54 Headache Medicine, v.4, n.2, p.54-58, Apr./May/Jun. 2013

Health related quality of life in children with

migraine. A controlled study

Saúde e qualidade de vida em crianças com migrânea.

Estudo controlado

ORIGINAL ARTICLEORIGINAL ARTICLE

ORIGINAL ARTICLE

Mateus Lage Martins

, Rafael Corrêa Valério

, Tales José Corrêa de Almeida

, Vitor Rodrigues Laender

Dilermando Fazito de Resende

, Mauro Eduardo Jurno

3,4

, Pedro Ferreira Moreira Filho

Medical Students, School of Medicine at Barbacena, MG, Brazil;

Professor of Statistics, School of Medicine

at Barbacena, MG, Brazil;

Professor and Preceptor, Internal Medicine Residency, School of Medicine at

Barbacena, MG, Professor of Post-Graduation, Universidade Federal Fluminense, Rio de Janeiro, RJ, Brazil

Professor of Post-Graduation, Universidade Federal Fluminense, Rio de Janeiro, RJ, Brazil

Martins

ML, Valério RC, Almeida TJ, Laender VR, Resende DF, Jurno ME, Moreira Filho PF.

Health related quality of life in children with migraine. A controlled study.

Headache Medicine. 2013;4(2):54-8

ABSTRACTABSTRACT

ABSTRACT

Background:Background:

Background: Headaches are prevalent in the pediatric

population. Migraine significantly impacts the health-related

quality of life (HRQoL) of sufferers.

Objective:Objective:

Objective: To measure

the impact of migraine on the HRQoL of children, by applying

the Brazilian version of the SF-36 in children with migraine

and in controls.

Methods:Methods:

Methods: In this cross-sectional study,

HRQoL was measured with the SF-36, and scores for the 8

domains of the test were contrasted comparing children (5

to 14 years) with and without migraine.

ResultsResults

Results

: Sample

consisted of 66 children (30 with migraine and 36 controls).

Mean age was 10.9 years for migraine (Standard Deviation

- SD = 3 years) and 10.4 for controls (SD = 3.1 years).

Proportion of children with low HRQoL scores was significantly

higher in the migraine group, relative to controls, for the 8

domains of the test: vitality, physical functioning, bodily pain,

general health perceptions, physical role functioning,

emotional role functioning, social role functioning, and

mental health.

Conclusion: Conclusion:

Conclusion: Children with migraine are

significantly impacted in their HRQoL, relative to children

without migraine.

Keywords:Keywords:

Keywords: Migraine; Migraine at childhood; Quality of life;

Short form 36; Brazilian SF-36

RESUMORESUMO

RESUMO

IntroduçãoIntrodução

Introdução

: As dores de cabeça são prevalentes na

população pediátrica. A migrânea afeta significativamente

a qualidade de saúde de vida (QV) dos doentes pediátricos.

Objetivo:Objetivo:

Objetivo: Avaliar o impacto da migrânea sobre a qualidade

de vida (QV) de crianças, através da aplicação da versão

brasileira do SF-36 em crianças migranosas e nos controles

sadios.

Métodos:Métodos:

Métodos: Estudo transversal, onde a QVRS foi

medida através do SF-36, e a pontuação para os oito

domínios do teste foram contrastadas comparando-se

crianças (5-14 anos) com e sem migrânea.

Resultados:Resultados:

Resultados: A

amostra foi composta por 66 crianças (30 com migrânea e

36 controles). A média de idade foi de 10,9 anos para

migrânea (Desvio Padrão - DP ± 3 anos) e 10,4 para os

controles (DP ± 3,1 anos). Proporção de crianças com

baixos índices de QV foi significativamente maior no grupo

de enxaqueca, em relação aos controles, para os oito

domínios do teste: capacidade funcional, aspectos físicos,

dor, vitalidade, aspectos emocionais, saúde mental, estado

geral de saúde mental, e mais uma questão de avaliação

comparativa de condições atual e de anos atrás.

ConcluConclu

Conclu

são:são:

são: As crianças com enxaqueca são significativamente

afetadas em sua QV, em relação às crianças sem enxaqueca.

alavrasalavras

alavras

chave:chave:

chave: Migrânea; Migrânea na infância;

Qualidade de vida; SF-36 versão brasileira

Headache Medicine, v.4, n.2, p.54-58, Apr./May/Jun. 2013 55

INTRODUCTION

Migraines represent an important public health

problem, burdening the individual sufferers, their families,

and the society. Costs associated with migraine are

significative as well, as it is the impact of the disease on

health-related quality of life (HRQoL) of the affected

sufferers.

(1,2)

Migraine is prevalent at all ages, including among

children and adolescents, being indeed the most common

primary headaches in the pediatric population.

