Management of children with headaches should take into account the presence of psychological problems and their interaction with the headache disorder. Assessment of children with headaches should also recognise factors that may predict the development of comorbid psychological problems (Table 1).

There is some evidence to suggest that early life events, health problems and behavioural characteristics may influence the development and predict the occurrence of headaches in childhood. A longitudinal study of over 1400 children from birth to age six years suggested that certain characteristics in a child’s life and health may predict the development of headaches at the age of six years ^[1][36]. These characteristics included an infant’s poor health and feeding problems at the age of nine months and sleeping difficulties at the age of three years. Headache in other family members, especially in the mother, predicted headaches in the preschool-age child. Travel sickness, nocturnal enuresis and the presence of long-term disease at the age of five years were strong predictors of later headaches. Also, at the age of five years, concentration difficulties, behavioural problems, unusual tiredness and, conversely, high sociability predicted headache ^[1][36].

In school-age children, it has been shown that a history of migraine in first-degree relatives and other pains and aches increase the risk and predict the occurrence of migraine ^[2][3][8,22]. However, the scores on the ‘anxious-depressed’ and ‘withdrawal’ subscales on the CBCL and the ‘externalising syndrome scale’ did not predict an increased risk for migraine or TTH, neither did the mean score of ‘total behaviour problems’ and ‘social competence scale’ ^[3][22].

In another longitudinal follow-up study, the occurrence of recurrent abdominal pain (RAP) in childhood predicted the development of psychological distress in young adults at age 18 years ^[4][37]. Experience with RAP over a short period of time significantly increased the risk for emotional distress disorders during young adulthood. Chronicity of RAP stretching over a longer period during childhood further increases the risk for later emotional distress disorders, depression and anxiety ^[4][37]. As there is a strong association between RAP and headaches in children, it is not unreasonable to deduce a similar risk for children with headaches ^[5][6][38,39].

A recent cross-sectional study compared children with primary headache and their mothers/caregivers to a matched control group and made an assessment of parents and children for emotional awareness using the Emotion Awareness Questionnaire, emotional experience using the Positive and Negative Affect Schedule and psychological adjustment using the Strength and Difficulties Questionnaire ^[7][40]. High headache frequency, regardless of the headache subtype, was closely related to the child’s emotional well-being. Also interestingly, the mother of children with high-frequency headaches had experienced less emotional clarity (DERS), and their children experienced overall more adjustment difficulties ^[7][40].

In recent meta-analyses of published studies, children and adolescents with migraine were shown to be more likely to have anxiety symptoms and disorders as well as depressive symptoms and disorders than healthy children and adolescents. Interestingly, the same results were seen in clinical and community/population-based samples, and there was no evidence of publication bias ^[8][41].

The natural course of headache in children is that of periods of high-frequency headache episodes (relapse) interspaced by periods of no or low-frequency headache (remission). In some children, chronic daily headache may become persistence, daily and disabling for years. The reason for transformation from episodic headache to chronic persistence headache is not clear, but several factors have been identified to contribute to such transformation, such as major depression and medication overuse as shown in a follow-up study of 122 adolescents for three years ^[9][42]. 

In a large retrospective study of 5316 children and adolescents with headaches, the risk of worsening headache was significantly associated with increasing child’s age, female sex, chronic migraine, status migrainosus, depressive symptoms, higher PedMIDAS scores and use of nutraceuticals ^[10][43]. Other factors may also predict the development of chronic headache as shown in table 1 above.

3. Conclusions

Affective disorders and primary headaches share common and complex pathophysiological pathways and clinical characteristics. The comorbidity of anxiety, depression, tension-type headache and migraine are frequently encountered in clinical practice and especially in children and adolescents attending specialist clinics with chronic daily headache. The relationship between headaches and psychological disorders is probably bidirectional, with one condition acting as a trigger to another. However, this relationship seems to be weaker in the general childhood population, as seen in population-based studies. Several factors may predict the increased risk of physical and psychological comorbidities, including female gender, highly frequent headache attacks, long history of chronic headaches, medication overuse and some personality traits. Assessment of children with chronic headaches should include an assessment and management of possible psychological comorbidities in order to achieve optimal management of childhood headaches. The use of appropriate screening tools for anxiety and depression may allow early diagnosis, treatment and prevention of worsening of the daily headache. Multidisciplinary approach and assessment is recommended for children and adolescents with chronic headache and psychological co-morbidities in order to achieve optimum management goals. Multidisciplinary team may include a paediatrician, a paediatric neurologist, a child psychiatrist, a child clinical psychologist and a paediatric nurse. Full co-operation of the child, the family and school teachers will be necessary.