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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.
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.
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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.