Original Article

Relationship of childhood headaches

with preferences in leisure time activities,
depression, anxiety and eating habits:
A population-based, cross-sectional study

Cephalalgia
2015, Vol. 35(6) 527537
! International Headache Society 2014
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0333102414547134
cep.sagepub.com

mer Bektas1, Cagatay Ugur2, Zeynep Bykl Gencturk3,

O
zlem Sireli2 and Gulhis Deda1
Ayla Aysev2, O
Abstract
Objectives: The objective of this article is to determine the relationship between headache frequency and socio-demographic data, personal characteristics, habits, daily activities, daily loss of ability, depression and anxiety in the headache
subtypes in the pediatric population.
Patients and methods: Our sample group was composed of approximately 5355 children aged between 9 and 18 years. An
eight-stage questionnaire was administered to the children. In the second stage of the study, headache subtypes were
created according to the ICHD-II criteria. The resulting data were compared according to the results of the headache
subtypes.
Results: In school-age children, the prevalence of recurrent headaches was 39.4%, and the prevalence of migraine was
10.3%. The subjects with migraine mostly preferred sedentary activities in their leisure time, and preferred less exercise
than the subjects with the other headache types. The PedMIDAS score of the children who preferred to play sports was
significantly lower than those who did not prefer to play sports. In the group that preferred reading books, an opposite
relationship was found. In overweight and obese migraine sufferers, other types of headache were found to be significantly higher.
Conclusions: In the management of treating childhood headaches, the association of psychiatric comorbidities should be
considered. To minimize disability, children should be directed to more useful physical activities.
Keywords
Pediatric headache, PedMIDAS, leisure time, depression, anxiety, habits
Date received: 2 January 2014; revised: 21 April 2014; 8 June 2014; 30 June 2014; accepted: 6 July 2014

Introduction
Epidemiological studies examining primary headaches
in childhood are increasing. In the literature, the rate of
childhood headache ranges from 5.9% to 82% (14).
This rate varies for tension-type headaches (TTH) (47)
and migraines (2,711) from 0.9% to 72.8% and 2.97%
to 28%, respectively. This wide distribution depends on
many things, such as methodological and geographical
dierences as well as socio-cultural and ethnic factors.
Ankara is the capital of the Republic of Turkey with a
population of 4,466,756 (2007 Turkey Statistical
Institute (TSI) data). Because it is located in the
middle of Anatolia, it receives immigrants from all
parts of Turkey. Surprisingly, its population has
increased over the past seven years by 40% (3,203,362
in 2000, TSI data).

In the last 30 years, the prevalence of migraine and

the frequency of headaches have increased considerably. This increase in incidence is alarming.
Changes in the lifestyles of children have been suggested as probable causes for this increase (12). A
1

Department of Pediatric Neurology, Ankara University Medical School,

Turkey
2
Department of Child and Adolescent Psychiatry, Ankara University
Medical School, Turkey
3
Department of Statistics, Ankara University Medical School, Turkey
Corresponding author:
mer Bektas, Ankara U
niversitesi Tp Fakultesi C
O
ocuk Saglg ve
Hastalklar, A.B.D. 06100 Cebeci, Ankara, Turkey.
Email: bektasomer@gmail.com

528
limited number of studies conducted show the relationship between headache and childrens lifestyle,
diet, and habits (1316). The number of studies that
show the relationship between psychiatric comorbidities and headaches is low (1719). Depression, anxiety, disability, and individual habits in children were
studied in a limited number of studies separately (13
19), but have not been studied in a comprehensive
manner. A study that showed the relationship between
the childrens leisure time and headaches was not performed comprehensively. The study herein will show
the prevalence of migraine and headaches in Turkish
children. In particular, the scope of our work was to
conduct a prevalence study to underscore the relationship between childhood headaches and leisure time
preferences, depression, anxiety, daily disability and
eating habits.

Methods
Study population
This cross-sectional study was conducted on schoolage children by the Departments of Child
Neurology and Child Psychiatry of Ankara
University between November 2011 and May 2012.
The study was performed on students in the fourth
through 12 th grades with ages ranging between 9
and 18 years.
This study was conducted in Ankara, the second
largest city and the capital of the Republic of Turkey.
The population cohort consisted of 5355 school-age
children among 12 schools. The schools were chosen
at random from six dierent districts of the Ankara
province. Within the six districts, one primary school
and one high school represented each of the districts for
a total of 12 schools that were chosen randomly. The
randomized selections were based on the TSI statistical
data previously released, indicating the distribution of
income level within each district. Using the demographic data on income, the districts were subdivided
into three groups. According to our results, 530,726
students, 9 to 18 years of age, were assigned to the
Ankara school system for the 20112012 education
year. A 95% condence interval (CI) was used to calculate the sample size with a 5% margin of error. The
average prevalence of headache subtypes was accepted
at 17.0% (d 0.01), which is consistent with previous
studies (20,21). The study cohort, as a result of the
calculations, consisted of 5365 school students (22).
From each school, 450 students were expected to take
part in the study. To reach a total of 450 students,
all the students from fourth through 12th

Cephalalgia 35(6)
grades participated in the study. Table 1 shows the distribution of the students from the each school used for
this study.

