Waldie et al.

The Journal of Headache and Pain 2014, 15:60

http://www.thejournalofheadacheandpain.com/content/15/1/60

RESEARCH ARTICLE

Open Access

Risk factors for migraine and tension-type

headache in 11 year old children
Karen E Waldie1*, John MD Thompson2, Yasmine Mia1, Rinki Murphy3, Clare Wall4 and Edwin A Mitchell2

Abstract
Background: Though migraine and tension type headache are both commonly diagnosed in childhood, little is
known about their determinants when diagnosed prior to puberty onset. Our aim was to determine psychosocial- and
health-related risk factors of migraine and tension-type headache in 11 year old children.
Methods: 871 New Zealand European children were enrolled in a longitudinal study at birth and data were
collected at birth, 1, 3.5, 7, and 11 years of age. Primary headache was determined at age 11 years based on the
International Headache Society. Perinatal factors assessed were small for gestational age status, sex, maternal
smoking during pregnancy, maternal perceived stress, and maternal school leaving age. Childhood factors
assessed were sleep duration, percent body fat, television watching, parent and self-reported total problem
behaviour, being bullied, and depression.
Results: Prevalence of migraine and tension-type headache was 10.5% and 18.6%, respectively. Both migraine and
TTH were significantly associated with self-reported problem behaviour in univariable logistic regression analyses.
Additionally, migraine was associated with reduced sleep duration, and both sleep and behaviour problems
remained significant after multivariable analyses. TTH was also significantly associated with antenatal maternal
smoking, higher body fat, and being bullied. For TTH, problem behaviour measured at ages 3.5 and 11 years both
remained significant after multivariable analysis. Being born small for gestational age was not associated with
either headache group.
Conclusions: Although they share some commonality, migraine and tension-type headache are separate entities
in childhood with different developmental characteristics. The association between primary headache and
problem behaviour requires further investigation.
Keywords: Migraine; Tension-type; Paediatrics; Small for gestational age; Longitudinal; Risk-factors; Paediatric

Background
Headache is one of the most frequently reported pain complaints in children and adolescents [1-3], with the prevalence increasing throughout childhood and peaking at
1113 years of age [4]. It has been estimated that around
6.1% to 13.6% of children suffer from migraine and 9.8% to
24.7% suffer from tension-type headache (TTH) [5-8]. Despite the high prevalence, there is a paucity of data on childhood headache relative to our knowledge of adult-onset
headache epidemiology. Understanding factors relating to
migraine and tension-type headache prior to puberty is important because environmental factors such as stress and
* Correspondence: k.waldie@auckland.ac.nz
1
School of Psychology, Faculty of Science, The University of Auckland, Private
Bag 92019, Auckland 1142, New Zealand
Full list of author information is available at the end of the article

other family variables may not be independent of the possible effects of subsequent hormonal changes on the developing teenager [9].
Childhood headache disorders should be recognised as
a significant health concern due to the considerable impact on the child and the family [10,11]. Compared to
headache-free children, concerns include greater rates of
absence from school [12,13], fewer and poorer peer relations including bullying [14-16], and general impairments in home life, school and leisure activities [17-20].
Although less common, migraine is considered to be
more severe and disabling than TTH and involves higher
rates of medication use [1].
Obesity, sleep disturbance, behavioural and psychiatric
problems have all been linked with childhood migraine

2014 Waldie et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.

Waldie et al. The Journal of Headache and Pain 2014, 15:60

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and/or TTH. As body mass increases, headache frequency and disability due to headache also increases
[21-23]. Difficulties falling asleep and maintaining sleep,
sleep breathing disorders and disorders of arousal have
been particularly associated with migraine [24-26]. Behavioural problems include concentration difficulties,
hyperactivity, and conduct problems [27,28]. Children
with headache also have more internalizing disorders,
particularly major depression [29] and anxiety [30,31],
than headache-free controls. It is not clear, however,
whether these associations are different between the two
types of headache in children, given their potentially distinct underlying pathophysiology [32].
Toward this end, we investigated risk factors for primary headache in preadolescent children using data collected from the Auckland Birthweight Collaborative
study (ABC), a longitudinal, casecontrol study of appropriate for gestational age (AGA) and small for gestational age (SGA) individuals born at term. SGA has been
associated with numerous adverse outcomes related to
cognition, health and behaviour [33-35]. As such, we
studied the association of birthweight and several other
antenatal, early life, and childhood risk factors with migraine and TTH at age 11 using the International Headache Society (IHS) classification system [36]. The use of
a prospective longitudinal study meant that we were able
to investigate factors earlier in life that may be associated with later headache diagnosis, without the problems
of retrospective recall such as distortion or forgetting
which may introduce bias.

