• adolescence;
  • headache;
  • pain;
  • psychological symptoms;
  • functional disability


  1. Top of page
  2. Abstract

Background.—The psychosocial impact of headache combined with other pains has previously been insufficiently investigated.

Objective.— The present study examined the prevalence of headache, its comorbidity with other pains and psychosocial impact among adolescents.

Methods.— 793 adolescents in a sample recruited from 8 schools in the middle of Sweden were assessed.

Results.—Forty-five percent of the adolescents reported ongoing pain during assessment and more than half of the adolescents reported at least one frequent pain during the previous 6 months. The most common pain among girls was headache (42%), but for boys muscle pain (32%) was most prevalent. Number of pains and perceived pain disability were also higher among girls than boys. One-third of the headache sufferers had headache only, while one-third reported one other frequent pain and the others had at least two other frequent pains. Overall, adolescents with frequent headaches had higher levels of anxiety or depressive symptoms, in addition to functional disability and usage of analgesic medication. Frequent headache sufferers reported more problems in everyday life areas than those with infrequent headaches.

Conclusions.—It is recommended that adolescents suffering from recurrent headaches routinely should be asked about the presence of other pains, anxiety and depressive symptoms, medication usage, in addition to psychosocial consequences in their everyday life activities. Longitudinal research is also needed to delineate causal relationships between psychosocial factors and recurrent pains, in particular regarding possible sex differences.


World Health Organization


Center of Epidemiologic Studies-Depression Child


Revised Children's Manifest Anxiety Scale


The Functional Disability Inventory


Illness Behavior Encouragement Scale


analysis of variance

In previous epidemiological studies, various somatic complaints were commonly reported by adolescents.1-4 A consistent pattern has been found in that girls report more somatic complaints as well as a higher frequency and severity than boys.1,2,4-6 In a review, Campo and Fritsch7 noted that headache and recurrent abdominal pain were the most common somatic complaints reported by 10% to 30% of children and adolescents. Other common complaints were limb pain, aching muscles, and growing pains reported by 5% to 20% of children and adolescents. Back pain has been found to be common among 8 to 17-year-old school children with an overall prevalence of 29% and it increases with age, in particular, among adolescent girls, with a prevalence rate of 58% among 17 year olds.8 In a recent prevalence study,4 69% of adolescents aged 12-15 years and 53% of 16 to 18 year olds had experienced pain within previous 3 months. The most common pains were limb, head, and abdominal pains in children 8 years of age or older. In two other studies, a prevalence estimate of about 40% of one or more pains occurring at least weekly among school children has been reported,9,10 indicating that multiple pains are common among school children.4,9,10

Besides being one of the most common pains among school children and adolescents,11,12 individuals with recurrent headache have also been found to experience other somatic complaints, stress, worry, and anxiety more often than those with infrequent headache or headache-free controls.13,14 In a recent longitudinal study, depressive and anxiety disorders were found to be associated with frequent headache among adolescent girls but not in boys.15 However, in a study of young individuals seeking treatment for headache complaints, psychological symptoms were only elevated for subjects experiencing headache at the time of assessment.16

Increased levels of psychological symptoms have been found not only among headache sufferers, but also among children with recurrent abdominal6,17 or musculoskeletal pain.18 To date, comparisons between headache sufferers and individuals with other types of pain or combinations of these pains in regard to comorbidity and psychosocial functioning are scarce.

Having pain can cause serious temporary or permanent impairment of everyday life functioning to the individual.6 Research on functional limitations in children with chronic or recurrent pain is almost nonexistent, and the need for further exploration of these areas has been emphasized.19 For example, recurrent pains might cause the child to use and rely on painkilling medication or stay home from school due to pain. In a nationwide study conducted in Iceland, about half of school children reporting weekly headache used painkillers during the previous month and two-thirds of those with more frequent headache used medication this often.20 Similar figures have also been reported in a recent international World Health Organization (WHO) study on school children's health.21 Although school absence for children and adolescents suffering from headache has been reported to be fairly low due to recurrent headache,22 for migraineurs, school absenteeism seems to be higher than for those suffering from nonmigrainous headache.23,24 Students with frequent headache have also been reported to be absent more often than those with infrequent headache.14 In a population-based study, headache activity reduced general satisfaction with life and health among school adolescents.25

In previous studies, prevalence rates of pain problems among children and adolescents in community populations4,9,10 have been examined; however, to the best of our knowledge, the psychosocial impact of pain problems have not been explored before in a large sample of school adolescents.

