Triggers and clinical changes of childhood primary headache characteristics during COVID-19 pandemic lockdown

Abstract

Objective

Children with primary headache are particularly vulnerable to the negative impacts of the pandemic due to factors like increased social isolation, disruption of sleep and impairment of healthy diet. We aimed to investigate the clinical changes and triggering factors for childhood primary headaches to demonstrate the impact of the pandemic lockdown.

Method

Children aged between 60 months and 18 years with headache complaint attending the general outpatient clinic between December 2019 and December 2020 were included in the study. Patients were classified according to ICHD-3 regarding clinical and laboratory data. Primary headaches diagnosed before (December 2019–March 2020) and during the pandemic lockdown (April 2020–December 2020) were divided into two groups as migraine and tension-type headache (TTH). Clinical picture and triggering factors were compared between groups to illustrate the effect of the lockdown.

Results

The study included 612 subjects, with 463 patients (76%) classified in the primary headache group and 149 (24%) in the secondary headache group. Among the first group, 267 patients (58%) had migraine and 196 patients (42%) had TTH. Comparisons between before and during the pandemic lockdown showed significant increased frequency of TTH, but no difference in the frequency and duration of migraine. Both screen exposure and sleep pattern changes were found to be significantly increased in the TTH group during the pandemic lockdown.

Discussion

We found a significant increase in the attack frequency for TTH patients during the pandemic lockdown. Reduction in screen time is an important strategy in preventing primary headache attacks in children.

Introduction

Headache is one of the most frequently reported health problems among children and frequency seems to increase with age. In a recent review of 64 cross-sectional studies published in 32 different countries and including a total of 227,249 subjects, the estimated overall mean prevalence of headache was 54.4% (95% CI 43.1–65.8) and the overall mean prevalence of migraine was 9.1% (95% CI 7.1–11.1) [1].

According to the third edition of the International Classification of Headache Disorders (ICHD-3), headache can be divided into two main categories as primary headache disorders like migraine and TTH and secondary headaches due to refractive errors, sinusitis, hypertension, brain tumour, dental caries, etc. [2]. It was clearly demonstrated that chronic headache, especially migraine, has an important impact on various areas of daily functioning. Headache can have a negative effect on quality of life, especially academic performance of children [3, 4]. Determination of triggering factors and headache category is very important for therapy and prognosis, but the inability of children to express their exact symptoms and lack of laboratory/neuroradiological diagnostic criteria make it challenging for clinicians [5].

Although the ongoing outbreak of coronavirus disease most prominently affects the respiratory system, there is emerging literature about its impact on the central and peripheral nervous systems [6]. Additionally, lifestyle changes, decreased social activities, increased screen exposure, and staying at home also have psychological and emotional effects which have received less emphasis so far [7]. It was previously documented that quarantine is a remarkable risk factor for psychological and psychiatric disturbances and patients with primary headache are particularly vulnerable to the drastic negative impacts of these factors [8]. This study aimed to analyse primary headache characteristics in childhood and investigate the impact of the pandemic lockdown.

Materials and methods

The research was conducted with children aged 60 months to 18 years with headache complaints, who attended the general outpatient clinic in Mardin State Hospital between December 2019 and December 2020. Demographic findings including age, gender, neonatal and family history were noted. At the initial visit, all patients filled out a detailed headache questionnaire. The questions about headaches were mainly designed to determine whether the patient suffered from headache or not. As far as headache is concerned, patients were asked about the occurrence of recurrent headache in their medical history. The survey questions/statements were prepared by ÖD and BK through discussions about the questions/statements in the third edition of the ICHD-3 [2]. Out of the 11 questions/statements, nine were designed to be answered on a scale about characteristics of the disease and two questions (questions no: 10, 11) were open ended involving the following points: (A) triggering factors and (B) accompanying findings. The age of onset, duration, frequency of attacks, location, character, severity, effect of physical activity, accompanying nausea, vomiting, and phono/photophobia were also noted. Participants were asked about triggering factors like sleep patterns, stress, hunger, fast food consumption, and increases in screen exposure. All patients were subjected to detailed physical and neurological examination and were evaluated by the ophthalmology and otolaryngology departments if necessary. Electroencephalogram (EEG) was performed in 43 patients, and lumbar puncture in two patients who were suspected of having high intracranial pressure.

