Pain Severity and Psychosocial Quality of Life in Adolescents with Migraine and Tension-Type Headache: Mediation by Perceived Expressed Emotion and Self-Esteem

Aims: To investigate perceived expressed emotion (EE) and self-esteem in adolescents with primary headaches and to assess the psychologic factors, especially perceived EE, that may play a mediating role in the relationship between pain severity and psychosocial quality of life (QoL). Methods: The sample of this single-center cross-sectional case-control study consisted of 102 adolescents with migraine without aura, 36 adolescents with tension-type headache (TTH), 62 age- and sex-matched healthy adolescents, and their parents. Perceived EE was evaluated with the Shortened Level of Expressed Emotion Scale (SLEES). The Rosenberg Self-Esteem Scale (RSS) was used to assess the self-esteem of the participants. Results: There were significant differences in both SLEES (F [2.199] = 7.913, P < .001) and RSS (F [2.199] = 8.138, P < .001) scores between the groups. When the two groups were compared in terms of SLEES score, adolescents with migraine and TTH had significantly higher levels of perceived EE and lower levels of self-esteem than their healthy peers. In mediation analyses, RSS and SLEES scores were found to be partial mediating factors in the relationship between pain severity and psychosocial QoL. Conclusion: Adolescents with migraine and TTH had higher perceived EE and lower self-esteem than their healthy peers. The most important result of this study was the demonstration that self-esteem and perceived EE can be two factors that play a mediating role in the relationship between headache and psychosocial QoL.

adolescents; migraine; perceived expressed emotion; self-esteem; tension-type headache

1. Bigal ME, Lipton RB. The epidemiology, burden, and comorbidities of migraine. Neurol Clin 2009;27:321–334.

2. Abu Bakar N, Tanprawate S, Lambru G, Torkamani M, Jahanshahi M, Matharu M. Quality of life in primary headache disorders: A review. Cephalalgia 2016;36:67–91.

3. Öztop DB, Tadelen B, Poyrazo-Lu HG, et al. Assessment of psychopathology and quality of life in children and adolescents with migraine. J Child Neurol 2016;31:837–842.

4. O’Brien HL, Slater SK. Comorbid psychological conditions in pediatric headache. Semin Pediatr Neurol 2016;23:68–70.

5. Gordon KE, Dooley JM, Wood EP. Self-reported headache frequency and features associated with frequent headaches in Canadian young adolescents. Headache 2004;44:555–561.

6. Stanford EA, Chambers CT, Biesanz JC, Chen E. The prevalence, trajectories and predictors of adolescent recurrent pain among adolescents: A population-based approach. Pain 2008;138:11–21.

7. Talarska D, Zgorzalewicz-Stachowiak M. The influence of selected factors on the quality of life of children with headaches. Adv Med Sci 2007;52(suppl 1):123–125.

8. Powers SW, Patton SR, Hommel KA, Hershey AD. Quality of life in paediatric migraine: Characterization of age related effects using PedsQL 4.0. Cephalalgia 2004;24:120–127.

9. Strine TW, Okoro CA, McGuire LC, Balluz LS. The associations among childhood headaches, emotional and behavioral difficulties, and health care use. Pediatrics 2006;117:1728–1735.

10. Siniatchkin M, Kirsch E, Arslan S, Stegemann S, Gerber W, Stephani U. Migraine and asthma in childhood: Evidence for specific asymmetric parent-child interactions in migraine and asthma families. Cephalalgia 2003;23:790–802.

11. Asarnow JR, Tompson M, Hamilton EB, Goldstein MJ, Guthrie D. Family-expressed emotion, childhood onset depression, and childhood-onset schizophrenia spectrum disorders: Is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression? J Abnorm Child Psychol 1994;22:129–146.

12. Brown GW, Monck EM, Carstairs GM, Wing JK. Influence of family life on the course of schizophrenic illness. Br J Prev Soc Med 1962;16:55–68.

13. Peris TS, Miklowitz DJ. Parental expressed emotion and youth psychopathology: New directions for an old construct. Child Psychiatry Hum Dev 2015;46:863–873.

14. Eray S, Uçar HN, Çetinkaya F, Eren E, Vural P. The relationship between perceived family climate and glycemic control in type 1 diabetes mellitus adolescent patients. J Clin Res Pediatr Endocrinol 2017;9:253–259.

15. Çolpan M, Eray S, Eren E, Vural AP. Perceived expressed emotion, emotional and behavioral problems and self esteem in obese adolescents: A case-control study. J Clin Res Pediatr Endocrinol 2018;10:357–363.

16. Uçar HN, Aydin Köker S, Tekin U. Irritability and perceived expressed emotion in adolescents with iron deficiency and iron deficiency anemia: A case-control study. J Pediatr Hematol Oncol 2020;42:403–409.

17. Ballús-Creus C, Rangel MV, Peñarroya A, Pérez J, Leff J. Expressed emotion among relatives of chronic pain patients, the interaction between relatives’ behaviours and patients’ pain experience. Int J Soc Psychiatry 2014;60:197–205.

18. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 2009;41:1149–1160.

19. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629–808.

20. Aydin M, Bozdag S, Kabakus N. Headaches in childhood [in Turkish]. Türkiye Klinikleri J Med Sci 2010;30:1928–1936.

21. Goodman R. The Strengths and Difficulties Questionnaire: A research note. J Child Psychol Psychiatry 1997;38:581–586.

22. Nelis SM, Rae G, Liddell C. The level of expressed emotion scale: A useful measure of expressed emotion in adolescents? J Adolesc 2011;34:311–318.

23. Rosenberg M. Rosenberg Self-Esteem Scale (RSE). Acceptance and commitment therapy measures package 1965;18:52–61.

24. Varni JW, Seid M, Rode CA. The PedsQL: Measurement model for the pediatric quality of life inventory. Med Care 1999:126–139.

25. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983;17:45–56.

26. Güvenir T, Özbek A, Baykara B, Arkar H, Sentürk B, ¡ncekas  S. Psychometric properties of the Turkish version of the Strengths and Difficulties Questionnaire (SDQ). Cocuk ve Genclik Ruh Sagligi Dergisi 2008;15:65–74.

27. Vural P, Sigirli D, Eray S, Ercan I, Kiliç EZ. The reliability and validity study of Shortened Level of Expressed Emotion Scale in adolescents. Turkiye Klinikleri J Med Sci 2013;33:191–199.

28. Çuhadarog˘lu F. Self-esteem in adolescents [in Turkish] [unpublished thesis]. Ankara, Turkey: Hacettepe University Faculty of Medicine, Department of Psychiatry, 1986.

29. Memik NÇ, Ag˘aog˘lu B, Coskun A, Üneri O, Karakaya I. The validity and reliability of the Turkish Pediatric Quality of Life Inventory for children 13–18 years old (in Turkish). Turk Psikiyatri Derg 2007;18:353–363.

30. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 2008;40:879–891.

31. Marusic A, Bhugra D. Editorial: One health only. Int J Soc Psychiatry 2008;54:483–485.

32. Roy R. Marital and family issues in patients with chronic pain. Psychother Psychosom 1982;37:1–12.

33. Painter JR, Seres JL, Newman RI. Assessing benefits of the pain center: Why some patients regress. Pain 1980;8:101–113.

34. Uçar HN, Aydin Köker S, Tekin U. Irritability and perceived expressed emotion in adolescents with iron deficiency and iron deficiency anemia: A case-control study. J Pediatr Hematol Oncol 2020;42:403–409.

35. Pinquart M, Shen Y. Behavior problems in children and adolescents with chronic physical illness: A meta analysis. J Pediatr Psychol 2011;36:1003–1016.

36. Pakalnis A, Butz C, Splaingard D, Kring D, Fong J. Emotional problems and prevalence of medication overuse in pediatric chronic daily headache. J Child Neurol 2007;22:1356–1359.

37. Machnes-Maayan D, Elazar M, Apter A, Zeharia A, Krispin O, Eidlitz-Markus T. Screening for psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain. Pediatr Neurol 2014;50:49–56.

38. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in US adolescents: Results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2011;50:32–45.

39. Kaynak Key FN, Donmez S, Tuzun U. Epidemiological and clinical characteristics with psychosocial aspects of tension- type headache in Turkish college students. Cephalalgia 2004;24:669–674.

40. Albers L, Straube A, Landgraf MN, Filippopulos F, Heinen F, von Kries R. Migraine and tension type headache in adolescents at grammar school in Germany–burden of disease and health care utilization. J Headache Pain 2015;16:534.

41. Bruijn J, Arts WF, Duivenvoorden H, Dijkstra N, Raat H, Passchier J. Quality of life in children with primary headache in a general hospital. Cephalalgia 2009;29:624–630.

42. Akça ÖF, Özkan M, Teber ST. Anxiety sensitivity and dissociative experiences in adolescents with migraine and tension type headache [in Turkish]. Anadolu Psikiyatri Dergisi 2013;14:161–166.

43. Esposito M, Gallai B, Parisi L, et al. Self-concept evaluation and migraine without aura in childhood. Neuropsychiatr Dis Treat 2013;9:1061–1066.

44. Tarantino S, De Ranieri C, Dionisi C, et al. Role of the attachment style in determining the association between headache features and psychological symptoms in migraine children and adolescents. An analytical observational case–control study. Headache 2017;57:266–275.

45. Rhee H. Prevalence and predictors of headaches in US adolescents. Headache 2000;40:528–538.

46. Rocha-Filho PA, Santos PV. Headaches, quality of life, and academic performance in schoolchildren and adolescents. Headache 2014;54:1194–1202.

47. Sowislo JF, Orth U. Does low self-esteem predict depression and anxiety? A meta -analysis of longitudinal studies. Psychol Bull 2013;139:213–240.