The aims of the present study were to examine frequency and severity of headache among school adolescents and its comorbidity with other pains; the influence of sex and age on the frequency of headache and other pains; and the psychosocial impact due to headache, ie, anxiety, depression, functional disability, and experienced illness behavior encouragement from the parents, in addition to school absence due to headache and the use of analgesic medication.


  1. Top of page
  2. Abstract


Seven hundred ninety-three adolescents from two cities in the middle of Sweden, Gävle and Uppsala (90,501 and 188,478 inhabitants, respectively) were included in the study (46% and 55%, respectively, from each city). Uppsala is a large university city, whereas Gävle, to a large extent, is an industrial city. The participants were 13 to 19 years old (mean  =  15.8, SD  =  1.6) and the sample consisted of 49% girls (n  =  385) and 51% boys (n  =  407). Eight schools participated in the study, and four classes from each school were randomly selected. The pupils attended four secondary schools (n  =  423, grade 7-9) and four high schools (n  =  370, grades 10-12) representing 53% and 47% of the whole sample, respectively. The high schools consisted of both theoretical (n  =  256, 69%) and vocational programs (n  =  114, 31%).


Written information was sent to the principal at each school, who were then contacted by telephone and asked about consent to the study. In the next step, letters were sent to all classroom teachers, who later were contacted by telephone for permission to class admission. The questionnaires were administered either by two psychology students or by a psychologist (Å.F.) and were filled out during one school lesson (40 minutes). All students received written as well as oral information about the study. Those who were absent during administration were later asked to fill out the questionnaire by the classroom teacher, who was provided with written instructions and a prepaid envelope to be returned.

Altogether, 124 of eligible (15.6%) students did not participate in the study. One hundred thirteen of students were absent at the day of data collection, and common reasons for absence were illness, truancy, or teaching of some of these students in small groups because of extra needs. Eleven students (1.3%) did not wish to fill out the questionnaire. After 3 weeks, 42 subjects from 2 classes were retested for reliability of the various pain items in the questionnaires.

Frequency and Severity of Pain.

First the participants were asked whether they experienced pain at the time of assessment, and if positively endorsed, they were further asked to specify their type of pain. Students also rated the frequency of headache and 6 other pain complaints: abdominal, muscle, back, and joint pain, in addition to tooth ache and ear pain, on the following 1-5 scale: 1, seldom or never; 2, one to three times a month; 3, once a week; 4, several times a week; and 5, daily. A rating of 3 or more was defined as a frequent pain problem, and a rating of 2 or less was considered an infrequent pain problem. The students also rated the pain problems according to how troublesome they were experienced by the subjects on the following scale: 1, no problem at all; 2, minor problem; 3, fairly problematic; 4, quite a lot problematic; and 5, extremely problematic. Frequency and perceived problems with pain were summarized into a composite measure pain index. For the different pain problems, there were high test-retest correlations for headache (r  =  0.83, P<0.001), back pain (r  =  0.83, P<0.001), joint pain (r  =  0.70, P<0.001), and for tooth ache (r  =  0.64, P<0.001), muscle pain (r  =  0.59, P<0.001). For abdominal pain and ear ache, the test-retest reliability was lower (r  =  0.40, P<0.01, and r  =  0.46, P<0.05, respectively).

Center of Epidemiologic Studies-Depression Child (CES-DC).

The CES-DC is an instrument for self-rating of depressive symptoms. It was originally developed for adults (CES-D)26 and has been adapted for children.27,28 It consists of 20 statements on which subjects are asked to rate the frequency of their symptoms during the previous week, where 0 is not at all, 1 is few times, 2 is now and then, and 3 is often. All ratings are summarized into a total score varying between 0 and 60. The 3-week test-retest correlation was r  =  0.78, P<0.05. Cronbach's alpha and split-half reliability were 0.86 and 0.87, respectively.

Revised Children's Manifest Anxiety Scale (RCMAS).

