Executive Functions, Anxiety, Social Participation and Quality of Life in Children with Migraine During COVID-19

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Kerem, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3890999/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To compare executive functions (EF), anxiety, social participation, and quality of life (QoL) between children with migraine and healthy controls during the COVID-19 pandemic, and to examine these parameters in children in each group who did vs. did not contract COVID-19. Background: Migraine is among the most prevalent headache disorders in children, especially in adolescents. Migraine is exacerbated by stress, and it holds potential to affect patients’ emotional and cognitive state and, by extension, their functioning and wellbeing – parameters that were also affected by the COVID-19 pandemic. Materials and Methods: A prospective cohort study. The patient group comprised children seen in our pediatric neurology clinic for migraine, and the control group was composed of aged-matched healthy children with no neurological findings or developmental disorders. Participants’ parents completed a health and demographic questionnaire, BRIEF (child/adolescent version), PedsQL, the State-Trait Anxiety Inventory for Children (STAIC) and CASP. Participants or their parents furnished information on whether the participant had contracted COVID-19. Results: 84 children and adolescents aged 6–17.5 participated in the study: 33 with migraine (17 boys, 16 girls); 51 healthy controls (28 boys, 23 girls). Children with migraine showed significantly lower EF due to reduced behavioral regulation, higher trait anxiety, and lower physical, emotional, and school related QoL. Reduced EFs correlated with intensity of migraine attacks, higher anxiety, reduced social participation, and reduced QoL. Lower social participation correlated with reduced QoL and predicted emotional and social QoL. The BRIEF metacognition scale predicted school-related QoL. Healthy children who contracted COVID-19 showed significantly lower EF than children with migraine in the inhibition (56.66±10.56 vs 45.71±7.12-, p=.013) and initiation (60.01±11.89 vs 46.01±6.54, p=.005) BRIEF scales, and in the general metacognition index (65.83±14.48 vs 46.75±9.19, p=.003). Healthy children who contracted COVID-19 had significantly worse initiation and working memory compared to those who did not contract COVID-19 (initiation: 60.01±11.89 vs 46.81±8.89, p=.007), working memory: 61.16±15.48 vs 47.21±11.06, p=.021). Conclusion: Migraine has a significant negative impact on executive functions in children and adolescents, even more than contracting COVID-19. Executive dysfunction influences their emotional state, participation in social activities, and quality of life. The COVID-19 pandemic had a less deleterious effect on migraine patients compared to the healthy control group. Further research on pediatric migraine is warranted. executive function anxiety participation quality of life children headache migraine. What is Known Patients with migraine have a lower quality of life compared to their healthy peers. The COVID-19 pandemic profoundly affected the wellbeing of children and adolescents. What is New: Migraine has a significant negative impact on executive functions in children and adolescents. The COVID-19 pandemic had a less deleterious effect on migraine patients compared to the healthy control group. Introduction Headaches are common in children and adolescents, and the most frequently reported pain complaint among those seeking medical attention [ 1 ]. Migraine is one of the most prevalent headache disorders in this population, especially among adolescents: the prevalence of migraine rises from 3% during the preschool years to 23% among high-schoolers [ 2 ]. Changes in sleep patterns, dietary habits, physical activity, and emotional stress all contribute to the worsening of migraine in children [ 3 , 4 ]. The COVID-19 pandemic profoundly affected the wellbeing of children and adolescents, impacting various aspects of their physical and mental health. Disrupted routines, prolonged periods of social isolation, increased screen time, and heightened stress and anxiety related to the pandemic have raised concerns about a potential amplification in the frequency and severity of childhood migraines. Indeed, numerous studies have documented an upsurge in migraine symptoms and frequency among children during the pandemic [ 5 – 7 ]. Additionally, restricted access to healthcare services and disrupted follow-up appointments during the pandemic added challenges to the management and treatment of childhood migraine [ 8 – 10 ]. Our study aimed to explore the impact of the COVID-19 pandemic on the executive functions (EF) and quality of life (QoL) of children with migraine and healthy controls, and to examine the impact – if any – of contracting COVID-19. We compared our outcome variables between children with migraine and healthy controls, then divided both groups based on whether the child had contracted COVID-19 during the pandemic. We conducted within- and between-group comparisons with respect to EF, anxiety, social participation, and QoL, and examined correlations between these variables. Based on the correlation results, we further examined whether EF, anxiety, participation, and migraine severity predicted QoL. Our main hypotheses were as follows: (1) Children with migraine would have significantly lower EF, higher anxiety scores, lower social participation, and lower QoL than healthy controls. (2) Of the four groups (children with migraine vs. healthy controls X children who did vs. did not contract COVID-19), children with migraine who were affected by COVID-19 would have the lowest EF, highest anxiety, lowest social participation, and lowest QoL. (3) Among children with migraine, significant correlations would be found between migraine severity (as measured by the PedMIDAS), EF, anxiety, participation, and QoL. (4) Migraine severity, EF, anxiety, and participation would significantly predict QoL. Materials and Methods Participants and procedure Out of 100 recruited, 84 children between the ages of 6 and 17.5 years, completed the study. The study group included 33 children with episodic migraine (17 boys, 16 girls) who were prospectively recruited from the outpatient pediatric neurology clinic at the Bnai Zion Medical Center during the years 2020–2022. The control group included 51 healthy children (28 boys, 23 girls) with no significant illness, no developmental disorders, and no neurological findings. Children from the study group were recruited during their visit to the neurology clinic. All children in the study group met the diagnostic criteria for migraine, according to the International Classification of Headache Disorders, 3rd edition (ICHD-3) [ 11 ]. Patients and their parents/caregivers were asked to complete the questionnaires during their clinic visit (after providing informed consent). Children from the control group were recruited through advertisements. Parents of 70 children responded, of whom 51 met the inclusion criteria (children age 6–17 with no significant illness, no developmental disorders, and no neurological findings). Again, informed consent was obtained from all participants. The controls were evaluated in their homes by a member of the research team. The study received ethics approval from the Bnai Zion Medical Center Ethics Review Board BNZ 185 − 20 and was conducted in accordance with the declaration of Helsinki. Demographic details of the study and control group are summarized in Table 1 . Table 1 Participants’ health and socio-demographic data, and characteristics related to the COVID-19 pandemic Children with migraine (N = 33) Healthy controls (N = 51) Age (years) Range 9-17.5 10–16 T p Mean ± SD 13.30 ± 2.93 12.51 ± 2.08 1.63 .11 N(%) χ 2 p Gender 0.9 .76 Female 16 (48.5%) 23 (45.1%) Male 17 (51.5%) 28 (54.9%) ADHD 9 (28.1%) 11 (22%) Parents’ education Mothers 4.61 .11 High school 6 (18.2%) 3 (6%) Vocational school 5 (15.2%) 4 (8%) Academic degree 22 (66.8%) 43 (86%) Fathers 1.44 .49 High school 4 (12.5%) 8 (16.3%) Vocational school 7 (21.9%) 6 (12.2%) Academic degree 21 (65.6%) 35 (71.5%) Household income 7.71 .02 Below average 10 (33.3%) 5 (10.2%) Average 11 (36.7%) 29 (59.2%) Above average 9 (30%) 15 (30.6%) Contracted COVID-19 (defined as developing symptoms) 13 (39.4%) 12(24%) 2.238 .13 COVID-19 era affected child’s emotional state 11(34.4%) 25(51%) 2.172 .14 Child maintained a daily routine 22(40.7%) 32(59.3%) .418 .52 COVID-19 era affected child’s academic performance 16(39%) 25(61%) .630 .73 ADHD = Attention Deficit Hyperactivity Disorder; SD = Standard Deviation Materials All patients in the study group underwent a physical and neurological assessment by a pediatric neurologist, and provided a thorough headache history. Patients (or their parents) also filled in the PedMIDAS questionnaire – a tool developed specifically to assess migraine disability in pediatric and adolescent patients, which has been tested and validated for ages 4 to 18 [ 12 ]. All participants (both migraine patients and controls) answered a set of general health questions, including whether or not the participant had contracted COVID-19 during the pandemic. We defined contracting COVID-19 as actually developing symptoms, not merely testing positive for the presence of the SARS-CoV-2 virus For the main measures, all participants filled in the following questionnaires: Behavior Rating Inventory of Executive Functions (BRIEF). The BRIEF is a behavioral rating measure for children and youth aged 5–18 years, which aims to measure EF as expressed in daily life situations (for example: “becomes upset with new situations”; “has a messy desk”; “is disturbed by change of teacher or class”; “does not check work for mistakes”; “has trouble concentrating on chores, schoolwork”). The BRIEF includes 86 items summarized into two indexes: the Behavioral Regulation Index (BRI), which includes inhibition, shifting, and emotional control scales; and the Metacognition Index (MI), which includes initiation, working memory, planning, organization of materials, and monitoring scales. The BRI and MI scores are combined to generate a Global Executive Composite (GEC) score. In the present study we used the BRIEF parents’ report. Parents rate how frequently the child expresses the behavior described in each item on a Likert scale ranging from 1 (infrequently) to 3 (often), such that higher scores indicate lower EF. All raw scores are converted to standard scores. A standard GEC score of 65 indicates deficiencies in executive functions. The BRIEF is considered to have good psychometric properties [ 14 – 16 ]. The State-Trait Anxiety Inventory for Children (STAIC) [ 17 ]. The STAIC comprises two indexes: the STAIC T-Anxiety scale, designed to measure a general proneness to anxious behavior rooted in the personality, and the STAIC S-Anxiety scale, which measures anxiety as a fleeting emotional state. The two indexes each include twenty statements that ask, respectively, how the child generally feels (trait anxiety), and how the child feels at a particular moment in time (state anxiety). Higher mean scores represent lower anxiety. The Child and Adolescent Scale of Participation (CASP) [ 18 ]. This scale measures the extent to which children participate in home, school, and community activities compared to children of the same age as reported by family caregivers. The CASP was developed as part of the Child and Family Follow-up Survey (CFFS) to monitor outcomes and needs of children with traumatic and other acquired brain injuries [ 18 ]. The content and methods used in the CASP and CFFS were informed by the International Classification of Functioning, along with other research addressing the social participation of children and youth with a range of disabilities. The CASP consists of 20 ordinal-scaled items in four subsections: home participation (6 items), community participation (4 items), school participation (5 items), and home and community living activities (5 items) (sample items can be found in the Results section, under Correlations). All items are rated on a four-point scale: “age expected (full