Study design
At each school, the study was conducted by a
team of six people including a child psychiatrist
and a child neurologist. The study was performed
in two stages. The rst stage consisted of a questionnaire of eight distinct sections. These forms
were administered to multiple study groups of
2530 people.
First stage. The rst four parts of the survey asked for
the participants general information (without stating
names), childhood depression scale, the Beck Anxiety
Inventory (BAI) (23), and eating habits. These surveys were completed by all the students participating
in the study. In the fth part of the survey, the individuals were asked if they had recurrent headaches. A
recurrent headache was dened as a headache (of at
least two occurrences during life) in the absence of an
underlying cause (infection, trauma, etc.). The
remaining two sections were completed by students
who gave a positive answer to this question.
Questionnaire 6 consisted of questions that were
designed according to Department of International
Classication of Headache Disorders, second edition
(ICHD-II). This questionnaire consisted of eight
questions about the headache episodes: frequency,
location, duration, pulsating quality, intensity (moderate or severe), the occurrence of nausea, vomiting,
photophobia and phonophobia, and aggravation by
routine physical activity. Part 7 focused on pain history, pain intensity (on a 10-point pain scale), and
whether he or she had been previously diagnosed
with migraine. In part 8, the pediatric Migraine
Disability Assessment Scale (PedMIDAS) was
applied. All the forms that were applied are included
in Appendix 1.
Second stage. The answers to part 6 were evaluated
according to the criteria in the ICHD-II. In the
second stage of the study, the students who were
assumed to have headaches and migraine were evaluated by a child neurologist, and a headache classication was made. The headaches were classied as
migraine, probable migraine, TTH and other headaches. The PedMIDAS was calculated. Students with
chronic illnesses, trauma history, those who did not
want to participate in the study, and those who had
communication problems or did not understand the
questions were excluded from the study.

529

Bektas et al.
Table 1. The distribution of all the students according to their schools.
A
Upper income group
n (%)
Mean age  SD

Primary education
a

431 (8)
208/223
10.93  1.36

High school
a

462 (8.6)
224/238
15.69  1.11

AB

Primary education
a

383 (7.2)
174/209
10.70  1.40

High school
a

493 (9.2)
239/254
15.70  1.11

Primary education

High school

814 (15.2)
382/432
10.82  1.39

955 (17.8)
463/492
15.69  1.11

CD

Middle income group

Primary education

High school

Primary education

High school

Primary education

High school

n (%)
Gender M/F
Mean age  SD

396 (7.4)a
198/198
10.99  1.37

430 (8)a
219/211
15.71  1.10

453 (8.5)a
230/223
10.96  1.35

483 (9)a
240/243
15.73  1.10

849 (15.9)
428/421
10.98  1.36

913 (17)
459/454
15.72  1.10

E
Lower income groups

Primary education

High school

903 (16.9)
461/442
11.04  1.36

921 (17.2)
454/467
15.70  1.10

TOTAL

Primary education

High school

n (%)
Gender M/F
Mean age  SD

2566 (48)
1271/1295
10.95  1.37

2789 (52)
1376/1413
15.71  1.10

n (%)
Gender M/F
Mean age  SD

Primary education
a

450 (8.4)
232/218
11.03  1.38

High school

EF

453 (8.5)
222/231
15.71  1.10

Primary education
a

453 (8.5)
229/224
11.05  1.35

High school
a

468 (8.7)
232/236
15.70  1.10

SD: standard deviation; M/F: male/female. Primary education: 9>14 ages (child). High school: 1418 ages (adolescent).an (%). p 0.107.

Consents received for work

In accordance with the Ministry of Education of the
Republic of Turkey, no student names, last names or
other identifying information were included. The questionnaires that were distributed to the students were
numbered; therefore, the numbers were used for identication instead of names and surnames. For the study
to be conducted, a written consent was obtained from
the Ministry of Education of the Republic of Turkey.
The questionnaires, which were sealed by the Ministry,
were duplicated and used. Consent was obtained from
the local ethics committee of Ankara University and
from the academic board of the Department of Child
Health and Diseases, Faculty of Medicine, Ankara
University. Written informed consent for the Turkish
version of the questionnaires used in the study was
received from the individuals and institutions that
own the copyright.

Scoring of depression, anxiety and PedMIDAS

scales that were used
For rating depression, a childhood depression scale
compiled by the Association of Turkish Child
Psychiatry, whose validity and reliability had been

previously proven, was used (Appendix 1). The children

with a depression score of 19 and above were considered depressive. The Turkish version of Beck anxiety
scores, whose validity and reliability had been previously proven, was used (Appendix 1). Scores of 21
and above were considered positive. These diagnoses
were also conrmed by a child psychiatrist in the
second stage. For the PedMIDAS scoring, its verbatim
Turkish version, whose validity and reliability had been
proven, was used (Appendix 1).
The extent of disability was divided into four grades
based on the total score on the PedMIDAS. Grade I
had scores ranging from 0 to 10, indicating little to no
disability. Grade II had scores ranging from 11 to 30,
indicating mild disability. Grade III had scores ranging
from 31 to 50, indicating moderate disability. Grade IV
had scores >50, which indicated severe disability.

Statistical evaluation of the study

The statistical evaluation of this study was conducted
blindly by the members of the Department of Statistics,
Faculty of Medicine, Ankara University.
Statistical analyses were performed using the statistical software for Windows (version 15 SPSS Inc,
Chicago, IL, USA). All variables, reported as mean

530
and standard deviation or as median, were analyzed by
the Kolmogorov-Smirnov test according to the distribution of the variables. Normally distributed data were
subjected to parametric statistical methods (student
t-test, one-way analysis of variance (ANOVA)). The
Kruskal-Wallis and the Mann-Whitney U nonparametric tests were also used to correlate the data, while
the chi-square test was used to determine proportions.
Following a gender and age adjustment, a multivariate
logistic regression analysis was used to determine the
associations between headache groups and others parameters (income levels, mothers and fathers education
level, obesity, anxiety, depression, habits, grade point
averages, and PedMIDAS scores). A 95% CI was
determined using an odds ratio (OR). A p value
0.05 was considered statistically signicant for this
study.
The null hypothesis:
HO: Childhood headaches are not triggered by sedentary activities, anxiety, depression, and dietary intake.
The alternative hypothesis HA was dened as
HA: Childhood headaches are triggered by sedentary
activities, anxiety, depression, and dietary intake.