The RCMAS is one of the most widely used instruments to measure anxiety symptoms in children and adolescents.29 Excluding the social desirability items, it consists of 28 items to be answered by subjects with a “No” (0) or “Yes” (1), and the responses are summarized into a total score ranging from 0 to 28. Examples of questions are: “I get nervous when things do not go the right way,” and “I often worry about something bad happening to me.” The RCMAS has been found to have good psychometric properties with an internal reliability estimate of 0.85.29 The 3-week test-retest correlation was r  =  0.88, P<0.05. Cronbach's alpha and split-half reliability were 0.88 and 0.88, respectively.

The Functional Disability Inventory (FDI).

The FDI is a measure developed by Walker and Greene (1991) to assess functional disability in children and adolescents when they are sick or ill. It covers several domains of consequences of illness related to physical and psychosocial functioning in everyday activities. Functional disability is defined as troubles in age-appropriate physical and psychosocial functioning due to physical health status. The original items were rephrased to address students' pain experience by changing “feeling sick or not well” to “when being in pain or having ache.” The FDI consists of 15 items and each item is scored on a 5-point scale, where 0 represents “no problem” in performing the activity and 4 is “impossible to perform” the activity. A total sum score is calculated varying between 0 and 60. The 3-week test-retest correlation was r  =  0.75, P<0.05. Cronbach's alpha and split-half reliability were 0.91 and 0.90, respectively.

Illness Behavior Encouragement Scale (IBES).

The IBES consists of 12 questions concerning what adolescents perceive their parents do when they are having a cold or gastrointestinal symptoms.30 The questionnaire is based on social learning theory and assesses how parent-child interactions may contribute to the development of a child's illness behavior. For example, a child does not have to do regular household chores or gets more attention from the parents. For this study, the questions were asked in regard to the adolescent's pain experiences, and the responses were rated on a 5-point scale, where 0 is “never” and 4 is “very often.” A total sum score was calculated with a higher score indicating more positive consequences for the subject when being in pain. The 3-week test-retest correlation was r  =  0.85, P<0.05. Cronbach's alpha and split-half reliability were 0.66 and 0.46, respectively.

Medication Usage, School Absence, and Leave.

The students were also asked to estimate their usage of painkilling medication on the following scale: “never/seldom,”“1 to 3 times a month,”“1 to 3 times a week,”“almost everyday,” and “everyday.”

School absence was estimated by asking students about the number of school hours they had been absent due to pain, and their responses were rated on the following scale: “0 hours,”“1 to 5 hours,”“6 to 10 hours,” or “more than 10 hours.” In addition, school leave was estimated by asking the students about the number of times during previous month they had left school due to pain and to grade their responses on the following scale: “never,”“1 to 3 times,”“4 to 6 times,” or “more than 6 times.”

Translation Procedure.

The FDI6 and the IBES30 were translated separately to Swedish by each of the authors. A native Englishman fluent in Swedish checked the translation, and corrected mistakes when disagreement occurred. The originator (Dr. Lynn Walker) gave her permission for translation.

Statistical Methods.

Analysis of variance (ANOVA) and t tests were used to estimate differences between group means for continuous measures, and for ordinal variables, Kruskal-Wallis rank test was used. Chi-square test was used to estimate associations between categorical variables, and for continuous variables, Pearson's product-moment correlation coefficients were used.


  1. Top of page
  2. Abstract

Pain Prevalence

Pain State at Assessment.

When filling out the questionnaires, 45% of the students reported 25 types of different ongoing pains. Of those subjects with ongoing pain, 22% reported headache, 14% reported back pain, and 11% had abdominal pain (menstrual pain not included). More than one-half of the adolescents (63%) reported at least one frequent pain (at least once a week), and many of them had several pains (see Table 1). When filling out the questionnaire, girls (54%) reported significantly more pain than boys did (39%), χ2(1)  =  216.79, P<0.001.

Table 1.—.  Number of Frequent Pains (Once a Week or More Often) Reported by Adolescents in the Whole Sample and by Sex. Figures in Percentages
 No Pain (n)One Pain (n)Two Pains (n)Three or More Pains (n)
  • a

    We were unable to identify the sex of one subject.

Girls (n = 385)28.6% (110)34.8% (134)21.8% (84)14.8% (57)
Boys (n = 407)39.8% (162)29.3% (122)17.4% (71)12.8% (52)
All (N = 793)a34.0%a (273)32.0% (256)19.6% (155)14.0% (109)
Type and Number of Pains.