participation),” “somewhat restricted,” “very restricted,” and “unable” (with a “not applicable” option for activities in which the child would not be expected to participate due to age, such as work). Most items are applicable to children aged five and older. Higher scores reflect greater age-expected participation. The CASP has reported evidence of test re-test reliability (Intraclass Correlation Coefficient = 0.94), internal consistency (α ≥ 0.96), and construct and discriminant validity. The Pediatric Quality of Life Inventory (PedsQL( [ 19 ]. We used Version 4.0 of the child’s report, which profiles children’s Health-Related Quality of Life (HRQoL) in four dimensions: physical functioning (eight items), emotional functioning (five items), social functioning (five items), and school functioning (five items). Emotional and social functioning are considered together in a higher-order dimension of psychosocial health. The child indicates the frequency of problems during the past month on a five-point Likert scale (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items are then transformed into a 0–100-point scale (0 = 100; 1 = 75; 2 = 50; 3 = 25; 4 = 0) to produce the HRQoL percentage. A higher percentage indicates a better HRQoL. Data analysis: Data was analyzed using SPSS-25 software. Descriptive statistics were calculated for all measures. Normality tests revealed normal distribution for most scales. Chi square analysis was used to test for significant differences between groups in relevant socio-demographic parameters, followed by z-tests where required. T-tests were used to test for differences between the groups in age and in total scores, while MANOVA was used to test for differences in the various subscales. Correlations between measures were examined using Pearson’s correlation test. Finally, stepwise linear regression was performed to examine the relative contribution of migraine severity, EFs, anxiety, and social participation to each of the QoL domains. Significance levels were adjusted to account for multiple testing for all analyses. Results For each of the main variables, we first report the results between the two main groups (children with migraine vs. healthy controls) without regard to whether or not they had contracted COVID-19. We then report comparisons between relevant subgroups. Executive functions The majority of children from both main groups (children with migraine and healthy controls) had normal BRIEF scores (86.2% of the former and 84.6% of the latter). Hence, no significant differences were found between the two main groups in total BRIEF scores. However, when comparing mean scores for the BRIEF subscales, healthy controls showed slightly lower initiation than children with migraine (see Table 2 ). Table 2 Comparing EF (BRIEF scores) between children with migraine and healthy controls Children with migraine (N = 30) Healthy controls (N = 39) BRIEF scores Mean ± SD Range Mean ± SD Range F(1,65) p Inhibition 48.96 ± 9.49 40–72 48.56 ± 11.13 36–81 1.509 .224 Shifting 55.76 ± 12.94 38–88 51.74 ± 10.99 38–75 .237 .628 Emotional control 55.80 ± 11.55 36–77 47.07 ± 10.32 35–72 2.837 .097 Initiation 48.80 ± 8.32 36–65 50.69 ± 10.70 35–77 5.263 .025 Working memory 52.66 ± 12.67 38–84 48.76 ± 11.97 36–84 .277 .600 Planning and organization 50.23 ± 12.20 38–82 50.53 ± 9.51 35–74 .838 .363 Organization of material 51.46 ± 11.00 34–71 47.15 ± 11.71 33–71 .858 .358 Monitoring 49.36 ± 10.09 36–75 45.79 ± 12.41 28–84 .009 .925 BRI 45.16 ± 11.25 39–80 48.58 ± 11.16 34–78 .247 .621 MI 51.43 ± 13.08 38–99 50.23 ± 12.62 31–86 3.107 .083 GEC 52.16 ± 10.35 38–75 48.43 ± 11.19 32–75 .036 .851 BRI = Behavioral Regulation Index, MI = Metacognition Index, GEC = Global Executive Composition, SD = Standard Deviation, BRIEF = Behavior Rating Inventory of Executive Function Executive functions in children with migraine vs. healthy controls (participants who did not contract COVID-19) In children who did not contract COVID-19, emotional control was significantly worse in children with migraine (57.77 ± 11.97) compared to healthy controls (45.72 ± 9.46) (F1,53 = 6.42, p = .014). Children with migraine also scored significantly worse on the organization of materials scale (52.51 ± 11.69) compared to healthy controls (46.71 ± 11.88) (F1,53 = 3.98, p = .05). Executive functions in children with migraine vs. healthy controls (participants who contracted COVID-19) Here an opposite trend was found: among children who had contracted COVID-19, healthy controls scored significantly worse than children with migraine in two of the BRIEF scales: inhibition (56.66 ± 10.56 vs 45.71 ± 7.12 for the controls and migraine group, respectively) (F1,53 = 7.81, p = .013) and initiation (60.01 ± 11.89 vs 46.01 ± 6.54, respectively) (F1,53 = 10.76, p = .005). In addition, healthy children scored worse in the overall metacognition index (65.83 ± 14.48 vs 46.75 ± 9.19, respectively (F1,53 = 11.77, p = .003). Executive functions in healthy children who did vs. did not contract COVID-19 Healthy children who contracted COVID-19 had significantly worse initiation and working memory compared to those who did not contract the disease (initiation: 60.01 ± 11.89 vs 46.81 ± 8.89, F = 8.74, p = .007; working memory: 61.16 ± 15.48 vs 47.21 ± 11.06, F = 6.13, p = .021). Executive functions in children with migraine who did vs. did not contract COVID-19 Among the children with migraine, the only significant difference between those who did vs. did not contract COVID-19 was found in monitoring. Monitoring was worse in children who did not contract COVID-19 (53.47 ± 10.48 vs 43.41 ± 6.64) (F = 8.56, p = .007). Anxiety Looking only at the two main groups (i.e., ignoring COVID-19 status), children with migraine had significantly higher state anxiety than healthy controls. We next compared anxiety within each of the two main groups by COVID-19 status. Among healthy children, we found differences between those who did vs. did not contract COVID-19 in both anxiety measures. Specifically, the COVID–yes group had significantly lower state anxiety compared to the COVID–no group (mean state = 1.86, SD = .33 vs mean state = 2.34, SD = .27, respectively, F 1,30 =18.64, p < .001), but higher trait anxiety (mean trait = 2.11, SD = .62 vs. mean trait = 1.34, SD = .38, respectively). By contrast, among children with migraine, there were no significant differences between the COVID subgroups in either state anxiety (mean = 2.41, SD = .48 vs mean = 2.26, SD = .31) or trait anxiety (mean = 1.69, SD = .38 vs mean = 1.74, SD = .43). Social participation No significant differences were found between children with migraine and healthy controls. In addition, no significant impact of contracting COVID-19 was found in either group: children did not differ based on COVID status in any of the participation scales. Quality of life Children with migraine had lower QoL than healthy controls in all measured domains. Significant differences between the groups were found in physical, emotional, and school-related QoL (see Table 3 ). Table 3 Correlations between executive functions (BRIEF) and social participation (CASP) among children with migraine CASP Home Community School Community living Total BRIEF scores (N = 20) Inhibition NS NS NS NS NS Shifting NS r=-.547* p = .012 NS r=-.539* p = .014 r=-.550* p = .012 Emotional control NS NS NS r=-.526* p = .017 r=-.537* p = .015 Initiation NS NS NS NS NS Working memory NS NS NS NS NS Planning and organization NS NS NS NS NS Organization of material NS NS NS NS NS Monitoring NS NS NS r=-.740** p = .000 r=-.716** p = .000 BRI NS r=-.463* p = .040 NS r=-.472* p = .036 r = .514* p = .020 MI NS NS NS NS NS GEC NS NS NS r=-.456* p = .043 r=-.465* p = .039 PedsQL scores (N = 23) Emotional NS r = .469* p = .024 NS r = .461* p = .027 r = .552** p = .006 Social NS NS NS r = .603** p = .002 r = .585** p = .003 School NS NS NS NS NS Psycho-social NS NS NS r = .518* p = .011 r = .546** p = .007 Total NS NS NS r = .477* p = .021 r = .535** p = .009 NS = Not Significant, BRI = Behavioral Regulation Index, MI = Metacognition Index, GEC = Global Executive Composition, BRIEF = Behavior Rating Inventory of Executive Function, CASP = Child and Adolescent Scale of Participation, PedsQL = Pediatric Quality of Life Inventory No significant interaction was found between main group and COVID-19 status. Within both the migraine and control groups, children who did vs. did not contract COVID-19 did not differ in any of the QoL domains. Discussion This study aimed to compare executive functions, anxiety, social participation, and quality of life between children with migraine and healthy controls; to explore relationships between the examined factors among children with migraine; and to examine the implications of contracting COVID-19 for the examined factors. We hypothesized that (1) children with migraine would have significantly lower EF, higher anxiety, lower participation and lower QoL than healthy controls; (2) children with migraine who contracted COVID-19 would have the lowest EF, highest anxiety, lowest participation, and lowest QoL of the four groups; (3) among children with migraine, significant correlations would be found between migraine severity and the four main variables; and (4) migraine severity, EF, anxiety, and participation would significantly predict QoL. Executive functions in pediatric migraine Our first hypothesis was largely supported. Looking only at the presence or absence of migraine and ignoring COVID-19 status, we found that migraine patients had worse executive functions, particularly in the emotional control and organization of materials scales. We also found that EF as measured by the BRIEF scale correlated with quality of life. Previous research has shown that individuals suffering from migraine may experience difficulties in various cognitive domains and executive functions. These studies have found challenges with selective and divided attention, working memory, short- and long-term verbal memory, information processing speed, cognitive flexibility and inhibitory control in individuals with migraine compared to healthy individuals [ 4 , 20 – 25 ]. Several mechanisms have been postulated to account for such executive function deficits in individuals with migraine. One theory proposes that disruptions in brain networks and changes in cerebral blood flow during migraine attacks could contribute to the impairment of executive functioning. The coexistence of migraine with other conditions known to impact executive functions, like anxiety and depression, may exacerbate these deficits even further [ 23 ]. There is also evidence that individuals with migraine may still exhibit cognitive impairments even during headache-free intervals, including executive function deficits. This suggests that the cognitive effects of migraine are not solely attributable to acute headache symptoms but may involve underlying neurobiological and neurochemical mechanisms [ 26 ]. Importantly, cognitive and EF impairments observed in individuals with migraine can have substantial consequences on their daily functioning, academic achievement, and overall quality of life, especially among children and adolescents. However, most studies about EF in children with migraine have used neuropsychological tests [ 4 , 20 – 22 ]. Our study used the BRIEF – an ecologically valid evaluation that reflects how EFs are expressed in daily life, and therefore conveys information about the implications of EF deficits outside the clinic setting. Understanding these real-life challenges may support the development of improved interventions aimed at meeting the child’s and family’s specific needs, and so improve both daily functioning and wellbeing [ 27 ]. Pediatric migraine, anxiety, and social participation In the current research, the most significant difference between children with migraine and healthy children was in emotional regulation. In this area, the BRIEF questionnaire includes questions related to exaggerated emotional responses, frequent mood changes, and irritability. Migraine is a disease associated with anxiety and emotional difficulties. Many studies have found stress to be the most common trigger for headaches, particularly stress related to school [ 28 , 29 ]. These