Methods
Study cohort

The ABC study is a longitudinal prospective cohort

study designed to investigate long-term growth and development in SGA and AGA children. Background information about the study design, subjects and the
recruitment procedures has been described elsewhere
[33]. Briefly, children born between 16 Oct.1995 and 12
Aug. 1996 to mothers who resided in the Waitemata
Health or Auckland Healthcare regions were eligible for
inclusion; and from 12 Aug.1996 to 30 Nov. 1997 babies
born in the Auckland Healthcare region were eligible to
participate. All children were born at 37 wk. gestation.
Infants were excluded from participation if they were
born from multiple births, had life threatening congenital problems, or were delivered at home. At birth, all
SGA (<10% percentile for gestational age) were selected
and a random sample of children born appropriate for
gestational age (AGA) as controls.
Children were initially assessed at birth (Phase 1; 1995
to 1997) and during subsequent follow-ups at 12 months
(Phase 2; 1996 to 1998), 3 5y (Phase 3; 1999 to 2001),
7y (Phase 4; 2002 to 2005) and 11y (Phase 5; 2008 to

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2010). Participation rates for non-European ethnic

groups were poor so analysis was restricted to European
children. A total of 871 infants were born to mothers
who identified themselves as European, of whom 385
(44.2%) were SGA and 486 were AGA. Of the 871 European babies enrolled at birth, 744 (85.4%) participated at
1 year, 550 (63.2%) at 3.5 years and 591 (67.9%) at 7 years
of age. There were 241 (40.8%) participants at 7 years of
age who were born SGA and 350 who were born AGA.
Demographic information and information about maternal health and lifestyle during pregnancy was collected by maternal interview and from obstetric records
at birth. At the age of 3.5 years, the children were directly assessed on measures of cognitive and physical development. Mothers were interviewed regarding the
childs health and development and demographic information was collected. At the age of 7 and then 11 years,
health, cognitive and physical abilities were again
assessed directly and information was collected from a
maternal interview.
Ethics approval for each phase of this study was obtained from the Northern Regional Ethics Committee.
Parents and guardians were required to sign a written
consent form to allow participation of their children in
the study at all assessment points. Assent was obtained
from each child at 11 years.
Outcome data

Information about headache was obtained by trained interviewers conducted at the Childrens Research Centre
at Starship Childrens Hospital or in the childs home at
11 years of age. Children who indicated they suffered
from headache in the past year were then asked about
the nature, duration and severity of the pain based on
IHS criteria [36]. Questions regarding medical history,
including medical doctor diagnosis of migraine and pain
medications used (prescription and over-the-counter)
were also included in the headache interview.
Covariates

Information collected at birth included socio-demographic

information (e.g., school leaving age, marital status), maternal smoking (Did you smoke during pregnancy? Yes/
No), and maternal perceived stress during pregnancy [37].
Sleep duration

When participants were aged 7 and 11, average sleep

duration (hours) was measured via actigraphy. Actigraphy is a non-invasive method used to study sleep-wake
patterns and circadian rhythms by assessing movement.
Parents completed a questionnaire on the day the actigraphy was performed, including what time the child
went to bed and rose in the morning. The analysis
period for the sleep data included the period from the

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bedtime to the rise time as given in the diary. Analysis

of actigraphy data required a complete collection of data
throughout the night (i.e. no time with monitor off or
missing data within the scoring interval). Sleep duration
was the time from sleep onset to sleep end time [38].
Sleep duration was recoded as less than 10 hours sleep
or more than 10 hours average sleep at age 7 (medium
split) and as less than 9.5 hours sleep or more than
9.5 hours average sleep at age 11.
Percent body fat

Children were assessed for percentage body fat at age

11 years using bio-electrical impedance BIM4 (Impedimed
Ltd, QLD, Australia). Children were assessed according to
equipment instructions, lying supine and bladder voided,
with electrodes placed according to manufacturers instructions on the wrist and ankles. A median split of the
data (Me = 25.69%, SD = 10.27) was used to create a higher
and lower body fat group.
Television watching

Mothers of 11 year old children were asked During a

normal week, how many hours a day (24 hours) does
your child watch television? Possible responses were
less than 1 hour 1-3 hours or 3+ hours.
Bullying

When participants were aged 11, they were asked if they

had experienced physical violence, verbal teasing, sexual
harassment or racist comments more than 5 times during the previous 6 months. Children who answered yes
to any of these questions were classified as having been
bullied.
Strengths and difficulties

The Strengths and Difficulties Questionnaire (SDQ) is a

behavioural screening questionnaire used to measure
five separate constructs of hyperactivity, emotion, conduct, peer and pro-social behaviours [39]. Questionnaires were administered at ages 3.5, 7 and 11. At ages
3.5, and 7 the questionnaire was completed by the
mother of the child, while at the age of 11 separate questionnaires were completed by both the mother and the
child themselves. Total difficulties were calculated by
adding together the scores on the hyperactivity, emotion,
conduct and peer subscales (pro social score is kept
separate). SDQ scores were coded as either normal or
borderline/abnormal.
Depression

At age 11, children in the study were classified as either

depressed or not depressed by using The Centre for
Epidemiological Studies Depression Scale for Children
(CES-DC). It is a 20 item self-report questionnaire with

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scores ranging from 0 to 60, with higher scores indicating depression.

Statistical analysis

Chi square tests for independence were conducted to assess associations between primary headache (migraine (Y/
N) and TTH (Y/N)) and prenatal and lifestyle/psychosocial covariates. The factors that were significantly associated with migraine or TTH were included as predictor
variables for two separate multivariable binary logistic regression analyses, each controlling for birthweight status.
Statistical significance was defined at the 5% level
and analyses were carried out using IBM SPSS software,
version 19.