The girls had a significantly higher number of pains than the boys, t (1.790)  =  2.22, P<0.05 (mean  =  1.3 and 1.1, respectively; see Table 1). The most common frequent pain among girls was headache (42%), whereas for boys, it was muscle pain (39%; see Table 2). Girls had significantly more headache than boys, t (1.790)  =  6.14, P<0.001, as well as abdominal pain, t (1.790)  =  2.75, P<0.01. On the other hand, boys had more muscle pain than girls, t (1.790)  =  2.92, P<0.001. As presented in Table 3, about twice as many girls (42%) as boys (24%) reported frequent headache. Girls also perceived more problems with headache than boys, t (1.740)  =  6.9, P<0.001, and had significantly higher headache index scores than boys, t (1.740)  =  7.4, P<0.001. Although boys had a higher frequency of muscle pain than girls, there was no difference in muscle pain index between the sexes.

Table 2.—.  Percentage of Adolescents Who Reported Frequent Pain (at Least Once a Week) at Different Locations in the Whole Sample and by Sex
Girls (n = 385)% (n)Boys (n = 407)% (n)All Subjects (n = 793)% (n)Sex Difference
  • *


  • **


Headache42 (160)Muscle pain32 (129) Headache33 (258)**
Muscle pain24 (94)Headache24 (98) Muscle pain28 (223)**
Back pain24 (92)Back pain20 (83) Back pain22 (175) 
Abdominal pain19 (73)Joint pain19 (78) Joint pain17 (135) 
Joint pain15 (57)Abdominal pain11 (44) Abdominal pain15 (117)*
Ear ache4 (17)Ear ache3 (13) Ear ache4 (30) 
Tooth ache3 (12)Tooth ache3 (11) Tooth ache3 (23) 
Table 3.—.  Distribution of Headache among Adolescents in the Whole Sample and by Sex. Figures in Percentages
Frequency of HeadacheGirls (n = 385)Boys (n = 407)All (n = 793)
Infrequent headache:   
seldom/never22.8 (88)38.6 (157)30.9 (245)
One to three times a month35.6 (137)37.6 (152)36.6 (290)
Frequent headache:   
At least once a week22.3 (86)14.0 (59)18.3 (145)
Several times a week15.9 (61)8.9 (36)12.2 (97)
Daily or almost daily3.4 (13)0.7 (3)2.0 (16)

Older subjects (16-18 years) had significantly more back pain than younger ones (13-15 years), t (1.791)  =  2.15, P<0.05 (mean  =  1.9 and 1.7, respectively), whereas younger adolescents had more joint pain, t (1.790)  =  1.99, P<0.05 (mean  =  2.2 and 2.0, respectively), and muscle pain than older ones, t (1.791)  =  2.54, P<0.05 (mean  =  1.8 and 1.6, respectively).

Headache and Comorbidity with Other Pains.

Approximately one-third of the subjects with frequent headache had headache only, one-third also suffered from one other frequent pain, and one-third suffered from 2 other frequent pains or more (see Figure 1). Adolescents with frequent headache (at least once a week; n = 258, 32%) reported the following other frequent pains: 32% muscle pain, 32% back pain, 25% abdominal pain, 23% joint pain, 7% ear ache, and 4% tooth ache. When comparing rates of frequent pain among adolescents in the whole sample (see Table 2), adolescents with frequent headaches had higher rates of abdominal pains (25% versus 15%) and back pain (32% versus 22%) than those with infrequent headache; however, differences were smaller for joint and muscle pain.


Figure 1.—. Number of frequent other pains (at least once a week) for subjects with frequent headache.

Download figure to PowerPoint

Anxiety and Depressive Symptoms.

Regardless of pain levels, girls had higher levels of anxiety than boys, t (1.790)  =  9.28, P<0.001 (mean = 10.1 for girls and 6.4 for boys) and depressive symptoms, t (1,790)  =  10.1, P<0.001 (mean  =  22.6 for girls and 15.9 for boys). To examine the influence of pain state at the time of assessment when filling out the psychological measures, 2 analyses were carried out specifically for adolescents without ongoing pain. The results of ANOVAs showed that adolescents with frequent headache had significantly higher scores than those with infrequent headache on the RCMAS, F (1.428)  =  24.71, P<0.001 and the CES-DC, F (1.428)  =  8.72, P<0.01. Significant main effects were found for sex in that girls had higher scores than boys. However, no interaction effects were found between sex and headache frequency. Correlations between frequency of headaches, anxiety, and depressive symptoms were positive but low for both boys and girls (see Table 4).

