Introduction

Studies in children have shown that obesity is a risk factor in terms of migraine frequency and severity.1 Rural children have a 26% greater odds of obesity, compared with urban children.2 Also, lower socioeconomic status is associated with higher pain prevalence, especially for childhood and adolescent headache.3 Comorbidities associated with childhood and adolescent obesity include sleep disorders, depression, as well as anxiety, and each of these overlap with migraine. Additionally, reported neurobiological links between migraine and regulation of body weight support the importance of monitoring body mass index (BMI) in rural pediatric patients with migraine.

The association between triggering of migraine and premonitory symptoms (i.e., food cravings, fatigue, and difficulty in sleeping) is based on the role of the hypothalamus in modulation of pain, control of appetite, and regulation of sleep.4 Relationships between hypothalamic peptides (orexin), amino acid neuropeptides (CGRP), adipocytokines (adiponectin and leptin), and neurotransmitters (serotonin) with migraine and satiety (feeling of fullness and suppression of hunger) are examples of the neurobiological associations influencing obesity and migraine.5

Obesity is recognized as one of the most important risk factors for obstructive sleep apnea syndrome (OSAS) in the pediatric population. OSAS is observed in the obese population due to several mechanisms such as adenotonsillar hypertrophy, reduced lung volume associated with fat deposition around the abdomen and thorax, and increased airway collapsibility due to presence of fat at the level of the pharyngeal soft tissue.6 Subsequently, pediatric migraine is a common comorbidity with OSAS due to disrupted sleep, hypercapnia, hypoxemia, elevation in systemic blood pressure, and elevated intracranial pressure.7

Adolescent headache is influenced by unhealthy lifestyle behaviors and depressed adolescents typically report unhealthier eating habits (processed foods, overeating, and binge eating), lower amounts of physical activity, higher sedentary behaviors, and greater screen time as compared with adolescents with no or lower depressive symptoms.8 Anxiety has been reported as the most prevalent psychiatric comorbidity in children with tension-type headache and migraines.9 Anxiety occurs more frequently in obese people when compared with those of normal weight.10 A bidirectional relationship between obesity and anxiety, as well as depression and anxiety, has been reported.8 11 Finally, undiagnosed depression and anxiety disorders increase the chronic nature of headaches, make headaches less responsive to treatment, and predict persistence of headache-related disability.

The above neurobiological links influencing obesity and migraine, as well as overlapping comorbidities, demonstrate the importance of monitoring BMI in rural children and adolescents presenting with headache. Migraine and obesity are considered public health problems which negatively impact quality of life.12 Given the prevalence of obesity in rural children and adolescents, treatment of migraine alone may not only lead to poor headache outcomes but also a failure to address weight concerns and other comorbidities. The purpose of this study is to (1) evaluate BMI in children and adolescents with migraine in a rural pediatric population, (2) evaluate the occurrence of comorbidities (OSAS, depression, and anxiety) in obese versus nonobese children and adolescents with migraine in a rural pediatric population, (3) determine if there is a significant difference in the presence of comorbidities between obese versus nonobese children and adolescents with migraine.

Methods

Results

Demographics and comorbidities of obese and nonobese children and adolescents are presented in Table 1. Ethnicity comprised primarily white Caucasian (94.9%), followed by Black (1.5%) children and adolescents. Participants ranged in age from 7 to 17 years old, with the mean age being 12.6 (SD = 3.2) years. The sample was 61.4% female. Age was categorized by 7 to 9 years (21.8%), 10 to 12 year (24.9%), and 13 to 17 year (53.4%). There was no significant difference between the children and adolescents with migraine who were categorized as obese versus not obese in terms of gender (p = 0.8587), age (p = 0.1703), or race (p = 0.7655). Approximately 26.4% (n = 171) of the children and adolescents diagnosed with migraine (n = 648) met the criteria for being obese. Comorbidities evaluated included OSAS, depression, and anxiety. OSAS was diagnosed in 12.5% (n = 81) of the children and adolescents with migraine. Specifically, among the obese migraineurs, 20% (n = 34) had obstructive sleep apnea, whereas among the nonobese migraineurs, only 9.9% had obstructive sleep apnea (p = 0.0007). There was no significant difference in anxiety or depression between the children and adolescents with migraine who were classified as obese or nonobese.

Descriptive statistics of BMI and weight status between male and female are presented in Table 2. The prevalence of obesity among the children and adolescents with migraine was 26.4%, with mean BMI 30.6 kg/m² (SD = 6.5), ranging from 20.0 to 58.5 kg/m². One-fifth of these migraineurs were overweight, with mean BMI 23.1 kg/m² (SD = 3.1), ranging from 17.4 to 29.4 kg/m². The distribution of weight categories between male and female was not statistically significantly different.

When looking at the number of comorbidities, as shown in Table 3, there was a significant difference in the mean number of comorbidities between those migraineurs who were classified as obese 0.75 (SD = 0.93) and those who were nonobese 0.56 (SD = 0.75; p = 0.015). The analyses of number of comorbidities suggest that although the proportion of cases with at least one comorbidity is similar to those without comorbidity among obese and nonobese migraineurs (p = 0.2136), the obese children and adolescents have a statistically and significantly higher percentage of at least two comorbidities (compared with those with one comorbidity) and three comorbidities (compared with those with two comorbidities) than nonobese individuals (p = 0.0098 and 0.0112, respectively).

Discussion

This is the first study to evaluate the association between obesity, migraine, and overlapping comorbidities in children and adolescents in rural West Virginia. The prevalence of adolescent obesity is 20.6% in the United States15 and approximately 47% of children and adolescents in rural West Virginia are either overweight or obese.16 In our sample (n = 648), almost half of the children and adolescents with migraine were overweight or obese and, of these, 26% were obese (Table 2).

