Neurol Sci (2015) 36 (Suppl 1):S97–S100 DOI 10.1007/s10072-015-2168-3
FICEF SYMPOSIUM
Migraine and lifestyle in childhood Gerardo Casucci • Veronica Villani • Florindo d’Onofrio • Antonio Russo
Ó Springer-Verlag Italia 2015
Abstract Migraine is one of the most frequently reported somatic complaints in childhood, with a negative impact on health-related quality of life. The incidence of migraine in childhood has substantially increased over the past 30 years, probably due to both increased awareness of the disease and lifestyle changes in this age group. Indeed, several conditions have been identified as risk factors for migraine in childhood. Amongst these, dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school and insufficient leisure time seem to play a critical role. Nevertheless, there are only few studies about the association between migraine and lifestyle in childhood, due to previous observations specifically focused on ‘‘headache’’ in children. In this brief review, we will concentrate upon recent studies aimed to explore migraine and lifestyle risk factors in childhood.
G. Casucci (&) Casa di Cura S. Francesco, Viale Europa 21, 82037 Telese Terme, Italy e-mail:
[email protected] V. Villani Neuro-Oncology Unit, ‘‘Regina Elena’’ National Cancer Institute, 00144 Rome, Italy F. d’Onofrio Neurology Unit, Headache Center, S.G. Moscati, 83100 Avellino, Italy A. Russo Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Headache Center, Second University of Naples, 80138 Naples, Italy
Keywords Migraine Childhood Children lifestyle Trigger factors
Introduction Migraine-related symptoms in childhood are a group of heterogeneous periodic and paroxysmal neurologic disorders [1]. Amongst these, cyclic vomiting, abdominal migraine and benign paroxysmal vertigo have been already defined by previous International Headache Society criteria as childhood periodic syndromes which are usually precursors** of migraine [2, 3]. Recently, the International Classification of Headache Disorders (ICHD-3 beta Version) [4] has replaced the ‘‘periodic symptoms’’ terminology with ‘‘episodic symptoms which are associated with migraine’’ and that will no longer be limited just to childhood. Similarly, headaches are not strictly related to adulthood but are very frequent during childhood, becoming more common during adolescence. Generally, headaches in childhood are subtended by primary headache syndromes with a significant negative impact on the quality of life and a high risk of developing in chronic and persistent form in adulthood [5]. Previous studies have emphasized the role of different risk factors for headache. Amongst these dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, smoking, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school and insufficient leisure time seem to be strictly related to migraine. Risk factors identification can be very important in the therapeutic approach, because a multimodal program including lifestyle modification and psychotherapeutic intervention, are necessary in children who experience migraine attacks. Nevertheless, previous observations have
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been focused on general ‘‘headaches’’ rather than on a specific migraine condition in childhood. For this reason, there are only few studies about association between migraine and lifestyle in children, to date. In this brief review, we will concentrate upon recent studies aimed to explore migraine and lifestyle-related risk factors in childhood.
Epidemiology Migraine is the most important cause of headache leading to a substantial impact on physical and mental health as well as on school performance and quality of life in children [6]. The estimated overall mean prevalence of headache was 54.4 % and the overall mean prevalence of migraine was 9.1 % [7]. Totally, 10.4 % of the children, predominantly the girls, received the diagnosis of migraine when they grew older [8]. Indeed, it is well known that children frequently change their headache prevalence and characteristics, and even the type of headache shows important changes in the course of the adolescence and adulthood, independently from the use of either pharmacological or behavioural treatment or both. Specifically, age influences the expression of some of the accompanying symptoms in the migraine. For example, headache exacerbation by physical activity and occurrence of aura phenomenon were more common in females with migraine. Otherwise, vomiting and phonophobia are referred more frequently in males with migraine [9, 10]. However, some authors support that migraine and tension-type headache should not be considered two different clinical conditions in childhood, but two aspects of the same spectrum of headache [11]. Moreover, both migraine and tension-type headache phenotypes during childhood equally predict migraine in puberty with significant changes in accompanying symptoms and pain quality and localization [12]. It is noteworthy that migraine predisposition in children population may be related to genetic factors. Indeed, the most important explaining factor for the migraine manifestations in 10-year-old children seems to be a positive family history of headache attacks [13]. This finding was to be expected, because genetic predisposition has been shown in migraine but not in non-migrainous headache [14, 15]. However, the incidence of childhood migraine has significantly increased over the last decades. The causes of the increase in migraine prevalence are not completely understood or known at this time.