Results
Of the 617 participants in this study, 42.8% reported
having experiencing at least one headache lasting 30 minutes or more in the past year (n = 264). From these,
10.5% were classified as experiencing migraines (n = 65)
and 18.6% were classified with TTH (n = 115).
Table 1 presents descriptive statistics for sex, pain duration, and parental socio-demographic information.
Males were slightly more likely to experience both migraine (n = 34, 52.3%) and TTH (n = 67, 58.3%) than females, but this difference was not statistically significant.
Males reported significantly greater pain intensity during
headache than females (t(266) = 2.17, p = .03) but there
were no sex differences in headache duration. As expected, those categorised as having migraine were significantly more likely to have been given a medical
diagnosis of migraine in the past than those with TTH.
Children with migraine were also significantly more
likely to complain of stomach aches than those with
TTH. There were no differences between groups in family socioeconomic status, maternal school leaving age or
marital status.
Univariate analyses

Results of Chi Square univariable analyses are presented

in Table 2. There were no differences in headache classification (migraine versus headache-free and TTH versus
headache-free) for those participants who were born
SGA compared with those who were born AGA. Maternal perceived stress (measured at birth, ages 3.5 and
7 years) were not associated with migraine or TTH.
Maternal smoking during pregnancy was significantly associated with TTH (p = .008), with 31.6% of
TTH sufferers having a mother who smoked during
pregnancy compared to 19.6% of children with no
headache. Maternal smoking in pregnancy was not associated with migraine.
Sleep duration at age 7 was marginally associated with
migraine (p = .05) but not TTH. Of those with migraine,

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Table 1 Descriptive statistics (percent in parentheses) for pain duration and socio-demographic variables as a function
of primary headache
Migraine

Tension type

N = 65 (10.5%)

N = 115 (18.6%)

p-value*

Duration (30 mins 1 hr)

6 (9.2)

62 (52.5)

<.001

Duration (1 72 hrs)

59 (90.8)

56 (47.5)

<.001

Given over-the-counter medication

57 (87.7)

102 (85.7)

>.05

Given medication prescribed by a medical doctor

7 (10.8)

14 (11.7)

>.05

Diagnosed with migraine by a medical doctor

10 (15.4)

5 (4.2)

.01

Frequent stomach aches in past year

35 (53.8)

38 (31.9)

.005

Marital status of parents: married/de factor

62 (95.4)

111 (92.5)

>.05

Marital status of parents: single and other

3 (4.6)

9 (7.5)

>.05

Mothers first child

39 (60.0)

67 (55.8)

>.05

Younger than 16

8 (12.3)

15 (13.2)

>.05

Older than 16

57 (87.7)

99 (86.8)

Maternal school leaving age

*from univariable Chi Square analyses.

58.0% slept for less than 10 hours per night compared to

43.1% of those with no headache disorder. Sleep duration at age 11 was not associated with migraine or
TTH. Average hours of television watching per day at
age 11 were not associated with migraine or TTH.
The parent-scored SDQ total difficulties score at
3.5 years was significantly associated with TTH (p = .032)
but not migraine. Of those with TTH, 26.7% had a borderline/abnormal score compared to 16.4% with no headache.
The parent-scored SDQ total difficulties score at 7 years
was not associated with primary headache.
When children themselves completed the SDQ at
11 years, the total difficulties score was significantly associated with both TTH (p = .039) and migraine (p < .001).
For those with migraine, 41.5% had a borderline/abnormal
score. For those with TTH, 23.5% had a borderline or
abnormal score compared with 15.1% of those with no
headache disorder. The hyperactivity subscale was the
only subscale individually related to any headache
group, with children rating themselves with borderline
or abnormal hyperactivity symptoms 2.29 times more
likely to have a migraine diagnosis than those without
headache (p = .007).
Being bullied in the past 6 months at age 11 was significantly related to TTH (p = .005) only, with 46.7% of
children with TTH experienced bullying compared to
31.9% of children with no headache.
Symptoms of depression at age 11 were slightly but
not significantly related to migraine (p = .06) only, with
12.5% of children with migraine were classified as depressed compared to 5.9% of children with no headache.
Percentage body fat measured at age 11 was significantly
associated with TTH but not with migraine. Children
with TTH had greater percentage body fat (mean =

29.28%, standard deviation (SD) =11.49) than children

without headache (mean = 26.21%, SD = 9.84; t(463) =
2.70, p = .007). Interestingly, there was no relationship
between body fat and IQ measured at age 11 (WISC-R)
for those with TTH (r = .102), but there was for children with migraine (r = .303, p = .015).
Multivariate analyses

The variables significantly associated with migraine from

the univariable analyses were sleep duration age 7 and
self-completed SDQ total difficulties score at age 11.
The results of the multivariable logistic regression analysis for migraine are presented in Table 3 and both variables remained significant. Children with less than
10 hours of sleep at night when they were 7 years of age
were more than 2 times more likely to complain of migraine headache than children who slept longer. A borderline/abnormal total difficulties score was associated
with an almost 4 times increased likelihood of suffering
from migraine compared with those who had a total difficulties score in the normal range. When the hyperactivity subscale was entered separately into the model,
both sleep and hyperactivity (OR 2.70 95% CI 1.28
5.70) remained significant.
The variables significantly associated with TTH in
univariable analyses were maternal smoking during pregnancy, total difficulties at 3.5, child-scored total difficulties score at 11, percent body fat at 11, and bullying at
11. The results of the multivariable logistic regression
analysis for TTH are presented in Table 4. Only total
difficulties at 3.5 and 11 remained significant predictors
of TTH. Children who had borderline/abnormal total
difficulties score at age 3.5 were 4 times more likely to
suffer from TTH compared with those in the normal

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Table 2 Headache classification at age 11 years in univariable analyses

No headache

Migraine

No

279 (80.4%)

53 (81.5%)

Yes

68 (19.6%)

12 (18.5%)

OR

TTH

1.89

78 (68.4%)

ref

36 (31.6%)