There were no significant differences in children and adolescents with migraines who were classified as obese versus not obese in terms of gender, age, or race (Table 1). In one of the largest studies examining weight diagnosis in a pediatric population, researchers found that increasing age was associated with an increasing prevalence of children with a BMI ≥85%.17 However, these findings may be different from the current study due to the age range which included children 2 to 12 years of age as compared with age of this current study ranged between 7 and 17 years. For example, in a national U.S. data study, the prevalence of obesity among preschool-aged children (2–5 years; 13.9%) was lower than among school-aged children (6–11 years; 18.4%) and adolescents (12–19 years; 20.6%).15 In the same study, researchers reported no statistically significant difference in the prevalence of obesity between male and female overall or by age group.15 Also, there were no statistically significant differences in the prevalence of obesity between male and female by race and Hispanic origin.15 Lack of reported findings with Hispanic and non-Hispanic black youth in the current study is associated with a lack of diversity in rural WV as evidenced by a racial/ethnic mix of 92% White, 4% Black, 0% Native American, 1% Asian, and 0% other with 1% Hispanic.18

OSAS occurs more frequently among children with obesity and is also a comorbidity with migraine. The prevalence of OSA has been reported at 44.6 to 56% in the obese pediatric population19 20 and 40 to 56.6% in children with migraine.21 22 The prevalence of this study was lower as 12.5% of the children and adolescents with migraine had OSAS and approximately 20% of those with OSAS were obese. These findings may be due to missed diagnoses of OSAS in this migraine population, as there is a general acknowledgment that the prevalence of OSAS is underestimated in children and adolescents.23 Undiagnosed OSAS can lead to hypertension; cardiovascular disease; metabolic disorders; obesity; neuropsychiatric, developmental and behavioral issues; poor school performance; and daytime sleepiness.23 Also, undiagnosed sleep disturbances are considered risk factors for more frequent and severe migraines, poorer headache prognosis, as well as headache chronification.24

There was no significant difference in anxiety or depression between the children and adolescents with migraine who were classified as obese or nonobese (Table 1). However, approximately 40% of obese migraineurs and 34% of nonobese migraineurs were diagnosed with either depression or anxiety. Previous studies have reported a prevalence of at least one psychiatric disorder among pediatric patients with headache ranging from 29.6 to 65.5%.9 25 These findings underscore the importance of monitoring for mental health issues when treating pediatric headache. Psychological consequences of childhood obesity include negative self-body image, weight-biased peer interactions, poor school experiences, and medical comorbidities which all interfere with the psychosocial development of a child.26 Given the bidirectional relationships, undiagnosed or untreated psychiatric comorbidities contribute to both the onset and chronification of primary headaches.11

There was a significant difference in the mean number of comorbidities between those migraineurs who were classified as obese versus those who were nonobese (p = 0.015; Table 3). The mean number of comorbidities was higher in the children and adolescents with migraine that are obese versus those who are nonobese. Approximately 24% of the obese migraineurs had at least two comorbidities whereas only 14.3% of the nonobese migraineurs had at least two comorbidities. Thus, 24% of the children and adolescents were diagnosed with obesity, migraine, and two (e.g., OSAS + depression, OSAS + anxiety, or anxiety + depression) or more comorbidities. Approximately 4.7% of the obese migraineurs had three comorbidities compared with 0.6% of the nonobese migraineurs. Therefore, 4.7% of the children and adolescents were diagnosed with obesity, migraine, depression, anxiety, and OSAS.

These findings demonstrate the importance of understanding the neurobiological links between migraine and obesity, as well as overlapping comorbidities. A thorough assessment to determine the presence of OSAS, depression, and anxiety can alert health care providers of the multifactorial contributors to migraine in the obese adolescent. Recognition and treatment of these overlapping comorbidities will optimize present, as well as future health outcomes in the pediatric migraine population.

Strengths and Limitations

Strengths of this study include large sample size and a geographically distinct rural clinic. Diagnosis of migraine was determined by headache specialists using classification standards.13

BMI was calculated based on adolescent height and weight measured by clinic staff and recorded in the EMR as opposed to self-reported heights and weights which may not be as accurate. Limitations include use of a cross-sectional study design, where results are correlative; thus, causality cannot be addressed. The researchers relied on diagnosis codes to determine the occurrence of comorbidities and were not able to evaluate depression and anxiety using valid and reliable instruments nor do the researchers know if all the adolescents were appropriately evaluated for mental health or sleep disorders. There may be the potential for under- or overreporting of the comorbidities. A variety of medications may impact headache, weight, and mood and this review did not collect data on medications. Also, use of a clinic-based sample limits generalizability of our findings.

Conclusion

The above findings underscore the importance of monitoring BMI in rural children and adolescents with migraine, as well as assessing overlapping comorbidities. Poor headache management during childhood leads to persistent headache into adulthood27 and overweight children and adolescents are more likely to be overweight adults with poor physical and mental health.28 When evaluating rural children and adolescents for primary headache, treatment can no longer be about migraine alone and must involve a holistic approach that includes evaluation of BMI. Given the association with migraine and overlapping comorbidities, obesity has been reported as a modifiable risk factor for migraine and weight loss as a feasible treatment option for improving headache outcomes.29 Childhood and adolescent primary headache is influenced by unhealthy lifestyle behaviors30 31 and addressing both mental health and obesity through a healthy lifestyle approach is also considered to be feasible and effective.26 Treatment of obese pediatric migraineurs should be targeted to therapies for restoring a healthy bodyweight that includes exercise, diet, and behavioral interventions for weight loss. Further research is needed for evaluating weight management strategies that provide significant results in both migraine and BMI outcomes for obese rural adolescents.