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PedMIDAS Development of a questionnaire to assess disability of migraines in children

PedMIDAS Development of a questionnaire to assess disability of migraines in children - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related

Development of a questionnaire to assess disability of
migraines in children
A.D. Hershey, MD, PhD; S.W. Powers, PhD; A.-L.B. Vockell, RN, MSN, CPNP;
S. LeCates, RN, MSN, CFNP; M.A. Kabbouche, MD; and M.K. Maynard, BS
Article abstract—Background: For adults, disability produced by migraines has been assessed with a migraine-specific
disability tool—MIDAS. The objective of this study was to develop and validate a similar tool that accurately depicts the
disability of headaches in school-age children and adolescents. Methods: A six-question tool (PedMIDAS) was developed
and administered to patients attending a tertiary referral center for pediatric headaches. Internal consistency and
test/retest reliability were assessed. Validity was assessed by correlating scores with headache frequency, severity, and
duration. Changes in the total score in response to treatment were assessed in a portion of the patients. Results: The
PedMIDAS questionnaire was administered to 441 patients for a total of 724 trials. The mean score at the initial visit was
44.3 � 47.9, whereas the overall mean score was 25.1 � 36.5. A 2-week test/retest reliability assessment for 56 patients
confirmed the stability of the instrument with a Pearson coefficient of 0.80. The correlation of the PedMIDAS score with
frequency, severity, and duration had Pearson’s coefficient values of 0.58, 0.27, and 0.23. The PedMIDAS score was
reduced to 20.0 � 32.3 (p � 0.0001) at the first follow-up assessment with subsequent continued reduction. Conclusions:
The PedMIDAS questionnaire provided a developmentally sensitive, reliable, and valid assessment of the disability of
childhood and adolescent headaches. This questionnaire provides a tool to assess the impact of migraines in children and
to monitor response to treatment. Further research should focus on additional validation of the PedMIDAS using a larger
population and sampling from other populations (e.g., primary care and community samples).
NEUROLOGY 2001;57:2034–2039
Up to 10.6% of children between the ages of 5 and 15
and 28% of adolescents between the ages of 15 and
19 may have migraine headaches.
These headaches
can impact a child’s life in multiple ways, including
restriction of school performance abilities and atten-
dance, home and family activities, and socialization
with friends. The impact may vary among attacks
depending on the severity, duration, and response to
therapy. We have previously demonstrated that
school absences can be one measure of disability in
children with headaches.
This, however, assesses
only part of the disability question.
For adults, disability has been assessed using the
Migraine Disability Assessment (MIDAS) question-
This tool assesses headache-related disabil-
ity using five questions related to missed or limited
paid work, school, or household work, and to family,
social, or leisure activities. The domains were chosen
due to the importance for adults aged 20 to 50. The
MIDAS questionnaire has been validated in popula-
tion based studies using test-retest reliability,
parison with a 90-day headache diary,
comparison to physicians’ clinical judgments of pain,
disability, and need for medical care.
The MIDAS questionnaire is limited in its useful-
ness for children and adolescents. It was developed
to quickly assess the degree of disability on an
adult’s day to day life activities. A child’s day to day
life varies greatly from that of an adult in the work-
force. School-related disability is a significant compo-
nent of a child’s quality of life. School disability can
include attendance, partial-day attendance, function-
ing at school, and the impact on homework. In addi-
tion, socialization, including both organized
activities and being with friends, is a major compo-
nent of a child’s quality of life. We present the devel-
opment of a developmentally sensitive, six-question
PedMIDAS questionnaire that can be easily adminis-
tered and understood by both parent and child to
assess the impact of recurrent headaches on a child’s
Methods. Patient population. Children were referred
by their primary care physician with limited internal re-
ferral to the Headache Center or to a general child neurol-
ogy clinic at a satellite facility for Cincinnati’s Children’s
Hospital Medical Center. At the initial evaluation, the chil-
dren and their parents were provided with a detailed ques-
Additional material related to this article can be found on the Neurology
Web site. Go to www.neurology.org and scroll down the Table of Con-
tents for the December 11 issue to find the link for this article.
