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Headache in Children with Tourette Syndrome
Headache in Children with Tourette Syndrome Debabrata Ghosh, MD, Prashant V. Rajan, Deepanjana Das, Priya Datta, A. David Rothner, MD, and Gerald Erenberg, MD Objective The authors analyzed the frequency of occurrence of headaches in children and adolescents with Tourette syndrome (TS) to address their possible inclusion as a comorbidity. Study design Using a prospective questionnaire, administered directly, we interviewed a total sample size of 109 patients with TS #21 years of age. The questionnaires were then analyzed according to the International Headache Society’s diagnostic criteria. Results We found headaches to be present in 55% of the patients, with the 2 most common headache types being migraine headaches and tension-type headaches. The rate of migraine headache within the TS group was found to be 4 times greater than that of the general pediatric population, as reported in the literature. In addition, the rate of tension-type headache was found to be more than 5 times greater than that of the general pediatric population. Conclusions Overall, the high rates of migraine and tension-type headache within this population support the proposition that headaches are a comorbidity of TS. (J Pediatr 2012;161:303-7).
T
ourette syndrome (TS) is an increasingly recognized problem in children, and it is estimated that almost 148 000 children in the United States have the motor or vocal tic disorder.1 It is well established that patients with TS can manifest various comorbidities such as attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), but whether headaches have a high frequency in children with TS is still unclear. One study found the prevalence of migraine headache to be 26.6% within a sample size of 60 children and adolescents with TS, suggesting similar abnormalities underlying both conditions.2 More recently, a study found a similar 25% prevalence for migraine headaches in a larger cohort of 100 children and adults with TS, as well as a 16% prevalence in the pediatric cohort specifically.3 Although prevalence statistics found in these 2 studies were significantly higher than those reported for migraine headaches within the general childhood population, the prevalence of other headache types needs to be documented in the pediatric cohort. Additionally, whether migraines or other headache types can be included as comorbidities of TS also needs to be investigated. Therefore, we used a questionnaire study to determine the prevalence of various headache types in a larger sample size of children with TS. By using a larger sample size of children, we hoped to better ascertain the prevalence of headache in children with TS and investigate other factors associated with the headache, searching for possible etiologies.
Methods We performed a prospective study with a questionnaire4 to investigate the prevalence of headaches in patients with TS, as well as to explore various characteristics of these headaches such as duration, associated symptoms, medications, pain sites, relieving factors, and triggers. Institutional review board approval was obtained from the Cleveland Clinic Foundation for the implementation of this study. Parental consent and patient assent were obtained from every family during the interview and were subsequently recorded. From July 2008 to August 2010, we studied children who were being treated at the Cleveland Clinic Pediatric Neurology Department for a confirmed diagnosis of TS. The diagnosis of TS was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria.5 Only patients of age #21 years were included. Following consultation with a TS specialist, we requested that the patient meet with a researcher in a private setting and answer the questions presented through the questionnaire. If the patient was too young to answer the questions, at least one parent or legal guardian accompanying the patient helped answer the questions. From the Pediatric Neurology Center, Children’s Hospital, Cleveland Clinic, Cleveland, OH The questionnaire4 (Appendix; available at www.jpeds.com) asked the patient D.G. received honoraria for serving as a consultant for if he or she had experienced any headache within the past 6 months and then asked Merz, Inc, and administers botulinum toxin in his clinical practice (20% effort) and bills for this procedure. A.R. for additional details with regard to the type of pain, site, frequency, and duration received grants from GlaxoSmithKline, Merck, and AstraZeneca and received honoraria for serving as a consultant for AstraZeneca and M.A.P. The other authors declare no conflicts of interest.
ADHD IHS OCD TS
Attention-deficit/hyperactivity disorder International Headache Society Obsessive-compulsive disorder Tourette syndrome
Presented as a poster at the 63rd Annual Meeting of the American Academy of Neurology in April 2011 in Honolulu, Hawaii. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.01.072
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of the headaches. Any associated symptoms or aura experienced during the event were also noted. All questions were presented verbally in a standardized manner, and ample time was given for verbal responses. Information that needed more extensive details (eg, medication use, medical history, diagnosis of other TS comorbidities) was attained from the clinical record. Afterward, all questionnaires were reviewed by both a researcher and the principal investigator for validity and reliability. Data Analysis All questionnaires were stored in a secure room, and data were inputted and analyzed on a secure computer network. The International Headache Society (IHS) diagnostic criteria for headaches6 were used to analyze the patient’s responses to the questionnaire and to determine the specific headache types being experienced. For analytic purposes, comparative statistics (ie, percentage rates) were used for calculation of prevalence rates. Twoproportion c2 analysis as well as c2 goodness of fit tests were used for tests of significance, with significance limits set at a = .05.
Figure. Distribution of headache in TS as a function of age. TTH, tension-type headache.
(3% vs 4%), and anxiety (8% vs 16%), respectively. No differences were significant statistically (P > .05).
Results The total sample group consisted of 109 individuals aged #21 years with a confirmed diagnosis of TS. Of the 109 individuals, 60 (55.0%) indicated that they had experienced a headache within the past 6 months. Other comorbidities of TS were also observed within the total sample, namely ADHD (58%), OCD (23%), mood disorder including depression (4%), and anxiety disorder (12%). The headache group (n = 60) consisted of 52 males and 8 females; 58 of the 60 subjects were of white/non-Hispanic race/ethnicity. The average age when interviewed was 14.3 3.7 years (range, 6-21 years). The total headache distribution, as well as subgroups of migraine and tension-type headaches, shown as a function of age has been plotted in the Figure. The nonheadache group (n = 49) consisted of 39 males and 10 females. Forty-two of the 49 in the nonheadache group were of white/non-Hispanic race/ ethnicity, and 7 were African-American individuals. The average age on presentation was 12.7 3.9 years (range, 6-21 years). Medications used in the migraine and tension-type headache cohorts of the headache group are detailed in Table I. The medications used in the nonheadache group included antipsychotics (22), stimulants (7), selective norepinephrine reuptake inhibitors (3), anxiolytics (1), selective serotonin reuptake inhibitors (15), serotoninnorepinephrine reuptake inhibitors (1), a2-agonists (13), and tetracyclic antidepressants (1). In total, 75% of the headache group and 69% of the nonheadache group were medicated, a difference that was not statistically significant (c2 = 0.191, P > .05). Rates of comorbidities of TS also were assessed in the headache vs the nonheadache groups: ADHD (67% vs 47%), OCD (20% vs 27%), mood disorder 304
Migraines A total of 19 individuals (17.4%) were diagnosed with either one or multiple types of migraine headaches or had headache symptoms indicative of migraine headaches according to the
Table I. Physical characteristics of headaches in migraine (n = 19) and tension-type headaches (n = 31) cohorts of patients with TS Physical characteristic Pain site Occipital Retroocular Holocranial Unilateral Bilateral Frontal Parietal/vertex Headache duration A few days 1 day A few hours 1 hour or less 30 minutes or less Medication use Antipsychotic Stimulant Selective norepinephrine reuptake inhibitor Anxiolytic Selective serotonin reuptake inhibitor Serotonin-norepinephrine reuptake inhibitor Tetracyclic antidepressant Tricylic antidepressant a2-Agonist Mood stabilizer
Migraine frequency, n
Tension-type headache frequency, n
3 3 11 7 12 8 2
9 2 6 4 3 13 5
1 8 3 7 0
0 1 2 16 13
8 7 4
15 8 0
2 2 0
5 10 1
0 1 1 1
1 2 5 3
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August 2012 IHS diagnostic criteria for migraine headaches.6 The types of migraine headaches were migraine with aura (5), migraine without aura (9), abdominal migraine (3), and sporadic hemiplegic migraine (2). Physical characteristics of headaches are detailed in Table I; triggers, relieving factors, and associated symptoms are presented in Table II. The average pain rating on a 10-point scale was 7.34 1.90. Of these 19 with migraines, 8 (42.1%) individuals cited a second type of headache in addition to their primary headache: migraine without aura (2), probable migraine without aura (3), probable migraine with aura (1), and frequent episodic tension-type headache (2). Probable migraine with or without aura indicates that the headache profile fulfilled all but one of the IHS diagnostic criteria for migraine with or without aura, respectively. Of the 19 individuals, 12 (63.2%) noted some disability in school, disability in activities, and/or interference in school attendance due to headaches. Tension-Type Headaches A total of 31 (28.4%) individuals presented headache profiles that indicated tension-type headaches in accordance with IHS criteria.6 The tension-type headaches presented by these individuals were frequent episodic (8), infrequent episodic (8), probable frequent episodic (10), and probable infrequent episodic (5). Probable frequent or probable