studies may explain the clear connection found between migraines and emotional regulation. Difficulty in emotional regulation contributes to difficulties in behavioral control, and may affect the functioning and quality of life of children with migraines [ 30 ]. Therefore, emotional regulation is a central target for intervention. In our study, children with migraine had significantly higher state anxiety than healthy controls, although no significant differences were found in social participation between children with migraine and healthy controls. This may reflect the relatively small sample size, as well as the unique effects of the COVID-19 pandemic, which restricted social interaction. Given that social participation is a critical factor in children’s development and wellbeing, future studies should examine this question in larger samples. Pediatric migraine and quality of life The other main outcome of the present study was that children with migraine had lower quality of life in various domains as compared to healthy controls. This finding is supported by previous reports. For example, Powers [ 3 , 31 ] found that migraine may reduce children’s QoL, and that this impact may differ by age group: teens reported lower school functioning than older and younger children, and younger children reported lower social functioning than older children and teens. Physical complaints as well as mental problems can adversely affect a patient’s quality of life [ 32 , 33 ]. This may be reflected directly by children’s self-reports, as found in our study. The present study is the first, to our knowledge, to find a correlation between the reduction in social quality of life in children with migraine and the PedMIDAS score. With respect to the association between school-related quality of life and the severity of migraines, the current findings partially support our third and fourth hypotheses. This finding is also in keeping with the existing literature. Numerous studies have found reciprocal relationships between migraines and school functioning, with school-related factors both triggering migraines and influenced by them [ 28 , 34 ]. Attendance and participation in school play a significant role in children’s lives, impacting their overall development, self-confidence, and self-esteem. Absence from elementary school significantly reduces current and future academic performance [ 35 ]. Involvement in school improves students’ attitudes toward learning and their academic achievement [ 36 ], enhances students’ emotional and social skills [ 37 ], and predicts a lower risk of drug use and delinquency [ 38 ]. Therefore, it is essential to find alternatives or accommodations for children who are absent from school or unable to participate while at school due to migraines. Future studies should continue how technology, including videoconferencing software such as Zoom, can allow children to participate in the educational process at school even if they are at home [ 39 ]. Effects of the COVID-19 pandemic on children with migraine Our study, conducted during the COVID-19 epidemic, explored the influence of this unique period on pediatric migraine headaches. We found no worsening of headaches during the pandemic among children with migraine. Moreover, our second hypothesis – positing that children with migraine who contracted COVID-19 would have the worst outcomes – was not supported. Interestingly, the only significant difference between children with migraine who did vs. did not contract COVID-19 was in was the monitoring scale of the BRIEF, with monitoring being worse in children who did not contract COVID-19. A similar pattern was seen when we measured quality of life: among participants who contracted COVID-19, quality of life was lower only among the control group, but not among the migraine patients. Another interesting finding is that among all groups, children who did not contract COVID-19 had lower EF and higher anxiety rates compared to those who did develop COVID-19 symptoms. This finding may suggest that, among children, fear and worry about COVID-19 typically had a more deleterious effect than contracting the disease itself. The influence of the COVID-19 pandemic on headache is a matter of debate. Al-Hashel [ 40 ] reported that the COVID-19 pandemic had a predominantly negative effect on adults with migraine, highlighting the need to identify risk factors associated with poorer outcomes. Reyes-Alvarez et al. [ 10 ] investigated 243 migraine patients, who responded to questions covering quarantine circumstances, alterations in working conditions, as well as symptoms of anxiety, depression, and fear of COVID-19. About half the migraine patients they surveyed reported a deterioration in symptoms, while about a third experienced no change in their migraine symptoms. According to Caronna et al. [ 7 ], approximately 50% of patients with headaches attributed to SARS-CoV-2 infection perceived the acute headache phase to be more severe than their typical migraine. Additionally, patients who experienced headaches during the acute phase of the infection showed higher rates of migraine exacerbation compared to those who did not. Fernández-de-las-Peñas et al. [ 41 ] found that six months after contracting COVID-19, approximately 60% of patients with a pre-existing history of migraine reported an increase in headache frequency, and around 20% reported an increase in headache intensity. Membrilla et al. [ 42 ] observed that patients with a history of migraine tend to experience longer and more intense headaches in the context of COVID-19, with these symptoms often manifesting earlier compared to individuals without a history of migraines. However, some studies investigating the presence of headaches in individuals with COVID-19 fail to clearly distinguish between those who had pre-existing primary headache disorders and those who did not, leading to uncertainty when assessing their connection [ 42 ]. It is well-known that lifestyle and behavioral factors can influence the trajectory of migraine attacks. The COVID-19 pandemic introduced unprecedented circumstances, including the implementation of lockdown measures, which significantly impacted people’s behaviors. A large study examining the effects of restrictions during the pandemic [ 9 ] found that brief periods of lockdown had the potential to improve certain measures related to migraines and overall wellbeing – perhaps a function of factors such increased ability to work from home, reduced demands from social activities, greater freedom to organize one’s own time. Likewise, Delussi et al. [ 43 ] found that individuals with migraine experienced an improvement in their headaches and reduced their use of medication during lockdown periods, particularly among those with lower depressive symptom scores. Apetti et al. [ 8 ] reported a similar trend, observing that primary headache disorders generally improved during lockdown, even among pediatric patients. The researchers attributed these positive outcomes to lifestyle modifications, particularly reductions in school-related stress. Considering the effects of COVID restrictions, Caronna et al. [ 7 ] reported varying results. While some patients they studied experienced improvement during lockdown, others found no significant difference or even a worsening of their usual headaches, accompanied by an increase in medication intake. These negative effects were often associated with sleep disturbances, anxiety, and depression. Limitations The research findings are based on a convenience sample with a small number of participants. Additionally, the groups were not completely matched in terms of socio-demographic measures. Finally, we did not examine other parameters that could affect quality of life and executive functions, such as anxiety, depression, stress, and behavioral disorders, which are known to be common in patients with migraines. Conclusion In our study, children with migraine exhibited higher anxiety and lower executive functions than healthy controls. Their reduced EF correlated with lower quality of life and with the intensity of the headache attacks. The COVID-19 pandemic did not have a clear worsening effect on migraine patients, as it had on the control group. Further research on pediatric migraine and its relationship with different aspects of the COVID-19 pandemic period is warranted. Declarations Author Contribution J.G. H.S. N.C. A.H. and B.E.Y. . were involved in planning and supervised the work,J.G. Z.H. A.S. K.N. and H.S. processed the , performed the analysis, .G. H.S. N.C. A.H. and B.E.Y drafted the manuscript anddesigned the tables. .J.G. Z.H. A.S. K.N. and H.S. aided in interpreting the results and worked on the manuscript. All authors discussed the results and commented on the manuscript. References Genizi J, Srugo I, Kerem NC (2013) The cross-ethnic variations in the prevalence of headache and other somatic complaints among adolescents in Northern Israel . J Headache Pain 14(1): 21–27. Al-Twaijri WA, Shevell MI (2002) Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatr Neurol 26: 365–368. Powers SW, Patton SR, Hommel KA, Hershey AD (2003) Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics 112(1 Pt 1):e1–5 doi: 10.1542/peds.112.1.e1 12. Riva D, Aggio F, Vago C (2006). Cognitive and behavioral effects of migraine in childhood and adolescence. Cephalalgia 26:596–603. Bonuccelli A, Depietri G, Baldaccini T, Ricciutelli I, Peroni D, Spalice A, Massimetti G, Morganti R, Orsini A, Striano P (2023) Essential headaches in developmental age: what is changed before, during and after the lockdown for COVID-19 pandemic. Clinical study. Front Pediatr 11:1166984. Dedeoglu Ö, Konuşkan B (2023). Triggers and clinical changes of childhood primary headache characteristics during COVID-19 pandemic lockdown. Acta Neurol Belg 23(1):215–220. Caronna E, van den Hoek TC, Bolay H, Garcia-Azorin D, Gago-Veiga AB, Valeriani M, Takizawa T, Messlinger K, Shapiro RE, Goadsby PJ, Ashina M, Tassorelli C, Diener HC, Terwindt GM, Pozo-Rosich P (2023) Headache attributed to SARS-CoV-2 infection, vaccination and the impact on primary headache disorders of the COVID-19 pandemic: a comprehensive review. Cephalalgia 43(1):3331024221131337. Apetti L, Loro PA, Di, Tarantino S, et al (2020) I stay at home with headache. A survey to investigate how the lockdown for COVID-19 impacted on headache in Italian children. Cephalalgia 40:1459–1473. Verhagen IE, van Casteren DS, de Vries Lentsch S, et al (2021) Effect of lockdown during COVID-19 on migraine: a longitudinal cohort study. Cephalalgia 41:865–870. Reyes-Alvarez MT, Bancalari E, Santana Vargas AD, Velez K, Rodríguez-Leyva I, Marfil A, Miranda S, Zegarra-Valdivia JA (2023) Impact of COVID-19 pandemic lockdown on migraine patients in Latin America. Int J Environ Res Public Health 20(4):3598. Headache Classification Committee of the International Headache Society (HIS) (2018) The International Classification of Headache Disorders, 3 rd Edition. Cephalalgia 38:1–211. Hershey AD, Powers SW, Vockell AL, LeCates S, Kabbouche MA, Maynard MK (2001) PedMIDAS: development of a questionnaire to assess disability of migraines in children. Neurology 57(11):2034–2039. Isquith, P. K., Roth, R. M., & Gioia, G. (2013). Contribution of rating scales to the assessment of executive functions. Applied Neuropsychology: Child, 2 (2), 125-132. ‏ Hendrickson NK, McCrimmon AW (2019) Test Review: Behavior Rating Inventory of Executive Function®, Second Edition (BRIEF®2) by Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. Canadian Journal of School Psychology 34(1):73–78. Gioia GA, Isquith PK, Guy SC, Kenworthy L (2000) Behavior Rating Inventory of Executive Function: BRIEF. Child Neuropsychology, 6, 235-238. McGill RJ, Snow JH (2021) Behavior Rating Inventory of Executive Function, Second Edition. The Twenty-First Mental Measurements Yearbook https://search-ebscohost-com.ezproxy.haifa.ac.il/login.aspx?direct=true&db=loh&AN=test.8651&site=eds-live&scope=site\ Spielberger CD, Edwards CD, Montouri J, Lushene R (1973) State-Trait Anxiety Inventory for Children (STAI-CH) [Database record]. APA PsycTests. https://doi.org/10.1037/t06497-000 Gary Bedell (2009) Further validation of the Child and Adolescent Scale of Participation (CASP), Developmental Neurorehabilitation, 12:5, 342-351. Varni JW, Seid M, Kurtin PS. (2001) PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 39: 800–12. Waldie K, Hausmann M, Milne B, Poulton R (2002) Migraine and cognitive function: a life-course study. Neurology 59:904–908. Villa T, Correa Moutran A, Sobirai Diaz L (2009) Visual attention in children with migraine: a controlled comparative study. Cephalalgia 29:631–634. Costa-Silva MA, Prado ACA, de Souza LC, Gomez RS, Teixeira AL (2016) Cognitive functioning in adolescents with migraine. Dement Neuropsychol 10(1):47–51. Martins IP, Gil-Gouveia R, Silva C, Maruta C, Oliveira AG (2012) Migraine, headaches, and cognition. Headache. 