OR

Maternal smoking during pregnancy

0.67

Maternal perceived stress during pregnancy

7.05**

2.08

0.93

3.33

Low (scores 013)

195(55.9%)

34 (60.9%)

ref

61 (65%)

ref

High (scores 1439)

154 (44.1%)

29 (39.1%)

1.49

52 (54%)

1.49

AGA

214 (60.6%)

38 (58.5%)

ref

63 (54.8%)

SGA

139 (39.4%)

27 (41.5%)

1.09

52 (45.2%)

Birth weight

0.11

Gender

1.22

0.16

ref
1.27
2.62

Female

178 (50.4%)

31 (47.7%)

ref

48 (41.7%)

ref

Male

175 (49.6%)

34 (52.3%)

1.12

67 (58.3%)

1.42

Normal

239 (83.6%)

44 (88.0%)

ref

63 (73.3%)

Borderline/Abnormal

47 (16.4%)

6 (12.0%)

0.69

23 (26.7%)

SDQ Total difficulties at 3.5 years, parent

0.63

Maternal perceived stress at 3.5 years

4.60*

0.39

ref
1.86
1.17

Low (scores 013)

167 (48.1%)

33 (52.4%)

ref

61 (54%)

ref

High (scores 1439)

180 (51.9%)

30 (47.6%)

1.08

52 (46%)

1.24

Normal

274 (87%)

45 (83.3%)

ref

86 (88.7%)

Borderline/Abnormal

41 (13%)

9 (16.7%)

1.34

11 (11.3%)

SDQ Total difficulties at 7 years, parent

0.52

Sleep duration at age 7

0.19

3.82*

ref
0.86
0.25

<10 hours

121 (43.1%)

29 (58.0%)

1.83

41 (46.1%)

1.13

=/>10 hours

160 (56.9%)

21 (42.0%)

ref

48 (53.9%)

ref

Low (scores 013)

69 (48.3%)

17 (51.5%)

ref

29 (55.8%)

High (scores 1439)

74 (51.7%)

16 (48.5%)

0.40

23 (44.2%)

Maternal perceived stress at 7 years

0.11

Sleep duration at age 11

0.86

0.06

ref
0.81
0.01

<9.5 hours

68 (46.6%)

11 (44%)

0.90

28 (47.5)

1.04

=/>9.5 hours

78 (53.4%)

14 (56%)

ref

31 (52.5)

ref

No depression

317 (94.1%)

56 (87.5%)

ref

105 (93.8%)

Depression

20 (5.9%)

8 (12.5%)

2.26

7 (6.3%)

Depression at 11 years

3.57

Bullied at 11 years

0.02

0.81

ref
1.06
7.73**

No

222 (68.1%)

36 (62.1%)

ref

57 (53.3%)

ref

Yes

104 (31.9%)

22 (37.9%)

1.30

50 (46.7%)

1.87

<1 hour

86 (27.3%)

13 (24.1%)

ref

22 (22.4%)

ref

1-3 hours

198 (62.9%)

34 (63.0%)

1.14

65 (66.3%)

1.28

3-5 hours

31 (9.8%)

7 (13.0%)

1.49

11 (11.2%)

1.39

Lower than median

180 (54.2%)

27 (43.5%)

ref

40 (37.0%)

ref

Higher than median

152 (45.8%)

35 (56.5%)

1.54

68 (63.0%)

2.01

Television watching at 11 years

0.62

Percent body fat at 11 years

0.96

2.38

9.62*

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Table 2 Headache classification at age 11 years in univariable analyses (Continued)

SDQ Total difficulties at 11 years, selfa

24.68**

Normal

298 (84.9%)

38 (58.5%)

Borderline/Abnormal

53 (15.1%)

27 (41.5%)

SDQ Total difficulties at 11 years, parenta

4.27*
ref

88 (76.5%)

4.0

27 (23.5%)

1.15

ref
1.73
0.09

Normal

306 (87.9%)

54 (15.9%)

ref

99 (86.8%)

ref

Borderline/Abnormal

42 (12.1%)

11 (23.1%)

1.48

15 (13.2%)

1.10

Note. *Significant at p < .05; ** p < .01; 2 = Pearson chi square.

Perceived stress in mothers categorised according to a median split.

Sleep duration categorised according to a median split and rounded to the nearest hour.
a
Scored using the Strengths and Difficulties Questionnaire (SDQ).

range. This trend was consistent when children themselves rated their difficulties at age 11. Children in the
borderline/abnormal range were over 4 times more likely
to be classified with TTH than children in the normal
difficulties range.

Discussion
Migraine is an episodic and disabling neurological condition affecting about 14% of the adult population [40]
while TTH is even more prevalent than migraine [41].
Relative to adults, little is known about the epidemiology
of primary headache in children. We found that migraine was associated with both reduced sleep duration
and problem behaviour. TTH was associated with antenatal maternal smoking, problem behaviour, higher body
fat, and being bullied.
Just under half (48%) of 11 year old ABC study members had reported experiencing at least one headache
lasting half an hour or more in the past year. From this,
the prevalence of primary headache was 10.5% for migraine and 18.6% for TTH. These rates accord well with
other studies [1-8]. Males and females were almost
equally likely to report symptoms of migraine and
TTH. Our lack of sex difference is consistent with previous research [1,4,31]. Headache prevalence in females
tends to increase with age [42]. After about 12 years of
age the female to male ratio is 1:3 for migraine and 4:5
for TTH [41-43]. This is most likely due to hormonal
changes during puberty [44,45] but may also be related
to gender differences in cognitive and social reactions
to pain [46].
Family socio-economic status was not significantly associated with either migraine or TTH, possibly due to

