Because headache has a significant impact on a child’s quality of life, affecting school performance and physical and social activities, recent investigations have begun to question the potential interaction with metacognitive processes that are developing during this same period.
In 1979, Flavell of Stanford University in California first described metacognition, including the cognitive processes, beliefs, and knowledge that combine to allow for understanding that one’s thoughts are unique, facilitate strategic planning and goal-setting, and the ability to read and assess one’s own mental state.
Metacognition develops throughout childhood to create evolving awareness of a child’s own thoughts, beliefs, and emotions, along with a sense that they can monitor and control these processes. He elaborated on this concept with theory of mind (ToM), which described the further development of this ability to empathetically apply self-knowledge to someone else’s state of mind in order to understand and predict their behavior. These are 2 critical developmental abilities that color a child’s perception of themselves and the world, but also influence their experience of that world, including pain.
Recent evidence has pointed to potential impairment of both metacognitive processes and ToM being associated with migraine in children. Patterns of impaired ToM have been seen with epilepsy, and in 1 study that evaluated children with headache and epilepsy. Various studies have shown that neurophysiologic functions including psychomotor ability and cognitive domains of information processing and attention are compromised in adults with headache.
A number of independent studies have indicated some involvement of organizational thinking related to metacognition in various neurologic conditions. A parental report on 75 children with Chiari malformation type 1, a developmental structural abnormality of the cerebellum in which brain tissue from the back of the brain protrudes into the spinal canal, found that 69% of pediatric patients had headaches as a complication. An overlapping one-third of participants in the study also demonstrated higher than normal impairment of executive function, particularly with regard to working memory.
Metacognition is strongly influenced by psychological factors, and chronic pain disorders are often accompanied by comorbid medical and psychological conditions. Children with headache can have comorbidities ranging from allergies, asthma, and sleep disorders to anxiety and depression.1 A large-scale Norwegian population-based study conducted in nearly 5000 adolescents from 1995 to 1997 found a higher incidence of anxiety and depression in participants with headache than participants without.5 The same study also reported a greater degree of attention deficits associated with migraine and nonclassifiable headache in patients aged 15 to 17 years.
Despite the overlaps that occur during this developmental period between headache and metacognition, direct evidence of a link has been lacking. Metacognitive processes and particularly ToM have been evaluated in many psychiatric diseases, but rarely in relation to migraine, and not at all in children.
Costa-Silva, of the Federal University of Minas Gerais, Belo Horizonte, Brazil, et al reported in 2016 that cognitive dysfunction is common in adolescents with headache, particularly adolescents with migraine. They found that adolescents with a migraine diagnosis were more readily distracted from learning tasks and demonstrated greater impairment of verbal memory, recognition, and recall than a control group without headache (n=28 and n=26, respectively).6 “Since the cognitive deficits found in adolescents with migraine are similar to those reported in adults with migraine, cognitive impairment seems to persist throughout life,” they concluded.
Executive function and other facets of metacognition develop throughout childhood and this process continues into early adulthood. Mahy, of the University of Oregon in Eugene, and colleagues, proposed that maturity of the brain in the development of executive function is “predicted to influence ToM maturity.” A similar evaluation by Luna, of the University of Pittsburgh in Pennsylvania, et al suggested that they are linked and vulnerable during the same adolescent life stage, particularly to the onset of mental conditions, such as depression and anxiety.
As tenuous connections have been made between migraine, depression, and anxiety in adolescents, researchers have also focused their investigations on the impact of pain on metacognition. “Their results suggest that psychological suffering due to body sickness can affect some mental representation and way to think,” according to a 2017 review by Faedda, a mood disorders specialist, and colleagues. The investigators suggested that the combined elements of headache and psychiatric and neurologic comorbidities may influence the ongoing development of metacognitive processes. They also theorized that mindfulness and cognitive behavioral therapy may significantly improve headaches and reduce the risks for psychiatric or behavioral comorbidities that often accompany chronic headache in children.
The Faedda review pointed to cognitive behavioral therapies as promoting improved metacognition by reducing rumination and worry, while biofeedback and relaxation skills have demonstrated reductions in headache frequency and pain. Studies of pain acceptance and pain self-efficacy in children have demonstrated direct correlations with depression, disability, and school functionality. Improvement in these features was associated with better quality of life and recovery from pain.
Faedda N, Natalucci G, Calderoni D, Cerutti R, Verdecchia P, Guidetti V. Metacognition and Headache: Which Is the Role in Childhood and Adolescence? Front Neurol. 2017 Dec 14;8:650.
Headache, in particular migraine, is one of the most frequent neurological symptoms in children and adolescents and it affects about 60% of children and adolescents all over the world. Headache can affect several areas of child's functioning, such as school, physical activities, peer, and family relationship. The global and severe burden of this disease requires a multidisciplinary strategy and an effective treatment addressed all of the patient's needs and based on cutting-edge scientific research. In recent years, research has focused on cognitive factors specifically in functions called metacognitive processes. Metacognition can be defined as the knowledge, beliefs, and cognitive processes involved in monitoring, control, and assessment of cognition. Metacognition seems to be closely related to the ability of theory of mind, the ability to infer, and reason about the mental states of other people in order to predict and explain own behavior. Recent studies found a relationship between metacognitive skills and anxiety, depression, motivation, academic performance, human social interactions, and stress symptoms. This relationship is very interesting for headache treatment, because these factors are the most commonly reported triggers in this disorder and there is a high comorbidity with anxiety and depression in children and adolescents with headache. So, headache and these comorbidities, in particular anxiety and depression, may have in common persistent and maladaptive patterns of thinking which are related to maladaptive metacognitive beliefs. Further research should assess metacognitive processes of children and adolescents with headache in order to increase their ability to control their own cognitive processes and consequently monitor factors which may trigger the attacks.