Migraine risk factors However, they probably involve multiple factors. For example, an increased awareness of migraine in childhood
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could be related to lifestyle changes in this age group. Lifestyle factors such as overweight, physical activity and smoking are associated with headache in adults, but studies about the importance of risk factors amongst children are scarce and only few studies have so far investigated the impact of the combination of these lifestyle factors in relation to migraine amongst children [16]. Nevertheless, the environmental and psychological factors may play an important role in migraine with onset in preschool age, and diagnostic–therapeutic approaches must take these factors into account [17]. In this context, a very interesting study [18] assessed the evolution of idiopathic headache with early onset and investigated the influence of early somatic disorders and ‘‘life events’’ on the onset and the course of headache. The authors found a significant association between early somatic disorders and persistence of headache and also between the presence of psychiatric disorders at the end of follow-up and the persistence of headache. ‘‘Life events’’, on one hand, whilst not showing a significant association with the headache progression, may nevertheless influence the headache course in some children. According to the importance of ‘‘life events’’ in the genesis of migraine, childhood maltreatment has been associated with an earlier age of migraine onset and could shed a light on the role of stress responses in migraine pathophysiology [19, 20]. Similarly, a recent review [21] has shown that children with low socioeconomic status experience more frequently headache attacks. On the other hand, childhood maltreatment and low socioeconomic status may be indirectly associated with migraine. Indeed, above-mentioned impacting life events cast the children into situations of extreme questioning of their lives and contribute to several others risk factors for migraine such as depression, anxiety and substance abuse in the course of patients’ life. Amongst lifestyle-related risk factors for migraine, a wide range of sleep disorders have been demonstrated in children [22]. Indeed, a correlation and comorbidity between migraine sleep disorders (such as insomnia, sleep apnoea, sleep bruxism and restless legs syndrome) exist due to common anatomical structures and neurochemical processes. Therefore, comorbid sleep conditions should be always considered in children experiencing migraine to improve management and to choose the most appropriate treatment [23]. Furthermore, migraine is associated with a number of comorbidities such as asthma, allergies and obesity [24, 25]. The latter is another chronic disorder that is very frequent in paediatric population. Previous studies, exploring the prevalence of obesity within a paediatric headache population, concluded that obesity seems to occur at greater frequency in children with migraine compared with the general population, showing a significant correlation between obesity and headache frequency and disability [26, 27]. Data from 2003 to 2006 demonstrated
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that 16.3 % of children and adolescent fulfilled criteria for overweight [28]. Children with overweight/obesity have a greater prevalence of headache compared with non-overweight children [29]. Moreover, obesity (and often body mass index of the patients) seems to be related to both the high frequency and degree of migraine attacks and the prevalence of the migraine [30]. Interestingly, a higher body mass index (BMI) score in girls with headache than those without headache has been observed [31]. Similarly, a more recent study [16] found a higher overweight prevalence in adolescent with headache than in those without headache. Although a clear comorbidity between migraine and obesity exists, the real link between them is still matter of debate and the basic nature of this association is still under debate. Migraine and obesity can probably have some common pathophysiologic pathways and share different mechanisms (e.g., inflammatory mediators). It follows that, for children who are overweight or at risk for overweight, educational intervention may be necessary to improve weight control and subsequent migraine treatment outcomes. For some children, behavioural weight management may be mandatory to facilitate appropriate lifestyle changes (increasing exercise and improving adherence to dietary guidelines) for effective weight control and optimal migraine management [30]. Moreover, the paediatric obesity could be associated with several other comorbidities such as type 2 diabetes mellitus, dyslipidemia, metabolic syndrome, hyperandrogenemia and hyperinsulinism, high blood pressure, proteinuria, nonalcoholic fatty liver disease, gallstones, orthopaedic pathologies, pseudotumor cerebri, and finally above-mentioned both psychosocial problems and sleep disorders [32]. Related to both obesity and overweight in childhood, diet has been shown to be a major risk factor in precipitation of headache in children with migraine [33]. Dietary triggers influence migraine attacks by means of the release of serotonin and norepinephrine, causing vasoconstriction or vasodilatation, or by direct stimulation of trigeminal ganglia, brainstem, and cortical neuronal pathways. The list of foods, beverages, and additives that trigger migraine includes cheese, chocolate, citrus fruits, hot dogs, monosodium glutamate, aspartame, fatty foods, ice cream, caffeine withdrawal, and alcoholic drinks, especially red wine and beer. Moreover, tyramine, phenylethylamine, histamine, nitrites and sulphites are involved in the mechanism of food intolerance headache. It is important to underline that underage drinking is a significant potential cause of recurrent migraine attacks in children, whereas immunoglobulin E-mediated food allergy is an infrequent and underrecognized but serious cause of migraine in children [34]. Finally, a recent study has demonstrated that an underreported but very important headache precipitant in children is the excessive gum-
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chewing [35]. Diet-related triggers should be investigated in the management of children with recurrent headaches.