Results
Overall evaluation results
The study was conducted with 2566 (48%) primary
school students and 2789 (58%) high school students.
Of the 5355 subjects who participated in the study, 2647
(49.4%) were male, and 2708 (50.6%) were female.
Elementary student enrollment consisted of 1271
(49.5%) male and 1295 (50.5%) female students. Of
the high school students enrolled in the study, 1376
(49.3%) participants were male and 1413 (50.7%)
were female. The mean age was 13.4  2.68, and the
range was 918. When the schools were divided
among themselves and according to income levels,
there was no signicant dierence in the average age
and gender distribution (p > 0.05) (Table 1).

Evaluation of the results in terms of prevalence

Of 5355 students, 2112 (39.4%) answered the question
Have you had recurrent headaches? positively. Of
these patients, 550 (10.3%) were diagnosed with
migraine, 523 (9.8%) were diagnosed with probable
migraine, 883 (16.5%) were diagnosed with TTH, and
157 (2.9%) were diagnosed as having other headaches.
The migraineurs were classied as 109 (2%) migraine
with aura and 441 (8.2%) migraine without aura. In all
headache subtypes, there was no signicant dierence
in terms of the gender distribution and mean age

Cephalalgia 35(6)
(p > 0.0.5) (Table 2). The headaches in the elementary
school students were classied as 3.4% (184) migraine,
3.9% (211) probable migraine, 6% (323) TTH, and
0.8% (44) other headaches. In the high school students,
headaches were classied as 6.8% (366) migraine, 5.8%
(312) probable migraine, 10.5% (560) TTH, and 2.1%
(113) other headaches. No signicant dierence was
found between headache subtypes and gender distribution (p > 0.05) (Table 2).
Next, we compared pre-pubertal versus pubertal
children for headache types. In this study, the age
that dened the cuto for pubertal children was set
at 11 years of age, which is consistent with a previously published report on the pubertal age of Turkish
children (24). Our study determined that 11.7% (442)
of the pubertal children had a migraine, 10.4% (394)
had a probable migraine, 17.7% (668) TTH, and
3.4% (128) had other headaches. However, prepubertal children had dierent ranges including
6.8% (108) migraine, 8.2% (129) probable migraine,
13.6% (215) TTH, and 1.8% (29) other headaches. A
comparison of pre-pubertal versus pubertal children
and the association with recurrent headaches is
shown in Figure 1.

Evaluation of the results in terms of

socio-economic aspects
When the headache subtypes were evaluated in terms of
the income levels, they did not dier signicantly
(p > 0.05). Migraine diagnosis among patients had no
observed statistical dierence with the fathers education level, but a strong statistical signicance with the
mothers education level. When the headache subtypes
were evaluated in terms of the number of siblings, they
did not dier signicantly (Table 2) (p > 0.05).

Evaluation of the results in terms of school

achievement and body mass index
When the headache subtypes were classied based on
obesity, 8.7% of migraine suerers, 6.9% of probable
migraineurs, 5.1% of TTH, and 5.7% of the other
headaches were observed to be obese. This dierence
was statistically signicant (p  0.05). The average of
body mass index was 4.20  3.52 for migraineurs,
9.19  3.00 for probable migraineurs, 9.19  3.16 for
TTH, and 1.20  3.02 for other headaches. When a
post-hoc analysis was performed, the grade point average of students suering from migraine was signicantly higher than students with probable migraine
and TTH (p  0.05). Studies of school success and
migraine association indicated that students with recurrent migraine had a grade point average of 71.1  10.36,
while probable migraineurs, TTH, and other

531

Bektas et al.

Table 2. The demographic data of the study group according to the headache classes, and comparisons of obesity, parental education
levels and grade point averages.
Migraine
n (%)a

Probable
migraine
n (%)

TTH
n (%)

Other
headaches
n (%)

Primary education

184 (33.5/3.4)

211 (40.3/3.9)

323 (36.6/6.0)

44 (28/0.8)

1804 (55.6/33.7)

High school

366 (66.5/6.8)

319 (59.7/6.8)

560 (63.4/10.5)

113 (72/2.1)

1438 (44.4/26.9)

Male

235 (42.7/4.4)

225 (43/4.2)

421 (47.7/7.9)

70 (44.6/1.3)

1696 (52.3/31.7)

Female

315 (57.3/5.9)

298 (57/5.6)

462 (57.3/8.6)

87 (55.4/1.6)

1546 (47.7/28.9)

Income level
Upper

194 (35.3/3.6)

158 (30.2/3.0)

279 (31.6/5.2)

50 (31.8/0.9)

1088 (33.6/20.3)

Middle

177 (32.2/3.3)

180 (34.4/3.4)

300 (34/5.6)

54 (34.4/1.0)

1051 (32.4/19.6)

Lower

179 (32.5/3.3)

185 (35.4/3.5)

304 (34.4/5.7)

53 (33.8/1.0)

1103 (34/20.6)

No headache

P1/p2

School
0.016 a/0.001 a

Gender
0.208/0.001 a

0.740/0.783

Mothers education
University

123 (22.4/3.8)

96 (18.4/4.1)

156 (17.7/7.4)

25 (15.9/1.4)

609 (18.8/11.4)

High school

226 (41.1/4.2)