(2,3)

Age

directly influences the prevalence of migraine and its

gender distribution. In adolescents and young adults, the

prevalence is higher in women. Before menarche,

prevalence is higher in boys than in girls.

(4)

Migraine at childhood is associated with impact on

the HRQoL at several domains, including social,

psychological and physical. It also impacts performance

at school, by being associated with absenteeism, early

dismissals, and missing physical or recreational activities.

Furthermore, pediatric migraine affects interpersonal and

family relationships.

(5)

It has been suggested that children

with migraine are sometimes as burdened as those with

arthritis or cancer.

(6)

The burden of migraine is complicated and

modified by its comorbidities. It has been reported that

children with headaches have levels of stress, fatigue

and somatic symptoms that are significantly different

than of those without headaches. They are also less

likely to report themselves as being happy and seem to

have an overall 10% decrease in their quality of life,

relative to controls.

(7)

Although the impact of migraine on the HRQoL is

well described for the adult population, important data

gaps exist for the pediatric population. Accordingly, the

aim of this study was to define the impact of migraine on

the HRQoL of children from 5 to 15 years, by applying

the Brazilian version of the SF-36 in children with migraine

and in controls. We found the topic of relevance, since it

provides an estimate of the impact of the disease from

the perspective of the affected sufferer, instead of their

parents or providers.

METHODS

This was a cross-sectional study, comparing two

groups of children from 5 to 14 years, with migraine with

or without aura (n = 30), and without headaches (control

group - n = 36).

Children with migraine were diagnosed by a

headache specialist as per the Second Edition of the

International Classification of Headache Disorders.

(8)

They

were selected among those registered at the neurology

service of the City Public Health Service (DEMASP).

Controls consisted of volunteers without headache,

selected among healthy children that were accompanying

their parents who were, in turn, patients at the same clinic.

All parents consented for their children to participate.

After consultation and agreeing to participate, all

children responded to the Brazilian SF-36, a validated

version of the Medical Outcome Study 36.

(9)

This

questionnaire assesses self-perception of health in its most

representative domains.

(10)

It is a non-disease specific self-

applied questionnaire

(10)

consisting of closed questions

clustered among 8 sections: vitality, physical functioning,

bodily pain, general health perceptions, physical role

functioning, emotional role functioning, social role

functioning, and mental health. For each section, scores

range from 0 to 100.

(9,11)

Based on the scores, the

following categories were defined: impaired quality of

life (0-60 points) and not impaired (61- 100).

The questionnaire was responded by the children,

who could consult their parents if difficult in comprehension

was evident. For children younger than seven, the

questionnaire was responded by the parents or

guardians.

(2,12)

Data were analyzed using Stata 10 (Stata Corp.,

College Station, Texas). Summary tables and

descriptive statistics (mean, standard deviation and

proportions) were calculated for each variable. For

proportions, contingency tables or ANOVA tables were

developed, and the Chi-squared (χ

), Fischer Test and

Fischer for ANOVA comparisons were used.

Multivariate analyses (multinomial logistic regression)

adjusted for age and gender. Significance level was

defined at the 5% level.

The study was approved the Ethics in Research

Committee of Universidade Presidente Antônio Carlos

(UNIPAC) (approval number 827/2010).

RESULTS

As mentioned, the migraine group consisted of 30

children (63.3% girls), contrasted with 36 controls (44.5%

girls, Chi

(2) = 2.3440, p = 0.126). A total of 13 children

with migraine had age from 5 to 10 year (43.3%), while

17 were from 11 to 15 (56.7%). In the control group,

50% of the children were in each age range. No significant

HEALTH RELATED QUALITY OF LIFE IN CHILDREN WITH MIGRAINE. A CONTROLLED STUDY

56 Headache Medicine, v.4, n.2, p.54-58, Apr./May/Jun. 2013

MARTINS ML, VALÉRIO RC, ALMEIDA TJ, LAENDER VR, RESENDE DF, JURNO ME, MOREIRA FIHO PF.

differences were seen when comparing the age categories

between groups (Chi

(1) = 0.2920, P = 0.589). Mean

age was 10.9 years in the migraine group (SD = 3) and

10.4 among controls (SD = 3.1). Differences were not

significant (F= 0.45, p = 0.5044).

Table 1 displays the frequency of participants that

were impaired in their HRQoL or each of the 8

components of the SF-36, with respective results of the

Fisher exact test or Chi-squared test. Proportion of

children with low HRQoL scores was significantly higher

in the migraine group, relative to controls, for the eight

domains of the test: vitality, physical functioning, bodily

pain, general health perceptions, physical role

functioning, emotional role functioning, social role

functioning, and mental health.

girls were numerically over-represented in the migraine

group. Children with migraine were slightly older as well.

Findings are discussed in the context of each category of

the SF-36.