Patients were classified according to ICHD-3 regarding clinical and laboratory data. After the pandemic lockdown was announced in March 2020 in Turkey, patients enrolled before that date (December 2019–March 2020) were included in the group “Before” the pandemic lockdown, while patients seen after that date (April 2020–December 2020) were included in the group “During” the pandemic lockdown. Clinical picture and triggering factors for primary headaches were compared during the pandemic lockdown and before the pandemic lockdown. Recommendations for lifestyle behaviour changes like maintaining regular sleep (9–12 h in primary school children, 8–10 h in adolescents), avoidance of skipping meals and having a healthy diet, adequate hydration, regular exercise, control of screen exposure time, avoiding triggering foods (caffeine, cheese, chocolate, red meat, and canned foods), decreasing daily stress, and avoiding the abuse of painkillers (not using analgesics such as acetaminophen and ibuprofen more than 3 times a week) were given to all study participants by the study investigators.

Qualitative findings were compared with the Chi-square test or Fisher’s exact test, and other findings were compared with mean values using the independent t test. A p value < 0.05 was considered significant. The study was approved by Diyarbakır Gazi Yaşargil Training and Research Hospital ethics committee (02.07.2021-811).

Results

The study included 612 participants. Of the participants, 59% were female (n = 367), while 41% were male (n = 273). The mean age of participants was 11.34 ± 2.7 years. According to ICHD-3, 76% (n = 463) of the patients were classified in the primary headache group and 24% (n = 149) were in the secondary headache group.

Primary headache

Migraine was diagnosed in 267 (58%) patients and TTH in 196 (42%) patients. All patients above 10 years of age (n = 214) were females; of these, 178 (84%) had migraine. Aura symptoms like blurred vision, zigzags and bright lights were described only by 0.5% of migraine patients. Among the 185 patients with primary headache before the pandemic lockdown, 105 (57%) had migraine and 80 (43%) had TTH. There was no statistically significant difference between mean values for age, gender and family history between patients before and during lockdown. There was no difference in the frequency and duration of attacks in migraine patients diagnosed before the pandemic lockdown with those diagnosed during the pandemic lockdown (p = 0.9; p = 0.73). However, a significant increase was found for the attack frequency of TTH (p = 0.001). Even though photophobia was the least common symptom among the migraine group with a percentage of 15% before the pandemic, it increased to 32% and became the most common symptom during the pandemic lockdown. The rate of photophobia was also increased in the TTH group with rates of 8% before and 13% during the pandemic lockdown. During the pandemic lockdown, the frequency of bilateral TTH was significantly higher than before lockdown (p = 0.001). Before the pandemic lockdown, 21% of migraine patients stated their headache developed with physical activity. Although this rate increased to 41% during the pandemic, it was not statistically significant (p = 0.14). Demographic data and characteristics of patients with primary headache before and during lockdown are shown in Table 1.

Table 1.

Demographic data and characteristics of patients with primary headache before and during lockdown

Demographic data	Migraine headache			Tension-type headache
	Before lockdown	During lockdown	p value	Before lockdown	During lockdown	p value
Number of patients (%)	105 (39%)	162 (61%)		80 (41%)	116 (59%)
Mean age in months	11.2	11.2	0.84	11	11.3	0.26
Gender (female/male)	65/40	103/59	0.78	53/27	72/44	0.55
Family history	40 (38.1%)	59 (36.4%)	0.72	27 (33.7%)	44 (37.9%)	0.51
Mean of attack frequency (per month)	1.39	1.4	0.9	1.31	1.89	0.001*
Characteristics of headache
Pulsating	77 (73%)	107(66%)	0.75	4 (5%)	5 (4%)	0.93
Compressive	16 (15%)	34 (20%)		47 (58%)	71 (61%)
Stinging	12 (11%)	21 (12%)		29 (36%)	40 (34%)
Mean duration of the attack in hours	9.8	8.5	0.73	10.6	11.2	0.59
Severe headache history	68 (64%)	110 (67%)	0.59	7 (8%)	15 (12%)	0.35
Localization (unilateral)	65 (61%)	103 (63%)	0.89	58 (72%)	24 (20%)	0.001*
Increase with physical activity	56 (53%)	110 (67%)	0.14	18 (22%)	33 (28%)	0.34
Nausea and vomiting	50 (47%)	59 (36%)	0.78	5 (6%)	12 (10%)	0.29
Photophobia	42 (40%)	86 (53%)	0.37	16 (20%)	26 (22%)	0.68
Phonophobia	43 (41%)	59 (36%)	0.46	10 (6%)	13(11%)	0.78