205 (39.2/3.8)

333 (37.7/6.2)

57 (36.3/1.1)

1184 (36.5/22.1)

Primary education

1449 (44.7/27.1)

201 (36.5/2.3)

222 (42.4/1.8)

394 (44.6/2.9)

75 (47.8/0.5)

Fathers education
University

172 (31.3/3.2)

158 (30.2/3.0)

266 (30.1/5.0)

47 (29.9/0.9)

914 (28.2/0.9)

High school

261 (47.5/4.9)

240 (45.9/4.5)

398 (45.1/7.4)

74 (47.1/1.4)

1405 (43.3/26.2)

Primary education

117 (21.3/2.2)

125 (23.9/2.3)

219 (24.8/4.1)

36 (22.9/0.7)

923 (28.5/17.2)

0.046 a/0.037 a

0.869/0.018 a

Obesity
Obese

48 (8.7/0.9)

36 (6.9/0.7)

45 (5.1/0.8)

9 (5.7/0.2)

203 (6.3/3.8)

Overweight

98 (17.8/1.8)

81 (15.5/1.5)

128 (14.5/2.4)

19 (12.1/0.4)

518 (16/9.7)

Non-Obese

404 (73.5/7.5)

406 (77.6/7.6)

710 (80.4/13.3)

129 (82.2/2.4)

2519 (77.7/47.1)

TOTAL
Age (mean  SD)

550 (100/10.3)
14.2  2.59

523 (100/9.8)
13.8  2.64

883 (100/16.5)
14.0  2.59

157 (100/2.9)
14.2  2.55

3242 (100/60.5)
13.0  2.65

Body mass index (mean  SD)

20.4  3.52

19.9  3.00

19.9  3.16

20.1  3.02

Number of siblings (mean  SD)

Grade point average (mean  SD)

19.4  2.97

0.040 a/0.089

0.093/0.060
0.021*/0.001*

2.0  0.98

2.0  1.18

1.95  0.92

2.0  0.95

1.99  0.95

0.097/0.108

71.1  10.36

73.2  11.96

73.8  13.82

74.4  11.73

75.2  12.35

0.001*/0.001*

Obese: >95 pounds. Overweight: 8595 pounds by age.ap < 0.05. SD: standard deviation. M/F: male/female. The first data show percentages in the
groups, the second data show overall distribution. The first p (P1) shows the statistical difference in the headache groups; the second p (P2) shows the
statistical difference in overall distribution children (including non-headache).

headache groups were 73.2  11.96, 73.8  13.82, and

74.4  11.73, respectively. Strikingly, a post-hoc analysis showed that the grade point average of children
with migraine was signicantly lower than all other
headaches (p  0.05).

Evaluation of the results related to nutrition

and habits
Of 550 students with migraine, 252 (45.8%) stated that
the attacks were triggered by food. One hundred and
eight students (19.6%) stated that cola and coee were
foods that triggered the attacks, 50 students (9.1%)
indicated a fried food reaction, 17 students (3.1%)
stated spicy food, 16 students (2.9%) stated chocolate,
15 students (2.7%) stated canned products, 13 students
(2.4%) stated tea, 13 students (2.4%) stated peanuts, 12
students (2.2%) stated cheese, and eight students

(1.5%) stated other foods (sausages, salami, sh,

fruit) as foods that triggered their attacks.
Of the individuals, 36.5% of migraine suerers (201),
32.7% of probable migraineurs (171), 28.8% of the
children with TTH (228), and 22.3% of the other headaches (35) stated that they did not have regular sleep
habits. This dierence was statistically signicant
(p 0.001). Of the migraine suerers, 51.8% of
migraine suerers (285) expressed that they went to
school without breakfast. Of the other headache
types, 50.7% of the probable migraineurs (265),
46.1% of the children with TTH (407), and 42% of
the other headaches (66) stated that they went to
school without breakfast (p 0.044).
Regarding leisure activities, 27.6% of migraine sufferers (152) stated that they spent their free time reading
books, 19.1% (105) spent it watching television (TV),
18.5% (102) reported playing on computers or surng

532

Cephalalgia 35(6)

Figure 1. Comparison of pre-pubertal versus pubertal children and recurrent headaches according to their subtypes.
TTH: tension-type headache.

the Internet, 10.5% (58) listened to music, and 11.3%

(62) played sports. Of the non-migraine patients, 18.9%
(910) said that they spent their free time reading books,
24.1% (1159) watching TV, 21% (1008) playing on
computers or surng the Internet, 12.7% (608) listening
to music, and 13.5% (649) spent their time playing
sports. This dierence was statistically signicant
(p 0.001). The daily liquid consumption of migraine
suerers was cola (mean: 1.2  0.71/median: 1/range:
04), coee (mean: 0.6  0.84/median: 0/range: 06)
and tea (mean: 2.0  1.93/median: 2/range: 012). The
results for cola in non-migraineurs was (mean:
1.0  0.73/median: 1/range: 07), while coee and tea
was mean: 0.4  0.70/median: 1/range: 05 and mean:
1.6  1.67/median: 1/range: 013, respectively. The
results showed that the migraine suerers consumption
was signicantly higher (p 0.001) (Table 3).
Additionally, caeine consumption by the school students was calculated. It was observed that consumption
was comparable between migraine suerers, whereas
consumption was statistically increased compared to
other headache subtypes (Table 3).