Table II. Other significant characteristics of headaches observed in patients with TS with migraine (n = 19) and tension-type headache (n = 31) Other characteristics Trigger Stress/excitement Dehydration Missing sleep Heat Missing meal Caffeine Certain foods (eg, sugar) Allergy Weather/humidity Relieving factors Rest/sleep Ibuprofen/pain relievers Prescription medication Vomiting Associated symptoms Nausea Vomiting Photophobia Phonophobia Personality changes/irritability Worsens when walking Abdominal pain Dizziness/confusion Decreased appetite Vision or speech loss Weakness hemibody Stuffy ears Changes in sensation
Migraine frequency, n
Tension-type headache frequency, n
12 2 10 1 3 3 5 0 0
10 1 5 2 3 0 1 5 2
17 19 4 1
19 20 0 0
15 18 21 19 10 15 6 8 8 6 2 0 3
4 2 11 10 6 2 3 8 3 0 2 1 0
Headache in Children with Tourette Syndrome
infrequent episodic tension-type headache indicates that the headache profile fulfilled all but one of the IHC diagnostic criteria for frequent episodic or infrequent episodic tension-type headache, respectively, and failed to fulfill the IHC criteria for migraine without aura.6 Physical characteristics of these headache profiles are detailed in Table I; other key diagnostic characteristics are reviewed in Table II. Of the 31 with tension-type headache, 4 (12.9%) individuals cited a second type of co-occurring headache: stabbing headache (1), probable frequent episodic tension-type headache (2), and migraine without aura (1). It should be noted that the statistics for the patient with the co-occurring migraine without aura headache was included in the migraine cohort. The average pain rating for the tension-type headache on a 10-point scale was 4.6 1.5. Of the 31 individuals, only 4 (12.9%) patients missed school days and/or noted interference in activities because of tension-type headache. Other Types of Headaches There were 12 individuals whose headache profiles were difficult to classify (primary headaches). These included nonmigraine headache with visual aura (1), nonmigraine headache with somatosensory aura (1), headache secondary to depressed affect (1), stabbing headache (2), headache secondary to neck/facial/eye muscle overuse due to tics (4), and headache, not classifiable (3). Medications specifically given in this group included antipsychotics (4), stimulants (1), selective norepinephrine reuptake inhibitors (2), anxiolytics (1), selective serotonin reuptake inhibitors (2), a2-agonists (2), and mood stabilizers (1). Table III reviews other recent studies that were carried out to determine the prevalence of various types of headaches in the general pediatric population. Table III also lists the study conducted by Kwak et al3 on headache in the general population with TS, which compared its statistical values with those of previous studies.
Discussion The average prevalence of headaches among the general pediatric population ranges from 23% to 33%, the average prevalence of migraines for the general pediatric group is approximately 5%, and that of tension-type headache is around 1% to 5%, as indicated by the general population comparison studies.7-10 These comparative values correlate with the prevalence found in the American Migraine Prevalence and Prevention study, which found the 1-year migraine rate to be 6.3% for children and adolescents between 12 and 17 years old.11 Another study found pediatric migraine rates to be 4% for a sample size of around 9000 children between the ages of 7 and 15 years.12 In our study, the prevalence of headaches in children and adolescents with TS discovered (55%) is markedly greater than that in the general pediatric population (30%). Moreover, the observed migraine headache rate for children 305
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Table III. Comparison of current study with results of previously published studies regarding headache prevalence in patients with TS and in children and adolescents in the general population Study
N
Average age (y)
Population
M:F ratio
Headache rate
Migraine headache rate
Tension-type headache rate
Current study Kwak et al (2003)3 Ayatollahi and Khosravi (2006)7 Milovanovic et al (2007)8 Akyol et al (2007)9 Ando et al (2007)10
109 100 2226 1259 7721 6472
14.7 4.14 20.2 14.2 N/A (range, 6-13 y) N/A (range, 7-12 y) 13.08 1.92 N/A (range, 12-15 y)
Pediatric patients with TS General patients with TS General pediatric General pediatric General pediatric General pediatric
5:1 3:1 1:1 N/A 1:1 1:1
53% N/A 31% 32.8% N/A 22.8%
18% 25% 1.7% 3.3% 9.7% 4.8%
27% N/A 5.5% 1.3% N/A N/A
N/A, not reported or is not applicable to the specific study. Adapted from Kwak et al.3
and adolescents with TS (17%) is almost 4 times that of the general pediatric population (5%).7-10 This is consistent with the results of Kwak et al in 2003.3 In addition, the tension-type headache rate for children with TS in our study (28%) is more than 5 times that reported in the rate for the general pediatric population (1%-5%).7,8 It should also be noted that only 4 patients in our sample experienced headaches that were secondary to facial or neck muscle overuse related to tics. This has strong implications for deeper etiologic pathophysiology shared between headache and TS, thereby supporting headaches as a comorbidity of TS. It is unlikely that use of medications influenced patterns found in our study because patients in the headache and nonheadache groups were medicated similarly. Whether specific medications could have individual causative or therapeutic effect on headache would have to be addressed in a larger prospective or a more focused clinical study. Comorbidities observed within our sample are comparable with expected rates of ADHD (61%), OCD (17%), mood disorders (10%), and anxiety disorder (16%).13 Moreover, it is well established that depression and mood disorders can influence headache patterns.14 However, only 3% of patients in the headache cohort showed comorbid depression, which was not different from the 4% of patients in the nonheadache cohort who had comorbid depression. The patterns of headache seen in our TS sample do not seem to be influenced by depression or other comorbidities. The headache group within our sample was largely male (M:F = 5:1), which is similar to the findings of Kwak et al (M:F = 3:1).3 This is in stark contrast to headache within the general pediatric population, which has a higher prevalence in female adolescents.11,15,16 Male predominance could be attributable to our largely male sample (83.4%) or to the fact that TS affects males more than females. The age distribution for our sample (Figure) confirms an increase in headache occurrence with age (centered around 14 and 15 years), a pattern that is similar for both migraine and tension-type headache groups. This age-related pattern for general headache12 and migraine15 also has been seen in the general pediatric population. Although the reason for the high incidence of tension-type headache in TS is as yet unknown, multiple experts propose 306
a similar etiology of both TS and migraine (ie, altered serotonin metabolism).2,3 However, additional study is needed to determine a possible biochemical link between TS and migraine headaches. The findings of this study are limited by the fact that the data collection was conducted via questionnaire, and often such data can be inaccurate due to patient recall bias or researcher reporting bias. The questionnaire was an adaptation from the study of headache in children by Hershey et al.4 Although the IHS criteria used in this study6 is the appropriate standard for headache analysis, it can be overly restrictive in a pediatric study, especially related to criteria for migraine. In addition, the general pediatric population rates used for comparison purposes were gathered from a literature review rather than our own control group. Thus, there may be the possibility of confounding variables such as genetics, psychosocial factors, education, socioeconomic status, and medication usage, along with underlying relationships (eg, sleep problems) that could affect headaches. Finally, the study was conducted at a tertiary care referral center, which could lead to referral bias. It is not known whether appropriate management of these primary headaches in children and adolescents with TS will help control the tics or other comorbidities. There is a need for a larger prospective study to answer that question. n Submitted for publication Oct 29, 2011; last revision received Dec 21, 2011; accepted Jan 31, 2012. Reprint requests: Debabrata Ghosh, MD, Pediatric Neurology Center, Desk S60, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. E-mail: [email protected]
References 1. Centers for Disease Control and Prevention. Prevalence of diagnosed Tourette syndrome in persons aged 6–17 years: United States, 2007. MMWR 2009;58:581-5. 2. Barabas G, Matthews WS, Ferrari M. Tourette’s syndrome and migraine. Arch Neurol 1984;41:871-2. 3. Kwak C, Vuong KD, Jankovic J. Migraine headache in patients with Tourette syndrome. Arch Neurol 2003;60:1595-8. 4. Hershey AD, Winner P, Kabbouche MA, Gladstein J, Yonker M, Lewis D, et al. Use of the ICHD-II criteria in the diagnosis of pediatric migraine headache. Headache 2005;45:1288-97.
