Migraine can be a disabling pain condition that episodicallyand often unpredictably impacts patients. For teens, this canmean missed activities. Teens may withdraw from activities withfriends and from school work. In adults with migraine, it isbelieved that there may be a connection between migraine anddepression. It is unclear whether these two conditions simplyoccur together, or whether one causes the other.
Suicidal ideation, or thinking about suicide, is more commonduring the teen years. These issues in the teen years are difficultbecause teens are still developing. The presence of an ongoinghealth condition, especially if it is under-recognized, likemigraine, may add further complications. There always needsto be an awareness of these issues when caring for teens withmigraine.
In this issue of Neurology®, a study by Dr. Wang and coauthors(Migraine and suicidal ideation in adolescents aged 13 to 15years. Neurology 2009;72:1146–1152) examined the connectionsbetween migraine and suicidal ideation in teens aged 13 to 15years. The goal of this study was to compare how often teenswith migraine had suicidal ideation compared to teens in general.The authors wanted to see whether teens with migraine had moresuicidal ideation and whether there were factors that couldpredict who of those teen sufferers would be at greatest risk.
The authors surveyed nearly 4,000 teens in middle school (seventhto ninth grade) in Taiwan. This is a large sample of the over9,000 middle school children of this age in the area. They includedteens in urban and rural schools. The survey was designed todescribe headaches, migraine, chronic daily headaches, and psychologicalor emotional issues in the teens. The teens completed the surveysin class with the help of teachers and school nurses. The surveyhad 4 parts: a demographic section, a headache questionnairebased on current standards, a depression assessment, and a disabilityassessment.
From the results of the survey, the authors were able to lookat four items:
The demographic features of teens with headache
The headachediagnosis using current standards
The presence of depressionand related psychological factors
The disability of teenswith migraine vs the total population
How common was migraine?
The authors found that headache was common in this group ofteens. Eighty-six percent reported having a headache in theirlifetime. About 62% had a headache within the 3 months of completingthe survey. Nearly a quarter of the teens reported having migraine."Probable migraine" was the most common (11.2% of the totalpopulation studied). After that, 8.7% teens had migraine withoutaura (for definition of aura, see below) and 3.5% had migrainewith aura.
Depression.
Using the Adolescent Depression Inventory, a test to measuredepression, a higher score was seen in girls. Teens with migrainescored higher than teens without migraine. There was a trendtoward more depression in teens who had migraine with aura.
Suicidal ideation.
Of all the teens surveyed, 337 (8.5%) reported thinking aboutsuicide in the month prior to the survey. This was higher ingirls than boys and higher in teens with depression. It waslowest in teens who lived with both biological parents. Forteens with any type of headache, both increased headache frequencyand increased disability were associated with increased suicidalthoughts. When headaches happened 7 to 14 times per month, 18%had suicidal ideation. For those who had more than 15 headachesper month, the rate of suicidal ideation was 28.6%. Teens withlow disability due to their headaches had a rate of suicidalthoughts (7.5%) that was similar to that in the general population(8.5%). However, teens with high disability experienced a highrate (44.4%) of suicidal thoughts.
When the authors examined the diagnosis of the headaches inthese teens, they found that suicidal thoughts were more commonin teens who had migraine with aura (23.9%) compared to teenswho had migraine without aura (15.9%) or probable migraine (13.7%).Although migraine with aura was less common than the other headacheconditions, they did find that these teens were 4.6 times morelikely to have suicidal thoughts than those teens without migraine.
When the authors tried to identify the main factors that wereimportant for suicidal ideation, they found that migraine withaura and high frequency of headaches (more than 7 days per month)were the most important independent factors.
This study emphasizes the importance of addressing psychologicalfactors in teens with headache. Frequency of headaches and disabilityincrease the risk of suicidal thoughts. In addition, the specificheadache type "migraine with aura" also contributes to thesethoughts.