From the Divisions of Neurology (Drs. Hershey and Kabbouche, and A.-L.B. Vockell and S. LeCates) and Psychology (Dr. Powers and M. Maynard),
Children’s Hospital Medical Center; and University of Cincinnati College of Medicine (Drs. Hershey, Powers, and Kabbouche), Cincinnati, OH.
Received June 1, 2001. Accepted in final form August 29, 2001.
Address correspondence and reprint requests to Dr. Andrew D. Hershey, Director, Headache Center, Division of Neurology, 3333 Burnet Avenue, Cincinnati,
OH 45229-3039; e-mail: Andrew.Hershey@CHMCC.ORG
2034 Copyright ? 2001 by AAN Enterprises, Inc.

tionnaire describing the features of their headaches as well
as their general health characteristics. The questionnaire
included the PedMIDAS questions (see the supplementary
data for this article; go to www.neurology.org) and a self-
report of the impact of the headaches on school and home
functioning as a percent of ability. The questionnaire was
completed together by the parent and child prior to the
evaluation, regardless of the child’s age. It was then re-
viewed with both the parent and child in detail at the first
clinic visit to assure accuracy of the information and assist
in medical decision making. A thorough history and gen-
eral physical and neurologic examination were performed.
The International Headache Society (IHS) criteria
and the
clinical impression were used for the headache diagnosis.
An abbreviated questionnaire, which also included the
PedMIDAS questions, was used for all subsequent visits
and reviewed with both the parent and child at the visit.
All of this information was entered into a comprehensive
computer database.
The information was entered prospec-
tively with ongoing review.
Development of the PedMIDAS questionnaire. The MI-
DAS questionnaire for adults was used as a template. A
similar 90-day time period was used. Six developmentally
appropriate questions were developed for the PedMIDAS
questionnaire by a multidisciplinary team of pediatric
headache specialists. These emphasized the impact of par-
tial days of school lost and reduction in socialization and
sport related activities. The first question (Q1) was based
on complete school days lost due to headaches. The second
question (Q2) was based on partial school days lost due to
headaches. These were days where the child either went to
school late or the parent was called to pick the child up
from school due to headaches. The third question (Q3)
related to functioning at school. The patients were asked to
report the number of school days that they functioned at
less than half of their abilities due to headaches. They
were asked not to count days that they also missed any
part of school within this count of lost functioning days.
The next question (Q4) focused on home activities, in-
cluding chores and homework, recording the number of
days that they were unable to do homework or chores at
home due to a headache. The final two questions related to
play and social activity, first (Q5) asking how many days
the child was unable to participate in play, sports, or social
activities due to headaches. The second question (Q6) re-
lated to how many of those days the child participated but
at less than 50% of full ability.
PedMIDAS was administered to patients attending the
Headache Center at Cincinnati Children’s Hospital or a
satellite clinic of Children’s Hospital Medical Center. The
patients were provided the questionnaire at their initial
visit and subsequent follow-up evaluations prior to being
seen. The PedMIDAS score was compared with some of the
headache features that are thought to contribute to the
disability of headaches. Frequency, severity, and duration
were compared using Pearson correlation coefficients. The
associated symptoms and effects of physical activity were
examined. For these comparisons, the PedMIDAS scores
were ordered lowest to highest and divided into quartiles
(lowest values represents first quartile). This was done to
differentiate the patients with the least disability (first
quartile) from those who were more severely disabled
(fourth quartile).
Internal consistency and test/retest reliability. The tool
was evaluated for internal consistency using a Cronbach’s
coefficient � assessment. Test/retest reliability was tested
on a subset of patients, who were contacted on average
14.4 � 2.1 (range 10 to 21) days after their initial evalua-
tion. This was performed by an independent investigator
(M.K.M.) from the Headache Center staff, with all ques-
tions concerning treatment or management referred to
other Headache Center staff. The patients were asked the
same six questions that they had previously answered at
the clinical visit to assess the stability of their initial
Statistics. Statistical analyses were performed with
means and standard deviations applied to z and p scores
using a normalized distribution. Pearson’s correlation coef-
ficients were used to compare series on trials and observa-
tions. A statistical standard of p � 0.01 was used
throughout the study to minimize the influence of poten-
tial interdependent variables.