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August 2012 5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000. 6. Headache Classification Subcommittee of the International Headache Society. The International classification of headache disorders: 2nd ed. Cephalalgia 2004;24(Suppl 1):9-160. 7. Ayotallahi SM, Khosravi A. Prevalence of migraine and tension-type headache in primary-school children in Shiraz. East Mediterr Health J 2006;12:809-17. 8. Milovanovic M, Jarebinski M, Martinovic Z. Prevalence of primary headaches in children from Belgrade, Serbia. Eur J Paediatr Neurol 2007;11:136-41. 9. Akyol A, Kiylioglu N, Aydin I, Erturk A, Kaya E, Telli E, et al. Epidemiology and clinical characteristics of migraine among school children in the Menderes region. Cephalalgia 2007;27:781-7. 10. Ando N, Fujimoto S, Ishikawa T, Tramoto J, Kobayashi S, Hattori A, et al. Prevalence and features of migraine in Japanese junior high school students aged 12-15 yr. Brain Dev 2007;29:482-5.
11. Bigal ME, Lipton RB, Winner P, Reed ML, Diamond S, Stewart WF, et al. Migraine in adolescents: association with socioeconomic status and family history. Neurology 2007;69:16-25. 12. Bille BS. Migraine in school children. A study of the incidence and shortterm prognosis, and a clinical, psychological and electroencephalographic comparison between children with migraine and matched controls. Acta Paediatr Suppl 1962;136:1-151. 13. Freeman RD, Tourette Syndrome International Database Consortium. Tic disorders and ADHD: answers from a world-wise clinical dataset on Tourette syndrome. Eur Child Adolesc Psychiatry 2007; 16:15-23. 14. Beghi E, Bussone G, D’Amico D, Cortelli P, Cevoli S, Manzoni G, et al. Headache, anxiety and depressive disorders: the HADAS study. J Headache Pain 2010;11:141-50. 15. Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ 1994;309:765. 16. Rhee H. Prevalence and predictors of headaches in US adolescents. Headache 2000;40:528-38.
50 Years Ago in THE JOURNAL OF PEDIATRICS Congenital Abnormalities of the Urinary System. III. Growth of the Kidney in Childhood—Determination of Normal Weight Oliver JT, Rubenstein M, Meyer R, Bernstein J. J Pediatr 1962, 61:256-261
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his is the third of a series of manuscripts that recently was also the subject of a 50 Years Ago piece in The Journal. The first commentary “Congenital Abnormalities of the Urinary System: I. A Post Mortem Survey of Developmental Anomalies and Acquired Congenital Lesions in a Children’s Hospital”1 focused on a detailed description of such abnormalities that continue to be important developmental and acquired kidney problems in pediatric patients today. The second commentary “Congenital Abnormalities of the Urinary System: II. Renal Cortical and Medullary Necrosis”2 was a clinical and pathologic description of cortical and medullary necrosis, which is also an important cause of acute kidney injury and chronic kidney disease in children today. This manuscript provided important information about the normal weight and length of the kidneys in children. The investigators studied pathologic samples from 510 post mortem examinations and they found that kidney mass, in terms of weight, and body size in terms of height, had a high correlation coefficient. Kidney weight also had a high degree of correlation with age. Importantly, SDs were generated so the normal ranges were established. The investigators also noted that some of the values falling at the lower limits of the normal range may actually represent kidneys whose functional capacity is inadequate and that such kidneys may be hypoplastic. The establishment of normal size and weight of the kidneys at all ages in children and defining the normal range was an important first step in the ability to recognize abnormal, small kidneys that are either dysplastic or hypoplastic or too large in such diseases as autosomal recessive or autosomal dominate polycystic kidney disease. Indeed, today a renal ultrasound to determine kidney size and length is an important tool in evaluating a child for renal disease. Sharon P. Andreoli, MD Division of Pediatric Nephrology James Whitcomb Riley Hospital for Children Indianapolis, Indiana http://dx.doi.org/10.1016/j.jpeds.2012.03.034
References 1. Rubenstein M, Meyer R, Bernstein J. Congenital Abnormalities of the Urinary System I. A postmortem survey of developmental anomalies and acquired congenital lesions in a children’s hospital. J Pediatr 1961;58:356-66. 2. Bernstein J, Meyer R. Congenital Abnormalities of the Urinary System II. Renal cortical and medullary necrosis. J Pediatr 1961;59:657-68.
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NUMBER________________________________________________________ GENDER
MALE
FEMALE
DATE_____________
AGE_______________
Relation of the person answering questions: _____________________________________________________ Current weight: ____________ (pounds)
Current height (feet/inches):________________
Year in school (if applicable): ________________
Academic grade: __________________________
Academic performance:
_ _Average
__Above average __Below Average
Type of schooling:
_ _ Regular __Learning Support (tutor)
_ _Special education
__other
Please describe any learning or behavior problems your child has at school: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Racial/Ethnic Background of your child (please circle): 1.
American Indian
2.
African-American
4. Asian American 5. Hispanic
3.
White/not Hispanic
6. Other or unknown
Please list any activities (i.e. Extra-curricular) that your child is involved in: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Do you think your child suffers from stress?
___Yes
___No
If Yes, Please explain and describe the stress (i.e.-school, friends, family, other): _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________
List the reason for your child’s visit to the doctor today: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Please list all your child’s past and present medical conditions and surgeries: ____________________ _______________________________
__________________________
____________________ _______________________________
__________________________
____________________ _______________________________
__________________________
Is your child slow or developmentally delayed or have a learning disorder, ADHD, speech impediment or any other special educational needs?
____Yes
_____No
If yes, Please specify: ______________________________________________________________ _________________________________________________________________ If yes, does your child receive any special help?(check all that apply) Learning disability class Physical, speech or occupational therapy Out of school tutor Other (explain)
_________________ __ _______________ _________________ _________________
Does your child have any specific behavioral problems? (Check all that apply) Severe temper tantrums Lack of socialization with peers
_____________________ _____________________
Anxiety
_____________________
Depression
_____________________
Sleep disorder
_____________________
Other (explain)
_____________________
Appendix. Cleveland Clinic Foundation Pediatric Headache Questionnaire. (Continues)
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Please list your child’s current medication: ____________________ _______________________
____________________
____________________
_____________________
_______________________
Does your child have a blood relative with headaches?