52(10):1471–1482. Vuralli D, Ayata C, Bolay H (2018) Cognitive dysfunction and migraine. J Headache Pain 19:109. Kaiser Pinotti L, Castro ADS, de Oliveira Garcia GH, Alvim PHP, Roza TH, Andrade FA, Kowacs PA, Massuda R (2023) Executive functions in migraine patients: a systematic review with meta-analysis. Cogn Neuropsychiatry 28(1):52–66. Rist PM, Kurth T (2013) Migraine and cognitive decline: a topical review. Headache 53(4):589–598. Gioia GA, Isquith PK, Retzlaff PD, Espy KA (2002) Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a clinical sample. Child Neuropsychol 8(4):249–257. Colombo B, Cetta I, Messina R, Filippi M. Stress in paediatric migraine: a trigger factor? Neurol Sci. 2020 Dec;41(Suppl 2):447-449. Solotareff L, Cuvellier JC, Duhamel A, Vallée L, Tich SNT. (2017) Trigger Factors in Childhood Migraine: A Prospective Clinic-Based Study From North of France. J Child Neurol. 32(8):754-758. Guidetti V, Cerutti R, Faedda N, Natalucci G. Migraine in childhood: an organic, biobehavioral, or psychosomatic disorder? Neurol Sci. 2019 May;40(Suppl 1):93-98. Powers SW, Patton SR, Hommel KA, Hershey AD (2004) Quality of life in paediatric migraine: characterization of age-related effects using PedsQL 4.0. Cephalalgia 24:120–127. Cavallini A1, Micieli G, Bussone G, Rossi F, Nappi G (1995) Headache and quality of life. Headache 35:29–35. Guthrie E, Jackson J, Shaffer J, Thompson D, Tomenson B, Creed F (2002) Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn’s disease. Am J Gastroenterol 97:1994–1999. Gazerani P. Migraine and Mood in Children. (2021) Behav Sci (Basel). 14;11(4):52. Sarah Cattan, Daniel A Kamhöfer, Martin Karlsson, Therese Nilsson. (2023) The Long-Term Effects of Student Absence: Evidence from Sweden, The Economic Journal. 133, 650, 888–903. Erdoğdu, M. Y. (2019). The mediating role of school engagement in the relationship between attitude toward learning and academic achievement. International Journal of Education and Literacy Studies, 7(2), 75-81. ‏ Durlak JA, Weissberg RP, Dymnicki AB, Taylor RD, Schellinger KB. (2011) The impact of enhancing students' social and emotional learning: a meta-analysis of school-based universal interventions. Child Dev. Jan-;82(1):405-32. Li Y, Zhang W, Liu J, Arbeit MR, Schwartz SJ, Bowers EP, Lerner RM. (2011) The role of school engagement in preventing adolescent delinquency and substance use: a survival analysis. J Adolesc.;34(6):1181-92. Zhang F, Litson K, Feldon DF. (20220 Social predictors of doctoral student mental health and well-being. PLoS One. 9;17(9):e0274273. Al-Hashel JY, Ismail II (2020) Impact of coronavirus disease 2019 (COVID-19) pandemic on patients with migraine: a web-based survey study. J Headache Pain 21(1):115. Fernández-de-las-Peñas C, Gómez-Mayordomo V, Cuadrado ML, et al (2021) The presence of headache at onset in SARS-CoV-2 infection is associated with long-term post-COVID headache and fatigue: a case-control study. Cephalalgia 41:1332–1341. Membrilla JA, de Lorenzo Í, Sastre M, et al (2020) Headache as a cardinal symptom of coronavirus disease 2019: a cross-sectional study. Headache 60:2176–2191. Delussi M, Gentile E, Coppola G, et al (2020) Investigating the effects of COVID-19 quarantine in migraine: an observational cross-sectional study from the Italian National Headache Registry (RICe). Front Neurol 11: 597881. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3890999","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":269355065,"identity":"bc644f7b-b981-4bac-a5a3-d4715d39e899","order_by":0,"name":"Jacob Genizi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYJCCAwwGbHJgxgNStBiDGQmk2JTYACKJ0iLv3nvw4I8CvvT5YYcfAm2xk9NtIKDF8My5hAMSBmy5G2+nGQC1JBubHSCkZUaOwQEDkJbZCSAtBxK3EdQy/w1QpQFbuuHs9A/EaZGX4DE4cMCALUFeOodIWwx4cgwONhiwGW6QzikAWkeEX+Tbzxh//PHnmLz87PTNHz5U2MkR1GIAUXAMyjAgoBxsSwOYqoExRsEoGAWjYBRgAgA8h0drd2Wr+wAAAABJRU5ErkJggg==","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Jacob","middleName":"","lastName":"Genizi","suffix":""},{"id":269355066,"identity":"e7b75777-5467-4eb1-b93b-10918c2a44cb","order_by":1,"name":"Hila Samet","email":"","orcid":"","institution":"University of Haifa","correspondingAuthor":false,"prefix":"","firstName":"Hila","middleName":"","lastName":"Samet","suffix":""},{"id":269355067,"identity":"590d1f9d-da8d-4b69-86fa-cd095ecebae1","order_by":2,"name":"Zaitoon Huseein","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Zaitoon","middleName":"","lastName":"Huseein","suffix":""},{"id":269355068,"identity":"c937876c-3af0-4ba3-b20b-4b8b8802fa64","order_by":3,"name":"Uriel Elimelech","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Uriel","middleName":"","lastName":"Elimelech","suffix":""},{"id":269355069,"identity":"8a2ad722-8641-4f42-b396-dd5e928bba79","order_by":4,"name":"Nogah C. Kerem","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nogah","middleName":"C.","lastName":"Kerem","suffix":""},{"id":269355070,"identity":"166c280d-f7a3-4ec1-9a13-98336a0a308d","order_by":5,"name":"Aharon Kessel","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Aharon","middleName":"","lastName":"Kessel","suffix":""},{"id":269355071,"identity":"a6fec143-c4d7-4832-b0b6-6d15baa900a2","order_by":6,"name":"Adel Shalata","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Adel","middleName":"","lastName":"Shalata","suffix":""},{"id":269355072,"identity":"9a98135e-01f7-4ebd-bea3-298e15c80b58","order_by":7,"name":"Keren Nathan","email":"","orcid":"","institution":"Bnai Zion Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Keren","middleName":"","lastName":"Nathan","suffix":""},{"id":269355073,"identity":"dbf9ba2d-315d-481a-afb6-f865459b421a","order_by":8,"name":"Batya Engel-Yeger","email":"","orcid":"","institution":"University of Haifa","correspondingAuthor":false,"prefix":"","firstName":"Batya","middleName":"","lastName":"Engel-Yeger","suffix":""}],"badges":[],"createdAt":"2024-01-23 12:02:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3890999/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3890999/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51539367,"identity":"d7d80e58-8baa-43ac-9d5f-d0a50860ce26","added_by":"auto","created_at":"2024-02-23 10:45:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":462763,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3890999/v1/2f71c175-d6db-461b-b59b-af5aa6188a04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Executive Functions, Anxiety, Social Participation and Quality of Life in Children with Migraine During COVID-19","fulltext":[{"header":"What is Known","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003ePatients with migraine have a lower quality of life compared to their healthy peers.\u003c/li\u003e\n \u003cli\u003eThe COVID-19 pandemic profoundly affected the wellbeing of children and adolescents.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWhat is New:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMigraine has a significant negative impact on executive functions in children and adolescents.\u003c/li\u003e\n \u003cli\u003eThe COVID-19 pandemic had a less deleterious effect on migraine patients compared to the healthy control group.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eHeadaches are common in children and adolescents, and the most frequently reported pain complaint among those seeking medical attention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Migraine is one of the most prevalent headache disorders in this population, especially among adolescents: the prevalence of migraine rises from 3% during the preschool years to 23% among high-schoolers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Changes in sleep patterns, dietary habits, physical activity, and emotional stress all contribute to the worsening of migraine in children [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic profoundly affected the wellbeing of children and adolescents, impacting various aspects of their physical and mental health. Disrupted routines, prolonged periods of social isolation, increased screen time, and heightened stress and anxiety related to the pandemic have raised concerns about a potential amplification in the frequency and severity of childhood migraines. Indeed, numerous studies have documented an upsurge in migraine symptoms and frequency among children during the pandemic [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, restricted access to healthcare services and disrupted follow-up appointments during the pandemic added challenges to the management and treatment of childhood migraine [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study aimed to explore the impact of the COVID-19 pandemic on the executive functions (EF) and quality of life (QoL) of children with migraine and healthy controls, and to examine the impact \u0026ndash; if any \u0026ndash; of contracting COVID-19. We compared our outcome variables between children with migraine and healthy controls, then divided both groups based on whether the child had contracted COVID-19 during the pandemic. We conducted within- and between-group comparisons with respect to EF, anxiety, social participation, and QoL, and examined correlations between these variables. Based on the correlation results, we further examined whether EF, anxiety, participation, and migraine severity predicted QoL.\u003c/p\u003e \u003cp\u003eOur main hypotheses were as follows: (1) Children with migraine would have significantly lower EF, higher anxiety scores, lower social participation, and lower QoL than healthy controls. (2) Of the four groups (children with migraine vs. healthy controls X children who did vs. did not contract COVID-19), children with migraine who were affected by COVID-19 would have the lowest EF, highest anxiety, lowest social participation, and lowest QoL. (3) Among children with migraine, significant correlations would be found between migraine severity (as measured by the PedMIDAS), EF, anxiety, participation, and QoL. (4) Migraine severity, EF, anxiety, and participation would significantly predict QoL.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedure\u003c/h2\u003e \u003cp\u003eOut of 100 recruited, 84 children between the ages of 6 and 17.5 years, completed the study. The study group included 33 children with episodic migraine (17 boys, 16 girls) who were prospectively recruited from the outpatient pediatric neurology clinic at the Bnai Zion Medical Center during the years 2020\u0026ndash;2022. The control group included 51 healthy children (28 boys, 23 girls) with no significant illness, no developmental disorders, and no neurological findings.\u003c/p\u003e \u003cp\u003eChildren from the study group were recruited during their visit to the neurology clinic. All children in the study group met the diagnostic criteria for migraine, according to the International Classification of Headache Disorders, 3rd edition (ICHD-3) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patients and their parents/caregivers were asked to complete the questionnaires during their clinic visit (after providing informed consent).\u003c/p\u003e \u003cp\u003eChildren from the control group were recruited through advertisements. Parents of 70 children responded, of whom 51 met the inclusion criteria (children age 6\u0026ndash;17 with no significant illness, no developmental disorders, and no neurological findings). Again, informed consent was obtained from all participants. The controls were evaluated in their homes by a member of the research team.