the small sample sizes in the lower socio-economic group

or because the components of SES likely to be contributing to headache is more accurately captured by other factors. This finding is consistent, however, with a number of
studies that failed to establish a link between socioeconomic status and headache [2,17,28,31]. A population
based study of Finnish school children did find a higher
risk of TTH for those children whose fathers were lower
level white collar workers as opposed to independent
traders/employees, but found no association between episodic TTH and family unemployment, economic problems and single parent families [7]. We similarly found no
association between headache and marital status.
Little is known about the influence of prenatal events
on the development of migraine and TTH in children.
Though studies have found evidence of a link between
maternal stress during pregnancy and negative outcomes
in children [47], we did not find any association between
perceived stress during pregnancy and offspring headache. There was also no difference in the rates of primary headache between the SGA and AGA groups.
Maternal smoking during pregnancy was significantly
associated with TTH but not with migraine. Arruda
and colleagues [48] similarly found that exposure to
prenatal tobacco was a risk factor for chronic daily
headache in children. It is unclear whether this association is due to socioeconomic factors or is specifically
health-related. Women who continue smoking throughout
pregnancy are generally of lower age, socio-economic status, level of education and occupational status than nonsmokers [49], and offspring are exposed to higher levels of
social disadvantage and family dysfunction throughout
childhood [50].

Table 3 Multivariable logistic regression results for migraine headache

95%
B

SE

Wald statistic

Odds ratio

Confidence interval

SGA/AGA

0.11

0.33

0.11

1.12

0.59

2.13

Sleep duration (at 7 years)

0.73

0.32

5.09

2.08*

1.10

3.94

Total difficulties (at 11 years) self-completed

1.48

0.34

19.27

4.41*

2.27

8.54

*p < .05.

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Table 4 Multivariable logistic regression results for tension type headache

B
Birthweight

0.18

SE
0.47

Wald
statistic

Odds
ratio

0.14

1.11

95%
confidence interval
0.58

2.12

Smoking during pregnancy

0.46

0.61

0.58

1.59

0.48

5.21

Total difficulties (at 3.5 years)

1.38

0.62

5.02

3.96*

1.19

13.21

Percent body fat (at 11 years)

0.34

0.43

0.63

1.41

0.76

4.72

Bullying (at 11 years)

0.64

0.46

1.91

1.90

0.60

3.28

Self-reported total difficulties (at 11 years)

1.48

0.34

19.27

4.41*

1.10

8.54

*p < .05.

It may also be that smoking during pregnancy has affected the childs neonatal environment, predisposing
them to develop headaches later in life. Smoking during
pregnancy has been linked to increased risk of numerous
childhood problems including asthma [51], attention
deficit disorder [52] and conduct disorder [50].
Percentage body fat at age 11 was associated with TTH.
These findings are supported by research by Hershey and
colleagues [53], who found that body mass was positively
associated with headache frequency in 913 children recruited from paediatric headache centres. Furthermore for
those children who were defined as overweight in the first
visit, drops in weight were significantly associated with
decreases in headache frequency at both 3 and 6 months
follow up. Earlier studies have also found associations between obesity and migraine frequency among children
[21-23] but there are no known reports of increased frequency or prevalence of TTH among overweight/obese
children or adults. It may be that children who have more
body fat may also have higher stress due to a lower selfesteem. It should be noted that this variable didnt remain
significant in our multivariable analysis, possibly due to low
statistical power. Further research with larger samples is
needed to determine the relationship between body weight
and headache disorder and the mechanism behind it.
One possible consequence of being a child with higher
body fat might be increased susceptibility to bullying by
peers. We found that bullying was not associated with
migraine but was significantly associated with TTH.
Children with TTH tend to be shier and less sociable
than children with migraine [28]. Further research is
needed to determine whether severity of bullying is associated with headache prevalence or frequency and
whether bullying is consistently associated with TTH rather than migraine.
Children with migraine were more likely to sleep for less
than 10 hours each night when they were 7 years of age
compared to those with no headache disorder. Several
prior studies have also demonstrated the co-occurrence
of sleep disturbances and migraine in children [2,24].
Although children with migraine in our study slept less

than children without headache, this did not seem to be

related to increased time watching television. Others
have similarly found no relationship between migraine
or TTH and hours spent using electronic equipment
such as television/computer/PlayStation [17]. One possible reason that our migraineurs are getting less sleep
is that they may also suffer from a periodic limb movement disorder [54]. This possibility will be tested at the
next ABC medical assessment.
The co-morbidity of sleep disorders and migraine in
childhood has led to the suggestion that they may have a
common genetic or pathophysiological mechanism [26].
The serotonergic system is likely to be involved, as it has
been implicated in the physiology of migraine and plays an
important role in the initiation and maintenance of sleep
activity [26]. Serotonin also plays an important role in
emotional disorders such as depression, which has also
been implicated in the physiology of migraine [31] and
studies with adults have found that depression precedes
migraine onset [55]. Although we did not find depression
was related to childhood migraine or TTH, analyses with
larger samples are needed to confirm this and to determine
whether serotonin links the underlying pathophysiology
between migraine, sleep problems and emotional disorders.
Though we didnt find an association between headache and depression, our results indicate that many
other areas of psychological functioning were significantly associated with childhood headache. This is consistent with a growing body of literature suggesting a
link between childhood headache disorders and emotional and behavioural difficulties [27-31]. In our study,
psychological functioning was assessed by parent report
at ages 3.5, 7, and 11 (and self-report at 11) using the
SDQ. This questionnaire assesses emotional symptoms,
conduct problems, hyperactivity/impulsivity, and peer
problems. Scores from these subgroups are summed to
provide a total difficulty score.
More specifically, migraine and TTH were both significantly associated with self-reported borderline/abnormal
score even after controlling for other risk factors. An earlier clinical study of behavioural and emotional difficulties