___Yes
___No
If yes, please list relationship to child and type of headache below: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ HEADACHE HISTORY: 1. In the past 6 months, has your child had any headaches? ________Yes
_________No
If you answered No to the above, you do not need to complete the rest of this questionnaire. If you answered yes, please complete the rest of this questionnaire. 2. How long has your child had headaches?(check one of the following) _______Less than one month
1-3months_________
3-6months_______
>6months
3. Are all your child’s headache the same? If NO, are some headaches stronger and other milder? _______Yes
_________NO
4. For your child’s headaches (if only one type) or the STRONGER headache, please answer the following A. Frequency: How often does your child experience headaches? (Check one of the following) A ___________ Very seldom B _____________ less than once per month C _____________ 1-3 times per month D _____________ once a week E _____________2-3 times per week F _____________More than 3 times per week G _____________At least once a day H ____________All the time (24 hours, 7 days a week) I____________ other (please explain)
_________________________________________
B. Severity of pain (circle one) 1. The headaches (a) do not interfere with normal activities (b)Stop some activities (c) Stop all activities PAIN RATING SCALES No pain
Moderate pain
Worst pain
------- -------- --------- -------------------- --------- --------- ---------- --------- --------0
1
0
2
2
3
4
4
5
6
6
7
8
8
9
10
10
2. On a scale of 0-10 (0=no pain and 10= the worst pain), what is the usual score of your child’s headache _______________ (see picture above) C. Site of pain (circle all that apply) B. The headaches are located at/on: (a) the whole head (b) The forehead (c) One side of the head (unilateral) (d) The top of the head (e) The back of the head (f) Other (explain) ______________________ D. Quality of the pain(circle one) c. the headaches are: (a) dull (b) Just sore (c) throbbing/pounding (d) Sharp (e) pressure/tightness/squeezing (f) Other (explain) ________________________________
Appendix. Continues. Headache in Children with Tourette Syndrome
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E. Aura symptoms : (circle all that apply) d. Before the headaches, my child……….
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(a) Has no symptom (b) Has changes in vision (c) Has changes in se nsation (d) Has changes in st rength (e) Has mood changes (f) Has changes in speech (g) looks pale (h) Other ____________________
F .Trigger factors (circle all that apply) e. My child’s headache seems to be caused by
(a) nothing that I can tell (b) Missing a meal (c) Missing sleep (d) stress/excitement (e) certain foods (sure) (f) Certain foods (suspected) (g) others(explain) __________________________________________________ G. Other symptoms: (circle all that apply) f. With the headache, my child (gets): (a) nothing else (b) Decreased appetite (c) Nausea (d) Vomiting (e) Bothered by light (f) Bothered by noise (g) Worsening headaches with walking (h) Abdominal pain (i) Weakness on one side of the body (j) Decreased vision (k) Changes in sensation (l) Confused (m) Problems with speech (n) Feels like the room is spinning (o) Personality changes (explain) __________________________________ (p) Other (explain)__________________________________ H. Relieving factors (check all that apply) g. My Childs headaches seem to get better with:
(a) rest (b) Sleep (c) Tylenol (d) ibuprofen (e) vomiting (f) nothing (g) Other (explain) __________________________________________________
I. Time-related factors (check all that apply) h. My child’s he adache usually occur
(a) at certain times of the year (Please list season)______________________ (b) mornings after waking__________ (c) Afternoon (during school) (d) evenings (after school, dinnertime, before Bed __________________________ (e) Middle of the night (f) only weekdays (g) Only weekends (h) Anytime
How long does the headache usually last? (Circle one) (a) 5 minutes or less (b) 30 minutes or less (c)1 hour or less (b) A few days (e) one day (f) a few days 6. If your child has only one type of headache, skip to question #7.If you have more than one type of headach, please answer the following about your child’s MILDER headache: A. Frequency: How often does your child experience headaches? (Check one of the following) A _____________ Very seldom B _____________ less than once per month C _____________ 1-3 times per month D _____________ once a week E _____________ 2-3 times per week F _____________ More than 3 times per week G _____________At least once a day H ____________All the time (24 hours, 7 days a week) I____________ other (please explain) _________________________________________
Appendix. Continues.
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B. Severity of pain (circle one) 1. The headaches (a) donot interfere with normal activities (b) Stop some activities (c) Stop all activities PAIN RATING SCALES No pain Moderate pain
Worst pain
------- -------- --------- -------------------- --------- --------- ---------- --------- --------0 1 2 3 4 5 6 7 8 9 10
0
2
4
6
8
10
2. on a scale of 0-10 (0=no pain and 10= the worst pain), what is the usual score of you _______________ (see picture above) C. Site of pain (circle all that apply) B. The headaches are located at/on:
D. Quality of the pain (circle one) c. The headaches are:
E. Aura symptoms : (circle all that apply) d. Before the headaches,
(a) the whole head (b) The forehead (c) One side of the head (unilateral) (d) The top of the head (e) The back of the head (f) other (explain) ______________________
(a) dull (b) Just sore (c) throbbing/pounding (d) Sharp (e) pressure/tightness/squeezing (f) Other (explain)________________________________ Has no symptom (b) Has changes in vision (c) Has changes in sensation (d) Has changes in strength (e) Has mood changes (f) Has changes in speech (g) looks pale (h) other ____________________
F .Trigger factors (circle all that apply) e. M
(a) nothing that I can tell (b) Missing a meal (c) Missing sleep (d) stress/excitement (e) certain foods (sure) (f) Certain foods (suspected) (g) others (explain) __________________________________________________ G. Other symptoms: (circle all that apply) f. With the headache, my child (gets): (a) nothing else (b) Decreased appetite (c) Nausea (d)Vomiting (e) Bothered by light (f) Bothered by noise (g) Worsening headaches with walking (h) Abdominal pain (j) Weakness on one side of the body (j) Decreased vision (k) Changes in sensation (l) Confused (m) Problems with speech (n) Feels like the room is spinning (o) Personality changes (explain) __________________________________ (p) Other (explain) _______________________________
Appendix. Continues. Headache in Children with Tourette Syndrome
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H. Relieving factors (check all that apply) g. My Childs headaches seem to get better with:
(a) rest (b) Sleep (c) Tylenol (d) Ibuprofen (e) Vomiting (f) nothing (g) Other (explain) __________________________________________________
I. Time-related factors (check all that apply) ually occurs
(a) at certain times of the year (please list Season)__________________________ (b) mornings after waking__________ (c) Afternoon (during school) (d)evenings (after _________________________
school, dinnertime, before bed)
(e) Middle of the night (f ) only weekdays (g) Only weekends (h) Anytime How long does the headache usually last? (Circle one) (a) 5 minutes or less (d)A few days
(b)30 minutes or less (e) one day
(c)1 hour or less (f) a few days
7. Between headache attacks, your child is (circle one): (a) Completely well
(b) still complains of headaches
(c) other _______________
8. Has your child ever had a CT scan or MRI of the brain to evaluate the headaches? ____Yes ________NO If yes, when and where?__________________________________________________ 9. What treatments have been tried to relieve pain at the time of the headache and what was the response? Name of treatment ________________
useful
not useful
any side effect
______________________________________________________
_____________________________________________________________________________________ 10. What daily treatments have been tried to prevent attacks and what was the result? Name of treatment
useful
not useful
any side effect
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________
11. What other non-drug treatment (i.e. diet, exercise, Name of treatment
useful
not useful
any side effect
12. Headache disability assessment: The following questions try to assess how much the headaches affect day-to day activity. Your answers should be based on the last THREE months. swers, so please put down your Ia) How many full school days were missed in the past 3 months due to headaches? __________ Ib) How many partial school days were missed in the past 3 months due to headaches? ______ ii) How many days in the past 3 months did your child function less than half his /her ability in school because of the headache(do not include the days you missed in the first 2 questions above? ______ iv) How many days did your child not participate in other activities (ie. Play, go out, sports etc) because of a headache? ______ v) How many days did your child participate in other activities, but functioned less than half your ability? ______ (do not include the days mentioned in the preceding question)
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13. Please list any additional comments (if any): _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________
_________________________
Date ___________________
Patient Signature (if Possible) ________________________ Parent/Guardian name (printed)
_________________________
_____________
Parent/Guardian signature Date
Please do not write below (physician use only) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________________
Appendix. Continued.