*p value < 0.05 significant

While 21% of migraine patients before the pandemic lockdown had screen exposure as a precipitating factor, this rate increased to 40%, which was statistically significant (p = 0.029). Concerning TTH, both screen exposure and sleep pattern changes were found to be significantly increased during the pandemic lockdown (p = 0.002; p = 0.001). The triggering factors for headache are shown in Table 2.

Table 2.

Comparison of triggers of primary headache before and during lock down

Triggers of primary headache	Migraine headache			Tension-type headache
	Before lockdown	During lockdown	p value	Before lockdown	During lockdown	p value
	Number of patients (%)	Number of patients (%)		Number of patients (%)	Number of patients (%)
Stress	27 (10%)	47(17%)	0.55	38 (19%)	70 (35%)	0.78
Hunger	55 (20%)	66 (24%)	0.62	33 (16%)	31 (16%)	0.37
Consumption of specific food	43 (16%)	46 (17%)	0.37	9 (4%)	17 (8%)	0.48
Sleep pattern changes	27 (10%)	43 (16%)	0.88	22 (11%)	60 (30%)	0.001*
Screen exposure	56 (21%)	108 (40%)	0.029*	44 (22%)	89 (45%)	0.002*

*p value < 0.05 = significant

Treatment of primary headache

The treatment was individualized for each patient considering age, personality and pain characteristics if necessary. Patients were recommended to attend a check-up visit at the end of the first month of treatment. A total of 211 migraine patients (86 patients attending before pandemic lockdown; 125 patients attending during pandemic lockdown) were administered pharmacological treatment for the following indications; 164 patients for more than one attack per week; 44 patients who stated their daily life was negatively affected by attacks; and three patients who were suspected of having hemiplegic migraine. The most preferred drug was flunarizine prescribed to 41%, the second drug was amitriptyline given to 18% and cyproheptadine hydrochloride was chosen for 16% of patients. Regarding the treatment of TTH, 17 of the patients before and 27 patients during the pandemic lockdown had prophylaxis with nonsteroidal anti-inflammatory treatment.

Secondary headache

Secondary headache was diagnosed in 149 patients (24%). On neurological examination, focal neurological deficit was found in three patients (central nervous system tumour), and sensory deficit in one patient (multiple sclerosis). Two patients with chronic headache and blurred vision had high CSF pressure and responded well to acetazolamide treatment. Myopia was revealed in 26 patients and astigmatism in 19 patients.

Laboratory

Eighty-eight percent of the patients had normal brain MRI. Pathological findings were detected as follows; 44 patients had sinusitis, 12 patients had arachnoid cyst, and one patient had cortical dysplasia. Cervical MRI was performed in two patients; one patient with neck pain and trauma history and one patient suspected of having multiple sclerosis. EEG was performed in 43 patients and four patients (one secondary to cortical dysplasia, three absence epilepsy) were diagnosed with epilepsy.