Table 4.—.  Correlations between Headache Frequency and the IBE, FDI, RCMAS, and CES-D for the Whole Sample and by Sex
HeadacheGirls (n = 385)Boys (n = 407)All (n = 793)
  • **


  • ***


School absence0.20***0.31**0.28***
School leave0.33**0.33**0.36**

Functional Impairment.


Regardless of pain, girls perceived more functional disability, t (1.790)  = 7.64, P<0.001 (mean  =  16.3 for girls and 10.8 for boys) than boys did. The results of an ANOVA showed that adolescents with frequent headache and no present pain at the time of assessment had significantly higher scores than those with infrequent headache on the FDI, F (1.428)  =  23.40, P<0.001. A significant main effect was found for sex, and girls had higher scores than boys.

The results of a 2-way ANOVA showed a significant interaction between sex and headache combined with other pains on the FDI, F (4.520)  =  2.71, P<0.05. Subsequent post hoc tests showed that girls with frequent headache only had significantly (P<0.05) more functional disability than boys did. For boys with frequent headache or headache combined with other pains, functional disability level increased, but decreased among girls. Overall, adolescents with frequent headache had more functional disability as reflected by significant differences (P<0.01) on all the FDI items as compared with those who had infrequent headache. The items with the largest differences between subjects with frequent headache and those with infrequent headache in disability scores are presented in Table 5.

Table 5.—.  Percentage of Adolescents with Infrequent Headache versus Those with Frequent Headache Who Reported Severe Problems with Everyday Life Activities on the FDI (range 0-60) When Having Pain
ItemInfrequent HeadacheFrequent Headache
Eating regular meals7.525.6
Being up all day without a nap or rest12.523.7
Being at school all day15.924.8
Reading or doing homework12.923.2
Running 100 meters14.428.3
Getting to sleep at night and staying asleep7.515.9

Although a positive and significant correlation between headache frequency and functional disability was found for the whole sample of adolescents (see Table 4), the estimates for each sex was significant only for boys. Headache also correlated positively to anxiety and depressive symptoms for all subjects.


Regardless of pain, girls perceived more illness behavior encouragement from the parents than boys, t (1.790)  =  6.14, P<0.001 (mean  =  19.8 for girls and 17.2 for boys). No significant difference was found between subjects with frequent headache and those with infrequent headache when subjects with ongoing pain were excluded from the analysis.

A significant interaction effect was found for sex and headache combined with other pains on the IBES, F (4.520)  =  3.75, P<0.05. Subsequent post hoc analyses showed that boys with frequent headache and one other frequent pain had significantly higher IBES scores than those with frequent headache only and 2 other frequent pains or more (P<0.05). By contrast, girls with frequent headache and one other frequent pain had significantly lower IBES scores than those with frequent headache only or 2 other frequent pains or more (P<0.05). There was no significant correlation between headache frequency and the total IBES score.

School Absenteeism and Medication Usage.

Out of the various pains, headache frequency showed the highest positive correlations to medication usage and leaving school, somewhat lower for school absence (see Table 4). The correlations between headache, school absence, and medication use was higher for boys. However, girls reported significantly more school absence than boys, z (1,N  =  792)  =  6.03, P<0.001, as well as leaving school more often due to pain, z (1,N  =  792)  =  6.35, P<0.001. Of subjects with frequent headache, 23% reported taking medication 1 to 3 times a week and 5% of them used painkilling medication almost daily or daily. Twenty percent of the adolescents with back pain, 18% of those with abdominal pain, and 8% of subjects with muscle pain reported taking medication as often as one to three times a week. For the whole sample, the corresponding figure was 9%. Subjects with high usage of pain medication also had higher number of pains compared with those who reported a low intake of painkillers, t (1.790)  =  7.64, P<0.001.

School Program.