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T
ourette syndrome (TS) is an increasingly recognized problem in children, and it is estimated that almost 148 000 children in the United States have the motor or vocal tic disorder.1 It is well established that patients with TS can manifest various comorbidities such as attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), but whether headaches have a high frequency in children with TS is still unclear. One study found the prevalence of migraine headache to be 26.6% within a sample size of 60 children and adolescents with TS, suggesting similar abnormalities underlying both conditions.2 More recently, a study found a similar 25% prevalence for migraine headaches in a larger cohort of 100 children and adults with TS, as well as a 16% prevalence in the pediatric cohort specifically.3 Although prevalence statistics found in these 2 studies were significantly higher than those reported for migraine headaches within the general childhood population, the prevalence of other headache types needs to be documented in the pediatric cohort. Additionally, whether migraines or other headache types can be included as comorbidities of TS also needs to be investigated. Therefore, we used a questionnaire study to determine the prevalence of various headache types in a larger sample size of children with TS. By using a larger sample size of children, we hoped to better ascertain the prevalence of headache in children with TS and investigate other factors associated with the headache, searching for possible etiologies.
Methods We performed a prospective study with a questionnaire4 to investigate the prevalence of headaches in patients with TS, as well as to explore various characteristics of these headaches such as duration, associated symptoms, medications, pain sites, relieving factors, and triggers. Institutional review board approval was obtained from the Cleveland Clinic Foundation for the implementation of this study. Parental consent and patient assent were obtained from every family during the interview and were subsequently recorded. From July 2008 to August 2010, we studied children who were being treated at the Cleveland Clinic Pediatric Neurology Department for a confirmed diagnosis of TS. The diagnosis of TS was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria.5 Only patients of age #21 years were included. Following consultation with a TS specialist, we requested that the patient meet with a researcher in a private setting and answer the questions presented through the questionnaire. If the patient was too young to answer the questions, at least one parent or legal guardian accompanying the patient helped answer the questions. From the Pediatric Neurology Center, Children’s Hospital, Cleveland Clinic, Cleveland, OH The questionnaire4 (Appendix; available at www.jpeds.com) asked the patient D.G. received honoraria for serving as a consultant for if he or she had experienced any headache within the past 6 months and then asked Merz, Inc, and administers botulinum toxin in his clinical practice (20% effort) and bills for this procedure. A.R. for additional details with regard to the type of pain, site, frequency, and duration received grants from GlaxoSmithKline, Merck, and AstraZeneca and received honoraria for serving as a consultant for AstraZeneca and M.A.P. The other authors declare no conflicts of interest.
ADHD IHS OCD TS
Attention-deficit/hyperactivity disorder International Headache Society Obsessive-compulsive disorder Tourette syndrome
Presented as a poster at the 63rd Annual Meeting of the American Academy of Neurology in April 2011 in Honolulu, Hawaii. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.01.072
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of the headaches. Any associated symptoms or aura experienced during the event were also noted. All questions were presented verbally in a standardized manner, and ample time was given for verbal responses. Information that needed more extensive details (eg, medication use, medical history, diagnosis of other TS comorbidities) was attained from the clinical record. Afterward, all questionnaires were reviewed by both a researcher and the principal investigator for validity and reliability. Data Analysis All questionnaires were stored in a secure room, and data were inputted and analyzed on a secure computer network. The International Headache Society (IHS) diagnostic criteria for headaches6 were used to analyze the patient’s responses to the questionnaire and to determine the specific headache types being experienced. For analytic purposes, comparative statistics (ie, percentage rates) were used for calculation of prevalence rates. Twoproportion c2 analysis as well as c2 goodness of fit tests were used for tests of significance, with significance limits set at a = .05.
Figure. Distribution of headache in TS as a function of age. TTH, tension-type headache.
(3% vs 4%), and anxiety (8% vs 16%), respectively. No differences were significant statistically (P > .05).
Results The total sample group consisted of 109 individuals aged #21 years with a confirmed diagnosis of TS. Of the 109 individuals, 60 (55.0%) indicated that they had experienced a headache within the past 6 months. Other comorbidities of TS were also observed within the total sample, namely ADHD (58%), OCD (23%), mood disorder including depression (4%), and anxiety disorder (12%). The headache group (n = 60) consisted of 52 males and 8 females; 58 of the 60 subjects were of white/non-Hispanic race/ethnicity. The average age when interviewed was 14.3 3.7 years (range, 6-21 years). The total headache distribution, as well as subgroups of migraine and tension-type headaches, shown as a function of age has been plotted in the Figure. The nonheadache group (n = 49) consisted of 39 males and 10 females. Forty-two of the 49 in the nonheadache group were of white/non-Hispanic race/ ethnicity, and 7 were African-American individuals. The average age on presentation was 12.7 3.9 years (range, 6-21 years). Medications used in the migraine and tension-type headache cohorts of the headache group are detailed in Table I. The medications used in the nonheadache group included antipsychotics (22), stimulants (7), selective norepinephrine reuptake inhibitors (3), anxiolytics (1), selective serotonin reuptake inhibitors (15), serotoninnorepinephrine reuptake inhibitors (1), a2-agonists (13), and tetracyclic antidepressants (1). In total, 75% of the headache group and 69% of the nonheadache group were medicated, a difference that was not statistically significant (c2 = 0.191, P > .05). Rates of comorbidities of TS also were assessed in the headache vs the nonheadache groups: ADHD (67% vs 47%), OCD (20% vs 27%), mood disorder 304
Migraines A total of 19 individuals (17.4%) were diagnosed with either one or multiple types of migraine headaches or had headache symptoms indicative of migraine headaches according to the
Table I. Physical characteristics of headaches in migraine (n = 19) and tension-type headaches (n = 31) cohorts of patients with TS Physical characteristic Pain site Occipital Retroocular Holocranial Unilateral Bilateral Frontal Parietal/vertex Headache duration A few days 1 day A few hours 1 hour or less 30 minutes or less Medication use Antipsychotic Stimulant Selective norepinephrine reuptake inhibitor Anxiolytic Selective serotonin reuptake inhibitor Serotonin-norepinephrine reuptake inhibitor Tetracyclic antidepressant Tricylic antidepressant a2-Agonist Mood stabilizer
Migraine frequency, n
Tension-type headache frequency, n
3 3 11 7 12 8 2
9 2 6 4 3 13 5
1 8 3 7 0
0 1 2 16 13
8 7 4
15 8 0
2 2 0
5 10 1
0 1 1 1
1 2 5 3
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August 2012 IHS diagnostic criteria for migraine headaches.6 The types of migraine headaches were migraine with aura (5), migraine without aura (9), abdominal migraine (3), and sporadic hemiplegic migraine (2). Physical characteristics of headaches are detailed in Table I; triggers, relieving factors, and associated symptoms are presented in Table II. The average pain rating on a 10-point scale was 7.34 1.90. Of these 19 with migraines, 8 (42.1%) individuals cited a second type of headache in addition to their primary headache: migraine without aura (2), probable migraine without aura (3), probable migraine with aura (1), and frequent episodic tension-type headache (2). Probable migraine with or without aura indicates that the headache profile fulfilled all but one of the IHS diagnostic criteria for migraine with or without aura, respectively. Of the 19 individuals, 12 (63.2%) noted some disability in school, disability in activities, and/or interference in school attendance due to headaches. Tension-Type Headaches A total of 31 (28.4%) individuals presented headache profiles that indicated tension-type headaches in accordance with IHS criteria.6 The tension-type headaches presented by these individuals were frequent episodic (8), infrequent episodic (8), probable frequent episodic (10), and probable infrequent episodic (5). Probable frequent or probable
