak