search text   Advanced Search

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Powers, S. W. Articles by Hershey, A. D. Search for Related Content PubMed PubMed Citation Articles by Powers, S. W. Articles by Hershey, A. D. Related Collections Neurology & Psychiatry

Quality of Life in Childhood Migraines: Clinical Impact and Comparison to Other Chronic Illnesses

Scott W. Powers, PhD^*,, Susana R. Patton, PhD^*, Kevin A. Hommel, PhD^* and Andrew D. Hershey, MD, PhD^,

^* Division of Psychology, Cincinnati Children’s Hospital Medical Center
Division of Neurology, Cincinnati Children’s Hospital Medical Center
University of Cincinnati College of Medicine, Cincinnati, Ohio

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Objective. Despite the high prevalence of headaches in youths, quality of life (QOL) has not been well examined. We examined QOL in a clinical sample of children with headaches and compared it with children with other chronic diseases.

Methods. A survey study was conducted of 572 consecutive patients (mean age, 11.4 ± 3.6 years) who presented with headaches to a children’s headache center. Children and parents completed the Pediatric Quality of Life Inventory, Version 4.0 and a standardized headache assessment. Results were compared with established norms for healthy and chronically ill children.

Results. Most patients (99%) had a clinical diagnosis of migraine: 85% met the International Headache Society migraine criteria, and 40% had chronic daily headaches. Total Pediatric Quality of Life Inventory, Version 4.0 score was lower for the entire group (73.1 ± 14.4) compared with healthy norms (83.0 ± 14.8) and lowest for children with chronic daily headaches (70.5 ± 15.5). The impact on QOL of children with migraine was similar to that of children with arthritis and cancer.

Conclusions. QOL of children with headaches is significantly affected by their health condition. The impact of headaches on QOL is similar to that found for other chronic illness conditions, with impairments in school and emotional functioning being the most prominent.

Key Words: pediatric • adolescents • headache • disability • headache treatment • migraine

Abbreviations: IHS, International Headache Society • QOL, quality of life • PedsQL 4.0, Pediatric Quality of Life Inventory, Version 4.0 • CDH, chronic daily headache

Headaches in children and adolescents are a common problem.¹ The majority of children who experience recurrent headaches have migraines. Prevalence estimates indicate that up to 10.6% of children ages 5 to 15 years² and 28% of adolescents between the ages of 15 and 19 years³ experience migraine headaches. Migraines have historically been diagnosed using clinical impression. To address the limitations of this method, the International Headache Society (IHS) developed defined criteria for headache diagnosis.⁴ These criteria, however, have been criticized for incompletely diagnosing childhood migraine disorders.^5,6 Revisions have been suggested and may be incorporated into the next update of the criteria, but currently the diagnosis of childhood migraine relies on both the IHS criteria and a clinical impression.^7,8

Recurrent headaches have an impact on a child’s life in a number of ways, including school absences and reduction in performance, decreased home and family interactions, and decreased socialization with peers. Using the Pediatric Migraine Disability Assessment (PedMIDAS), a questionnaire that assesses disability in school, home, and play activities, children reported moderate to severe disability.⁹ Related to children’s objective disability is their subjective evaluation of disability and the impact of headaches on their quality of life (QOL).

Health-related QOL is a multidimensional concept that reflects the impact of disease and treatment on a patient’s subjective evaluation of his or her functioning and emotional well-being.^10–12 QOL is an important construct to assess, especially as it relates to treatment effectiveness and patient satisfaction.^13,14 There is little programmatic research investigating QOL as an outcome measure in pediatric chronic illness conditions.^13,15 This is primarily because of a lack of appropriate and practical measures of QOL for children. The Pediatric Quality of Life Inventory, Version 4.0 (PedsQL 4.0) is a generic measure of QOL, which has been developed for use with children from age 2 to 18 years and allows a comparison of QOL effects across acute and chronic health conditions and with healthy children.¹⁶ It allows for child self-report and parent-proxy report of QOL. This measure has been validated for use with children with cancer, rheumatoid disease, diabetes, and orthopedic conditions.¹⁶ Results have indicated that children’s QOL is adversely affected because of an acute or chronic health condition and that QOL is differentially affected by a child’s health condition.¹⁶

There is little research examining the QOL of children with migraine headaches despite the high prevalence of this disorder. The few available studies have consistently found headaches to have an adverse impact on children’s QOL. In a study of 20 headache patients ages 9 to 18 years, children experienced more somatic complaints, lower general well-being, and more physiologic anxiety and were less communicative than matched healthy control subjects.¹⁷ Adolescents (n = 159) with headaches reported worse psychological functioning, more physical symptoms, a poorer functioning status, and less satisfaction with life and health than healthy adolescents.¹⁸ No research has examined the QOL of young children with headaches or evaluated the impact of headaches on QOL in comparison with other chronic illness conditions. Advances in pharmacological and biobehavioral treatments for headache over the last several years make the assessment of QOL in children essential. The present study reports on the QOL of a large clinical sample of children with headaches. Also, QOL in children with headaches is compared with data for a number of other pediatric disorders, including arthritis and cancer.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Subjects
Children were referred by their primary care physician to the Headache Center at Cincinnati Children’s Hospital Medical Center. For the children between the ages of 5 and 18 years, data were collected from both children and parents. For the children between 2 and 4 years old, data were collected from the parents only. Families completed a detailed questionnaire describing features of their child’s headaches and general health as well as the age-appropriate version of the PedsQL 4.0 at the child’s initial appointment. These data were reviewed with families during their clinic visit to ensure accuracy and to assist in headache diagnosis and treatment. Clinical diagnoses and a diagnosis using the IHS criteria⁴ were obtained on the basis of medical history and neurologic examination. Families who attend the Headache Center agreed for information collected during clinical care to be used for research purposes and were informed that all data are presented as group findings with no individual identifiers. A generally uniform and effective multidisciplinary treatment program is provided by the Headache Center.^19–28

The normative comparison group (N = 730) included healthy children who were assessed either in physicians’ offices during well-child checks or by telephone and whose parents did not report the presence of a chronic health condition.¹⁶ The comparison group of children with cancer (N = 339) included individuals with acute lymphocytic leukemia (50%), brain tumor (7%), non-Hodgkin’s lymphoma (6%), Hodgkin’s lymphoma (3%), Wilm’s tumor (6%), and other cancers (28%).²⁹ The comparison group of children with rheumatologic disease (N = 271) included individuals with juvenile rheumatoid arthritis (30%), systemic lupus erythematosus (8%), juvenile fibromyalgia (13%), spondyloarthritis (11%), and other rheumatic diseases (38%).³⁰

Measures
On the Headache Center intake questionnaire, patients indicated the average severity of their headaches using a 10-point scale (10 = most severe pain). The duration of headache pain was reported according to the duration of their shortest, longest, and average headaches. Headache frequency was reported as the average number of headache days that occurred per month during the past 3 months. Diagnosis was made using both clinical impression and the IHS criteria. The IHS criteria for migraine without aura are having at least 5 headaches that last untreated between 2 and 48 hours for children younger than 15 years or 4 to 72 hours if older than 15 years, having 2 of 4 features (pulsatile quality, focal location, aggravated by physical activity, and moderate to severe pain), having associated symptoms of nausea and/or vomiting or photophobia and phonophobia, and having a normal neurologic examination and the headache not associated with a secondary cause.⁴

The PedsQL 4.0^16,31 is a 23-item measure that takes 5 minutes to complete and evaluates children’s QOL in 4 areas of functioning: physical functioning (8 items), emotional functioning (5 items), social functioning (5 items), and school functioning (5 items). The PedsQL 4.0 has 2 forms: a child self-report form and a parent-report form. The child self-report includes 3 age ranges: young child (5–7 years), child (8–12 years), and adolescent (13–18 years). The parent report includes an additional toddler (2–4 years) age range. To complete the PedsQL 4.0, respondents are asked to indicate how much of a problem each item has been during the past month. For the child self-report (8–18 years) and the parent-report forms, respondents use a 5-point Likert scale to rate the item severity (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). However, for the younger children (5–7 years), a simplified 3-point Likert scale, anchored with a happy and a sad face, is used (0 = not at all a problem; 2 = sometimes a problem; 4 = a lot of a problem).

The PedsQL 4.0 is designed to yield a total QOL score; 2 summary scores—the Physical Health Summary Score and the Psychosocial Health Summary Score—and 3 subscale scores—Emotional, Social, and School Functioning—(yielding a total of 1 total score and 5 summary/subscale scores). To obtain a total score, the items are reverse-scored and transformed to a 0 to 100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, 4 = 0). The 3-point Likert scale is scored 0 = 100, 2 = 50, and 4 = 0. The Physical Health Summary Score (8 items) is the same as the Physical Functioning Subscale. The Psychosocial Health Summary Score (15 items) is a mean score (computed as the sum of the items divided by the number of items answered in the Emotional, Social, and School Functioning Subscales).¹⁶ Scale scores are computed as the sum of the items divided by the number of items answered.¹⁶ Previous research with the PedsQL 4.0 demonstrates good internal consistency ( child = 0.88, parent = 0.90) and construct validity in healthy children and children with acute or chronic illnesses.^16,31

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Demographics and Headache Parameters
This study evaluated 572 children (aged 2–4: 14; aged 5–7: 72; aged 8–12: 257; aged 13–18: 229). Ninety-nine percent had a clinical diagnosis of migraine; 85% met the IHS criteria for migraine or migraine with aura, a difference that reflects the sensitivity of the IHS criteria among children.^3,6–8 Forty percent of children met criteria for chronic daily headaches (CDHs).^19,32 Children’s mean age at study enrollment was 11.4 ± 3.6 years. In contrast, the mean age of onset for headaches was 8.1 ± 3.6 years. The sample was nearly split on gender (316 girls versus 256 boys). The racial distribution of children was as follows: 509 white, 56 black, and 7 other. Children’s mean headache frequency was 13.4 ± 10.5 headaches per month. The mean severity of headaches was 6.7 ± 1.8. The mean duration of children’s typical headaches was 8.9 ± 13.0 hours.

PedsQL 4.0 Scores
Table 1 presents means and standard deviations for each subscale of the PedsQL 4.0 for children with clinical migraine, IHS migraine, and CDH compared with the healthy children population scores¹⁶ for all ages. Internal consistency reliability coefficients³³ are presented for the headache samples only. Parallel descriptive data are presented for parent-report scales in Table 2 along with internal consistency reliability data for the headache samples.

View larger version (23K): [in this window] [in a new window]   Fig 1. PedsQL 4.0 child self-report scores across disease groups. Data presented for healthy children, children with headaches, and children with rheumatoid diseases and cancer. The full range of the PedsQL 4.0 is 0 to 100. This figure uses a more limited range for presentation.

View larger version (21K): [in this window] [in a new window]   Fig 2. PedsQL 4.0 parent-report scores across disease groups. Data presented for healthy children, children with headaches, and children with rheumatoid diseases and cancer. The full range of the PedsQL 4.0 is 0 to 100. This figure uses a more limited range for presentation.

Comparisons With Children With Chronic Illness
The present sample of headache patients demonstrated PedsQL 4.0 scores that were similar to other chronic disease groups.^29,30 According to child self-report data, statistical comparisons of QOL for children with headaches and children with rheumatoid conditions or cancer found no differences in total QOL scores. Differences were found when comparing children on subscale scores (P < 0.002). Children with headaches reported higher physical functioning and higher social functioning than children with rheumatoid conditions or cancer. They reported lower school functioning and emotional functioning than children with rheumatoid conditions or cancer. For parent report data, no differences were found when total QOL scores were compared. Differences were observed for individual subscale scores (P < 0.002). Similar to child self-report, parents of children with headaches reported higher physical functioning and higher social functioning than parents of children with rheumatoid conditions or cancer. Parents of children with headaches reported lower school functioning and emotional functioning when compared with parents of children with rheumatoid disease. However, there were no differences in these subscale scores when parents of children with headaches were compared with parents of children with cancer. Figures 1 and 2 present data across these 3 disease groups for child self-report and parent-report data, respectively.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Children’s QOL is an emerging area of research with potential relationships to treatment effectiveness and families’ satisfaction with their care.^13,14 Previous research investigating QOL in children with headaches has used standardized self-report measures that evaluate the impact of recurrent headaches on children’s psychological functioning or a disease-specific measure of QOL.^17,18 The use of standardized self-report measures can evaluate symptoms that are related to QOL but cannot offer an estimate of the impact of recurrent headaches on other important areas of functioning (eg, school, social activities).¹³ Disease-specific QOL measures preclude the ability to compare children’s QOL scores across chronic illness conditions, which limits the scope of these studies.¹³ The PedsQL 4.0 offers a practical measure of QOL, which can be administered in a busy clinic setting and offers the opportunity to compare QOL across disease conditions.

