Editorial on "Behavioral and emotional symptoms and primary headaches in children: a population-based study" by Arruda and Bigal.

To advance empirically supported care and improve outcomes for children and adolescents with headache, it is important to develop evidence regarding the impact of headaches on everyday life. Helping our patients to achieve good headache control, quality of life and emotional and behavioral health are core objectives of multidisciplinary treatment. From clinical experience, providers of care for youth and adults with headache appreciate the life context of their patients and have an interest in understanding the psychological functioning of those for whom they provide care. Indeed, many studies have assessed psychological functioning using a wide variety of instruments and methodological approaches. Almost all have been cross-sectional, association studies. The majority of investigations have included clinical samples; some have been community or population based. In pediatrics, the general finding is that children and adolescents with headache, including migraine, report (almost always based on caregiver viewpoint) some elevations on measures of internalizing behaviors (for example, anxiety, mood, somatic symptoms); but most youth with headache do not meet the criteria for psychiatric disorder and formal diagnosis (when youth and families participate in validated, structured clinical interviews). Suggestions for how to incorporate what is known today into pediatric headache clinical practice have been made (1,2,3). There is a clear need for data from more methodologically rigorous investigations and development of more evidence-based approaches for meeting the goals of good headache control, quality of life, and emotional and behavioral health for children and adolescents with headache. For our understanding of psychological functioning to better translate into improved care and outcomes, methodologies that incorporate theoretical models of the possible relations between migraine and psychological symptoms, longitudinal designs, multiinformant protocols, clarity on the implications of symptom reports as compared to diagnosis-based assessments, and testing of the impact of interventions directed at headache, psychological functioning, or both will need to be applied. Arruda and Bigal (4) describe a population-based study in Brazil examining the associations between headaches and psychological symptoms reported by caregivers in younger, school-age children (ages 5–11). The investigators obtained data from children registered in a public school system in one city. The second edition of the International Classification of Headache Disorders (ICHD-2) criteria and a reliable, valid caregiver report measure of psychological symptoms were used. A high participation rate (92.5%) was accomplished. The study found that children with migraine and tension-type headache had elevated internalizing scores on the Child Behavior Checklist (CBCL) relative to youth without headache. Differences were not found for externalizing behaviors. While there may be some concerns with multiple statistical comparisons across scales and sub-scales of a psychometric instrument such as the CBCL, domains of somatic, anxiety-depressive, social, attention, internalizing and total score were found to be more impacted for the headache groups than the comparison group. Children diagnosed with migraine had higher scores than those with tension-type headache. For both the migraine and tension-type headache groups, headache frequency was positively associated with psychological symptoms. The clinical meaningfulness of the differences observed is unclear. While this study is cross-sectional and focused on assessment of association of headache and