Evaluation of anxiety, depression and

PedMIDAS scores
Of the migraine suerers, 43.5% (239) had higher anxiety
scores, while 19.8% (949) of the non-migraine students
had higher anxiety scores (p 0.001). The average BAI
score in migraine suerers was 17.5  12.19 (median 17),
and it was 12.5  10.41 (median 10) in non-migraine students, respectively. In 29.6% of the migraine suerers
(148), the depression scores were high, but this score
was high in only 13.8% of non-migraine students (662)

(p  0.05). The average depression score in migraine-suffering students was 13.6  6.80 (median: 13), while nonmigraine students had a score of 2.12  6.60 (median 11).
The PedMIDAS average in migraineurs and nonmigraine students was 12.6  11.80 (median: 11/range:
090), and 4.9  9.10 (median: 0/range: 0120), respectively (p  0.05) (Table 4).
A comparison of the PedMIDAS scores of the subjects who had positive anxiety, depression, and obesity
in the headache subtypes is shown in Figure 2. In
Figure 3, a comparison of the PedMIDAS scores of
migraine suerers who prefer music, sports, television,
computers, and books for leisure time activities and
those who do not prefer these activities is given.
After age and gender were adjusted, a multivariate
logistic regression analysis was performed on all the
variables between students with and without migraine.
This analysis determined that the mothers education
level (OR: 1.63, 95% CI: 1.122.20, p 0.001), the presence of obesity (OR: 1.50, 95% CI: 1.112.01,
p 0.007), a low grade point average (OR: 0.97, 95%
CI: 0.960.98, p 0.001), the presence of anxiety (OR:
1.45, 95% CI: 1.161.82, p 0.001) and a high
PedMIDAS score (OR: 7.68, 95% CI: 4.9811.87,
p 0.001) were related to migraine (not shown).
While there was a positive correlation between migraine
and body mass index, anxiety, depression, and
PedMIDAS scores, there was a negative correlation
with grade point average.

Discussion
In this study, we found that the prevalence of recurrent
headaches was 39.4% and the prevalence of migraine

533

Bektas et al.
Table 3. Comparison of headache classes in terms of daily activities, eating habits and habits.
Migraine
n (%)

Probable
migraine
n (%)

TTH
n (%)

Other
headaches
n (%)

No headache

p1/p2

Regular sleep habits

No

201 (36.5)

171 (32.7)

228 (28.8)

35 (22.3)

673 (20.8)

Yes

349 (63.5)

352 (67.3)

655 (74.2)

122 (77.7)

2569 (79.2)

285 (51.8)

265 (50.7)

407 (46.1)

66 (42)

902 (27.8)

265 (48.2)

258 (49.3)

476 (53.9)

91 (58)

2340 (72.2)

Regular breakfast habits

No
Yes

0.001*/0.001*

0.044*/0.001*

Leisure activities
Books

152 (27.6)

Television

105 (19.1)

Computers or Internet

86 (16.4)
110 (21)

159 (18)

33 (21)

632 (19.5)

208 (23.6)

39 (24.8)

802 (24.7)

102 (18.5)

95 (18.2)

178 (20.2)

23 (14.6)

712 (22)

Music

58 (10.5)

91 (17.4)

128 (14.5)

28 (17.8)

361 (11.1)

Sports
Others

62 (11.3)
71 (12.9)

84 (16.1)
57 (10.9)

117 (13.3)
93 (10.5)

23 (14.6)
11 (7)

425 (13.1)
310 (9.6)

No

294 (53.4)

381 (72.8)

Yes

256 (46.6)

142 (27.2)

108 (19.6)

38 (7.3)

Fried foods

49 (8.9)

29 (5.5)

Chocolate
Canned products

15 (2.7)
15 (2.7)

13 (2.5)
8 (1.5)

Spicy food

17 (3.1)

10 (1.9)

Tea

13 (2.4)

28 (5.4)

Peanuts

13 (2.4)

7 (1.3)

Cheese

18 (3.3)

6 (0.6)

Activation of food

Foods that triggered the attacks

Cola and coffee

Others
TOTAL
Beverages consumed daily  SD
Cola consumption
Coffee consumption
Tea consumption
Caffeine consumption

8 (1.5)

3 (2.1)

550 (100)

523 (100)

0.001*/0.001*

0.001*/

0.008*/

883 (100)

157 (100)

3242 (100)

1.2  0.71
0.6  0.84

1.1  0.67
0.5  0.79

1.1  0.71
0.4  0.73

0.9  0.78
0.3  0.67

0.9  0.73
0.4  0.68

0.007 a/0.001*
0.001 b/0.001*

2.0  1.93

1.7  1.63

1.9  1.86

1.8  1.93

1.5  1.60

0.010 c/0.001*

210.3  143.68

186.2  127.60

184.6  135.88

166.1  134.78

160.4  119.86

0.001 d/0.001*

According to the post-hoc analysis, migraineurs have significantly higher cola consumption than the other headache groups.
According to a post-hoc analysis, in coffee consumption, migraineurs have significantly higher coffee consumption than those with TTH and other
headaches.
c
According to a post-hoc analysis, migraineurs have significantly higher tea consumption than possible migraineurs.
d
According to the post-hoc analysis, migraineurs have significantly higher cola consumption than the other headache groups.
Cola in cans (330 ml100 ml/13 mg caffeine), coffee in cups (200 ml100 ml/60 mg caffeine), tea in glasses (150 ml100 ml/28 mg caffeine).
The first p (p1) shows the statistical difference in the headache groups. The second p (p2) shows the statistical difference in overall distribution children
(including non-headache).
TTH: tension-type headache; SD: standard deviation.
b

was 10.3% in school-age children. Our rates were lower

compared to another study conducted on Turkish children that found a 59% prevalence of recurrent headaches and a 14.5% of migraine (2). The main objective
of our study was not to determine the prevalence. When
we consider the size of our sample group, the age range,
and migration rate to the province of Ankara from all
over Turkey, we think our rates are important in terms
of reecting the averages in Turkey.