Conclusions Altogether, these observations emphasize the impact of several lifestyle-related risk factors for migraine in children. Physician and patient’s awareness of lifestyle could have a significant impact on the quality of life of children with migraine. Indeed, the management of children with migraine should consist primarily of lifestyle triggers identification and avoidance [36]. Therefore, comorbid conditions should be always screened in children with migraine to improve patient management and to choose the most appropriate treatment. Acknowledgments This project has been supported by Italian Headache Foundation (FICEF), Italy. Conflict of interest
The authors declare no conflict of interest.
References 1. Gelfand AA (2013) Migraine and childhood periodic syndromes in children and adolescents. Curr Opin Neurol 26(3):262–268 2. Headache Classification Committee of the International Headache Society (1988) Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 8(Suppl 7):1–96 3. Headache Classification Subcommittee of the International Headache Society (2004) The international classification of headache disorders, 2nd edition. Cephalalgia 24(Suppl 1):9–160 4. Headache Classification Committee of the International Headache Society (2013) The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 33(9):629–808 5. Straube A, Heinen F, Ebinger F, von Kries R (2013) Headache in school children: prevalence and risk factors. Dtsch Arztebl Int 110(48):811–818 ¨ zge A, Antonaci F, Natriashvili S, Guidetti V, 6. Termine C, O Wo¨ber-Bingo¨l C (2011) Overview of diagnosis and management of paediatric headache. Part II: therapeutic management. J Headache Pain 12(1):25–34 7. Wo¨ber-Bingo¨l C (2013) Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep 17(6):341 ¨ , Kaleag˘ası 8. Ozge A, Sas¸ maz T, Bug˘daycı R, Cakmak SE, Kurt AO SH, Siva A (2013) The prevalence of chronic and episodic migraine in children and adolescents. Eur J Neurol 20(1):95–101 9. Kienbacher C, Wo¨ber C, Zesch HE, Hafferl-Gattermayer A, Posch M, Karwautz A, Zormann A, Berger G, Zebenholzer K, Konrad A, Wo¨ber-Bingo¨l C (2006) Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study. Cephalalgia 26(7):820–830 10. Wo¨ber-Bingo¨l C, Wo¨ber C, Wagner-Ennsgraber C, Zebenholzer K, Vesely C, Geldner J, Karwautz A (1996) IHS criteria and gender: a study on migraine and tension-type headache in children and adolescents. Cephalalgia 16(2):107–112 11. Silberstein SD (1990) Twenty questions about headaches in children and adolescents. Headache 30(11):716–724
123
S100 12. Virtanen R, Aromaa M, Rautava P, Metsa¨honkala L, Anttila P, Helenius H, Sillanpa¨a¨ M (2007) Changing headache from preschool age to puberty. A controlled study. Cephalalgia 27(4):294–303 13. Anttila P, Metsa¨honkala L, Helenius H, Sillanpa¨a¨ M (2000) Predisposing and provoking factors in childhood headache. Headache 40(5):351–356 14. Ulrich V, Gervil M, Kyvik KO, Olesen J, Russell MB (1999) Evidence of a genetic factor in migraine with aura: a populationbased Danish twin study. Ann Neurol 45(2):242–246 15. Larsson B, Bille B, Pedersen NL (1995) Genetic influence in headaches: a Swedish twin study. Headache 35(9):513–519 16. Robberstad L, Dyb G, Hagen K, Stovner LJ, Holmen TL, Zwart J-A (2010) An unfavorable lifestyle and recurrent headaches among adolescents: the HUNT study. Neurology 75(8):712–717 17. Casucci G, Terlizzi R, Cevoli S (2014) Headache in school age. Neurol