\u003c/p\u003e \u003cp\u003e The study received ethics approval from the Bnai Zion Medical Center Ethics Review Board BNZ 185\u0026thinsp;\u0026minus;\u0026thinsp;20 and was conducted in accordance with the declaration of Helsinki. Demographic details of the study and control group are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; health and socio-demographic data, and characteristics related to the COVID-19 pandemic\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChildren with migraine\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003cp\u003econtrols\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9-17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (51.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents\u0026rsquo; education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (66.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFathers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (65.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (71.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (59.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContracted COVID-19 (defined as developing symptoms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (39.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID-19 era affected child\u0026rsquo;s emotional state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25(51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild maintained a daily routine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(40.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32(59.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID-19 era affected child\u0026rsquo;s academic performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25(61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eADHD\u0026thinsp;=\u0026thinsp;Attention Deficit Hyperactivity Disorder; SD\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eAll patients in the study group underwent a physical and neurological assessment by a pediatric neurologist, and provided a thorough headache history. Patients (or their parents) also filled in the PedMIDAS questionnaire \u0026ndash; a tool developed specifically to assess migraine disability in pediatric and adolescent patients, which has been tested and validated for ages 4 to 18 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. All participants (both migraine patients and controls) answered a set of general health questions, including whether or not the participant had contracted COVID-19 during the pandemic. We defined contracting COVID-19 as actually developing symptoms, not merely testing positive for the presence of the SARS-CoV-2 virus\u003c/p\u003e \u003cp\u003eFor the main measures, all participants filled in the following questionnaires:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eBehavior Rating Inventory of Executive Functions (BRIEF).\u003c/em\u003e The BRIEF is a behavioral rating measure for children and youth aged 5\u0026ndash;18 years, which aims to measure EF as expressed in daily life situations (for example: \u0026ldquo;becomes upset with new situations\u0026rdquo;; \u0026ldquo;has a messy desk\u0026rdquo;; \u0026ldquo;is disturbed by change of teacher or class\u0026rdquo;; \u0026ldquo;does not check work for mistakes\u0026rdquo;; \u0026ldquo;has trouble concentrating on chores, schoolwork\u0026rdquo;). The BRIEF includes 86 items summarized into two indexes: the Behavioral Regulation Index (BRI), which includes inhibition, shifting, and emotional control scales; and the Metacognition Index (MI), which includes initiation, working memory, planning, organization of materials, and monitoring scales. The BRI and MI scores are combined to generate a Global Executive Composite (GEC) score. In the present study we used the BRIEF parents\u0026rsquo; report. Parents rate how frequently the child expresses the behavior described in each item on a Likert scale ranging from 1 (infrequently) to 3 (often), such that higher scores indicate lower EF. All raw scores are converted to standard scores. A standard GEC score of 65 indicates deficiencies in executive functions. The BRIEF is considered to have good psychometric properties [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThe State-Trait Anxiety Inventory for Children (STAIC)\u003c/em\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The STAIC comprises two indexes: the STAIC T-Anxiety scale, designed to measure a general proneness to anxious behavior rooted in the personality, and the STAIC S-Anxiety scale, which measures anxiety as a fleeting emotional state. The two indexes each include twenty statements that ask, respectively, how the child generally feels (trait anxiety), and how the child feels at a particular moment in time (state anxiety). Higher mean scores represent lower anxiety.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThe Child and Adolescent Scale of Participation (CASP)\u003c/em\u003e [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This scale measures the extent to which children participate in home, school, and community activities compared to children of the same age as reported by family caregivers. The CASP was developed as part of the Child and Family Follow-up Survey (CFFS) to monitor outcomes and needs of children with traumatic and other acquired brain injuries [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The content and methods used in the CASP and CFFS were informed by the International Classification of Functioning, along with other research addressing the social participation of children and youth with a range of disabilities. The CASP consists of 20 ordinal-scaled items in four subsections: home participation (6 items), community participation (4 items), school participation (5 items), and home and community living activities (5 items) (sample items can be found in the \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eResults\u003c/span\u003e section, under Correlations). All items are rated on a four-point scale: \u0026ldquo;age expected (full participation),\u0026rdquo; \u0026ldquo;somewhat restricted,\u0026rdquo; \u0026ldquo;very restricted,\u0026rdquo; and \u0026ldquo;unable\u0026rdquo; (with a \u0026ldquo;not applicable\u0026rdquo; option for activities in which the child would not be expected to participate due to age, such as work). Most items are applicable to children aged five and older. Higher scores reflect greater age-expected participation. The CASP has reported evidence of test re-test reliability (Intraclass Correlation Coefficient\u0026thinsp;=\u0026thinsp;0.94), internal consistency (α\u0026thinsp;\u0026ge;\u0026thinsp;0.96), and construct and discriminant validity.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThe Pediatric Quality of Life Inventory (PedsQL(\u003c/em\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. We used Version 4.0 of the child\u0026rsquo;s report, which profiles children\u0026rsquo;s Health-Related Quality of Life (HRQoL) in four dimensions: physical functioning (eight items), emotional functioning (five items), social functioning (five items), and school functioning (five items). Emotional and social functioning are considered together in a higher-order dimension of psychosocial health. The child indicates the frequency of problems during the past month on a five-point Likert scale (0\u0026thinsp;=\u0026thinsp;never a problem; 1\u0026thinsp;=\u0026thinsp;almost never a problem; 2\u0026thinsp;=\u0026thinsp;sometimes a problem; 3\u0026thinsp;=\u0026thinsp;often a problem; 4\u0026thinsp;=\u0026thinsp;almost always a problem). Items are then transformed into a 0\u0026ndash;100-point scale (0\u0026thinsp;=\u0026thinsp;100; 1\u0026thinsp;=\u0026thinsp;75; 2\u0026thinsp;=\u0026thinsp;50; 3\u0026thinsp;=\u0026thinsp;25; 4\u0026thinsp;=\u0026thinsp;0) to produce the HRQoL percentage. A higher percentage indicates a better HRQoL.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eData was analyzed using SPSS-25 software. Descriptive statistics were calculated for all measures. Normality tests revealed normal distribution for most scales. Chi square analysis was used to test for significant differences between groups in relevant socio-demographic parameters, followed by z-tests where required. T-tests were used to test for differences between the groups in age and in total scores, while MANOVA was used to test for differences in the various subscales. Correlations between measures were examined using Pearson\u0026rsquo;s correlation test. Finally, stepwise linear regression was performed to examine the relative contribution of migraine severity, EFs, anxiety, and social participation to each of the QoL domains. Significance levels were adjusted to account for multiple testing for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFor each of the main variables, we first report the results between the two main groups (children with migraine vs. healthy controls) without regard to whether or not they had contracted COVID-19. We then report comparisons between relevant subgroups.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions\u003c/h2\u003e \u003cp\u003eThe majority of children from both main groups (children with migraine and healthy controls) had normal BRIEF scores (86.2% of the former and 84.6% of the latter). Hence, no significant differences were found between the two main groups in total BRIEF scores. However, when comparing mean scores for the BRIEF subscales, healthy controls showed slightly lower initiation than children with migraine (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparing EF (BRIEF scores) between children with migraine and healthy controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eChildren with migraine\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eHealthy controls\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRIEF scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF(1,65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.96\u0026thinsp;\u0026plusmn;\u0026thinsp;9.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.56\u0026thinsp;\u0026plusmn;\u0026thinsp;11.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u0026ndash;81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.224\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShifting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.76\u0026thinsp;\u0026plusmn;\u0026thinsp;12.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026ndash;88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.74\u0026thinsp;\u0026plusmn;\u0026thinsp;10.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u0026ndash;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.07\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitiation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e48.80\u0026thinsp;\u0026plusmn;\u0026thinsp;8.32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e36\u0026ndash;65\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e50.69\u0026thinsp;\u0026plusmn;\u0026thinsp;10.70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e35\u0026ndash;77\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e5.263\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.76\u0026thinsp;\u0026plusmn;\u0026thinsp;11.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlanning and organization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.23\u0026thinsp;\u0026plusmn;\u0026thinsp;12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026ndash;82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.53\u0026thinsp;\u0026plusmn;\u0026thinsp;9.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.838\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.363\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization of material\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.46\u0026thinsp;\u0026plusmn;\u0026thinsp;11.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u0026ndash;71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.15\u0026thinsp;\u0026plusmn;\u0026thinsp;11.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u0026ndash;71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.358\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.36\u0026thinsp;\u0026plusmn;\u0026thinsp;10.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.79\u0026thinsp;\u0026plusmn;\u0026thinsp;12.