Teens with frequent headaches need to be asked about suicidalthoughts. Health care providers and families need to have aplan in place to deal with these thoughts and their consequences.Determining the type of headache using standardized criteriamay help assess the risk.
This study examines the baseline suicidal thoughts in a populationof teens. It would be interesting and useful to understand thepsychology and biology of headaches that are responsible forthese findings. It also needs to be investigated whether effectivetreatment reverses these suicidal thoughts. It is not knownwhether the increased suicidal thoughts extend to suicide attemptsor suicide itself. If either of these does increase, it raisesthe urgency of recognizing and treating recurrent headache andmigraine.
Migraine is a recurrent headache disorder with specific featuresand associated symptoms. It is often underrecognized due toa misunderstanding of these features.
The International Classification of Headache Disorders, 2ndEdition, outlines the rules for diagnosing all headache types.1For migraine these criteria require the following:
Recurrent headaches (at least five) that last untreated between4 and 72 hours
At least two of the following features:
Locationin a specific part of the head
Moderate to severepain
Athrobbing quality
Worsening or stopping activity
In addition to these features (a–d above), the headachesmust also have nausea and/or vomiting, or light and sound sensitivity.
Finally, the neurologic examination should be normal and thereshould be no secondary causes of headache clearly evident.
In addition to the symptoms of migraine without aura—aneurologic warning that they are going to have a migraine—patientswho have migraine with aura need to have at least two headacheswith an aura. These auras are typically either visual, sensory,or cause difficulty talking. The auras should go away completelyand last between 5 minutes and 1 hour. The headache should startwithin 1 hour of the start of the aura.
These criteria are modified for the diagnosis in children andteens. Children tend to have shorter headaches that are morelikely to be on both sides of the head. Young children may haveproblems describing their headache symptoms. To account forthese issues, the criteria allow for some differences. Childrenare allowed to have a duration of 1 to 72 hours and a locationon both sides of the head. Some of the symptoms may be reportedby the parents. Migraine, however, remains a disease of patientreport. This explains why "probable migraine" was the most frequentdiagnosis noted in the current study.
Migraine can affect a child’s and family’s lives.As more migraines occur, there is an increase in these psychosocialstressors to the teen. This involves lost school days and adecrease in time spent with friends. Teens with migraine alsomight fear being different from their friends.2,3 For parents,their child’s migraine can lead to lost days of work,anxiety of seeing their children in pain, and sometimes doubtabout their child’s condition.
In addition, migraine is seen as a neurologic condition. Duringattacks there may be clear neurologic changes, especially ifaura is present. There is also research that has shown thatthere are mild neurologic problems between attacks.4 It is likelythat psychosocial and neurologic factors together result inunique psychological risks.
WHAT NEEDS TO BE DONE TO HELP MINIMIZE THIS PROBLEM?
Physicians and parents need to recognize and manage headachewell to limit its psychological impact. Recognition requiresunderstanding that headache is a problem and that migraine,if not properly cared for, may get worse. It is also importantto diagnose any other conditions that are often seen with headaches,including psychiatric conditions and psychological stresses.
Successful treatment can stop an individual attack and preventmore attacks. Also, treatment should include helping teens learnhow to cope with migraine. Because suicidal ideation is increased,it is also clear that this should be addressed with a specificplan.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. Cephalalgia 2004;24(suppl 1):1–160.
Hershey AD, Powers SW, Vockell AL, LeCates SL, Segers A, Kabbouche MA. Development of a patient-based grading scale for PedMIDAS. Cephalalgia 2004;24:844–849.[Medline]
Vannatta K, Getzoff EA, Gilman DK, Noll RB, Gerhardt CA, Powers SW, et al. Friendships and social interactions of school-aged children with migraine. Cephalalgia 2008;28:734–743.[Medline]
Jakubowski M, Silberstein S, Ashkenazi A, Burstein R. Can allodynic migraine patients be identified interictally using a questionnaire? Neurology 2005;65:1419–1422.[Abstract/Free Full Text]
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