© Springer International Publishing Switzerland 2015
Aksel Siva and Christian Lampl (eds.)Case-Based Diagnosis and Management of Headache DisordersHeadache10.1007/978-3-319-06886-2_1313. When Headache Becomes “Troublesome” in a Child: What May Be Behind Chronification of Pediatric Migraine?
(1)
Department of Pediatrics and Child and Adolescent Neuropsychiatry, “Sapienza” University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
13.1 Case Description
L., a 12-year-old boy, was admitted because of worsening recurrent headaches. He described having three attacks a week for the past 3 months. Pain was located in the parietal area on one side; it was throbbing and would last about 4 h with photophobia and phonophobia, nausea, and, at times, vomiting. His parents mentioned that he would stop most of his daily activities during his headache attacks and that his mood became depressed. Headache attacks had started at the age of 7 years and were infrequent initially but had increased in frequency and duration in the past year. He had been admitted to a pediatric emergency department three times within the past year. L. had used a number of analgesics and triptans and was also given preventive therapies, all without result.
13.2 Collecting the Clinical History of the Family
The family consists of four persons: father, mother, and two children. The older sister was not present during the first observation. The posture and gesture of the parents was highly rigid, with the parents on both sides and the child in the center. During the history taking the mother continuously interrupted the doctor and, mainly, the child. The father read the newspaper throughout.
13.2.1 Family History
There was no significant medical or neurological family history other than the father’s migraine-type headaches that he had experienced since he was 8 years old. Neither the mother nor the sister had any type of headache, including migraine.
13.2.2 Personal History
Pregnancy and delivery were normal: the patient’s weight at birth was 3.1 kg; he was breast-fed appropriately; developmental milestones were normal; he achieved sphincter control at age 2.8 years; and he had regular sleep-wake rhythm. He had had most of the exanthematic illnesses such as smallpox, mumps, chickenpox, measles, rubella, and scarlet fever. At age 5 years he was admitted to the hospital for an appendectomy. The mother stressed the difficulties the child experienced on attending primary school, with an initially very high level of anxiety that obliged the family to introduce the child to the classroom progressively to avoid a high level of distress.
13.2.3 Examinations
The patient underwent a complete blood count, contrast nuclear magnetic resonance imaging, and electroencephalography, all of which were normal. All general and neurological examinations also were normal.
13.3 First Step: Talks with the Parents and the Child
We decided to speak with the parents and, in a separate setting, with the child.
13.3.1 The Father
Highly surprised at our approach, he spoke of himself for long periods, referring to a history of low levels of mood without any awareness of a possibility of depression, altered sleep-wake rhythm (he is a concierge), lack of concentration, and temper tantrums with a low level of impulse control.
13.3.2 The Mother
She was more willing to speak. She seemed to be uncompromising and indifferent to the situation of the child and, at the same time, angry with L. She considered the problem of her son mainly a “bother.” In the last 6 months she had also been admitted with a generalized anxiety disorder.
Both of the parents emphasized the difficulties of the child in school, and held his teachers responsible for his difficulties and stress.
13.3.3 The Child
In the first talk the boy was shy, never looking at the interviewer with his eyes always staring at the floor. The doctor was obliged to almost force him to answer. The answers were monosyllabic.
After more than half an hour, He began to describe in a detailed way all of the single characteristics of his headache and to stress how he felt depressed. Gradually, he stated, he decided not to go out with friends because of a “lack of energy” and to break off with sports: “I am in a situation without a future, I really do not know how to get out of this.” He was also worried about his poor school performance and the high number of school absences (7 in 1 month).
13.4 Second Step: Tests and Further Talks with the Child
At the end of the first step, an evaluation using psychometric tests was suggested in addition to three talks with the child. Parent training was suggested to the couple. No preventive therapy was decided upon.
13.4.1 Test Results
The first is a test to analyze the level of anxiety (A), depression (D), presence of eating disorders (ED), obsessive-compulsive disorder (O), somatization (S), phobias (PH), and hypochondria (H). The patient scored high levels of A, D, O, and S.
The PSPS-Jr rates all aspects connected to perfectionistic behavior. The patient scored values over the mean line.
13.4.2 The Three Talks with the Child
After the second talk the child began to be cooperative, revealing his worries and impotence regarding his father’s behavior toward his wife and child, which tended to be violent both physically and psychologically.
This behavior is associated with a continuous devaluation of the child. In the previous 6 months his father changed his hours of work and spent more time at home, deeply worsening the situation.
13.5 Third Step: Psychotherapy, Parent Training, and Contact with the Teachers
A 1-week session of cognitive psychotherapy with the child was programmed, and parent training was proposed.
We also decided to contact his teachers.
13.5.1 Teacher Contact
The teachers pointed out the child’s tendency of isolation, and emphasized the progressive withdrawal that became worse in the last year. His behavior was totally different with the only male teacher, when he would become highly aggressive and disturb all the activities of the group.
13.5.2 Parent Training
The attempt at parent training was unsuccessful, mainly because of the opposition of the father who, after a time, became very aggressive with the doctor and with his wife when she tried to analyze the couple’s relationship and his behavior toward his relatives.
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