Using sex and age as covariates in the following ANOVAs, subjects taking the theoretical programs reported more headache, F (1.366)  =  6.04, P<0.05 (mean  =  2.3 and 1.8, respectively) and joint pain than those in the vocational programs, F (1.366)  =  5.65, P<0.05 (mean  =  1.7 and 1.4, respectively). Subjects in the theoretical programs also perceived more anxiety, F (1.366)  =  13.16, P<0.001 (mean  =  9.4 and 5.7, respectively) as well as depressive symptoms, F (1.366)  =  4.80, P<0.05, (mean  =  20.6 and 15.4, respectively) than those taking the vocational programs.


  1. Top of page
  2. Abstract

The results of the present study showed that frequent headache is a common health problem among school adolescents, in particular among girls, in addition to experiences of other pain problems such as abdominal and muscle pains. The number of pains and perceived pain disability was also higher among girls than boys. Comorbidity with other pain was also high in that about two-thirds of the frequent headache sufferers reported at least one other frequent pain. Adolescents with frequent headaches had higher levels of anxiety or depressive symptoms, in addition to functional disability and medication usage.

The prevalence rates of headache in this study are similar to figures reported in the recent WHO study for 15-year-old adolescents,21 but are also in accordance with the results of recent other studies in the field.4,10,19 Although headache and abdominal pains were more frequent among girls, muscle pain was more common among boys. The preponderance of such pain localizations among boys might be attributed to higher levels of physical activity than girls.21,31 However, no difference in perception of muscle pain severity was found between the sexes.

In most previous comparisons between subjects with recurrent headaches and headache-free controls, almost no consideration has been taken in regard to influences of other pains among headache sufferers. In the present study, approximately two-thirds of the subjects with frequent headache also reported at least one other pain. These findings suggest that previous studies have overestimated differences between, eg, headache sufferers and headache-free controls, in regard to their psychological functioning. In addition, outcomes of various treatments might depend on the number and type of other pains comorbid with recurrent headache. Therefore, when examining pain comorbidity with headache, the prevalence rates of other pains in normative samples are of particular interest.

In a large epidemiological study, Egger and collaborators15 have recently shown that adolescent girls with frequent headaches have higher levels of depressive and anxiety disorders as assessed by semistructured interviews than those with infrequent headaches. Depressed girls with frequent headaches missed school and used medication more often than those who were nondepressed; however, such associations were not found for boys. This distinct gender difference was attributed to central nervous system serotonergic dysfunction common to disinhibition of central pain regulation as well as regulation of depression.

In a previous study, Holroyd and coworkers16 found that pain-state at the time of assessment mediated most of increased levels of psychological symptoms among young adult headache sufferers. When these pain levels were controlled for, differences between headache sufferers and headache-free controls disappeared. By contrast, in the present study, adolescents with frequent headache but no ongoing pain at the time of assessment still reported higher levels of psychological problems than those with infrequent headache did. The psychological impact of pain among girls may aggravate their existing pain problems, however, to a lower degree than for boys. This issue should be further examined to increase our knowledge of gender differences regarding influences of recurrent pain.

Overall, girls with frequent headache but no other pain reported significantly more functional disability than boys did. However, girls with frequent headache reported lower disability levels when combined with other frequent pains, while these levels increased among boys when combined with other frequent pains. This somewhat surprising finding might be attributed to girls being more concerned or more sensitive to bodily signs, sometimes leading to “misinterpretation” of normal bodily fluctuations.

Furthermore, subjects with frequent headache had more functional disability on all the FDI items reflecting problems in several everyday life areas as compared with those who had infrequent headache. Such consequences of pain have been scarcely investigated in previous epidemiological research. In a recent study of adolescents with acute migraine, several disability items were in line with the present study, for example: “Do something with a friend, ability to participate in sports.”32 These results show that headache probably has large impact on common everyday activities. To be able to perform everyday activities such as participating in sports or playing with friends are probably important areas for adolescents, and limitations in these areas can probably have negative psychological consequences. Restriction in common daily activities, eg, influences on school adaptation and achievement for the individual, should be included in the assessment of psychosocial functioning among adolescents with recurrent headaches.