Waldie et al. The Journal of Headache and Pain 2014, 15:60

http://www.thejournalofheadacheandpain.com/content/15/1/60

found that children with TTH have more behavioural,

emotional and temperamental difficulties than those with
migraine [28] while a later study from a paediatric headache centre found the reverse [31]. In particular, migraine
was associated with a borderline/abnormal score on the
hyperactivity/impulsivity subscale of the SDQ, consistent
with an earlier study [56]. Despite some inconsistencies,
findings suggest that primary headache in childhood is
complicated by, or occurs due to, a combination of a predisposition and psychosocial and behavioural difficulties.

Conclusions
Our findings support the view that migraine and TTH
should be considered separate entities in childhood [but
see 17 for an alternate view]. While both migraine and
TTH were associated with more self-reported total difficulties at age 11 years, we found a number of independent risk factors. TTH was associated with smoking
during pregnancy, parent-reported total difficulties at
age 3.5 years, higher percent body fat, and being bullied
at age 11. Migraine was independently associated with
reduced sleep duration at 7 years, consistent with reports that psychological problems and sleep issues are
often linked with migraine.
A number of important limitations of our study need
to be discussed. Firstly, although the overall sample
size was large (n = 617), the combination of the prevalence of headache type and other factors with low
prevalence such as depression resulted in small case
sizes for those factors. Secondly, our participants were
from New Zealand European families and did not include Maori and Pacific families. This was due to low
response rate from non-European families during the
earlier follow-up phases. Thirdly, we did not have access to medical information from first degree relatives
and therefore could not include family history of headache in our analyses. Fourthly, our findings are correlational and should not be interpreted as factors that
necessarily cause headache disorder.
Despite the many limitations, there were some particular strengths of our study. For example, much of the
research into childhood headaches is conducted using
clinical samples from speciality headache centres. Results from these studies may therefore not generalize to
the general population. Moreover, many studies do not
differentiate between general headache and disorder
subtypes, or they use non-standardised classification
systems to diagnose headache, making it difficult to
compare results across studies. Broadly representative
cohort studies using internationally recognized headache diagnostic criteria might more reliably determine
if differences exist between children who suffer from
primary headaches and from those who do not and
whether differences exist between headache groups.

Page 8 of 9

In summary, a number of health-related and psychosocial risk factors were associated with childhood headache in our cohort study. Future studies are planned to
determine if there is an association between primary
headache and common illnesses/diseases in childhood.
Further work to determine risk factors of migraine and
TTH will help ensure that earlier diagnosis and effective
treatment occurs.
Abbreviations
ABC: Auckland Birthweight Collaborative; AGA: Appropriate for gestational
age; IHS: International Headache Society; SGA: Small for gestational age;
SDQ: Strengths & Difficulties Questionnaire; TTH: Tension-type headache.
Competing interests
The authors declare that they have no competing interests.
Authors contribution
KW wrote the first draft of the manuscript and supervised the student
working on a subset of this data. JMD is the Deputy Director of the ABC
study and oversaw all data analyses. YM is the Masters student who
conducted analyses for a subset of the analyses in this manuscript and
contributed to some of the writing. CW contributed to the design of the
study and edited a draft of the manuscript. RM contributed to the design of
the study and edited a draft of the manuscript. EAM is the Director of the
ABC study, contributed to the design of this study, and read and approved
the final manuscript. All authors read and approved the final manuscript.
Acknowledgements
The ABC study group also includes Mrs Elizabeth Robinson, Dr David Becroft
and Professor Chris Wild. The initial study was funded by the Health
Research Council of New Zealand. The 12 month postal questionnaire was
funded by Hawkes Bay Medical Research Foundation. The 3.5 year follow-up
study was funded by Child Health Research Foundation, Becroft Foundation
and Auckland Medical Research Foundation. The 7 year follow-up study was
funded by Child Health Research Foundation. The 11 year follow-up was
funded by Child Health Research Foundation and the National Heart
Foundation. EA Mitchell and JMD Thompson are supported by CureKids.
The 3, 7 and 11 year follow-ups were conducted in the Childrens Research
Centre which is supported in part by the Starship Foundation and the
Auckland District Health Board. We acknowledge the assistance of Gail
Gillies, Barbara Rotherham, and Helen Nagels for contacting or assessing
]the participants. We sincerely thank the parents and children for
participating in this study.
Author details
1
School of Psychology, Faculty of Science, The University of Auckland, Private
Bag 92019, Auckland 1142, New Zealand. 2Department of Paediatrics, The
University of Auckland, Auckland, New Zealand. 3Department of Medicine,
The University of Auckland, Auckland, New Zealand. 4Discipline of Nutrition,
The University of Auckland, Auckland, New Zealand.
Received: 26 June 2014 Accepted: 6 September 2014
Published: 10 September 2014
References
1. Anttila P (2006) Tension-type headache in childhood and adolescence.
Lancet Neurol 5:268274
2. Pogliani L, Spiri D, Penagini F, Di Nello F, Duca P, Zuccotti VG (2011)
Headache in children and adolescents aged 618 years in northern Italy:
prevalence and risk factors. Eur J Paediatr Neurol 15:234240
3. Rhee H (2000) Prevalence and predictors of headaches in US adolescents.
Headache 30:528538
4. Fearon P, Hotopf M (2001) Relation between headache in childhood and
physical and psychiatric symptoms in adulthood: National birth cohort
study. BMJ 322:1145
5. Abu-Arefeh I, Russell G (1994) Prevalence of headache and migraine in
school children. BMJ 309:765769