Sci 35(Suppl 1):31–35 18. Balottin U, Termine C, Nicoli F, Quadrelli M, Ferrari-Ginevra O, Lanzi G (2005) Idiopathic headache in children under six years of age: a follow-up study. Headache 45(6):705–715 19. Tietjen GE, Brandes JL, Peterlin BL, Eloff A, Dafer RM, Stein MR, Drexler E, Martin VT, Hutchinson S, Aurora SK, Recober A, Herial NA, Utley C, White L, Khuder SA (2010) Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification. Headache 50(1):32–41 20. Russo A, Tessitore A, Giordano A, Corbo D, Marcuccio L, De Stefano M, Salemi F, Conforti R, Esposito F, Tedeschi G (2012) Executive resting-state network connectivity in migraine without aura. Cephalalgia 32(14):1041–1048 21. Is¸ ik U, Topuzog˘lu A, Ay P, Ersu RH, Arman AR, Onsu¨z MF, Karavus¸ M, Dag˘li E (2009) The prevalence of headache and its association with socioeconomic status among schoolchildren in Istanbul, Turkey. Headache 49(5):697–703 22. Miller VA, Palermo TM, Powers SW, Scher MS, Hershey AD (2003) Migraine headaches and sleep disturbances in children. Headache 43(4):362–368 23. Guidetti V, Dosi C, Bruni O (2014) The relationship between sleep and headache in children: implications for treatment. Cephalalgia 34(10):767–776 24. Wo¨ber-Bingo¨l C¸, Hershey A (2011) Migraine co-morbidities in children. In: Schoenen J, Sandor P, Dodick D (eds) Co-morbidity
123
Neurol Sci (2015) 36 (Suppl 1):S97–S100
25. 26.
27. 28.
29.
30.
31.
32.
33.
34. 35.
36.
in migraine—clinical aspects, prevalence, mechanisms and management. Wiley-Blackwell, Hoboken, pp 122–132 Scher AI, Bigal ME, Lipton RB (2005) Comorbidity of migraine. Curr Opin Neurol 18(3):305–310 Hershey AD, Powers SW, Nelson TD, Kabbouche MA, Winner P, Yonker M, Linder SL, Bicknese A, Sowel MK, McClintock W, American Headache Society Pediatric Adolescent Section (2009) Obesity in the pediatric headache population: a multicenter study. Headache 49(2):170–177 Kinik ST, Alehan F, Erol I, Kanra AR (2010) Obesity and paediatric migraine. Cephalalgia 30(1):105–109 Ogden CL, Carroll MD, Flegal KM (2008) High body mass index for age among US children and adolescents, 2003–2006. JAMA 299(20):2401–2405 Bond DS, Roth J, Nash JM, Wing RR (2011) Migraine and obesity: epidemiology, possible mechanisms and the potential role of weight loss treatment. Obes Rev 12(501):362–371 Verrotti A, Di Fonzo A, Penta L, Agostinelli S, Parisi P (2014) Obesity and headache/migraine: the importance of weight reduction through lifestyle modifications. BioMed Research International, article ID 420858 Lateef TM, Merikangas KR, He J, Kalaydjian A, Khoromi S, Knight E, Nelson KB (2009) Headache in a national sample of American children: prevalence and comorbidity. J Child Neurol 24(5):536–543 August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, Silverstein JH, Speiser PW, Styne DM, Montori VM (2008) Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab 93(12):4576–4599 Peatfield RC, Glover V, Littlewood JT, Sandler M, Clifford RF (1984) The prevalence of diet-induced migraine. Cephalalgia 4(3):179–183 Millichap JG, Yee MM (2003) The diet factor in pediatric and adolescent migraine. Pediatr Neurol 28(1):9–15 Watemberg N, Matar M, Har-Gil M, Mahajnah M (2014) The influence of excessive chewing gum use on headache frequency and severity among adolescents. Pediatr Neurol 50(1):69–72 Matarese CA, Mack KJ (2010) Management considerations in the treatment of migraine in adolescents. Adolesc Health Med Ther 1:21–30