Results. Patient and headache characteristics. A total
of 441 patients with a clinical diagnosis of migraine com-
pleted the PedMIDAS questionnaire. A total of 371 (84%)
of these patients met the IHS criteria for migraine or mi-
graine with aura. This difference is due to the lack of
sensitivity of the IHS criteria for migraine headaches in
Table 1 characterizes the features of these pa-
tients. The mean age at onset of headaches was 8.4 � 3.7,
whereas the mean age when the questionnaire was com-
Table 1 Patient and headache characteristics
Clinical diagnosis
of migraine
IHS diagnosis
of migraine
No. of patients 441 371
No. of trials 724 611
Male 187 162
Female 254 209
Age at trial, y
6–11 253 215
12–18 390 378
�18 52 13
Frequency at time of
�6 385 331
6–12 150 135
13–24 88 77
�24 101 68
Nausea, % 56.1 64.6
Vomiting, % 24.3 31.6
Photophobia, % 76.6 81.3
Phonophobia, % 64.8 70.3
Aggravated by physical
activity, %
67.3 77.8
IHS � International Headache Society.
December (1 of 2) 2001 NEUROLOGY 57 2035

pleted was 13.0 � 3.3. The female to male ratio was 1.4:
1.0. The racial distribution was 92.5% white, 6.3% black,
and 1.1% other. The mean headache frequency was 9.5 �
9.5 headaches per month, whereas the mean severity was
5.6 � 2.3 on a 10-point pain scale and the mean duration
was 6.2 � 11.5 hours.
Internal consistency and reliability. Internal consis-
tency. The internal consistency was assessed using a
Cronbach’s coefficient � assessment. For those patients
with a clinical diagnosis of migraine, the six questions had
a Cronbach’s coefficient � value of 0.78. For the IHS migraine
patients, the Cronbach’s coefficient � value was 0.77.
Test/retest reliability. The reproducibility of the Ped-
MIDAS questionnaire was assessed using a test/retest for-
mat. Fifty-six patients who completed the questionnaire at
their initial evaluation were contacted between 10 and 21
days after the visit (mean 14.4 � 2.1 days). The mean
frequency, severity, and duration of the headaches in these
patients were 16.1 � 10.1 headaches per month, 6.9 � 1.8
out of 10, and 10.3 � 17.2 hours. None of these values were
statistically different than the values of the entire group.
The mean PedMIDAS score at the initial evaluation was
53.1 � 47.2, whereas the mean PedMIDAS score on the
retest was 72.1 � 50.8 (not significantly different). The
Pearson’s correlation was 0.80. For the individual ques-
tions the correlation was best for question 1 (table 2).
PedMIDAS characterization. A total of 724 trials were
administered to 441 patients with a clinical diagnosis of
migraine, whereas 611 trials were administered to 371
patients with an IHS diagnosis of migraine. The mean
PedMIDAS score was 25.0 � 36.3 for the entire group; it
was 24.7 � 33.2 for those who met the IHS criteria for
migraine. The PedMIDAS score was compared with a vari-
ety of headache features including frequency, severity, and
duration. Table 3 contains data for those patients who met
the IHS criteria for migraine. See the online version of this
article at www.neurology.org for data for those patients
who met the clinical diagnosis of migraine.
PedMIDAS related to headache frequency. The PedMI-
DAS score correlated with the frequency of the headaches
with a Pearson’s correlation coefficient of 0.62. By compar-
ison the Spearman’s correlation coefficient was 0.64. Fig-
ure 1 demonstrates this correlation for all of the
PedMIDAS scores obtained. The greatest correlation was
with question 3 and 4; question 2 had the least correlation.
Using a definition of 15 or more headaches per month
for chronic daily headaches,
the mean PedMIDAS score
for patients with chronic daily headaches was 61.8 � 50.5,
whereas for those without chronic daily headaches the
PedMIDAS score was 16.1 � 14.7. When only chronic daily
headaches were considered, there was a reduced Pearson’s
correlation coefficient (0.13) with the best correlation seen
for question 4 (0.14). For those without chronic daily head-
aches, the best correlations were with questions 3 (0.38)
and 4 (0.39) with an overall correlation of 0.51. Table 3
Table 2 Scores and test/retest reliability of PedMIDAS
Questions Test Retest Correlation
Q1 4.4 � 5.6 5.0 � 6.0 0.76
Q2 2.2 � 4.3 4.2 � 7.8 0.16
Q3 12.9 � 15.0 15.6 � 14.4 0.59
Q4 14.1 � 15.9 19.4 � 19.6 0.73
Q5 8.9 � 12.6 14.0 � 15.9 0.31
Q6 10.6 � 15.9 13.9 � 15.9 0.53
Total 53.1 � 47.2 72.1 � 50.8 0.80
Table 3 PedMIDAS scores and correlation of scores with headache features
Scores vs frequency Correlation with headache features
Correlation with
Total �15/mo �15/mo Frequency Severity Duration Home School
Q1 1.8 � 3.4 1.6 � 2.8 3.3 � 4.8 0.25 0.23 0.12 �0.21 �0.34
Q2 1.3 � 2.6 1.1 � 1.8 2.4 � 4.3 0.25 0.13 0.16 �0.04 �0.13
Q3 5.7 � 10.0 3.3 � 4.8 15.5 � 16.3 0.54 0.19 0.21 �0.04 0.07
Q4 6.4 � 10.4 4.2 � 4.9 15.8 � 17.3 0.51 0.23 0.13 �0.14 �0.01
Q5 5.1 � 9.2 3.4 � 4.5 12.3 � 15.9 0.43 0.18 0.10 �0.20 �0.12
Q6 4.5 � 9.4 2.5 � 4.1 12.5 � 16.3 0.47 0.20 0.25 �0.00 0.09
Total 26.6 � 26.3 16.1 � 14.7 61.8 � 50.5 0.62 0.27 0.21 �0.14 �0.03
Figure 1. Comparison of PedMIDAS score with headache
frequency. The patient’s or parent’s recollected headache
frequency over the 3 months prior to the PedMIDAS trial
were compared to the PedMIDAS score for the same time
period. The equation for the trendline was y � 0.81x.
2036 NEUROLOGY 57 December (1 of 2) 2001

contains the values for each of the six questions within
these groups.
PedMIDAS related to headache severity. When the
PedMIDAS score was compared with the severity of the
headaches the Pearson’s correlation coefficient was 0.27;
the Spearman’s correlation coefficient was 0.38. The great-
est correlations were with questions 1 and 4, whereas
question 2 had the least correlation. The patients who
reported a severity greater than the mean had a Pearson’s
correlation coefficient of 0.09 with the PedMIDAS score
whereas those with a severity less than the mean severity
had a Pearson’s correlation coefficient of 0.24.
PedMIDAS related to headache duration. The PedMI-
DAS score was related to the duration of headaches with a
Pearson’s correlation coefficient of 0.21; the Spearman’s
correlation coefficient was 0.24. The duration varied
greatly for the patients on their initial evaluation with a
mean duration of 9.0 � 13.8 hours. With treatment the
mean duration was reduced to 4.1 � 8.7 hours. The Pear-
son’s correlation coefficient for the PedMIDAS and dura-
tion at the initial visit was 0.09; for all of the return visits
the coefficient was 0.25.
PedMIDAS related to associated symptoms. The most
common associated symptoms in the patients examined
were nausea, vomiting, photophobia, and phonophobia (ta-
ble 1), as expected. When the lowest and highest quartile
of PedMIDAS scores were examined, the mean PedMIDAS
score for the lowest quartile was 3.3 � 2.6; the mean score
for the highest quartile was 79.6 � 42.2. A higher percent-
age of patients in the highest quartile reported each asso-
ciated symptom, with 76.6% reporting nausea, 30.5%
reporting vomiting, 95.3% reporting photophobia, and
91.6% reporting phonophobia. This contrasted with the
lowest quartile, where 56.1%, 30.8%, 69.1%, and 50.5%
reported each of the respective associated symptoms. A
similar result was observed for the impact on activity
worsening a headache, with 88.8% in the highest quartile
and 64.5% in the lowest quartile.
