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Children and adolescents who presented to an outpatient neurology clinic for a new visit during the COVID-19 pandemic had lower headache disability scores than those who came to the clinic in earlier years, a retrospective analysis showed.

The pandemic period -- from April 2020 to April 2022 in this study -- was associated with less headache disability in pediatric patients, even after adjusting for headache frequency, reported Brian LaGrant, MD, of Children's Hospital of Philadelphia, in a presentation at the American Headache Society annual meeting.

"The COVID-19 pandemic caused major changes to daily life: there was virtual schooling, decreased peer interaction, and increased screen time when children were doing homework and attending class," LaGrant noted.

Research , particularly during lockdowns, showed many children had improvement in headache intensity and frequency, he observed. "This was thought to be due to decreases in their overall anxiety and decreased school effort overall," he said.

But there's been little research to show how changes that occurred later in the pandemic affected headache disability in children and adolescents, he pointed out. "Our objective was to characterize headache disability before and during the COVID-19 pandemic and examine associated factors," he said.

Prior research has tied pediatric headache to seasonal cycles, with headaches typically worsening at the and improving during summer break. Other studies have shown that pediatric headache disability is related to and .

In their study, LaGrant and colleagues performed a retrospective analysis of questionnaires completed by patients during a new outpatient neurology visit for headache at Children's Hospital of Philadelphia between June 2017 and April 2022. Visits in March 2020 or earlier were considered pre-pandemic.

The researchers quantified headache disability using the Pediatric Migraine Disability Assessment (), which assigns disability grades from 0 (no disability) to 50 or more (severe disability). PedMIDAS consists of six questions related to headache disability in the past 90 days, with three questions about school life and three questions about home and extracurricular life. Patients with incomplete PedMIDAS scores were excluded.

Headache frequency was defined as continuous, three or more headaches per week, one to two headaches per week, or less than one headache per week.

Overall, 9,006 patients 5 to 21 years old were included in the analysis. Patients 12 and younger were classified as children (45% of sample); those 13 and up were classified as adolescents (55% of sample).

Most study participants were female (64%) and most had episodic headache (66%). A total of 29% of patients had continuous headache with fluctuation; 4% had continuous and constant headache.

Headache frequency had the single largest effect on PedMIDAS scores. Compared with pediatric patients who had headaches less frequently than weekly, those with continuous headaches, three or more headaches per week, or one to two headaches per week had increased odds of higher PedMIDAS scores (ORs of 6.2, 3.5, and 2.4, respectively, P<0.001 for all).

Adolescents had increased odds of higher disability scores than younger children (OR 1.9, P<0.001). The pandemic period was negatively associated with higher disability scores despite adjusting for headache frequency (OR 0.65, P<0.001). School versus summer months (July and August) did not affect disability odds in a fully adjusted model.

The findings may reflect that changes in school related to the COVID pandemic affected the ability to cope with headaches in ways that caused less disability, LaGrant suggested. For example, later school start times or more flexible start times may have led to decreased headache disability, he said.

"We confirmed several findings from the literature," LaGrant noted. "One was that headache frequency was the main driver of headache disability. Second was that older age was strongly related to greater headache disability."

"But more interestingly, we found that the presence of COVID-19 had an independent role in decreasing headache disability, even after accounting for headache frequency in these analyses. And overall, there was decreased seasonal variation as well," he added.

The analysis had several limitations, LaGrant acknowledged. The data were cross-sectional and subject to recall bias. In addition, "the presence of COVID-19 was highly variable throughout the 2 years, ranging from lockdowns to more liberal social restrictions," he said.

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