The Relations between Attention Deficit Hyperactivity Disorder and Headaches in a Non-Clinical Sample of Adolescents-Juniper Publishers
Juniper Publishers-Journal of Pediatrics
Introduction
Primary headaches are common in the pediatric
population [1-3], predominantly migraine and tension type headaches
(TTH) [4]. Since primary headaches may be disabling to children, several
studies focused on the impact of headache on school performance [5-6],
however the impact was reported to be minimal for most of the children
[7]. Attention deficit hyperactivity disorder (ADHD) is also common
among the pediatric population, and is considered to be very an
important factor leading to poor academic performance. The worldwide
prevalence of attention deficit disorder was shown to be 5.3% [8], and
in the United States the prevalence was found to be higher, at 8% for
children aged 8 to 15 years [9].
Although the association between primary headaches and emotional and
behavioral problems in children has been previously described [10-11],
the prevalence of ADHD among children with headaches as well as their
association with headache duration and frequency remains unclear. It may
be due to the fact that many children with ADHD have emotional
disorders such as anxious disorders or depressive disorder, as a co
morbid diagnosis. Numerous studies in adults with migraine, showed
impairment in tasks such as psychomotor speed, attention, language
[12-13] and executive functions [14], while others failed to confirm
these findings [15]. In adults with tension type headache no cognitive
dysfunction was identified [16].
Numerous psychological predictors for the emergence
of headaches in the pediatric age group were identified, among them:
concentration difficulties, emotional rigidity, deliberation,
hyperactivity and stress among the family or at school [17-18]. On
the other hand, frequent headaches may increase distractibility, in
any child, but particularly in children with primary short attention
span and thus may hold a negative impact on school work and
performance. In a previous study [3] we have demonstrated an
association between headaches, ADHD and school achievements
among children who were referred to a pediatric neurology clinic
for headaches. However, it was found that children who had
headaches in addition to another complaint (somatic complaint)
were more likely to be referred to a pediatric neurology clinic than
were children who only complained of headaches [19], therefore
it was questionable whether the conclusions of our previous
study could be implied to a more general pediatric population.
To overcome this potential bias we performed the current study,
which was conducted in a high- school setting, therefore with a
non- clinical sample of students. The purpose of the present study
was to assess the prevalence of primary headaches among highschool
students and to study the relations between headache
presence, type of headache and ADHD.
Method and Patients
Study design - Cohort study, transversal, observational.
Patients -10th grade high- school students attending schools
in Haifa, Israel. All gave informed assents to the study and their
parents gave an informed consent via e- mail. There were no
exclusion criteria other than not consenting to participation in the
study.
Methods - Students anonymously filled a computerized
general health questionnaire, that was designed for assessing the
prevalence of headaches among high- school students and its’
associations with other comorbidities and risk taking behaviors.
The questionnaire included questions about demographics,
whether students had headaches or not (and if they had - their
characteristics, including age at onset, location, quality, frequency,
duration, aura, associating symptoms, and family history). It also
included questions about ADHD (previous diagnosis, related
symptoms, medications recommended and taken), school
achievements, risk taking behaviors and other known diagnoses
(physical and psychological alike). The prevalence of headaches
and their types was assessed, and diagnosis of tension type
headache or migraine was made according to the international
classification of headache disorders (2nd edition) [20]. Headache
association with ADHD was then assessed.
Statistical analysis - Data were summarized as proportions
or means and standard deviations. Bivariate analyses of the
associations between headache diagnosis, frequency and duration
of headache and background factors (gender, learning disorders,
attention deficit disorder and school functioning) were conducted
with Mann-Whitney U tests. Multivariate analyses of the
associations between headache diagnosis and learning disorders,
attention deficit and school functioning, were conducted with nominal regressions. Multivariate analyses of the associations
between frequency and duration of headache and learning
disorders, attention deficit disorder and school functioning, were
conducted with logistic regressions. Analyses for the total sample,
in both nominal and logistic regressions, were adjusted for gender.
P value of ≤ 0.05 was considered as statistically significant.
Results
310 questionnaires were filled by tenth grade students (ages
15-16), 279 were completed and analyzed, of which 158 (57%)
were boys and 121 (43%) girls. 230 students (81%) complained
about headaches (88% of the girls and 76% of the boys, p=0.08).
However only 110 students (48%), 47 boys and 63 girls, gave a
full description of the characteristics of their headaches, so a
diagnosis was feasible according to the international classification
of headache disorders (2nd edition) [21]. Out of those, 55 students
(50%) matched a diagnosis of migraine, 42 of them (76%) without
aura and 13 (24%) with aura. Males and females had the same
prevalence of migraine (47% of the males, 52% of the females). 29
students (26%) matched a diagnosis of Tension Type Headache,
without difference between the genders (p=0.13). In 26 students
(24%) headache characteristics did not match any primary
headache diagnosis (19% of the males, 27% of the females).
