In my part of the country, there has been a gradual transition from remote learning to hybrid learning to full in-person learning, starting this spring. And as we all experience, there are significant stressors with all this change. Kids are happy to be back at school with their friends, teachers, feeling sort of ‘back to normal’. For most, this is a happy change, though something to get used to again.
But with any change, there is also stress. They are worried about getting up early and getting to school on time. They are worried about keeping up with their school work. They are worried about the social situations, such as bullying, starting up again. And for kids and teens with headaches, they are worried about the effect of being in the school environment, with bright lights and loud noise, making headaches worse. Considering the number of distress calls we have been getting, there is a lot of worry and struggle going on. While this is expected to some degree for all students, people with headaches are more apt to feel stress and distress.
Psychiatric co-morbidities, such as anxiety or depression, are quite commonly found in people with headache and migraine. They share the same risk factors, such as environmental stressors and genetic predisposition. Having a headache history may predispose a patient to psychopathology and psychopathology may predispose a patient to headache. In adults, longitudinal studies have provided evidence for bidirectional associations between psychopathology and headache.
Genetic predisposition can apply to both the patient and/or parents, related to migraine and headache, as well as depression, anxiety, and bipolar disorder. It is possible that depression and migraine may partly share underlying genetic risk factor. Often these disorders can be seen all throughout the family tree.
At this time in our children’s lives, environmental stressors are many. They include: personal experience with pandemic concerns; personal exposure to violence; neglect in the home, school or community (witnessing domestic violence, bullying); other forms of adversity (losses, poverty, and disease); and lack of meaningful social supports. Young people can respond to these stressors with:
- internalizing (anxiety, depression, PTSD, eating disorder, social withdrawal, isolation, and loneliness, low self esteem), or
- externalizing (antisocial behavior, problems with attention, concentration, hyperactivity, substance abuse, smoking), or
- somatic complaints (headache, other pain complaints, overweight, insomnia).
The result of exposure to such stressors can be adaptive or maladaptive development, coping and functioning. We know that stress is the most common headache and migraine trigger. Chronic daily headaches with all day, every day pain is made worse in times of stress. The key is to recognize the situation and therapeutically intervene to promote adaptive coping and resilience.
What does this mean in the day to day interactions with our patients and families? We can expect more distress and difficulty coping. There is more need for emotional support and nurturing. Knowing the resources in your community is key, and it helps to have list of them readily available.
Recognizing that your patients with headache are physiologically predisposed to psychological distress will help you be ready for the numerous calls, and help you to respond with compassion and care. Preparation is everything, especially when the world feels overwhelming to our families. My guess is that preparation would also be helpful for all of us too.
For more information about pediatric and adolescent headache management, check out my book, Getting Ahead of Pediatric Headaches. :