Characterizing sleep, headache-related disability, and psychological functioning among adolescents with continuous...

Youth with continuous headache are understudied, are presumed to be more psychosocially complex and impaired than youth with remitting headache presentations, and are at risk for poor clinical outcomes. Given links between sleep and pain, characterizing sleep among youth with continuous headache may inform intervention targets. This study was undertaken to describe the sleep characteristics of a sample of treatment-seeking adolescents with continuous headache and contextualize these data by comparing the sleep-wake behavior of youth with continuous headache to youth with noncontinuous headaches and healthy teens. We hypothesized that youth with continuous headache would have worse sleep quality than youth with noncontinuous headaches and healthy adolescents. Secondary analyses tested associations between sleep and psychosocial functioning among youth with continuous headache.

This cross-sectional observational study focused on a pilot sample of 26 adolescents (aged 12-17 years) who reported continuous headache for at least 1 month prior to presenting for interdisciplinary specialty care. Study enrollment ran from October 2019 to August 2020. Data at initial study visits were collected regarding participant/family demographics, headache characteristics and diagnosis (using International Classification of Headache Disorders, 3rd edition criteria), and headache-related disability (as measured using the PedMIDAS). Participants also completed questionnaires regarding their sleep behavior (Adolescent Sleep Wake Scale [ASWS]), insomnia symptoms (Pediatric Insomnia Severity Index), sleep hygiene (Adolescent Sleep Hygiene Scale), and mood/anxiety symptoms (Patient-Report Outcome Measure Information System, Anxiety and Depressive Symptoms scales). Participants' scores on sleep measures were described in the context of published clinical cutoffs. Scores on the ASWS were also compared to those of an age-, sex-, and race-matched sample of 26 youth with noncontinuous headaches, and published norms for adolescents without chronic pain. Finally, we examined associations among sleep variables, PedMIDAS scores, and psychological symptoms.

More than 60% of youth with continuous headache reported clinically elevated insomnia symptoms, and more than one third reported clinically meaningful difficulties with sleep hygiene. ASWS scores were not significantly different between participants with continuous headaches and youth with noncontinuous headaches due to migraine. ASWS "falling asleep and re-initiating sleep" (mean = 4.1 [SD = 1.1], normative mean = 4.7, t [25] = -3.1, p = 0.005) and "return to wakefulness" (mean = 2.1 [SD = 1.1], normative mean = 3.3, t [25] = -5.5, p < 0.001) subscale scores were worse than those of youth without chronic pain conditions. Insomnia symptoms and sleep hygiene difficulties were significantly associated with youth anxiety symptoms. ASWS scores on the "falling asleep and re-initiating sleep" subscale were associated with youth depressive symptoms.

High rates of clinically meaningful sleep difficulties were identified in youth with continuous headache. Although sleep-wake difficulties were not significantly different from a comparison sample of youth with noncontinuous headaches, future research is needed to examine the role of sleep in long-term clinical outcomes for youth with high-frequency headache conditions like continuous headache. Screening and targeted interventions focused on sleep difficulties should be incorporated into treatment for these youth.