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.16\u0026thinsp;\u0026plusmn;\u0026thinsp;11.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.58\u0026thinsp;\u0026plusmn;\u0026thinsp;11.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.43\u0026thinsp;\u0026plusmn;\u0026thinsp;13.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026ndash;99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.23\u0026thinsp;\u0026plusmn;\u0026thinsp;12.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u0026ndash;86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGEC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.16\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.43\u0026thinsp;\u0026plusmn;\u0026thinsp;11.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.851\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBRI\u0026thinsp;=\u0026thinsp;Behavioral Regulation Index, MI\u0026thinsp;=\u0026thinsp;Metacognition Index, GEC\u0026thinsp;=\u0026thinsp;Global Executive Composition, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, BRIEF\u0026thinsp;=\u0026thinsp;Behavior Rating Inventory of Executive Function\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions in children with migraine vs. healthy controls (participants who did not contract COVID-19)\u003c/h2\u003e \u003cp\u003eIn children who did not contract COVID-19, emotional control was significantly worse in children with migraine (57.77\u0026thinsp;\u0026plusmn;\u0026thinsp;11.97) compared to healthy controls (45.72\u0026thinsp;\u0026plusmn;\u0026thinsp;9.46) (F1,53\u0026thinsp;=\u0026thinsp;6.42, p\u0026thinsp;=\u0026thinsp;.014). Children with migraine also scored significantly worse on the organization of materials scale (52.51\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69) compared to healthy controls (46.71\u0026thinsp;\u0026plusmn;\u0026thinsp;11.88) (F1,53\u0026thinsp;=\u0026thinsp;3.98, p\u0026thinsp;=\u0026thinsp;.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions in children with migraine vs. healthy controls (participants who contracted COVID-19)\u003c/h2\u003e \u003cp\u003eHere an opposite trend was found: among children who had contracted COVID-19, healthy controls scored significantly worse than children with migraine in two of the BRIEF scales: inhibition (56.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56 vs 45.71\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12 for the controls and migraine group, respectively) (F1,53\u0026thinsp;=\u0026thinsp;7.81, p\u0026thinsp;=\u0026thinsp;.013) and initiation (60.01\u0026thinsp;\u0026plusmn;\u0026thinsp;11.89 vs 46.01\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54, respectively) (F1,53\u0026thinsp;=\u0026thinsp;10.76, p\u0026thinsp;=\u0026thinsp;.005). In addition, healthy children scored worse in the overall metacognition index (65.83\u0026thinsp;\u0026plusmn;\u0026thinsp;14.48 vs 46.75\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19, respectively (F1,53\u0026thinsp;=\u0026thinsp;11.77, p\u0026thinsp;=\u0026thinsp;.003).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions in healthy children who did vs. did not contract COVID-19\u003c/h2\u003e \u003cp\u003eHealthy children who contracted COVID-19 had significantly worse initiation and working memory compared to those who did not contract the disease (initiation: 60.01\u0026thinsp;\u0026plusmn;\u0026thinsp;11.89 vs 46.81\u0026thinsp;\u0026plusmn;\u0026thinsp;8.89, F\u0026thinsp;=\u0026thinsp;8.74, p\u0026thinsp;=\u0026thinsp;.007; working memory: 61.16\u0026thinsp;\u0026plusmn;\u0026thinsp;15.48 vs 47.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.06, F\u0026thinsp;=\u0026thinsp;6.13, p\u0026thinsp;=\u0026thinsp;.021).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions in children with migraine who did vs. did not contract COVID-19\u003c/h2\u003e \u003cp\u003eAmong the children with migraine, the only significant difference between those who did vs. did not contract COVID-19 was found in monitoring. Monitoring was worse in children who did not contract COVID-19 (53.47\u0026thinsp;\u0026plusmn;\u0026thinsp;10.48 vs 43.41\u0026thinsp;\u0026plusmn;\u0026thinsp;6.64) (F\u0026thinsp;=\u0026thinsp;8.56, p\u0026thinsp;=\u0026thinsp;.007).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAnxiety\u003c/h2\u003e \u003cp\u003eLooking only at the two main groups (i.e., ignoring COVID-19 status), children with migraine had significantly higher state anxiety than healthy controls.\u003c/p\u003e \u003cp\u003eWe next compared anxiety within each of the two main groups by COVID-19 status. Among healthy children, we found differences between those who did vs. did not contract COVID-19 in both anxiety measures. Specifically, the COVID\u0026ndash;yes group had significantly lower state anxiety compared to the COVID\u0026ndash;no group (mean state\u0026thinsp;=\u0026thinsp;1.86, SD\u0026thinsp;=\u0026thinsp;.33 vs mean state\u0026thinsp;=\u0026thinsp;2.34, SD\u0026thinsp;=\u0026thinsp;.27, respectively, F \u003csub\u003e1,30\u003c/sub\u003e=18.64, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), but higher trait anxiety (mean trait\u0026thinsp;=\u0026thinsp;2.11, SD\u0026thinsp;=\u0026thinsp;.62 vs. mean trait\u0026thinsp;=\u0026thinsp;1.34, SD\u0026thinsp;=\u0026thinsp;.38, respectively). By contrast, among children with migraine, there were no significant differences between the COVID subgroups in either state anxiety (mean\u0026thinsp;=\u0026thinsp;2.41, SD\u0026thinsp;=\u0026thinsp;.48 vs mean\u0026thinsp;=\u0026thinsp;2.26, SD\u0026thinsp;=\u0026thinsp;.31) or trait anxiety (mean\u0026thinsp;=\u0026thinsp;1.69, SD\u0026thinsp;=\u0026thinsp;.38 vs mean\u0026thinsp;=\u0026thinsp;1.74, SD\u0026thinsp;=\u0026thinsp;.43).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSocial participation\u003c/h2\u003e \u003cp\u003eNo significant differences were found between children with migraine and healthy controls. In addition, no significant impact of contracting COVID-19 was found in either group: children did not differ based on COVID status in any of the participation scales.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003eChildren with migraine had lower QoL than healthy controls in all measured domains. Significant differences between the groups were found in physical, emotional, and school-related QoL (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between executive functions (BRIEF) and social participation (CASP) among children with migraine\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eCASP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunity living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRIEF scores (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShifting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er=-.547*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er=-.539*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er=-.550*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er=-.526*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er=-.537*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlanning and organization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization of material\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er=-.740**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er=-.716**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er=-.463*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er=-.472*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.514*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGEC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er=-.456*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er=-.465*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedsQL scores (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.469*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.461*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.552**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.603**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.585**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsycho-social\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.518*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.546**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.477*\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u0026thinsp;=\u0026thinsp;.535**\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNS\u0026thinsp;=\u0026thinsp;Not Significant, BRI\u0026thinsp;=\u0026thinsp;Behavioral Regulation Index, MI\u0026thinsp;=\u0026thinsp;Metacognition Index, GEC\u0026thinsp;=\u0026thinsp;Global Executive Composition, BRIEF\u0026thinsp;=\u0026thinsp;Behavior Rating Inventory of Executive Function, CASP\u0026thinsp;=\u0026thinsp;Child and Adolescent Scale of Participation, PedsQL\u0026thinsp;=\u0026thinsp;Pediatric Quality of Life Inventory\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo significant interaction was found between main group and COVID-19 status. Within both the migraine and control groups, children who did vs. did not contract COVID-19 did not differ in any of the QoL domains.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to compare executive functions, anxiety, social participation, and quality of life between children with migraine and healthy controls; to explore relationships between the examined factors among children with migraine; and to examine the implications of contracting COVID-19 for the examined factors. We hypothesized that (1) children with migraine would have significantly lower EF, higher anxiety, lower participation and lower QoL than healthy controls; (2) children with migraine who contracted COVID-19 would have the lowest EF, highest anxiety, lowest participation, and lowest QoL of the four groups; (3) among children with migraine, significant correlations would be found between migraine severity and the four main variables; and (4) migraine severity, EF, anxiety, and participation would significantly predict QoL.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eExecutive functions in pediatric migraine\u003c/h2\u003e \u003cp\u003eOur first hypothesis was largely supported. Looking only at the presence or absence of migraine and ignoring COVID-19 status, we found that migraine patients had worse executive functions, particularly in the emotional control and organization of materials scales. We also found that EF as measured by the BRIEF scale correlated with quality of life.\u003c/p\u003e \u003cp\u003ePrevious research has shown that individuals suffering from migraine may experience difficulties in various cognitive domains and executive functions. These studies have found challenges with selective and divided attention, working memory, short- and long-term verbal memory, information processing speed, cognitive flexibility and inhibitory control in individuals with migraine compared to healthy individuals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Several mechanisms have been postulated to account for such executive function deficits in individuals with migraine. One theory proposes that disruptions in brain networks and changes in cerebral blood flow during migraine attacks could contribute to the impairment of executive functioning. The coexistence of migraine with other conditions known to impact executive functions, like anxiety and depression, may exacerbate these deficits even further [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. There is also evidence that individuals with migraine may still exhibit cognitive impairments even during headache-free intervals, including executive function deficits. This suggests that the cognitive effects of migraine are not solely attributable to acute headache symptoms but may involve underlying neurobiological and neurochemical mechanisms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, cognitive and EF impairments observed in individuals with migraine can have substantial consequences on their daily functioning, academic achievement, and overall quality of life, especially among children and adolescents. However, most studies about EF in children with migraine have used neuropsychological tests [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our study used the BRIEF \u0026ndash; an ecologically valid evaluation that reflects how EFs are expressed in daily life, and therefore conveys information about the implications of EF deficits outside the clinic setting. Understanding these real-life challenges may support the development of improved interventions aimed at meeting the child\u0026rsquo;s and family\u0026rsquo;s specific needs, and so improve both daily functioning and wellbeing [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePediatric migraine, anxiety, and social participation\u003c/h2\u003e \u003cp\u003eIn the current research, the most significant difference between children with migraine and healthy children was in emotional regulation. In this area, the BRIEF questionnaire includes questions related to exaggerated emotional responses, frequent mood changes, and irritability. Migraine is a disease associated with anxiety and emotional difficulties. Many studies have found stress to be the most common trigger for headaches, particularly stress related to school [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These studies may explain the clear connection found between migraines and emotional regulation. Difficulty in emotional regulation contributes to difficulties in behavioral control, and may affect the functioning and quality of life of children with migraines [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Therefore, emotional regulation is a central target for intervention.