Suggestions for a Biopsychosocial Approach to Treating Children and Adolescents Who Present With Headache

Authors

  • Scott W. Powers PhD, ABPP,

  • Deborah Kruglak Gilman PhD,

  • Andrew D. Hershey MD, PhD


  • From the Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Dr. Powers); Department of Psychology, Columbus Children's Hospital, Columbus, OH (Dr. Gilman); Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Dr. Hershey); and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH (Drs. Powers and Hershey).

Address all correspondence to Dr. Scott Powers, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2015, Cincinnati, OH 45229-3039.

Abstract

An evidence-based, biopsychosocial approach to the care of pediatric patients who present with the complaint of headache is recommended. This approach informs diagnosis and management decisions, is critical for maximizing adherence to the prescribed headache treatment regimen, and incorporates assessment of the impact of headache on a child/adolescent's quality of life, disability, and emotional functioning. Very often, successful treatment of headache leads to improvements in disability and emotional functioning. When this is not the case, or when the work-up shows that comorbid headache and psychiatric disorders are present for a patient, a more comprehensive treatment approach that includes the active collaboration of pediatric specialists in headache care and mental health care is warranted.

The vast majority of children and adolescents who experience headaches, including those who report recurrent headaches, do not evidence a diagnosable psychiatric condition. Many of these pediatric patients, however, do report that headaches significantly impact quality of life and result in notable disability, and studies show that symptoms of anxiety and sadness are not uncommon in youth with recurrent headaches. A few of these pediatric patients, upon presentation for treatment of headache, are also exhibiting symptoms that indicate the presence of a comorbid psychological/psychiatric condition such as an anxiety disorder or depression. Evolving research is beginning to examine longitudinally the relation between headache and psychopathology in youth, but conclusions pertinent to practice are premature at this time. So, based upon the current evidence base, how should headache care providers who serve children, adolescents, and families approach the evaluation and treatment of patients who present with the complaint of headache? A biopsychosocial model of care offers some direction. This model informs the process of diagnosis, management/intervention, and measurement of outcomes.

Diagnosis.— Use of standardized and recognized criteria for the diagnosis of headache and psychological disorders is necessary (eg, ICHD-II, DSM-IV-TR). In addition, incorporating reliable and valid pediatric-specific measures of quality of life and headache disability is important. In the majority of cases, a headache diagnosis(ses) will be made and report of some (or notable) impact on quality of life and disability will be present. In a minority of cases, symptoms of anxiety, sadness, and/or anger will be present and will likely be contributing to the challenge of coping with headache pain. In even fewer cases, comorbid headache and psychiatric conditions will be diagnosed. Use of reliable, valid, pediatric-specific measures of psychological symptoms, in addition to standardized diagnostic criteria, can be quite useful in understanding a patient's psychological functioning.

Management/Treatment.— Treatment strategies should be based on the findings of the diagnostic evaluation and should address the antecedent and contributing factors. A comprehensive, evidence-based approach to treating the headache disorder(s) is necessary, and should include lifestyle changes, abortive therapy, and consideration of prevention therapy (including nonpharmacological and pharmacological modalities) for recurrent headache. Incorporation of an understanding of the impact of headache on quality of life and disability into the treatment plan, particularly as it relates to promoting adherence with the prescribed intervention regimen, is also indicated. In those cases in which co-morbid headache and psychological disorders are present at the time of presentation for treatment, interventions that complement one another and offer evidence based care for both conditions should be suggested. This type of approach will likely involve the collaboration of the patient, family, headache specialist, and a specialist in the mental health care of children and adolescents, if possible. For most cases, a nonpharmacological approach to the psychological condition is the first optimal step in a treatment regimen that addresses both the headache condition and the diagnosed psychological disorder. At times, pharmacological interventions for both conditions may be suggested based on evidence-based care guidelines.

Measurement of Outcomes.— In addition to parameters of headache experience (frequency, duration, intensity, quality), assessment of changes in quality of life and disability is necessary. In those cases in which symptoms of anxiety, sadness, and/or anger were present at diagnosis, assessment of these feelings may also be of use in examining outcomes. For those patients with comorbid presentations, assessment of changes in key features of both conditions is indicated. In typical practice, the primary intervention regimen will be directed toward reducing the symptoms of the headache disorder. This will be the case for those patients who also report disability and elevations on measures of anxiety and depression (but not with a psychiatric condition that meets clinical criteria for a diagnosis). With successful management of the headaches, it should be determined if the patient's report of emotional symptoms and disability improve. This is often the case. When this does not occur, a reassessment of ongoing concerns for the child or adolescent is indicated. In this instance, additional treatment may be needed to help the child or adolescent with the ongoing concerns (eg, problems with adherence to the headache treatment regimen, increase in severity of psychological symptoms, improvement in headache but not in emotional status).

Summary.— In conclusion, attention to the impact of headache on a child/adolescent's quality of life, disability, and emotional functioning is a key aspect of an evidence-based, biopsychosocial approach to the care of pediatric patients who present with the complaint of headache. This approach will inform diagnosis and management decisions, and will be critical for maximizing adherence to the prescribed headache treatment regimen. Very often, successful treatment of headache leads to improvements in disability and emotional functioning. When this is not the case, or when the work-up shows that comorbid headache and psychiatric disorders are present for a patient, a more comprehensive treatment approach that includes the active collaboration of pediatric specialists in headache care and mental health care is warranted.

Conflict of Interest:  None

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