Findings of this study demonstrate that the PedsQL 4.0 can be an effective measure of QOL for children with migraine, a common yet understudied disorder of childhood. This measure demonstrates adequate internal consistency and interrater reliability between parents and children. We found that children’s QOL is adversely affected in all areas of functioning when compared with norms for healthy children. Specific areas of functional impairment were noted on the Psychosocial Health Factor Score and the School Functioning subscale. Comparisons made within the headache sample found that children with CDH reported the greatest impairment compared with healthy norms. Notable areas of impairment included the School Functioning subscale, Emotional Functioning subscale, and Physical Health Factor Score. Children who met IHS criteria for migraine also reported impaired QOL with specific deficits noted in the common areas of School Functioning, Emotional Functioning, and the Psychosocial Health Factor Score. Children’s QOL scores were comparable between children who met a clinical diagnosis of migraine versus those who also met IHS criteria.

The PedsQL 4.0 scores of children with migraine were compared with scores obtained from children with other chronic illness conditions. To date, there are no studies that specifically compare the QOL of children who have headaches with children who have other chronic health conditions. However, previous research with adults with migraine found them to report more impairment on measures of pain, role disability, and social functioning than adults with hypertension, osteoarthritis, and type 2 diabetes.³⁵ We found that children with migraines reported a similar pattern of disability as children with rheumatoid disease or cancer. When compared statistically, children with migraine self-reported more impairment in School Functioning and Emotional Functioning than children in the other chronic illness groups. Because of the unpredictable nature of migraine headaches, families must react to headache episodes with little advanced preparation. Without advance warning, it is difficult to "plan" for school absences by collecting classroom lessons or homework assignments in advance. On returning to school, children with headaches may spend a significant amount of time completing old assignments while learning new material. This burden may contribute to parents’ and children’s perception of greater impairment in school functioning. Their emotional functioning may also suffer if migraines are perceived as unpredictable and severe. These comparisons help to provide a context for understanding the impact of headaches on children’s QOL and suggest that children with migraines can experience comparable or more severe impairment as children with other serious chronic illness conditions.

Although the current sample is representative of the population of children seen at the Cincinnati Children’s Headache Center and the Cincinnati metropolitan area, additional research is needed with other samples to determine the generalizability of these findings. It will be important to evaluate other variables such as the type of health care facility, geographical location, family ethnicity, and other demographic characteristics. QOL was measured by both self-report and parent report, showing agreement across sources. However, self- and other report methods are vulnerable to subject bias, and objective measures of the impact of headaches on children’s daily life should be added in future investigations. Although the PedsQL 4.0 provides a valid and practical means of evaluating QOL in children and families within a busy clinic setting, it does not provide a complete assessment of the many specific psychosocial variables that may compose the QOL construct; variables such as family functioning, depression, and social support would be better assessed through multiple measures. This study suggests that future investigation of QOL in children with headaches could help to optimize evaluation and management of this common health problem. Such investigation should incorporate general measures of QOL and disease-specific measures (eg, Pediatric Migraine Disability Assessment [PedMIDAS]),⁹ as this combination approach to the assessment of QOL is becoming the standard for the field.^13,29,30

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Headaches are common in children and adolescents. This report validates the use of PedsQL 4.0 in migraine patients who are aged 2 to 18. It further demonstrates that headaches in children and adolescents affect QOL at levels equivalent to or greater than other chronic illnesses of childhood—illnesses that are often considered more severe and debilitating than "having headaches." Pediatricians often see children and adolescents with migraine. Knowing that the headaches can significantly affect QOL could lead to better headache evaluation and management for this very common condition of childhood.

	ACKNOWLEDGMENTS

 
We thank the following individuals for assisting with subject recruitment and data management: Anna-Liisa Vockell, RN, MSN, CPNP; Susan LeCates, RN, MSN, CFNP; Marielle Kabbouche, MD; Ann Seger, RN; Molly Heidemann; and Racquel Henry (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH). We also thank Jim Varni, PhD (Children’s Hospital and Health Center, San Diego, CA), for feedback during the preparation of this manuscript.

	FOOTNOTES

 
Received for publication Dec 4, 2002; Accepted Feb 20, 2003.