Table II. Other significant characteristics of headaches observed in patients with TS with migraine (n = 19) and tension-type headache (n = 31) Other characteristics Trigger Stress/excitement Dehydration Missing sleep Heat Missing meal Caffeine Certain foods (eg, sugar) Allergy Weather/humidity Relieving factors Rest/sleep Ibuprofen/pain relievers Prescription medication Vomiting Associated symptoms Nausea Vomiting Photophobia Phonophobia Personality changes/irritability Worsens when walking Abdominal pain Dizziness/confusion Decreased appetite Vision or speech loss Weakness hemibody Stuffy ears Changes in sensation
Migraine frequency, n
Tension-type headache frequency, n
12 2 10 1 3 3 5 0 0
10 1 5 2 3 0 1 5 2
17 19 4 1
19 20 0 0
15 18 21 19 10 15 6 8 8 6 2 0 3
4 2 11 10 6 2 3 8 3 0 2 1 0
Headache in Children with Tourette Syndrome
infrequent episodic tension-type headache indicates that the headache profile fulfilled all but one of the IHC diagnostic criteria for frequent episodic or infrequent episodic tension-type headache, respectively, and failed to fulfill the IHC criteria for migraine without aura.6 Physical characteristics of these headache profiles are detailed in Table I; other key diagnostic characteristics are reviewed in Table II. Of the 31 with tension-type headache, 4 (12.9%) individuals cited a second type of co-occurring headache: stabbing headache (1), probable frequent episodic tension-type headache (2), and migraine without aura (1). It should be noted that the statistics for the patient with the co-occurring migraine without aura headache was included in the migraine cohort. The average pain rating for the tension-type headache on a 10-point scale was 4.6 1.5. Of the 31 individuals, only 4 (12.9%) patients missed school days and/or noted interference in activities because of tension-type headache. Other Types of Headaches There were 12 individuals whose headache profiles were difficult to classify (primary headaches). These included nonmigraine headache with visual aura (1), nonmigraine headache with somatosensory aura (1), headache secondary to depressed affect (1), stabbing headache (2), headache secondary to neck/facial/eye muscle overuse due to tics (4), and headache, not classifiable (3). Medications specifically given in this group included antipsychotics (4), stimulants (1), selective norepinephrine reuptake inhibitors (2), anxiolytics (1), selective serotonin reuptake inhibitors (2), a2-agonists (2), and mood stabilizers (1). Table III reviews other recent studies that were carried out to determine the prevalence of various types of headaches in the general pediatric population. Table III also lists the study conducted by Kwak et al3 on headache in the general population with TS, which compared its statistical values with those of previous studies.
Discussion The average prevalence of headaches among the general pediatric population ranges from 23% to 33%, the average prevalence of migraines for the general pediatric group is approximately 5%, and that of tension-type headache is around 1% to 5%, as indicated by the general population comparison studies.7-10 These comparative values correlate with the prevalence found in the American Migraine Prevalence and Prevention study, which found the 1-year migraine rate to be 6.3% for children and adolescents between 12 and 17 years old.11 Another study found pediatric migraine rates to be 4% for a sample size of around 9000 children between the ages of 7 and 15 years.12 In our study, the prevalence of headaches in children and adolescents with TS discovered (55%) is markedly greater than that in the general pediatric population (30%). Moreover, the observed migraine headache rate for children 305
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Table III. Comparison of current study with results of previously published studies regarding headache prevalence in patients with TS and in children and adolescents in the general population Study
N
Average age (y)
Population
M:F ratio
Headache rate
Migraine headache rate
Tension-type headache rate
Current study Kwak et al (2003)3 Ayatollahi and Khosravi (2006)7 Milovanovic et al (2007)8 Akyol et al (2007)9 Ando et al (2007)10
109 100 2226 1259 7721 6472
14.7 4.14 20.2 14.2 N/A (range, 6-13 y) N/A (range, 7-12 y) 13.08 1.92 N/A (range, 12-15 y)
Pediatric patients with TS General patients with TS General pediatric General pediatric General pediatric General pediatric
5:1 3:1 1:1 N/A 1:1 1:1
53% N/A 31% 32.8% N/A 22.8%
18% 25% 1.7% 3.3% 9.7% 4.8%
27% N/A 5.5% 1.3% N/A N/A
N/A, not reported or is not applicable to the specific study. Adapted from Kwak et al.3
and adolescents with TS (17%) is almost 4 times that of the general pediatric population (5%).7-10 This is consistent with the results of Kwak et al in 2003.3 In addition, the tension-type headache rate for children with TS in our study (28%) is more than 5 times that reported in the rate for the general pediatric population (1%-5%).7,8 It should also be noted that only 4 patients in our sample experienced headaches that were secondary to facial or neck muscle overuse related to tics. This has strong implications for deeper etiologic pathophysiology shared between headache and TS, thereby supporting headaches as a comorbidity of TS. It is unlikely that use of medications influenced patterns found in our study because patients in the headache and nonheadache groups were medicated similarly. Whether specific medications could have individual causative or therapeutic effect on headache would have to be addressed in a larger prospective or a more focused clinical study. Comorbidities observed within our sample are comparable with expected rates of ADHD (61%), OCD (17%), mood disorders (10%), and anxiety disorder (16%).13 Moreover, it is well established that depression and mood disorders can influence headache patterns.14 However, only 3% of patients in the headache cohort showed comorbid depression, which was not different from the 4% of patients in the nonheadache cohort who had comorbid depression. The patterns of headache seen in our TS sample do not seem to be influenced by depression or other comorbidities. The headache group within our sample was largely male (M:F = 5:1), which is similar to the findings of Kwak et al (M:F = 3:1).3 This is in stark contrast to headache within the general pediatric population, which has a higher prevalence in female adolescents.11,15,16 Male predominance could be attributable to our largely male sample (83.4%) or to the fact that TS affects males more than females. The age distribution for our sample (Figure) confirms an increase in headache occurrence with age (centered around 14 and 15 years), a pattern that is similar for both migraine and tension-type headache groups. This age-related pattern for general headache12 and migraine15 also has been seen in the general pediatric population. Although the reason for the high incidence of tension-type headache in TS is as yet unknown, multiple experts propose 306
a similar etiology of both TS and migraine (ie, altered serotonin metabolism).2,3 However, additional study is needed to determine a possible biochemical link between TS and migraine headaches. The findings of this study are limited by the fact that the data collection was conducted via questionnaire, and often such data can be inaccurate due to patient recall bias or researcher reporting bias. The questionnaire was an adaptation from the study of headache in children by Hershey et al.4 Although the IHS criteria used in this study6 is the appropriate standard for headache analysis, it can be overly restrictive in a pediatric study, especially related to criteria for migraine. In addition, the general pediatric population rates used for comparison purposes were gathered from a literature review rather than our own control group. Thus, there may be the possibility of confounding variables such as genetics, psychosocial factors, education, socioeconomic status, and medication usage, along with underlying relationships (eg, sleep problems) that could affect headaches. Finally, the study was conducted at a tertiary care referral center, which could lead to referral bias. It is not known whether appropriate management of these primary headaches in children and adolescents with TS will help control the tics or other comorbidities. There is a need for a larger prospective study to answer that question. n Submitted for publication Oct 29, 2011; last revision received Dec 21, 2011; accepted Jan 31, 2012. Reprint requests: Debabrata Ghosh, MD, Pediatric Neurology Center, Desk S60, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. E-mail: [email protected]
References 1. Centers for Disease Control and Prevention. Prevalence of diagnosed Tourette syndrome in persons aged 6–17 years: United States, 2007. MMWR 2009;58:581-5. 2. Barabas G, Matthews WS, Ferrari M. Tourette’s syndrome and migraine. Arch Neurol 1984;41:871-2. 3. Kwak C, Vuong KD, Jankovic J. Migraine headache in patients with Tourette syndrome. Arch Neurol 2003;60:1595-8. 4. Hershey AD, Winner P, Kabbouche MA, Gladstein J, Yonker M, Lewis D, et al. Use of the ICHD-II criteria in the diagnosis of pediatric migraine headache. Headache 2005;45:1288-97.