Changes in the emotional status during puberty are

important, so it should be determined if the emotional
problem/change is a comorbidity or the primary issue
(12). Symptoms of depression, which include sadness,
tearfulness, withdrawal from activities, and hopelessness, need to be checked (12). In studies that focused
on migraine and were performed on adults, the rate of
anxiety and depression was found to be 2 to 5.3 times
higher in migraine patients. The presence of comorbid

534

Cephalalgia 35(6)

Table 4. Comparison of headache classes according to anxiety, depression and PedMIDAS scores and their levels.
Migraine
n (%)

Probable
migraine
n (%)

Other
headaches
n (%)

TTH
n (%)

No headache
n (%)

p1/p2

Depression
No

402 (73.1)

405 (77.4)

719 (81.4)

2888 (89.1)

131 (83.4)

Yes

148 (29.6)

118 (22.6)

164 (18.6)

354 (10.9)

26 (16.6)

Anxiety
No

311 (56.5)

346 (66.2)

559 (63.1)

109 (69.4)

2842 (87.7)

Mild

210 (38.2)

155 (29.6)

271 (30.7)

46 (29.3)

368 (11.4)

27 (4.9)

21 (4.0)

45 (5.1)

2 (1.3)

29 (0.9)

2 (0.4)

1 (0.2)

8 (0.9)

Grade 1

218 (39.7)

330 (63.1)

818 (92.6)

142 (290.4)

Grade 2

266 (48.5)

155 (29.6)

52 (5.9)

10 (6.4)

Grade 3
Grade 4

56 (10.2)
9 (1.6)

31 (5.9)
7 (1.3)

9 (1.0)
4 (0.5)

4 (2.5)
1 (0.6)

Moderate
Severe

0.001*/0.001*

0.001*/0.006*

3 (0.1)

PedMIDAS

0.001*/

TOTAL

550 (100)

523 (100)

883 (100)

157 (100)

Anxiety
(mean  SD)

17.5  12.19

16.3  11.38

18.5  11.92

15.1  9.75

10.2  8.88

0.001*/0.001*

Depression
(mean  SD)
PedMIDAS
(mean  SD)

13.6  6.80

13.1  6.96

12.0  6.47

11.1  5.87

9.3  6.17

0.001*/0.001*

PedMIDAS
(mean  SD) M/F

3242 (100)

12.6  11.80

8.6  13.74

2.4  6.80

3.2  7.50

0.001*/

11.5  10.83/
13.5  12.42

7.5  12.36/
9.5  14.66

2.3  5.99/
2.5  7.47

2.3  4.20/
3.9  9.31

0.001*/

TTH: tension-type headache; PedMIDAS: pediatric Migraine Disability Assessment Scale; SD: standard deviation; M/F: male/female. The first p (p1) shows the
statistical difference in the headache groups. The second p (p2) shows the statistical difference in overall distribution children (including non-headache).
*Statistically significant.

Figure 2. Comparison of the PedMIDAS scores of individuals who have anxiety, depression and obesity in the headache subtypes.
PedMIDAS: pediatric Migraine Disability Assessment Scale; TTH: tension-type headache.

psychiatric diagnoses is thought to complicate treatment outcomes in headache (25,26). Some studies conducted on children showed that TTH had a relationship
with anxiety and psychiatric comorbidities that

included depression (27). Studies conducted on children

and adolescents indicated that the general prevalence of
anxiety disorders ranged between 2% and 24% (26,27).
The prevalence of major depression ranged from 0.2%

Bektas et al.

535

Figure 3. Comparison of the PedMIDAS scores of migraine patients who prefer sports, music, books, computer and television to
pass their leisure time and those who do not enjoy these activities.
PedMIDAS: pediatric Migraine Disability Assessment Scale.

to 17% (2731). When dysthymia and the prevalence of

minor unclassied depression are added, this rate is
higher. Our prevalence of anxiety in children without
headaches was 22.8%, and the prevalence of depression
was 16.6%, which were similar to previous studies. In
our study, we found that the prevalence of anxiety,
especially in migraineurs (43.5%), and the prevalence
of depression (29.6%) were much higher than that of
the general population and those with other types of
headache. The PedMIDAS scores of migraineur children with depression and anxiety were signicantly
higher than the other types of headaches. These data
may show us that, in the management of migraine treatment, psychiatric comorbidities should be considered as
much as TTH.
Previous studies showed a lack of statistical signicance between the familys income level and migraine
(10,32), however; other studies showed that migraine
was more frequent in societies with low socio-economic
levels (33). In our study, we did not nd dierences
between migraine and family income level. Consistent
with previous studies, we found that the migraine rates
were signicantly higher in female students. The education levels of the mothers were signicantly higher in
children who had migraine. We thought that this might
be due to the prescriptive life that educated mothers
imposed on their children and the stress that result in
the children.
Diet, lifestyle, and habits are perceived as factors
aecting headaches in children. Many studies conducted on adults investigated the eects of lifestyle
and diet on headaches (34). A previous study showed
that inadequate uid intake, irregular meals, and dietrelated factors such as high caeine consumption