The highest correlation between headache frequency and disability was found for medication usage. A large proportion (9%) of all school adolescents reported taking painkilling medication at least 1 to 3 times a week, and 2% reported daily use. These figures are in line with the results of other school-based Scandinavian investigations. For example, Kristiansdottir (1993) reported a high percentage (46%) of subjects with weekly headache having used medication during previous month. Such findings are also in line with the results of the recent WHO report.21 More importantly, students who consumed the most medications also reported higher amounts of pain, in addition to higher levels of anxiety, depression, and functional disability than those taking less medication. These findings are also in line with the results of the Egger study (1998). In future research, students should be asked to specify their use and type of painkilling medication in a diary because global retrospective reports might produce overestimates of analgesic consumption. For example in school-based treatment studies, few adolescents with chronic headaches have reported frequent use of painkilling medication in daily diary recordings.33 It is concluded that subjects who report a high intake of painkilling medication constitute a particular risk group for developing emotional problems such as depressive and anxiety symptoms or disorders. Overconsumption of painkillers because of frequent headaches might also induce and aggravate headaches among adolescents.

In previous research, higher levels of somatic symptoms have been reported among school adolescents attending the practical programs and being dissatisfied with their school situation.34 In contrast, in our study, students in the theoretical programs had higher levels of headache, anxiety, and depressive symptoms, suggesting that they might feel higher achievement demands in school.

Although estimates of test-retest reliability for the IBES was good, Cronbach's alpha as well as the split-half reliability coefficients were poor. However, due to rephrasing of the IBES items in regard to children's pain in the present study, adolescents without pain might have misunderstood some of the issues, thus producing a lower homogeneity. The test-retest scores for the various pain types were high for headache, back pain, and joint pain, but were low for abdominal pain, muscle pain, and ear ache, suggesting that estimates of the latter pains are less reliable. Another explanation might be that the former types of pain have a stronger impact on the adolescents' memory. For example, having a headache may be more disturbing to their ability to concentrate in the classroom and thus more easy to remember than having a muscle pain.

Some limitations of the present study should be emphasized. Because the adolescents were asked to report their symptoms once and retrospectively, there is a risk for biased estimates of the various pain complaints. Overall, however, the test-retest correlations were high for most of common pain symptoms. The study was restricted to addressing pain problems among adolescents in two moderate-sized cities; however, students from rural areas attending the schools were also included.

To the best of the authors' knowledge, this is the first study examining the psychosocial impact of different pain types in a large sample of school adolescents. It is recommended that adolescents routinely should be asked about the presence of other pains when their headaches are assessed or treated. Furthermore, adolescents should be thoroughly asked about psychosocial consequences of their recurrent headaches, in particular in regard to their daily activities, in addition to medication usage. In future research, the use of diaries will further increase the validity of information regarding pain experiences among adolescents. Longitudinal research is also needed to delineate causal relationships between psychosocial factors and recurrent pains, in particular regarding possible sex differences.