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August 2012 5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000. 6. Headache Classification Subcommittee of the International Headache Society. The International classification of headache disorders: 2nd ed. Cephalalgia 2004;24(Suppl 1):9-160. 7. Ayotallahi SM, Khosravi A. Prevalence of migraine and tension-type headache in primary-school children in Shiraz. East Mediterr Health J 2006;12:809-17. 8. Milovanovic M, Jarebinski M, Martinovic Z. Prevalence of primary headaches in children from Belgrade, Serbia. Eur J Paediatr Neurol 2007;11:136-41. 9. Akyol A, Kiylioglu N, Aydin I, Erturk A, Kaya E, Telli E, et al. Epidemiology and clinical characteristics of migraine among school children in the Menderes region. Cephalalgia 2007;27:781-7. 10. Ando N, Fujimoto S, Ishikawa T, Tramoto J, Kobayashi S, Hattori A, et al. Prevalence and features of migraine in Japanese junior high school students aged 12-15 yr. Brain Dev 2007;29:482-5.
11. Bigal ME, Lipton RB, Winner P, Reed ML, Diamond S, Stewart WF, et al. Migraine in adolescents: association with socioeconomic status and family history. Neurology 2007;69:16-25. 12. Bille BS. Migraine in school children. A study of the incidence and shortterm prognosis, and a clinical, psychological and electroencephalographic comparison between children with migraine and matched controls. Acta Paediatr Suppl 1962;136:1-151. 13. Freeman RD, Tourette Syndrome International Database Consortium. Tic disorders and ADHD: answers from a world-wise clinical dataset on Tourette syndrome. Eur Child Adolesc Psychiatry 2007; 16:15-23. 14. Beghi E, Bussone G, D’Amico D, Cortelli P, Cevoli S, Manzoni G, et al. Headache, anxiety and depressive disorders: the HADAS study. J Headache Pain 2010;11:141-50. 15. Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ 1994;309:765. 16. Rhee H. Prevalence and predictors of headaches in US adolescents. Headache 2000;40:528-38.
50 Years Ago in THE JOURNAL OF PEDIATRICS Congenital Abnormalities of the Urinary System. III. Growth of the Kidney in Childhood—Determination of Normal Weight Oliver JT, Rubenstein M, Meyer R, Bernstein J. J Pediatr 1962, 61:256-261
T
his is the third of a series of manuscripts that recently was also the subject of a 50 Years Ago piece in The Journal. The first commentary “Congenital Abnormalities of the Urinary System: I. A Post Mortem Survey of Developmental Anomalies and Acquired Congenital Lesions in a Children’s Hospital”1 focused on a detailed description of such abnormalities that continue to be important developmental and acquired kidney problems in pediatric patients today. The second commentary “Congenital Abnormalities of the Urinary System: II. Renal Cortical and Medullary Necrosis”2 was a clinical and pathologic description of cortical and medullary necrosis, which is also an important cause of acute kidney injury and chronic kidney disease in children today. This manuscript provided important information about the normal weight and length of the kidneys in children. The investigators studied pathologic samples from 510 post mortem examinations and they found that kidney mass, in terms of weight, and body size in terms of height, had a high correlation coefficient. Kidney weight also had a high degree of correlation with age. Importantly, SDs were generated so the normal ranges were established. The investigators also noted that some of the values falling at the lower limits of the normal range may actually represent kidneys whose functional capacity is inadequate and that such kidneys may be hypoplastic. The establishment of normal size and weight of the kidneys at all ages in children and defining the normal range was an important first step in the ability to recognize abnormal, small kidneys that are either dysplastic or hypoplastic or too large in such diseases as autosomal recessive or autosomal dominate polycystic kidney disease. Indeed, today a renal ultrasound to determine kidney size and length is an important tool in evaluating a child for renal disease. Sharon P. Andreoli, MD Division of Pediatric Nephrology James Whitcomb Riley Hospital for Children Indianapolis, Indiana http://dx.doi.org/10.1016/j.jpeds.2012.03.034
References 1. Rubenstein M, Meyer R, Bernstein J. Congenital Abnormalities of the Urinary System I. A postmortem survey of developmental anomalies and acquired congenital lesions in a children’s hospital. J Pediatr 1961;58:356-66. 2. Bernstein J, Meyer R. Congenital Abnormalities of the Urinary System II. Renal cortical and medullary necrosis. J Pediatr 1961;59:657-68.
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NUMBER________________________________________________________ GENDER
MALE
FEMALE
DATE_____________
AGE_______________
Relation of the person answering questions: _____________________________________________________ Current weight: ____________ (pounds)
Current height (feet/inches):________________
Year in school (if applicable): ________________
Academic grade: __________________________
Academic performance:
_ _Average
__Above average __Below Average
Type of schooling:
_ _ Regular __Learning Support (tutor)
_ _Special education
__other
Please describe any learning or behavior problems your child has at school: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Racial/Ethnic Background of your child (please circle): 1.
American Indian
2.
African-American
4. Asian American 5. Hispanic
3.
White/not Hispanic
6. Other or unknown
Please list any activities (i.e. Extra-curricular) that your child is involved in: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Do you think your child suffers from stress?
___Yes
___No
If Yes, Please explain and describe the stress (i.e.-school, friends, family, other): _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________
List the reason for your child’s visit to the doctor today: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ Please list all your child’s past and present medical conditions and surgeries: ____________________ _______________________________
__________________________
____________________ _______________________________
__________________________
____________________ _______________________________
__________________________
Is your child slow or developmentally delayed or have a learning disorder, ADHD, speech impediment or any other special educational needs?
____Yes
_____No
If yes, Please specify: ______________________________________________________________ _________________________________________________________________ If yes, does your child receive any special help?(check all that apply) Learning disability class Physical, speech or occupational therapy Out of school tutor Other (explain)
_________________ __ _______________ _________________ _________________
Does your child have any specific behavioral problems? (Check all that apply) Severe temper tantrums Lack of socialization with peers
_____________________ _____________________
Anxiety
_____________________
Depression
_____________________
Sleep disorder
_____________________
Other (explain)
_____________________
Appendix. Cleveland Clinic Foundation Pediatric Headache Questionnaire. (Continues)
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Please list your child’s current medication: ____________________ _______________________
____________________
____________________
_____________________
_______________________
Does your child have a blood relative with headaches?