increased the frequency and duration of attacks and

triggered the attacks (35). It was shown that some
other habits, including smoking and alcohol consumption, were related to headaches (36,37). In a small
number of studies conducted on children, it was
shown that caeine consumption, irregular breakfasts,
and a lack of regular sleep habits had a relation with
headaches (1316,35). In these studies, the sample
groups were small, the age ranges were narrow, and
the income status was not taken into consideration or
the studies covered only certain types of headaches.
In our study, it was found that a lack of regular sleep
and irregular breakfast habits were signicantly higher
in children with headache than in those without headaches. These observations were signicantly higher in
migraineurs than in those with other headache types. It
was observed that children with migraine mostly preferred to spend their leisure time reading books. They
did not prefer photophobia sources such as television,
the Internet, and phonophobia sources such as music.
The relationship between reduced physical activity and
migraine was previously shown. It was based on the
hypothesis that patients avoided exercise because physical activity could trigger the attacks (36). In our study,
we observed that migraineurs preferred sports in leisure
time less often than the patients with other headache
types. The PedMIDAS scores of the children who spent
their free time playing sports were lower. This nding
supports the studies that indicated that physical activity
had a positive impact on the management of migraine
treatment (13). Scores were higher in children who preferred reading books, watching TV, and using computers in their spare time (Figure 3). Collectively, this
suggests that reduced physical activity is a risk factor

536
for migraine suerers and that these patients should be
persuaded to perform more physical activity.
A limited amount of physical activity contributes to
obesity and being overweight in patients with recurrent
headaches. Recent data showed a relationship between
obesity and migraine (38). The mechanisms that
link obesity with the frequency of a migraine attack
are uncertain, but they may be connected from a biochemical perspective (39). It is known that obesity is a
proinammatory and prothrombotic state, and neurovascular inammation might be an important mechanism of migraine. It is thought that obesity triggers
pain by releasing proinammatory mediators such as
calcitonin gene-related peptide and substance P, resulting in the stimulation of the trigeminal ganglion
nociceptor (39).
In our study, the rate of headache activation through
foods was found to be as high as 46.6% in migraineurs.
Caeinated beverages such as cola and coee and fried
foods were the primary triggers among the foods that
caused attacks. Although cola, coee and tea trigger
migraine attacks, the rate of consumption was signicantly higher in the migraineurs. In our study, migraineurs had higher levels of maternal education but a
lower grade point average. Because there is a competitive examination system in our country, we think that
pressure from educated parents contributes to the headaches. The pressure and stress could potentially be the
root of increased consumption of caeinated beverages

Cephalalgia 35(6)
and tea, which have a stimulating eect to increase
study habits even though these beverages trigger
attacks.
Our study has some limitations. Like many other
cross-sectional studies, our study was performed
using a specic time-point questionnaire and was
not carried out in a time-dependent fashion. The
headache classication was determined based on the
valid ICHD-II criteria at the initiation of the study
and not the newly drafted ICHD 3-beta criteria. In
addition, the parents or guardians of the children
were not interviewed for this study as advised by
the Ministry of National Education. We were advised
not to ask questions that pertained to menarche or
alcohol consumption, since the children may not provide an honest answer.
In this comprehensive study, we broadly present the
headache prevalence and the distribution of chronic
headaches, the eects of diet, lifestyles and habits on
headache, the relationship between anxiety, depression
and headaches, and the loss of daily life activity in
school children and dierent socio-economic groups.
This study showed a relationship between recurrent
headaches with caeinated beverages, obesity, lack of
regular sleep, irregular breakfast habits, parental education level, depression and anxiety. We believe that
this comprehensive synoptic study will shed light on
studies that will be conducted on pathophysiology
and treatment in the future.

Clinical implications
. We found that the prevalence of recurrent headaches was 39.4% and the prevalence of migraine was 10.3%
in school-age children.
. The pediatric Migraine Disability Assessment Scale (PedMIDAS) scores of the children who spent their free
time playing sports were lower. The score was higher in children who preferred reading books, watching TV,
and using computers in their spare time.
. The mothers education level, the presence of obesity, a low grade point average, the presence of anxiety, and
a high PedMIDAS score were related to migraine.
Funding

References

This research received no specic grant from any funding

agency in the public, commercial, or not-for-prot sectors.

1. Bille BS. Migraine in school children. A study of the incidence and short-term prognosis, and a clinical, psychological and electroencephalographic comparison between
children with migraine and matched controls. Acta
Paediatr Suppl 1962; 136: 1151.
2. Ozge A, Bugdayci R, Sasmaz T, et al. The sensitivity and
specificity of the case definition criteria in diagnosis of
headache: A school-based epidemiological study of 5562
children in Mersin. Cephalalgia 2002; 22: 791798.
3. Karli N, Akgoz S, Zarifoglu M, et al. Clinical characteristics of tension-type headache and migraine in
adolescents: A student-based study. Headache 2006; 46:
399412.

Conflict of interest
None declared.

Acknowledgments
_
We would like to thank Dr Levent Inanc,
Dr Ozan Akinci, Dr
Idil Daloglu, Dr Ays e Kartal, Dr Arzu Ymaz, Neva Bektas,
Assoc. Prof Dr Ersoy Civelek, Ozge Tras, Dr Ali Rza
Yamur, Dr Betul, Dr Elif and Dr Serife Bektas and all the
teachers who helped us.