Reprint requests to (S.W.P.) Headache Center, Division of Psychology, Cincinnati Children’s Hospital, MLC: D-3015, 3333 Burnet Ave, Cincinnati, OH 45229-3039. E-mail: Scott.Powers{at}cchmc.org

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Bille B. Migraine in school children. Acta Paediatr.1962; 51 :16 –151
2. Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ.1994; 309 :765 –769[Abstract/Free Full Text]
3. Split W, Neuman W. Epidemiology of migraine among students from randomly selected secondary schools in Lodz. Headache.1999; 39 :494 –501[CrossRef][ISI][Medline]
4. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia.1988; 8(suppl 7) :1 –96
5. deGrauw TJ, Hershey AD, Powers SW, Bentti AL. Diagnosis of migraine in children attending a pediatric headache clinic. Headache.1999; 39 :481 –485[CrossRef][ISI][Medline]
6. Winner P, Martinez W, Mate L, Bello, L. Classification of pediatric migraine: proposed revisions to the IHS criteria. Headache.1995; 35 :407 –410[CrossRef][ISI][Medline]
7. Winner P, Wasiewski W, Gladstein J, Linder S. Multicenter prospective evaluation of proposed pediatric migraine revisions to the IHS criteria. Pediatric Headache Committee of the American Association for the Study of Headache. Headache.1997; 36 :545 –548
8. Seshia SS, Wolstein JR, Adams C, Booth FA, Reggin JD. International headache society criteria and childhood headache. Dev Med Child Neurol.1994; 36 :419 –428[Medline]
9. Hershey AD, Powers SW, Vockell AL, LeCates S, Kabbouche MA, Maynard MK. PedMIDAS: development of a questionnaire to assess disability of migraines in children. Neurology.2001; 57 :2034 –2039[Abstract/Free Full Text]
10. Bandell-Hoekstra I, Abu-Saad HH, Passchier J, Knipschild P. Recurrent headache, coping, and quality of life in children: a review. Headache.2000; 40 :357 –370[CrossRef][ISI][Medline]
11. World Health Organization. Constitution of the World Health Organization Basic Documents. Geneva, Switzerland: World Health Organization; 1948
12. Varni JW, Seid M, Rode CA. The PedsQL: measurement model for the pediatric quality of life inventory. Med Care.1999; 37 :126 –139[CrossRef][ISI][Medline]
13. Eiser C, Morse R. A review of measures of quality of life for children with chronic illness. Arch Dis Child.2001; 84 :205 –211[Abstract/Free Full Text]
14. Testa MA, Simonson DC. Assessment of quality-of-life outcomes. N Engl J Med.1996; 334 :835 –840[Free Full Text]
15. Seid M, Sadler B, Peddecors K, Kurtin P. Accountability: Protecting the Well Being of America’s Children and Those Who Care for Them. Alexandria, VA: National Association of Children’s Hospital and Related Institutions; 1997
16. Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care.2001; 39 :800 –812[CrossRef][ISI][Medline]
17. Engstrom I. Mental health and psychological functioning in children and adolescents with inflammatory bowel disease: a comparison with children having other chronic illnesses and with healthy children. J Child Psychol Psychiatry.1992; 33 :563 –582[CrossRef][ISI][Medline]
18. Langeveld JH, Koot HM, Loonen MC, Hazebroek-Kampschreur AA, Passchier J. A quality of life instrument for adolescents with chronic headache. Cephalalgia.1996; 16 :183 –196[CrossRef][ISI][Medline]
19. Hershey AD, Powers SW, Bentti AL, LeCates S, deGrauw TJ. Characterization of chronic daily headaches in children in a multidisciplinary headache center. Neurology.2001; 56 :1032 –1037[Abstract/Free Full Text]
20. Hamalainen M, Hoppu K, Valkeila E, Santavuori P. Ibuprofen or acetaminophen for the acute treatment of migraine in children: a double-blind, randomized, placebo-controlled, cross-over study. Neurology.1997; 48 :103 –107[Abstract/Free Full Text]
21. Winner P, Lewis D, Visser H, Jiang K, Ahrens S, Evans J. Rizatriptan 5 mg for the acute treatment of migraine in adolescents: a randomized, double-blind, placebo-controlled study. Headache.2002; 42 :49 –55[CrossRef][Medline]
22. Winner P, Rothner A, Saper J, et al. A randomized, double-blind, placebo-controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics.2000; 106 :989 –997[Abstract/Free Full Text]
23. Ueberall M, Wenzel D. Intranasal sumatriptan for the acute treatment of migraine in children. Neurology.1999; 52 :1507 –1510[Abstract/Free Full Text]
24. Hershey AD, Powers SW, LeCates S, Bentti A-L. Effectiveness of nasal sumatriptan in 5- to 12-year-old children. Headache.2001; 41 :693 –697[CrossRef][ISI][Medline]
25. Hershey AD, Powers SW, Bentti AL, Degrauw TJ. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. Headache.2000; 40 :539 –549[CrossRef][ISI][Medline]
26. Hershey AD, Powers SW, Vockell A-L, LeCates S, Kabbouche M. Effectiveness of topiramate in the prevention of childhood headaches. Headache.2002; 42 :810 –818[CrossRef][ISI][Medline]
27. Powers SW, Mitchell MJ, Byars KC, Bentti AL, LeCates SL, Hershey AD. A pilot study of one-session biofeedback training in pediatric headache. Neurology.2001; 56 :133[Free Full Text]
28. Powers SW, Hershey AD. Biofeedback for childhood migraine. In: Maria BL, ed. Current Management in Child Neurology. 2nd ed. Lewiston, NY: BC Decker; 2002:83–85
29. Varni JW, Burwinkle TM, Katz ER, Meeske K, Dickinson P. The PedsQL in pediatric cancer: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module. Cancer.2002; 94 :2090 –2106[CrossRef][ISI][Medline]
30. Varni JW, Seid M, Smith KT, Burwinkle T, Brown J, Szer IS. The PedsQL in pediatric rheumatology: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory Generic Core Scales and Rheumatology Module. Arthritis Rheum.2002; 46 :714 –725[CrossRef][ISI][Medline]
31. Varni JW, Seid M, Knight T, Uzark K, Szer I. The PedsQL^TM 4.0 Generic Core Scales: sensitivity, responsiveness, and impact on clinical decision-making. J Behav Med.2002; 25 :175 –193[CrossRef][ISI][Medline]
32. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology.1996; 47 :871 –875[Abstract/Free Full Text]
33. Cronbach L. Coefficient alpha and the internal structure of tests. Psychometrika.1951; 16 :297 –334[CrossRef][ISI]
34. Cohen J. A power primer. Psychol Bull.1992; 112 :155 –159[CrossRef][ISI]
35. Osterhaus JT, Townsend RJ, Gandek B, Ware JE Jr. Measuring the functional status and well-being of patients with migraine headache. Headache.1994; 34 :337 –343[CrossRef][ISI][Medline]