___Yes
___No
If yes, please list relationship to child and type of headache below: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________ HEADACHE HISTORY: 1. In the past 6 months, has your child had any headaches? ________Yes
_________No
If you answered No to the above, you do not need to complete the rest of this questionnaire. If you answered yes, please complete the rest of this questionnaire. 2. How long has your child had headaches?(check one of the following) _______Less than one month
1-3months_________
3-6months_______
>6months
3. Are all your child’s headache the same? If NO, are some headaches stronger and other milder? _______Yes
_________NO
4. For your child’s headaches (if only one type) or the STRONGER headache, please answer the following A. Frequency: How often does your child experience headaches? (Check one of the following) A ___________ Very seldom B _____________ less than once per month C _____________ 1-3 times per month D _____________ once a week E _____________2-3 times per week F _____________More than 3 times per week G _____________At least once a day H ____________All the time (24 hours, 7 days a week) I____________ other (please explain)
_________________________________________
B. Severity of pain (circle one) 1. The headaches (a) do not interfere with normal activities (b)Stop some activities (c) Stop all activities PAIN RATING SCALES No pain
Moderate pain
Worst pain
------- -------- --------- -------------------- --------- --------- ---------- --------- --------0
1
0
2
2
3
4
4
5
6
6
7
8
8
9
10
10
2. On a scale of 0-10 (0=no pain and 10= the worst pain), what is the usual score of your child’s headache _______________ (see picture above) C. Site of pain (circle all that apply) B. The headaches are located at/on: (a) the whole head (b) The forehead (c) One side of the head (unilateral) (d) The top of the head (e) The back of the head (f) Other (explain) ______________________ D. Quality of the pain(circle one) c. the headaches are: (a) dull (b) Just sore (c) throbbing/pounding (d) Sharp (e) pressure/tightness/squeezing (f) Other (explain) ________________________________
Appendix. Continues. Headache in Children with Tourette Syndrome
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E. Aura symptoms : (circle all that apply) d. Before the headaches, my child……….
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(a) Has no symptom (b) Has changes in vision (c) Has changes in se nsation (d) Has changes in st rength (e) Has mood changes (f) Has changes in speech (g) looks pale (h) Other ____________________
F .Trigger factors (circle all that apply) e. My child’s headache seems to be caused by
(a) nothing that I can tell (b) Missing a meal (c) Missing sleep (d) stress/excitement (e) certain foods (sure) (f) Certain foods (suspected) (g) others(explain) __________________________________________________ G. Other symptoms: (circle all that apply) f. With the headache, my child (gets): (a) nothing else (b) Decreased appetite (c) Nausea (d) Vomiting (e) Bothered by light (f) Bothered by noise (g) Worsening headaches with walking (h) Abdominal pain (i) Weakness on one side of the body (j) Decreased vision (k) Changes in sensation (l) Confused (m) Problems with speech (n) Feels like the room is spinning (o) Personality changes (explain) __________________________________ (p) Other (explain)__________________________________ H. Relieving factors (check all that apply) g. My Childs headaches seem to get better with:
(a) rest (b) Sleep (c) Tylenol (d) ibuprofen (e) vomiting (f) nothing (g) Other (explain) __________________________________________________
I. Time-related factors (check all that apply) h. My child’s he adache usually occur
(a) at certain times of the year (Please list season)______________________ (b) mornings after waking__________ (c) Afternoon (during school) (d) evenings (after school, dinnertime, before Bed __________________________ (e) Middle of the night (f) only weekdays (g) Only weekends (h) Anytime
How long does the headache usually last? (Circle one) (a) 5 minutes or less (b) 30 minutes or less (c)1 hour or less (b) A few days (e) one day (f) a few days 6. If your child has only one type of headache, skip to question #7.If you have more than one type of headach, please answer the following about your child’s MILDER headache: A. Frequency: How often does your child experience headaches? (Check one of the following) A _____________ Very seldom B _____________ less than once per month C _____________ 1-3 times per month D _____________ once a week E _____________ 2-3 times per week F _____________ More than 3 times per week G _____________At least once a day H ____________All the time (24 hours, 7 days a week) I____________ other (please explain) _________________________________________
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B. Severity of pain (circle one) 1. The headaches (a) donot interfere with normal activities (b) Stop some activities (c) Stop all activities PAIN RATING SCALES No pain Moderate pain
Worst pain
------- -------- --------- -------------------- --------- --------- ---------- --------- --------0 1 2 3 4 5 6 7 8 9 10
0
2
4
6
8
10
2. on a scale of 0-10 (0=no pain and 10= the worst pain), what is the usual score of you _______________ (see picture above) C. Site of pain (circle all that apply) B. The headaches are located at/on:
D. Quality of the pain (circle one) c. The headaches are:
E. Aura symptoms : (circle all that apply) d. Before the headaches,
(a) the whole head (b) The forehead (c) One side of the head (unilateral) (d) The top of the head (e) The back of the head (f) other (explain) ______________________
(a) dull (b) Just sore (c) throbbing/pounding (d) Sharp (e) pressure/tightness/squeezing (f) Other (explain)________________________________ Has no symptom (b) Has changes in vision (c) Has changes in sensation (d) Has changes in strength (e) Has mood changes (f) Has changes in speech (g) looks pale (h) other ____________________
F .Trigger factors (circle all that apply) e. M
(a) nothing that I can tell (b) Missing a meal (c) Missing sleep (d) stress/excitement (e) certain foods (sure) (f) Certain foods (suspected) (g) others (explain) __________________________________________________ G. Other symptoms: (circle all that apply) f. With the headache, my child (gets): (a) nothing else (b) Decreased appetite (c) Nausea (d)Vomiting (e) Bothered by light (f) Bothered by noise (g) Worsening headaches with walking (h) Abdominal pain (j) Weakness on one side of the body (j) Decreased vision (k) Changes in sensation (l) Confused (m) Problems with speech (n) Feels like the room is spinning (o) Personality changes (explain) __________________________________ (p) Other (explain) _______________________________
Appendix. Continues. Headache in Children with Tourette Syndrome
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THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 161, No. 2
H. Relieving factors (check all that apply) g. My Childs headaches seem to get better with:
(a) rest (b) Sleep (c) Tylenol (d) Ibuprofen (e) Vomiting (f) nothing (g) Other (explain) __________________________________________________
I. Time-related factors (check all that apply) ually occurs
(a) at certain times of the year (please list Season)__________________________ (b) mornings after waking__________ (c) Afternoon (during school) (d)evenings (after _________________________
school, dinnertime, before bed)
(e) Middle of the night (f ) only weekdays (g) Only weekends (h) Anytime How long does the headache usually last? (Circle one) (a) 5 minutes or less (d)A few days
(b)30 minutes or less (e) one day
(c)1 hour or less (f) a few days
7. Between headache attacks, your child is (circle one): (a) Completely well
(b) still complains of headaches
(c) other _______________
8. Has your child ever had a CT scan or MRI of the brain to evaluate the headaches? ____Yes ________NO If yes, when and where?__________________________________________________ 9. What treatments have been tried to relieve pain at the time of the headache and what was the response? Name of treatment ________________
useful
not useful
any side effect
______________________________________________________
_____________________________________________________________________________________ 10. What daily treatments have been tried to prevent attacks and what was the result? Name of treatment
useful
not useful
any side effect
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________
11. What other non-drug treatment (i.e. diet, exercise, Name of treatment
useful
not useful
any side effect
12. Headache disability assessment: The following questions try to assess how much the headaches affect day-to day activity. Your answers should be based on the last THREE months. swers, so please put down your Ia) How many full school days were missed in the past 3 months due to headaches? __________ Ib) How many partial school days were missed in the past 3 months due to headaches? ______ ii) How many days in the past 3 months did your child function less than half his /her ability in school because of the headache(do not include the days you missed in the first 2 questions above? ______ iv) How many days did your child not participate in other activities (ie. Play, go out, sports etc) because of a headache? ______ v) How many days did your child participate in other activities, but functioned less than half your ability? ______ (do not include the days mentioned in the preceding question)
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13. Please list any additional comments (if any): _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________
_________________________
Date ___________________
Patient Signature (if Possible) ________________________ Parent/Guardian name (printed)
_________________________
_____________
Parent/Guardian signature Date
Please do not write below (physician use only) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________________
Appendix. Continued.
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