Waldie et al. The Journal of Headache and Pain 2014, 15:60

http://www.thejournalofheadacheandpain.com/content/15/1/60

6.
7.

8.
9.

10.
11.
12.
13.

14.

15.
16.
17.

18.

19.

20.

21.

22.
23.
24.

25.
26.

27.
28.

29.

30.
31.

32.

Annequin D, Tourniaire B, Massiou H (2000) Migraine and headache in

childhood and adolescence. Pediatr Clin North Am 47:617631
Anttila P, Metsahonkala L, Aromaa M, Sourander A, Salminen J, Helenius H,
Alanen P, Sillanp M (2002) Determinants of tension-type headache in
children. Cephalalgia 22:401408
Arruda MA, Guidetti V, Galli F, Albuquerque RCAP, Bigal ME (2010) Primary
headaches in childhood a population-based study. Cephalalgia 30:10561064
Antonaci F, Voiticovschi-Iosob C, Di Stefano AL, Galli F, Ozge A, Antonaci UB
(2014) The evolution of headache from childhood to adulthood: a review of
the literature. J Headache Pain 15:15
Kernick D, Reinhold D, Campbell JL (2009) Impact of headache on young
people in a school population. Br J Gen Pract 59:678681
Monteith TS, Sprenger T (2010) Tension type headache in adolescence and
childhood: Where are we now? Curr Pain Headache Rep 14:424430
Winner P, Hershey AD (2007) Epidemiology and diagnosis of migraine in
children. Curr Pain Headache Rep 11:375382
Karawutz A, Wober C, Lang T, Bock A, Wagner-Ennsgraber C, Vesley C,
Kienbacher C, Wober-Bingol C (1999) Psychosocial factors in children and
adolescents with migraine and tension-type headache: a controlled study
and review of the literature. Cephalalgia 19:3243
Fekkes M, Pijpers FIM, Verleoove-Vanhorick SP (2004) Bullying behavior and
associations with psychosomatic complaints and depression in victims.
J Paediatr 144:1722
Metsahonkala L, Sillanpaa M, Tuominen J (1998) Social environment and
headache in 89-year-old children: a follow-up study. Headache 38:222228
Williams K, Chambers M, Logan S, Robinson D (1996) Association of common
health symptoms with bullying in primary school children. BMJ 313:1719
Kroner-Herwig B, Gassmann J (2012) Headache disorders in children
and adolescents: their association with psychological, behavioural, and
socio-environmental factors. Headache 52:13871401
Powers SW, Patton SR, Hommel KA, Hershey AD (2003) Quality of life in
childhood migraines: clinical impact and comparison to other chronic
illnesses. Pediatrics 112:15
Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P (2005)
Pain among children and adolescents: restrictions in daily living and
triggering factors. Pediatrics 115:152162
Strine TW, Okoro CA, McGuire LC, Balluz LS (2006) The associations among
childhood headaches, emotional and behavioral difficulties and health care
use. Pediatrics 117:17281735
Hershey DA, Powers WS, Nelson DT, Kabbouche AM, Yonker M, Linder LS,
Bicknese A, Sowel KM, McClintock W, the American Headache Society
Pediatric Adolescent Section (2009) Obesity in the pediatric headache
population: a multicenter study. Headache 49:170177
Kinik ST, Alehan F, Erol I, Kanra AR (2009) Obesity and paediatric migraine.
Cephalalgia 30:105109
Verrotti A, Di Fonzo A, Agostinelli S, Coppola G, Margiotta M, Parisi P (2012)
Obese children suffer more often from migraine. Acta Paediatr 101:416421
Bruni O, Fabrizi P, Ottaviano S, Cortesi F, Giannotti F, Guidetti V (1997)
Prevalence of sleep disorder in childhood and adolescence with headache:
a casecontrol study. Cephalalgia 17:492498
Aromaa M, Rautava P, Helenius H, Sillanpaa ML (1998) Factors of early life as
predictors of headache in children at school entry. Headache 38:2330
Carotenuto M, Guidetti V, Ruju F, Galli F, Tagliente FR, Pascotto A (2005)
Headache disorders as risk factors for sleep disturbances in school aged
children. J Headache Pain 6:268270
Egger HL, Angold A, Costello EJ (1998) Headaches and psychopathology in
children and adolescents. J Am Acad Child Adolesc Psychiatry 37:951958
Mazzone L, Vitiello B, Incorpora G, Mazzone D (2005) Behavioural and
temperamental characteristics of children and adolescents suffering from
primary headache. Cephalalgia 26:194201
Just U, Oelkers R, Bender S, Parzer P, Ebinger F, Weisbrod M, Resch F (2003)
Emotional and behavioural problems in children and adolescents with
primary headache. Cephalalgia 23:206213
Maratos J, Wilkinson M (1982) Migraine in children: a medical and
psychiatric study. Cephalalgia 2:179187
Vannatta K, Getzoff AE, Powers WS, Noll RB, Gerhardt AC, Hershey DA (2008)
Multiple perspectives on the psychological functioning of children with and
without migraine. Headache 48:9941004
Tarantino S, Capuano A, Vigevano F, Valeriani M (2014) Primary headache
pathophysiology in children: the contribution of clinical neurophysiology.
Clin Neurophysiol 125:612