Natalucci G, Faedda N, Quinzi A, Fegatelli DA, Fazi M, Verdecchia P, Sabatello U, Catino E, Cerutti R, Guidetti V. Metacognition and theory of mind in children with migraine and children with internalizing disorders. Neurol Sci. 2019 May;40(Suppl 1):187-189.
No abstract. From the article:
For this preliminary study, 34 pre-adolescents (18 males and 14 females mean age = 11 years) with migraine without aura (MWoA) are been recruited, following the ICHD-3 beta criteria. The second group was composed of 32 children and adolescents (16 females and 18 males mean age = 10 years) with diagnosis of anxiety or depression based on the ICD-10 classification. To assess levels of ToM, all the subjects completed the Domain of Social Perception included in the NEPSY-II. This subtest investigates the ability to recognize the intentions and the people point of view and the ability to understand how these affect others’ behaviors. For metacognitive abilities was used the Italian validated version of the Metacognitions Questionnaire for Children (MCQ-C). It comprises 22 items and 5 subscales: positive meta-worry (PMW), negative meta-worry (NMW), superstition, punishment and responsibility (SPR), and cognitive monitoring (CM). Higher total scores suggest greater negative metacognitive activity...
The comparison between internalizing subjects and migraineurs in the MCQ-C showed that the former has obtained higher scores in NMW, CM, and in MCQ.tot then the latter. Regarding levels of alexithymia and ToM, there were no significant differences between the two samples. Moreover, concerning the differences between males and females both had similar mean scores in each questionnaire.
This study attains significant and interesting results. First of all, the fact that there were no differences between the two groups on the AQC can be due to a similar lack in describing and recognizing emotion in both disorders. In the literature, it is shown that both children with anxiety and/or depression and those with primary headache, compared with the control group, show higher levels of alexithymia. We can therefore suppose that at the base of these high levels of alexithymia, there is an underlying suffering that can undermine the process of recognition and representation of emotions. So, both in internalizing disorders and in migraine, there is a continuous suffering which can influence this ability, resulting in similar levels of alexithymia. The same happened for the ToM construct. In the NEPSY-II test, no differences emerged between the two groups. In this case, the role of ToM is still controversial in the development and maintenance of disorders such as migraine, anxiety, and depression. We can hypothesize that, as in alexithymia, a state of common suffering can produce similar results. On the other hand, it is also possible that the capacities related to ToM are independent of the pathologies studied and that it is a skill that is not damaged by subject suffering. Concerning metacognitive abilities, children with internalizing disorders have shown higher levels in CM, NMW, and in the total score. Some authors suggest that dysfunctional patterns in metacognition would be the fundamental basis for most psychological disorders. For example, Wells stressed the role of metacognitive beliefs in the development and maintenance of emotional disorders, especially the generalized anxiety disorder (GAD). The central point is that positive beliefs about the benefits of worry and negative beliefs about the danger and uncontrollability of worry are associated with pathological worry. In the light of this theory, applied to childhood and adolescence, our results are in line with the association between greater metacognitive beliefs and greater anxious and internalizing symptoms and we can assume that greater CM is linked to more internalizing symptoms. Children and adolescents with internalizing symptoms also obtained higher level in NMW subscale than subject with MWoA. Findings on the presence of NMW in youth with anxiety disorders are varied. In some studies, the NMW scale emerged as the strongest predictor of worry and a greater predictor of anxiety than the other metacognitive processes and age. These studies confirm our results and we can assume that negative metacognitive beliefs, as well as CM, can be extended to all internalizing disorders in the developmental age, and not only to anxiety disorders. Concerning the subscale of PMW, we did not find any difference. Some studies indicate that more positive metacognitive beliefs are associated to internalizing symptoms. However, there are also data that indicate the independence of the two variables, suggesting that positive worrying do not influence anxiety and depression symptoms. Finally, even on SPR, no significant differences were found. We can suppose that both groups use this metacognitive strategy to cope with their problems related to the disease. Conclusively, in relation to gender differences, our results show no difference between males and females in each test, indicating the lack of a gender effect. This finding is interesting because it is recognized that girls, especially adolescents, endorsed more metacognitive processes than boys. Our data do not confirm what emerged from other studies. From this study, we can conclude that maladaptive cognitive beliefs are index of a greater presence of internalizing symptoms, both anxious and depressive. Nonetheless, children and adolescents with MWoA have some anxious or depressive symptoms; they do not have such a strong impact on metacognitive abilities. In addition, the lack of difference in the scores of alexithymia and in TOM can support the hypothesis that for alexithymia the continuous suffering can affect the abilities to recognize and to express emotions, and that ToM is not influenced by this suffering. Future studies will be needed to verify if the levels of these psychological construct are different between healthy controls, subjects with internalizing disorders and with migraine. It would also be interesting to compare different type of headache and/or compare subjects with primary headache, subjects with emotional disorders and subjects with double diagnosis (headache + emotional disorder).