Background: Headache Society (IHS) criteria for episodic tension-type headache were included in the present study. Pain characteristics, associated symptoms, and stress-triggering factors were evaluated. Psychiatric and psychosocial evaluations were performed according to DSM-IV criteria.

Results: Pain was bilateral in 93.7% of patients and bitemporal in 50% of children. The intensity of pain increased with motion and stress in more than half of the patients, while pain decreased with rest and massage in 43.7% of patients. Ten of the 16 (62.5%) patients were diagnosed as having a psychiatric disorder. The most common stress-triggering factors were difficulty in adaptation at school and relationship problems with family members. All of the children reported 26 stress factors. Of these stress factors, 20 (76.9%) were reported by children diagnosed with psychiatric disorder.

Conclusion: These results suggest that in children with tension-type headache a thorough psychiatric evaluation should be performed to rule out underlying psychiatric disorders.

Comments.—The comorbidity of migraine and psychiatric illnesses, such as anxiety and depression, is well established. The comorbidity of tension-type headache with psychiatric illness is less well described. Guidetti et al have described in their textbook (Guidetti V, Russell G, Sillanpaa M, Winner P, eds. Headache and Migraine in Childhood and Adolescence. London: Martin Dunitz Ltd; 2002) and we have found at our office that a careful evaluation for comorbid psychiatric conditions in children with migraine and chronic daily headache (CDH), especially in adolescents with CDH, is critical in developing a treatment plan. SJT

I agree with Dr. Tepper that with the clinical context of headache in terms of comorbid psychiatric conditions, it is important in choosing an appropriate treatment that is synergistic in treating both conditions. Whilst this is obviously a small study involving only 16 patients, it highlights potentially important comorbidity, which if confirmed in larger studies has important implications for the delivery of effective care. Integrated services that holistically treat the patient with headache are more likely to effectively address patient needs. DSM