Among the students who reported to have headaches: 27%
were diagnosed as having ADHD, compared to 22.5% in the group
that didn’t have headaches, no significant statistical difference was
found. No difference was found in headache prevalence among
students with ADHD between those taking medications such as
methylphenidate and those not.
Discussion
The present study demonstrates a high rate (81%) of
adolescents that complain about headaches. Our findings are
similar to the published data concerning pediatric headache
[3,21] including a higher rate among girls (88% VS 76%) [22].
According to the international classification of headache disorders
[20] headache description matched migraine in about 50% of the
students, with a proceeding Aura in 24% of the cases with no
difference between boys and girls. These findings do not match
data collected from other studies, done with clinical samples
of children and adolescentsv [3,23]. These studies described a
higher rate of migraine among girls. The rate of TTH in our study
was relatively low (26%), with a high percentage of cases (24%)
in which the description of headache did match any primary
headache diagnosis.
A high rate of ADHD (26%) was found in our study. Leviton
[19] was one of the first to report about the relation between
headaches and academic difficulties: he reported that out of 150
elementary-school children who were referred to his clinic due
to recurrent headaches, approximately 40% also had academic
difficulties. The high prevalence of ADHD found in our study
is in accordance with other recent studies, which found a high incidence of hyperactivity and impulsivity symptoms in children
with headache, when compared with their peers [11,24]. In a
population- based study on healthy 4 to17 year-old children, done
by Strine et al. [10], children with frequent headaches were 2.6
times more likely to have inattention and hyperactivity.
A previous study we have conducted also indicated a high rate
of ADHD and learning disabilities in children referred to pediatric
neurology clinics due to recurrent episodes of headaches: 28% of
them had ADHD, 24.7% had learning disabilities, and 12% had
both [3].
In our present study we found no significant differences in
the prevalence of ADHD between the students having headaches
and those who did not. Two possible explanations to that are
the relatively small sample size, and the inclusion of those who
had infrequent episodes of headache in the “headache group”.
A significant difference was found between students with and
without headache in relation to a subjective report of having
symptoms of ADHD and learning disabilities, without having a
formal diagnosis of these disorders: Those with headaches had a
much higher rate of this unpleasant notion than their peers who
did not report having headaches. These findings may be explained
from two standpoints: The first is that significant headaches could
interrupt with school work and hold a negative impact on academic
achievements, as was shown in a recent study [25]. Hence, those
students who have headaches and do not succeed may search
for an “objective barrier” for being unsuccessful, such as having
ADHD or a learning disability, even when a formal assessment
was not done. From the other hand, stress in the school setting
was shown to be a contributor for headaches in children and
adolescents. Therefore those students who experience difficulties
with school work, but do not “hold a title” that enables them
to be more comfortable with their difficulties (such as ADHD
or learning disabilities) might feel more stressed than their
peers who have formal diagnoses, hence receive assistance and
probably more acceptance of their difficulties from their teachers/
peers/ parents. Those students may have a higher level of stress,
and therefore may be more prone to having headaches. This is in
accordance with Strine’s report that children who exhibit high
level of emotional, attention, language and peer problems, were
significantly more likely to have their difficulties interfere with
classroom learning and leisure activities [10].
The subjects in our study were high- school students,
and not
adolescents who seek for medical advice in a clinical setting. The
choice of a non- clinical sample of subjects has an advantage in
evaluating the correlation between two symptoms as it overcomes
the “Berkson’s principle”. Joseph Berkson demonstrated [26] that
people, who seek medical care, are more likely to have more than
one medical problem. Therefore, the relationship of two diseases
should not be studied in those who seek for medical care, according
to Berkson’s principle. The choice of studying a non- clinical sample
in the current study versus studying patients who were referred to a
neurology clinic due to headaches in our previous study could
explain the differences in the prevalence of ADHD found between
the two studies. Using a computerized survey for assessing health
and behavioral challenges in adolescents was previously shown to
be a valid method in numerous studies [27-28].
Limitations
A computerized survey has its disadvantages due to the lack
of personal communication that may allow further explanations in
order to avoid misinterpretations either by the students filling the
questionnaire, or by the investigators analyzing it. This possible
misinterpretation of some questions by the students might be a
contributor for the relatively high percentage of students (24%)
that the description of their headache did not match any primary
headache diagnosis, and to the relatively high rate of students
reporting they were diagnosed with ADHD. It should also be noted
that headache as a somatic complaint could be a part of emotional
status and we didn’t look at the student’s emotional status as well
as at sleep disorder and others ADHD comorbidities.
Conclusion
Our study demonstrated that headache is a frequent complaint
among high school students, and that ADHD was not more frequent
among students suffering from headaches when compared to their
peers who did not report having headache episodes. However,
students with learning difficulties but without a formal diagnosis
of ADHD reported more headaches, possibly due to an elevated
stress level, that might lead to a higher rate of headache episodes.
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