Functional capacityFunctional capacity

Functional capacity

While nearly one third of the children with migraine

had low scores on this domain, the same was not seen in

the control group (p<0.001), suggesting the impact of

migraine. For the studied age, this impact is probably

reflected in school performance (although absenteeism

was not assessed by us), either directly driven by migraine

or due to conditions comorbid to migraine.

(12)

In a study

conducted in Austria, children with migraine lost an

average of 9 school days per year, while in Italy,

absenteeism could be as high as 17 days in 3 months.

(13,14)

Physical functioningPhysical functioning

Physical functioning

Nearly 70% of the children with migraine had low

scores in this domain, relative to 2.8% in those with control,

demonstrating the impact of migraine on physical

functioning. Previous studies suggest that nearly 80% of

the children with migraine have symptoms that are

important enough to interfere in their ability to play sports

or games, which, per se, impacts the HRQoL at this age.

(15)

Furthermore, children with migraine are more likely than

those without migraine of reporting fatigue and tiredness.

(2)

ainain

ain

While the vast majority of controls (97%) had high

scores on this domain, less than half of those with migraine

had it ( p<0.001), suggesting that children with migraine

have other types of pain more frequently than controls.

Several of migraine comorbidities cause pain, and children

with migraine also seem more likely to be diagnosed with

conditions such as ear infections or gastric problems, which

also cause pain.

(13)

General health perceptionGeneral health perception

General health perception

Children with migraine were significantly more likely

to have low scores in this domain relative to controls

(36.7% vs. 5.6%, p<0.002) a finding supported by

previous reports. In a study conducted in Italy, children

with headaches had psychological, physical and social

impairments, and higher levels of stress and somatic

DISCUSSION

Herein we contrasted the HRQoL of children as a

function of migraine status. Groups did not differ

significantly as a function of age and gender, although

Headache Medicine, v.4, n.2, p.54-58, Apr./May/Jun. 2013 57

symptoms, relative to controls.

(16)

Of interest is that children

with migraine indeed detect that their health is negatively

affected when fulfilling the SF-36, relative to children without

migraine.

VitalityVitality

Vitality

As for the other categories, important differences were

seen between groups (low scores in 43.3% vs. 5.6%,

p<0.001). In a study conducted in India, 58% of children

with migraine had low scores in this domain, affecting

their daily activities,

(15)

and confirming the impact of

migraine on vitality.

Social aspectsSocial aspects

Social aspects

While 97.2% of controls had high score in this

domain, the same happened in 63.3% of children with

migraine (p<0.001), meaning that over one third of

children with migraine are socially impacted, a fact that

has been previously reported. Children with headaches

are nearly three times more likely to have emotional

symptoms and behavioral problems that impact their

relationships within family, at school, while playing, and

overall.

(17)

Due to their headaches, children with migraine

may avoid certain activities that are common for the age

and are relevant to group playing.

Emotional aspectsEmotional aspects

Emotional aspects

Once more, differences were significant when

comparing children negatively affected in this domain

(43.3% vs 11.1%, p = 0.003). Several studies suggest

that children with migraine are more likely to report

symptoms of anxiety and depression, relative to children

without headaches.

(2)

Vulnerability, defined as the

personality trait that predisposes to anxiety and

depression, also contribute to HRQoL impact.

(17)

It has

also been reported that excessive concerning and even

catastrophism is more likely in those with migraine,

negatively affecting their emotional health.

(2)

Mental healthMental health

Mental health

Only 2.8% of the control children had low scores in

this domain, relative to 43.3% in those with migraine

(p <0.001). Of all HRQoL domains, psychological

functioning is likely the best investigated, often with the

use of disease-specific questionnaires for depression and

anxiety. These studies confirm the high prevalence of

anxiety and depression symptoms in children with

migraine.

(2)

Stress, mainly at school, also influences the

relationship between migraine and HRQoL, and

dissatisfaction with life was higher in migraineurs with high

levels of stress, relative to migraineurs without increased

stress.

(18)

CONCLUSIONS

Migraine impacts HRQoL in all of the domains

measured by the SF-36. Limitations of this study include

the relatively small sample size, although we emphasize

that all comparisons were significant. Since the study was

conducted in a general neurology clinic (not pediatric

neurology), available cases were indeed limited.

Nonetheless, our study adds to the field, since few studies

on the topic of HRQoL in children with migraine have

been conducted. Our findings suggest that therapeutic

interventions aiming not only to improve migraine, but

also to improve HRQoL of affected children are of

importance.

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Correspondence

Mauro Eduardo JurnoMauro Eduardo Jurno

Mauro Eduardo Jurno

Rua Fernando Laguardia, 45 -

Santa Tereza II

36201-118 – Barbacena, MG, Brazil

jurno@uol.com.br

MARTINS ML, VALÉRIO RC, ALMEIDA TJ, LAENDER VR, RESENDE DF, JURNO ME, MOREIRA FIHO PF.