  1. Top of page
  2. Abstract
  • 1
    Larsson BS. Somatic complaints and their relationship to depressive symptoms in Swedish adolescents. J Child Psychol Psychiatry. 1991;32(5):821-832.
  • 2
    Garber J, Walker LS, Zeman J. Somatization symptoms in a community sample of children and adolescents: further validation of the children's somatization inventory. J Consulting Clin Psychol. 1991;3(4):588-595.
  • 3
    Goodman JE, McGrath PJ. The epidemiology of pain in children and adolescents: a review. Pain. 1991;(46):247-264.
  • 4
    Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, et al. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51-58.
  • 5
    Beiter M, Ingersoll G, Ganser J, Donald P. Relationships of somatic symptoms to behavioral and emotional risk in young adolescents. J Pediatr. 1991;118: 473-478.
  • 6
    Walker LS, Greene JW. The functional disability inventory: measuring a neglected dimension of child health status. J Pediatr Psychol. 1991;16(1):39-58.
  • 7
    Campo JV, Fritsch SL. Somatization in children and adolescents. J Am Acad Child Adolescent Psychiatry. 1994;33(9):1223-1235.
  • 8
    Brattberg G, Wickman V. Prevalence of back pain and headache in Swedish schoolchildren: a questionnaire survey. Pain Clinic. 1992;5(4):211-220.
  • 9
    Kristjansdottir G. Prevalence of pain combinations and overall pain: a study of headache, stomach pain and back pain among school-children. Scand J Social Med. 1997;25: 58-63.
  • 10
    Borge A, Nordhagen R. Recurrent pain symptoms in children and parents. Acta Paediatr Scand. 2000;89: 1479-1483.
  • 11
    Bille B. Migraine in schoolchildren. Acta Paediatr Scand. 1962;51(Suppl. 136):1-151.
  • 12
    Berg K, Erhver M, Erneholm M, Gundevall C, Wennberg I, Wettergren L. Self-reported health status and use of medical care by 3500 adolescents in Western Sweden. Acta Paediatr Scand. 1991;80: 837-843.
  • 13
    Carlsson J, Larsson B, Mark A. Psychosocial functioning in schoolchildren with recurrent headaches. Headache. 1996;36: 77-82.
  • 14
    Martin-Herz SP, Smith MS, McMahon RJ. Psychosocial factors associated with headache in junior high school students. J Pediatr Psychol. 1999;24(1):13-23.
  • 15
    Egger HL, Angold A, Costello EJ. Headaches and psychopathology in children and adolescents. J Am Acad Child Adolescents Psychiatry. 1998;37(9):951-958.
  • 16
    Holroyd KA, France JL, Nash JM, Hursey KG. Pain state as artifact in the psychological assessment of recurrent headache sufferers. Pain. 1993;53: 229-235.
  • 17
    Scharff L. Recurrent abdominal pain in children: a review of psychological factors and treatment. Clin Psychol Rev. 1997;17(2):145-166.
  • 18
    Mikkelsen M, Sourander A, Salminen J. Psychiatric symptoms in preadolescents with musculoskeletal pain and fibromyalgia. Pediatrics. 1997;100(2):220-227.
  • 19
    Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. Dev Behav Pediatr. 2000;21: 58-69.
  • 20
    Kristjansdottir G, Wahlberg V. Sociodemographic differences in the prevalence of self-reported headaches in Icelandic schoolchildren. Headache. 1993;33: 376-380.
  • 21
    Scheidt P, Overpeck MD, Wyatt W, Aszmann A. Health Behaviour in School-Aged Children: A WHO Cross-National Study (HBSC) International Report. Copenhagen: World Health Organization Regional Office for Europe; 1997/98.
  • 22
    Metsähonkala L. Headache and school: review. Headache Quarterly. 1998;9(3):233-236.
  • 23
    Larsson B. Recurrent headaches in children and adolescents. In: McGrathPJ, FinleyGA, eds. Chronic and Recurrent Pain in Children and Adolescents: Progress in Pain Research and Management. Seattle, Washington: IASP; 1999.
  • 24
    Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. Br Med J. 1994;309: 765-769.
  • 25
    Langefeld J. Quality of life in adolescents with migraine and other headache. In: Medical Psychology and Psychotherapy. Erasmus University, Rotterdam, The Netherlands; 1998: 141.
  • 26
    Weisman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke BZ. Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol. 1977;106: 203-204.
  • 27
    Schoenbach VJ, Kaplan BH, Grimson RC, Wagner EH. Use of a symptom scale to study the prevalence of a depressive syndrome in young adolescents. Am J Epidemiol. 1982;116: 791-800.
  • 28
    Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales. J Am Acad Child Adolescent Psychiatry. 1991;30: 58-66.
  • 29
    Reynolds CR, Richmond BO. What I think and feel: a revised measure of children's manifest anxiety. J Abnormal Child Psychol. 1997;25(1):15-20.
  • 30
    Walker LS, Zeeman JL. Parental response to child illness behavior. J Pediatr Psychol. 1992;17(1):49-71.
  • 31
    Cale L, Almond L. Physical activity levels of secondary-aged children: a review of the evidence. Health Education J. 1992;51: 94-99.
  • 32
    Hartmaier SL, DeMuro Mercon C, Linder S, Winner P, Santanello N. Development of a brief 24-hour adolescent migraine functioning questionnaire. Headache. 2000;41: 150-156.
  • 33
    Larsson B, Melin L. The psychological treatment of recurrent headache in adolescents: short-term outcome and its prediction. Headache. 1988;24: 187-194.
  • 34
    Hammarström A, Janlert U, Theorell T. Youth unemployment and ill health: results from a 2-year follow-up study. Social Sci Med. 1988;26(10):1025-1033.