Discussion

This study investigated the impact of the pandemic lockdown on childhood primary headache characteristics. There is clear evidence in the literature about the negative effects of the pandemic on the psychological and physical well-being of children and adults [8]; however, little information is available about the effect on prevalence of primary headache in children. Concordant with our results, a nationwide study in Austria and studies performed in school samples from Vienna and Istanbul found the prevalence of migraine was slightly higher than TTH [9, 10]. When the literature was evaluated, we could find just two studies performed on children about pandemic effects on migraine. An Italian study asked participants to express a general opinion about the “trend of the headache” and revealed an improvement in frequency and intensity of symptoms during lockdown. The symptoms of patients were found to improve in 323 patients (46%), remained stable in 277 (39%) and worsened in 107 (15%) [11]. Similarly, Dallavalle et al. demonstrated significant reductions in the intensity and frequency of migraine symptoms in children and adolescents during the COVID-19 lockdown phase [12]. Contrary to these studies, a cross-sectional, internet-based study performed with adult patients found that 59.6% of the respondents reported increased worsening of migraine frequency and 10.3% reported a transformation to chronic migraine. Severity was also increased for 64.1% of the respondents [13]. Likewise, Martinez et al. investigating habits and medical care during lockdown, found out that 47.3% of patients reported subjective worsening of migraine symptoms during the lockdown, while 14% reported improvement [14]. Studies in the adult period generally demonstrate an increasing trend in the frequency and severity of migraine, nonetheless two studies showed improvements similar to childhood studies [15, 16]. Migraine attacks are thought to be caused by natural fluctuations in neuronal excitability with precipitation by trigger factors like sleep deprivation, hunger, etc. [17]. Although we expected that migraine attacks would be aggravated during lockdown, there was no difference in the frequency and duration of migraine attacks.

TTH has not been as thoroughly investigated as migraine so far and unfortunately this is also valid during the pandemic lockdown. One study of medical personnel during the pandemic revealed a significant relationship between TTH, excessive daytime sleepiness, sleep quality and fatigue syndrome [18]. The triggers for TTH include the same triggers as for migraine headaches; however, emotional stress such as depression and anxiety play a larger role [19]. Papetti et al. in their study of children with headache pointed out that 88% of the responders were receiving online education and about 50% of patients reported a reduction in school effort. They found that headache improvement was strongly correlated with the decrease in school anxiety and school effort. Consequently, although screen exposure was increased, the decrease in daily effort caused a reduction in headaches [11]. In our study despite the increase in screen time, there was no increase in migraine frequency during the pandemic lock down. Similar to our study, Hassel et al. did not find a correlation between worsening of migraine frequency and severity with age and screen time exposure. However, they found correlations with disruption of sleep, dietary habits, and presence of symptoms of anxiety and depression [13]. In the current study, both screen exposure and sleep pattern changes were found to be significantly increased during the pandemic lockdown in TTH patients.

There are some limitations of this study. First of all, headache characteristics were investigated via questionnaire; the results were based on the responses of the patients, with the potential for reporting bias. Secondly this cohort did not include testing for COVID-19 or questioning about current or previous infection so there may also be some patients who were not tested for COVID-19 due to the lack of other accompanying symptoms. The effect of COVID-19 disease could have affected migraine and TTH findings in the study participants. Also, we ignored emotional factors while investigating trigger factors and did not obtain sufficient information about socio-economic factors.

Conclusion and recommendations

Characteristics and triggers of primary headaches changed during the pandemic lockdown, in addition to specific physical manifestations. New strategies are needed to deliver quality care for children with primary headaches during pandemic lockdowns. In addition to controlling psychological distress and screen time exposure, maintaining regular sleep hygiene, healthy diet and good hydration should be ensured. Large-scale longitudinal studies are needed to develop appropriate management strategies for childhood primary headache.

Author contributions

ÖD contributed to conception and design, acquisition and analysis, drafted the manuscript and agrees to be accountable for all aspects of work ensuring integrity and accuracy and there is no potential conflict of interest. BK contributed to conception and design, acquisition and analysis, drafted the manuscript and agrees to be accountable for all aspects of work ensuring integrity and accuracy and there is no potential conflict of interest. All authors read and approved the final version of the manuscript.

Funding

There was no funding.

Availability of data and material

Not applicable.

Declarations

All procedures performed in studies involving human participants were in accordance with the ethical standarts of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standarts.

Conflict of interest

There is no conflict of interest.

Code availability

Not applicable.

Consent to participate

Written informed consent was obtained from the parent of the patient.