537

Bektas et al.
4. Akyol A, Kiylioglu N, Aydin I, et al. Epidemiology
and clinical characteristics of migraine among school
children in the Menderes region. Cephalalgia 2007; 27:
781787.
5. Arruda MA, Guidetti V, Galli F, et al. Primary headaches in childhooda population-based study.
Cephalalgia 2010; 30: 10561064.
6. Anttila P. Tension-type headache in childhood and adolescence. Lancet Neurol 2006; 5: 268274.
7. Barea LM, Tannhauser M and Rotta NT. An epidemiological study of headache among children and adolescents
of southern Brazil. Cephalalgia 1996; 16: 545549.
8. Split W and Neuman W. Epidemiology of migraine
among students from randomly selected secondary
schools in Lodz. Headache 1999; 39: 494501.
9. Raieli V, Raimondo D, Cammalleri R, et al. Migraine
headaches in adolescents: A student population-based
study in Monreale. Cephalalgia 1995; 15: 512.
10. Mavromichalis I, Anagnostopoulos D, Metaxas N, et al.
Prevalence of migraine in schoolchildren and some clinical comparisons between migraine with and without
aura. Headache 1999; 39: 728736.
11. Lu SR, Fuh JL, Juang KD, et al. Migraine in adolescents
aged 1315: A student population-based study in Taiwan.
Cephalalgia 2000; 20: 479485.
12. Ozge A, Termine C, Antonaci F, et al. Overview of diagnosis and management of paediatric headache. Part I:
Diagnosis. J Headache Pain 2011; 12: 1323.
13. Robberstad L, Dyb G, Hagen K, et al. An unfavorable
lifestyle and recurrent headaches among adolescents: The
HUNT Study. Neurology 2010; 75: 712717.
14. Roth-Isigkeit A, Thyen U, Stoven H, et al. Pain among
children and adolescents: Restrictions in daily living and
triggering factors. Pediatrics 2005; 115: 152162.
15. Powers SW, Gilman DK and Hershey AD. Headache
and psychological functioning in children and adolescents. Headache 2006; 46: 14041415.
16. Milde-Busch A, Blaschek A, Borggrafe I, et al. Associations of diet and lifestyle with headache in high-school
students: Results from a cross-sectional study. Headache
2010; 50: 11041114.
17. Mazzone L, Vitiello B, Incorpora G, et al. Behavioural
and temperamental characteristics of children and adolescents suffering from primary headache. Cephalalgia
2006; 26: 194201.
18. Just U, Oelkers R, Bender S, et al. Emotional and behavioural problems in children and adolescents with primary
headache. Cephalalgia 2003; 23: 206213.
19. Amouroux R and Rousseau-Salvador C. Anxiety and
depression in children and adolescents with migraine: A
review of the literature [article in French]. Encephale
2008; 34: 504510.
20. Fuh JL, Wang SJ, Lu SR, et al. Headache disability
among adolescents: A student population-based study.
Headache 2010; 50: 210218.
21. Karli N, Akis N, Zarifoglu M, et al. Headache prevalence in adolescents aged 12 to 17: A student-based

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.
34.
35.

36.

37.

38.

39.

epidemiological study in Bursa. Headache 2006; 46:

649655.
Daniel WW. Biostatistics: A foundation for analysis in the
health sciences, 7th edn. New York: John Wiley & Sons,
1999.
Sahin NH and Sahin N. Reliability and validity of the
Turkish version of the Automatic Thoughts Questionnaire. J Clin Psychol 1992; 48: 334340.
Neyzi O, Furman A, Bundak R, et al. Growth references
for Turkish children aged 6 to 18 years. Acta Paediatr
2006; 95: 16351641.
Baskin SM and Smitherman TA. Migraine and psychiatric disorders: Comorbidities, mechanisms, and clinical
applications. Neurol Sci 2009; 30(Suppl 1): S61S65.
Heckman BD, Holroyd KA, Himawan L, et al. Do psychiatric comorbidities influence headache treatment outcomes? Results of a naturalistic longitudinal treatment
study. Pain 2009; 146: 5664.
Slater SK, Kashikar-Zuck SM, Allen JR, et al. Psychiatric comorbidity in pediatric chronic daily headache.
Cephalalgia 2012; 32: 11161122.
Merikangas KR, Nakamura EF and Kessler RC. Epidemiology of mental disorders in children and adolescents.
Dialogues Clin Neurosci 2009; 11: 720.
Guidetti V, Galli F, Fabrizi P, et al. Headache and psychiatric comorbidity: Clinical aspects and outcome in an
8-year follow-up study. Cephalalgia 1998; 18: 455462.
Virtanen R, Aromaa M, Koskenvuo M, et al. Externalizing problem behaviors and headache: A follow-up study
of adolescent Finnish twins. Pediatrics 2004; 114:
981987.
Merikangas KR, Angst J and Isler H. Migraine and psychopathology. Results of the Zurich cohort study of
young adults. Arch Gen Psychiatry 1990; 47: 849853.
Ofovwe GE and Ofili AN. Prevalence and impact of
headache and migraine among secondary school students
in Nigeria. Headache 2010; 50: 15701575.
Bigal ME and Lipton RB. Overview on the prevalence
and impact of migraine. J Headache Pain 2004; 5: 8891.
Bigal ME and Lipton RB. Modifiable risk factors for
migraine progression. Headache 2006; 46: 13341343.
Milde-Busch A, Blaschek A, Borggrafe I, et al. Associations of diet and lifestyle with headache in high-school
students: Results from a cross-sectional study. Headache
2010; 50: 11041114.
Panconesi A. Alcohol and migraine: Trigger factor, consumption, mechanisms. A review. J Headache Pain 2008;
9: 1927.
Molarius A, Tegelberg A and Ohrvik J. Socio-economic
factors, lifestyle, and headache disordersa populationbased study in Sweden. Headache 2008; 48: 14261437.
Verrotti A, Di Fonzo A, Agostinelli S, et al. Obese children suffer more often from migraine. Acta Paediatr
2012; 101: e416e421.
Peterlin BL, Rapoport AM and Kurth T. Migraine and
obesity: Epidemiology, mechanisms, and implications.
Headache 2010; 50: 631648.