This article has been cited by other articles:

				P. Brna, K. Gordon, and J. Dooley Canadian Adolescents With Migraine: Impaired Health-Related Quality of Life J Child Neurol, January 1, 2008; 23(1): 39 - 43. [Abstract] [PDF]

				J. E. A. Staals, K. P. J. Braun, K. E. H. van Loo-Maurus, and J. S. H. Vles Stenting for Coarctation of the Aorta Precipitating Migraine With Aura J Child Neurol, March 1, 2007; 22(3): 321 - 323. [Abstract] [PDF]

				D. W. Lewis Pediatric Migraine Pediatr. Rev., February 1, 2007; 28(2): 43 - 53. [Full Text] [PDF]

				M. Connelly and M. A. Rapoff Assessing Health-Related Quality of Life in Children with Recurrent Headache: Reliability and Validity of the PedsQLTM 4.0 in a Pediatric Headache Sample J. Pediatr. Psychol., August 1, 2006; 31(7): 698 - 702. [Abstract] [Full Text] [PDF]

				R. Riddle, C. N. Ryser, A. A. Morton, J. D. Sampson, R. H. Browne, M. G. Punaro, and R. J. Gatchel The Impact on Health-Related Quality of Life from Non-Steroidal Anti-Inflammatory Drugs, Methotrexate, or Steroids in Treatment for Juvenile Idiopathic Arthritis J. Pediatr. Psychol., April 1, 2006; 31(3): 262 - 271. [Abstract] [Full Text] [PDF]

				F. Andrasik and M. S. Schwartz Behavioral Assessment and Treatment of Pediatric Headache Behav Modif, January 1, 2006; 30(1): 93 - 113. [Abstract] [PDF]

				A. D. Hershey and P. K. Winner Pediatric Migraine: Recognition and Treatment J Am Osteopath Assoc, April 1, 2005; 105(4_suppl): 2S - 8S. [Abstract] [Full Text] [PDF]

				S. Wallace Migraines often a missed diagnosis in children AAP News, March 1, 2004; 24(3): 122 - 122. [Full Text] [PDF]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Powers, S. W. Articles by Hershey, A. D. Search for Related Content PubMed PubMed Citation Articles by Powers, S. W. Articles by Hershey, A. D. Related Collections Neurology & Psychiatry

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2003 American Academy of Pediatrics. All rights reserved.