Headache in Autism Spectrum Disorders

Abstract

Gastrointestinal (GI) disorders are among the most common medical conditions associated with autism spectrum disorders (ASD). These conditions include chronic constipation or diarrhea and irritable and inflammatory bowel symptoms. The pain and discomfort caused by GI symptoms can worsen behavior and even trigger regression in children with ASD. Headache and related disorders may affect children with ASD as an additional problem to keep in mind when evaluating pain of uncertain origin in this vulnerable population. Headache and migraine are mainly diagnosed by clinical history with a thorough evaluation of primary and associated symptoms and the core communication difficulties of ASD may represent a serious flaw in doing it. Abdominal migraine is a subtype of migraine that deserves attention because it has similarities with gastrointestinal symptoms observed in children with ASD. In addition ASD and migraine are both comorbid with anxiety and a subgroup of individuals with ASD present with anxiety disorders further complicating the overall picture.

Appendices

Supplementary S1: Autism Spectrum Disorder - 5th ed.; DSM–5; American Psychiatric Association, 2013

14.1.1 Diagnostic Criteria

• A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

  • 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

  • 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

  • 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

    Specify current severity: Severity is based on social communication impairments and restricted repetitive patterns of behavior.

• B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

  • 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

  • 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

  • 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

  • 4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

    Specify current severity:Severity is based on social communication impairments and restricted, repetitive patterns of behavior.

• C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

• D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

• E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Supplementary S2: Abdominal Migraine Modified by Winner P. [16]

14.1.1 Description

An idiopathic disorder seen mainly in children as recurrent attacks of moderate to severe midline abdominal pain, associated with vasomotor symptoms, nausea and vomiting, lasting 2–72 h, and with normality between episodes. Headache does not occur during these episodes.

14.1.2 Diagnostic Criteria

• A. At least five attacks of abdominal pain, fulfilling criteria B–D.

• B. Pain has at least two of the following three characteristics:

  • 1. Midline location, periumbilical, or poorly localized

  • 2. Dull or “just sore” quality

  • 3. Moderate or severe intensity

• C. During attacks, at least two of the following:

  • 1. Anorexia

  • 2. Nausea

  • 3. Vomiting

  • 4. Pallor

• D. Attacks last 2–72 h when untreated or unsuccessfully treated.

• E. Complete freedom from symptoms between attacks.

• F. Not attributed to another disorder.