\u003c/p\u003e \u003cp\u003eIn our study, children with migraine had significantly higher state anxiety than healthy controls, although no significant differences were found in social participation between children with migraine and healthy controls. This may reflect the relatively small sample size, as well as the unique effects of the COVID-19 pandemic, which restricted social interaction. Given that social participation is a critical factor in children\u0026rsquo;s development and wellbeing, future studies should examine this question in larger samples.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePediatric migraine and quality of life\u003c/h2\u003e \u003cp\u003eThe other main outcome of the present study was that children with migraine had lower quality of life in various domains as compared to healthy controls. This finding is supported by previous reports. For example, Powers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] found that migraine may reduce children\u0026rsquo;s QoL, and that this impact may differ by age group: teens reported lower school functioning than older and younger children, and younger children reported lower social functioning than older children and teens. Physical complaints as well as mental problems can adversely affect a patient\u0026rsquo;s quality of life [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This may be reflected directly by children\u0026rsquo;s self-reports, as found in our study. The present study is the first, to our knowledge, to find a correlation between the reduction in social quality of life in children with migraine and the PedMIDAS score.\u003c/p\u003e \u003cp\u003eWith respect to the association between school-related quality of life and the severity of migraines, the current findings partially support our third and fourth hypotheses. This finding is also in keeping with the existing literature. Numerous studies have found reciprocal relationships between migraines and school functioning, with school-related factors both triggering migraines and influenced by them [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Attendance and participation in school play a significant role in children\u0026rsquo;s lives, impacting their overall development, self-confidence, and self-esteem. Absence from elementary school significantly reduces current and future academic performance [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Involvement in school improves students\u0026rsquo; attitudes toward learning and their academic achievement [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], enhances students\u0026rsquo; emotional and social skills [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and predicts a lower risk of drug use and delinquency [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, it is essential to find alternatives or accommodations for children who are absent from school or unable to participate while at school due to migraines. Future studies should continue how technology, including videoconferencing software such as Zoom, can allow children to participate in the educational process at school even if they are at home [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEffects of the COVID-19 pandemic on children with migraine\u003c/h2\u003e \u003cp\u003eOur study, conducted during the COVID-19 epidemic, explored the influence of this unique period on pediatric migraine headaches. We found no worsening of headaches during the pandemic among children with migraine. Moreover, our second hypothesis \u0026ndash; positing that children with migraine who contracted COVID-19 would have the worst outcomes \u0026ndash; was not supported. Interestingly, the only significant difference between children with migraine who did vs. did not contract COVID-19 was in was the monitoring scale of the BRIEF, with monitoring being worse in children who did not contract COVID-19. A similar pattern was seen when we measured quality of life: among participants who contracted COVID-19, quality of life was lower only among the control group, but not among the migraine patients.\u003c/p\u003e \u003cp\u003eAnother interesting finding is that among all groups, children who did not contract COVID-19 had lower EF and higher anxiety rates compared to those who did develop COVID-19 symptoms. This finding may suggest that, among children, fear and worry about COVID-19 typically had a more deleterious effect than contracting the disease itself.\u003c/p\u003e \u003cp\u003eThe influence of the COVID-19 pandemic on headache is a matter of debate. Al-Hashel [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] reported that the COVID-19 pandemic had a predominantly negative effect on adults with migraine, highlighting the need to identify risk factors associated with poorer outcomes. Reyes-Alvarez et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] investigated 243 migraine patients, who responded to questions covering quarantine circumstances, alterations in working conditions, as well as symptoms of anxiety, depression, and fear of COVID-19. About half the migraine patients they surveyed reported a deterioration in symptoms, while about a third experienced no change in their migraine symptoms.\u003c/p\u003e \u003cp\u003eAccording to Caronna et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], approximately 50% of patients with headaches attributed to SARS-CoV-2 infection perceived the acute headache phase to be more severe than their typical migraine. Additionally, patients who experienced headaches during the acute phase of the infection showed higher rates of migraine exacerbation compared to those who did not. Fern\u0026aacute;ndez-de-las-Pe\u0026ntilde;as et al. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] found that six months after contracting COVID-19, approximately 60% of patients with a pre-existing history of migraine reported an increase in headache frequency, and around 20% reported an increase in headache intensity. Membrilla et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] observed that patients with a history of migraine tend to experience longer and more intense headaches in the context of COVID-19, with these symptoms often manifesting earlier compared to individuals without a history of migraines. However, some studies investigating the presence of headaches in individuals with COVID-19 fail to clearly distinguish between those who had pre-existing primary headache disorders and those who did not, leading to uncertainty when assessing their connection [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is well-known that lifestyle and behavioral factors can influence the trajectory of migraine attacks. The COVID-19 pandemic introduced unprecedented circumstances, including the implementation of lockdown measures, which significantly impacted people\u0026rsquo;s behaviors. A large study examining the effects of restrictions during the pandemic [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that brief periods of lockdown had the potential to improve certain measures related to migraines and overall wellbeing \u0026ndash; perhaps a function of factors such increased ability to work from home, reduced demands from social activities, greater freedom to organize one\u0026rsquo;s own time. Likewise,\u003c/p\u003e \u003cp\u003eDelussi et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] found that individuals with migraine experienced an improvement in their headaches and reduced their use of medication during lockdown periods, particularly among those with lower depressive symptom scores. Apetti et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported a similar trend, observing that primary headache disorders generally improved during lockdown, even among pediatric patients. The researchers attributed these positive outcomes to lifestyle modifications, particularly reductions in school-related stress.\u003c/p\u003e \u003cp\u003eConsidering the effects of COVID restrictions, Caronna et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported varying results. While some patients they studied experienced improvement during lockdown, others found no significant difference or even a worsening of their usual headaches, accompanied by an increase in medication intake. These negative effects were often associated with sleep disturbances, anxiety, and depression.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe research findings are based on a convenience sample with a small number of participants. Additionally, the groups were not completely matched in terms of socio-demographic measures. Finally, we did not examine other parameters that could affect quality of life and executive functions, such as anxiety, depression, stress, and behavioral disorders, which are known to be common in patients with migraines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn our study, children with migraine exhibited higher anxiety and lower executive functions than healthy controls. Their reduced EF correlated with lower quality of life and with the intensity of the headache attacks. The COVID-19 pandemic did not have a clear worsening effect on migraine patients, as it had on the control group. Further research on pediatric migraine and its relationship with different aspects of the COVID-19 pandemic period is warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.G. H.S. N.C. A.H. and B.E.Y. . were involved in planning and supervised the work,J.G. Z.H. A.S. K.N. and H.S. processed the , performed the analysis, .G. H.S. N.C. A.H. and B.E.Y drafted the manuscript anddesigned the tables. .J.G. Z.H. A.S. K.N. and H.S. aided in interpreting the results and worked on the manuscript. All authors discussed the results and commented on the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGenizi J, Srugo I, Kerem NC (2013) The cross-ethnic variations in the prevalence of headache and other somatic complaints among adolescents in Northern Israel\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e J Headache Pain 14(1): 21\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eAl-Twaijri WA, Shevell MI (2002) Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatr Neurol 26: 365\u0026ndash;368.\u003c/li\u003e\n\u003cli\u003ePowers SW, Patton SR, Hommel KA, Hershey AD (2003) Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics 112(1 Pt 1):e1\u0026ndash;5 doi: 10.1542/peds.112.1.e1 12.\u003c/li\u003e\n\u003cli\u003eRiva D, Aggio F, Vago C (2006). Cognitive and behavioral effects of migraine in childhood and adolescence. Cephalalgia 26:596\u0026ndash;603.\u003c/li\u003e\n\u003cli\u003eBonuccelli A, Depietri G, Baldaccini T, Ricciutelli I, Peroni D, Spalice A, Massimetti G, Morganti R, Orsini A, Striano P (2023) Essential headaches in developmental age: what is changed before, during and after the lockdown for COVID-19 pandemic. Clinical study. Front Pediatr 11:1166984.