Page 9 of 9

33. Thompson JMD, Clark PM, Robinson E, Becroft DMO, Pattison NS, Glavish N,
Pryor JE, Wild CJ, Rees K, Mitchell EA (2001) Risk factors for small-forgestational-age babies: the Auckland birthweight collaborative study.
J Paediatr Child Health 37:369375
34. Gale CR, Martyn CN (2004) Birth weight and later risk of depression in a
national birth cohort. Br J Psychiatry 184:2833
35. Indredavik MS, Vik T, Heyerdahl S, Kulseng S, Fayers P, Brubakk A-M (2004)
Psychiatric symptoms and disorders in adolescents with low birth weight.
Arch Dis Child Fetal Neonatal Ed 89:445450
36. International Headache Society (2013) The International classification of
headache disorders, 3rd edition (beta version). Part one: THE primary
headaches. Cephalalgia 33:629808
37. Cohen S, Kamarck T, Memslstein R (1983) A global measure of perceived
stress. J Health Soc Behav 24:385396
38. Nixon GM, Thompson JMD, Han DY, Becroft DMO, Clark PM, Robinson E,
Waldie KE, Wild CJ, Black PN, Mitchell EA (2008) Short sleep duration in
middle childhood: risk factors and consequences. Sleep 31:7178
39. Goodman R (1999) The extended version of the Strengths and Difficulties
Questionnaire as a guide to child psychiatric caseness and consequent
burden. J Child Psychol Psychiatr 40:791799
40. Stovner LJ, Zwart JA, Hagen K, Terwindt GM, Pascual J (2006) Epidemiology
of headache in Europe. Eur J Neurol 13:333345
41. Rasmussen BK, Jensen R, Schroll M, Olesen J (1991) Epidemiology of headache
in a general population - a prevalence study. J Clin Epidemiol 44:11471157
42. Laurell K, Larsson B, Eeg-Olofsson O (2004) Prevalence of headache in
Swedish schoolchildren, with a focus on tension-type headache. Cephalalgia
24:380388
43. Lipton RB, Bigal EM (2005) The epidemiology of migraine. Am J Med 118:310
44. Unalp A, Dirik E, Kurul S (2007) Prevalence and clinical findings of migraine
and tension-type headache in adolescents. Pediatr Int 49:943949
45. Rasmussen KB (1993) Migraine and tension- type headache in a general
population: precipitating factors, female hormones, sleep pattern and
relation to lifestyle. Pain 53:6572
46. Lynch MA, Kashikar-Zuck S, Goldschneider RK, Jones AB (2007) Sex and age
differences in coping styles among children with chronic pain. J Pain
Symptom Manage 33:208216
47. Talge N, Neal C, Glover V (2007) Antenatal maternal stress and long-term
effects on child neurodevelopment: how and why? J Child Psychol
Psychiatry 48:245261
48. Arruda MA, Guidetti V, Galli F, Albuquerque R, Bigal ME (2011) Prenatal
exposure to tobacco and alcohol are associated with chronic daily headaches
at childhood: a population based study. Arq Neuropsiquiatr 69:2733
49. Ebert ML, Fahy K (2007) Why do women continue to smoke in pregnancy?
Women Birth 20:161168
50. Fergusson MD, Woodward JL, Horwood J (1998) Maternal smoking during
pregnancy and psychiatric adjustment in late adolescence. Arch Gen
Psychiatry 55:721727
51. Gilliland DF, Li Y, Peters MJ (2001) Effects of maternal smoking during
pregnancy and environmental tobacco smoke on asthma and wheezing in
children. Am J Respir Crit Care Med 163:429436
52. Milberger S, Biederman J, Faraone SV, Chen L, Jones J (1996) Is maternal
smoking during pregnancy a risk factor for attention deficit hyperactivity
disorder in children? Am J Psychiatry 153:11381142
53. Hershey DA, Winner P, Marielle A, Kabbouche JG, Yonker M, Lewis D,
Pearlman E, Linder LS, Rothner D, Powers WS (2005) Use of the ICHD-II
Criteria in the Diagnosis of Pediatric Migraine. Headache 45:12881297
54. Esposito M, Parisi P, Miano S, Carotenuto M (2013) Migraine and periodic
limb movement disorders in sleep in children: a preliminary casecontrol
study. J Headache Pain 14:57
55. Waldie KE, Poulton R (2002) Physical and psychological correlates of primary
headache in young adulthood: A 26 year longitudinal study. J Neurol
Neurosurg Psychiatry 72:8692
56. Parisi P, Verrotti A, Paolino MC, Ferretti A, Raucci U, Moavero R, Villa MP,
Curatolo P (2014) Headache and attention deficit and hyperactivity disorder
in children: common condition with complex relation and disabling
consequences. Epilepsy Behav 32:7275
doi:10.1186/1129-2377-15-60
Cite this article as: Waldie et al.: Risk factors for migraine and tension-type
headache in 11 year old children. The Journal of Headache and Pain
2014 15:60.