\u003c/li\u003e\n\u003cli\u003eDedeoglu \u0026Ouml;, Konuşkan B (2023). Triggers and clinical changes of childhood primary headache characteristics during COVID-19 pandemic lockdown. Acta Neurol Belg 23(1):215\u0026ndash;220.\u003c/li\u003e\n\u003cli\u003eCaronna E, van den Hoek TC, Bolay H, Garcia-Azorin D, Gago-Veiga AB, Valeriani M, Takizawa T, Messlinger K, Shapiro RE, Goadsby PJ, Ashina M, Tassorelli C, Diener HC, Terwindt GM, Pozo-Rosich P (2023) Headache attributed to SARS-CoV-2 infection, vaccination and the impact on primary headache disorders of the COVID-19 pandemic: a comprehensive review. Cephalalgia 43(1):3331024221131337.\u003c/li\u003e\n\u003cli\u003eApetti L, Loro PA, Di, Tarantino S, et al (2020) I stay at home with headache. A survey to investigate how the lockdown for COVID-19 impacted on headache in Italian children. Cephalalgia 40:1459\u0026ndash;1473.\u003c/li\u003e\n\u003cli\u003eVerhagen IE, van Casteren DS, de Vries Lentsch S, et al (2021) Effect of lockdown during COVID-19 on migraine: a longitudinal cohort study. Cephalalgia 41:865\u0026ndash;870.\u003c/li\u003e\n\u003cli\u003eReyes-Alvarez MT, Bancalari E, Santana Vargas AD, Velez K, Rodr\u0026iacute;guez-Leyva I, Marfil A, Miranda S, Zegarra-Valdivia JA (2023) Impact of COVID-19 pandemic lockdown on migraine patients in Latin America. Int J Environ Res Public Health 20(4):3598. Headache Classification Committee of the International Headache Society (HIS) (2018) The International Classification of Headache Disorders, 3\u003csup\u003erd\u003c/sup\u003e Edition. Cephalalgia 38:1\u0026ndash;211.\u003c/li\u003e\n\u003cli\u003eHershey AD, Powers SW, Vockell AL, LeCates S, Kabbouche MA, Maynard MK (2001) PedMIDAS: development of a questionnaire to assess disability of migraines in children. Neurology 57(11):2034\u0026ndash;2039.\u003c/li\u003e\n\u003cli\u003eIsquith, P. K., Roth, R. M., \u0026amp; Gioia, G. (2013). Contribution of rating scales to the assessment of executive functions. Applied Neuropsychology: Child, \u003cem\u003e2\u003c/em\u003e(2), 125-132.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e \u003c/li\u003e\n\u003cli\u003eHendrickson NK, McCrimmon AW (2019) Test Review: Behavior Rating Inventory of Executive Function\u0026reg;, Second Edition (BRIEF\u0026reg;2) by Gioia, G. A.,\u003c/li\u003e\n\u003cli\u003eIsquith, P. K., Guy, S. C., \u0026amp; Kenworthy, L. Canadian Journal of School Psychology 34(1):73\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eGioia GA, Isquith PK, Guy SC, Kenworthy L (2000) Behavior Rating Inventory of Executive Function: BRIEF. Child Neuropsychology, 6, 235-238.\u003c/li\u003e\n\u003cli\u003eMcGill RJ, Snow JH (2021) Behavior Rating Inventory of Executive Function, Second Edition. The Twenty-First Mental Measurements Yearbook https://search-ebscohost-com.ezproxy.haifa.ac.il/login.aspx?direct=true\u0026amp;db=loh\u0026amp;AN=test.8651\u0026amp;site=eds-live\u0026amp;scope=site\\\u003c/li\u003e\n\u003cli\u003eSpielberger CD, Edwards CD, Montouri J, Lushene R (1973) State-Trait Anxiety Inventory for Children (STAI-CH) [Database record]. APA PsycTests. https://doi.org/10.1037/t06497-000\u003c/li\u003e\n\u003cli\u003eGary Bedell (2009) Further validation of the Child and Adolescent Scale of Participation (CASP), Developmental Neurorehabilitation, 12:5, 342-351. \u003c/li\u003e\n\u003cli\u003eVarni JW, Seid M, Kurtin PS. (2001) PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 39: 800\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eWaldie K, Hausmann M, Milne B, Poulton R (2002) Migraine and cognitive function: a life-course study. Neurology 59:904\u0026ndash;908.\u003c/li\u003e\n\u003cli\u003eVilla T, Correa Moutran A, Sobirai Diaz L (2009) Visual attention in children with migraine: a controlled comparative study. Cephalalgia 29:631\u0026ndash;634.\u003c/li\u003e\n\u003cli\u003eCosta-Silva MA, Prado ACA, de Souza LC, Gomez RS, Teixeira AL (2016) Cognitive functioning in adolescents with migraine. Dement Neuropsychol 10(1):47\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eMartins IP, Gil-Gouveia R, Silva C, Maruta C, Oliveira AG (2012) Migraine, headaches, and cognition. Headache. 52(10):1471\u0026ndash;1482.\u003c/li\u003e\n\u003cli\u003eVuralli D, Ayata C, Bolay H (2018) Cognitive dysfunction and migraine. J Headache Pain 19:109.\u003c/li\u003e\n\u003cli\u003eKaiser Pinotti L, Castro ADS, de Oliveira Garcia GH, Alvim PHP, Roza TH, Andrade FA, Kowacs PA, Massuda R (2023) Executive functions in migraine patients: a systematic review with meta-analysis. Cogn Neuropsychiatry 28(1):52\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eRist PM, Kurth T (2013) Migraine and cognitive decline: a topical review. Headache 53(4):589\u0026ndash;598.\u003c/li\u003e\n\u003cli\u003eGioia GA, Isquith PK, Retzlaff PD, Espy KA (2002) Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a clinical sample. Child Neuropsychol 8(4):249\u0026ndash;257.\u003c/li\u003e\n\u003cli\u003eColombo B, Cetta I, Messina R, Filippi M. Stress in paediatric migraine: a trigger factor? Neurol Sci. 2020 Dec;41(Suppl 2):447-449.\u003c/li\u003e\n\u003cli\u003eSolotareff L, Cuvellier JC, Duhamel A, Vall\u0026eacute;e L, Tich SNT. (2017) Trigger Factors in Childhood Migraine: A Prospective Clinic-Based Study From North of France. J Child Neurol. 32(8):754-758.\u003c/li\u003e\n\u003cli\u003eGuidetti V, Cerutti R, Faedda N, Natalucci G. Migraine in childhood: an organic, biobehavioral, or psychosomatic disorder? Neurol Sci. 2019 May;40(Suppl 1):93-98.\u003c/li\u003e\n\u003cli\u003ePowers SW, Patton SR, Hommel KA, Hershey AD (2004) Quality of life in paediatric migraine: characterization of age-related effects using PedsQL 4.0. Cephalalgia 24:120\u0026ndash;127.\u003c/li\u003e\n\u003cli\u003eCavallini A1, Micieli G, Bussone G, Rossi F, Nappi G (1995) Headache and quality of life. Headache 35:29\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eGuthrie E, Jackson J, Shaffer J, Thompson D, Tomenson B, Creed F (2002) Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn\u0026rsquo;s disease. Am J Gastroenterol 97:1994\u0026ndash;1999.\u003c/li\u003e\n\u003cli\u003eGazerani P. Migraine and Mood in Children. (2021) Behav Sci (Basel). 14;11(4):52.\u003c/li\u003e\n\u003cli\u003eSarah Cattan, Daniel A Kamh\u0026ouml;fer, Martin Karlsson, Therese Nilsson. (2023) The Long-Term Effects of Student Absence: Evidence from Sweden, The Economic Journal. 133, 650, 888\u0026ndash;903.\u003c/li\u003e\n\u003cli\u003eErdoğdu, M. Y. (2019). The mediating role of school engagement in the relationship between attitude toward learning and academic achievement. International Journal of Education and Literacy Studies, 7(2), 75-81.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eDurlak JA, Weissberg RP, Dymnicki AB, Taylor RD, Schellinger KB. (2011) The impact of enhancing students\u0026apos; social and emotional learning: a meta-analysis of school-based universal interventions. Child Dev. Jan-;82(1):405-32.\u003c/li\u003e\n\u003cli\u003eLi Y, Zhang W, Liu J, Arbeit MR, Schwartz SJ, Bowers EP, Lerner RM. (2011) The role of school engagement in preventing adolescent delinquency and substance use: a survival analysis. J Adolesc.;34(6):1181-92.\u003c/li\u003e\n\u003cli\u003eZhang F, Litson K, Feldon DF. (20220 Social predictors of doctoral student mental health and well-being. PLoS One. 9;17(9):e0274273.\u003c/li\u003e\n\u003cli\u003eAl-Hashel JY, Ismail II (2020) Impact of coronavirus disease 2019 (COVID-19) pandemic on patients with migraine: a web-based survey study. J Headache Pain 21(1):115.\u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez-de-las-Pe\u0026ntilde;as C, G\u0026oacute;mez-Mayordomo V, Cuadrado ML, et al (2021) The presence of headache at onset in SARS-CoV-2 infection is associated with long-term post-COVID headache and fatigue: a case-control study. Cephalalgia 41:1332\u0026ndash;1341.\u003c/li\u003e\n\u003cli\u003eMembrilla JA, de Lorenzo \u0026Iacute;, Sastre M, et al (2020) Headache as a cardinal symptom of coronavirus disease 2019: a cross-sectional study. Headache 60:2176\u0026ndash;2191.\u003c/li\u003e\n\u003cli\u003eDelussi M, Gentile E, Coppola G, et al (2020) Investigating the effects of COVID-19 quarantine in migraine: an observational cross-sectional study from the Italian National Headache Registry (RICe). Front Neurol 11: 597881.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"executive function, anxiety, participation, quality of life, children, headache, migraine.","lastPublishedDoi":"10.21203/rs.3.rs-3890999/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3890999/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To compare executive functions (EF), anxiety, social participation, and quality of life (QoL) between children with migraine and healthy controls during the COVID-19 pandemic, and to examine these parameters in children in each group who did vs. did not contract COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMigraine is among the most prevalent headache disorders in children, especially in adolescents. Migraine is exacerbated by stress, and it holds potential to affect patients’ emotional and cognitive state and, by extension, their functioning and wellbeing – parameters that were also affected by the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e A prospective cohort study. The patient group comprised children seen in our pediatric neurology clinic for migraine, and the control group was composed of aged-matched healthy children with no neurological findings or developmental disorders. Participants’ parents completed a health and demographic questionnaire, BRIEF (child/adolescent version), PedsQL, the State-Trait Anxiety Inventory for Children (STAIC) and CASP. Participants or their parents furnished information on whether the participant had contracted COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 84 children and adolescents aged 6–17.5 participated in the study: 33 with migraine (17 boys, 16 girls); 51 healthy controls (28 boys, 23 girls). Children with migraine showed significantly lower EF due to reduced behavioral regulation, higher trait anxiety, and lower physical, emotional, and school related QoL. Reduced EFs correlated with intensity of migraine attacks, higher anxiety, reduced social participation, and reduced QoL. Lower social participation correlated with reduced QoL and predicted emotional and social QoL. The BRIEF metacognition scale predicted school-related QoL. Healthy children who contracted COVID-19 showed significantly lower EF than children with migraine in the inhibition (56.66±10.56 vs 45.71±7.12-, p=.013) and initiation (60.01±11.89 vs 46.01±6.54, p=.005) BRIEF scales, and in the general metacognition index (65.83±14.48 vs 46.75±9.19, p=.003).\u003c/p\u003e\n\u003cp\u003eHealthy children who contracted COVID-19 had significantly worse initiation and working memory compared to those who did not contract COVID-19 (initiation: 60.01±11.89 vs 46.81±8.89, p=.007), working memory: 61.16±15.48 vs 47.21±11.06, p=.021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Migraine has a significant negative impact on executive functions in children and adolescents, even more than contracting COVID-19. Executive dysfunction influences their emotional state, participation in social activities, and quality of life. The COVID-19 pandemic had a less deleterious effect on migraine patients compared to the healthy control group. Further research on pediatric migraine is warranted.\u003c/p\u003e","manuscriptTitle":"Executive Functions, Anxiety, Social Participation and Quality of Life in Children with Migraine During COVID-19","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-30 06:48:00","doi":"10.21203/rs.3.rs-3890999/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6862286-6ff5-44f2-b0b7-3c790bbd8949","owner":[],"postedDate":"January 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-23T10:37:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-30 06:48:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3890999","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3890999","identity":"rs-3890999","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}