PedMIDAS related to school and home functional ability.
The patients were asked to rate their functional ability
during a headache attack both at school and at home. The
mean percent of functional ability at school was 39.5 �
24.8%, whereas at home the mean percent of functional
ability was 33.7 � 26.6% (100% represents full functional
ability). The Pearson’s correlation coefficient when com-
pared with PedMIDAS was �0.03 for school functioning; it
was �0.14 for functioning at home. The correlation is neg-
ative due a lower functional ability relating to a higher
disability. When the individual questions were evaluated
the correlation that was best for school functioning was
question 1 (absence from school) and for home functioning
question 5 (absence from social and sports activities) (table
3, table 4, data at www.neurology.org).
When the individual domains of the PedMIDAS were
evaluated, the impact on school-related activities (Q1, Q2,
and Q3) had a mean score of 8.8 � 12.3. The impact on
home-related activities (Q4) had a mean score of 6.4 �
10.4, whereas the impact on social-related activities (Q5
and Q6) was 9.5 � 15.6.
Treatment response evaluated with PedMIDAS. The
PedMIDAS questionnaire was administered to 206 pa-
tients at their initial evaluation. The mean PedMIDAS
score was 41.7 � 42.8. The mean PedMIDAS score was
reduced to 19.3 � 28.5 for 148 seen at a first follow-up
evaluation. This trend continued for subsequent evalua-
tions with the mean scores at the second through sixth
subsequent evaluations being 14.8 � 21.4, 11.9 � 13.6,
15.1 � 17.9, 10.7 � 12.8, and 12.6 � 10.8. There was a
significant improvement in the score compared with either
the initial evaluation or the first follow-up evaluation (fig-
ure 2). This improvement was supported by similar im-
provements in headache frequency (14.0 � 10.6 initially,
7.3 � 8.3 at first follow-up, p � 0.0001), severity (6.9 � 1.8
initially, 5.3 � 2.2 at first follow-up, p � 0.0001), and
duration (9.7 � 14.6 initially, 4.6 � 8.1 at first follow-up, p
� 0.0001).
A group of patients were followed longitudinally. A total
of 107 patients have been seen at both an initial evalua-
tion and a first follow-up assessment, whereas 34 patients
have been seen for an initial evaluation and two follow-up
assessments. For the 107 patients seen twice, the mean
PedMIDAS score was 40.1 � 42.0 initially; it decreased to
19.5 � 30.3 at the first follow-up (p � 0.0001). A total of
70.1% of the patients had an improvement in their PedMI-
DAS score, whereas only 24.7% worsened. This corre-
sponded to a similar improvement in their headache
frequency (15.2 � 9.6 to 7.9 � 9.1, p � 0.0001), severity
(7.0 � 1.8 to 4.9 � 2.3, p � 0.0001), and duration (9.0 �
13.7 to 4.7 � 8.2, p � 0.01). For the patients seen three
times, the initial mean PedMIDAS score was 37.3 � 42.8;
at the first follow-up the mean score was 21.7 � 35.3 (p �
0.051) and at the second follow-up the score was 16.7 �
30.0 (p � 0.011).
Discussion. Headache disability as determined by
the impact of recurrent headaches on a patient’s
quality of life has been demonstrated in adults with
migraines but is only beginning to be assessed in
children and adolescents. In adults, however, many
of the instruments developed were not practical for a
typical clinical practice. MIDAS was developed to fill
this role and has been shown to correlate with physi-
cian’s perception of disability.
The MIDAS question-
Figure 2. Response to treatment. The PedMIDAS score
was evaluated for each visit. The improvement in PedMI-
DAS score was significant for all follow-up evaluations in
comparison to the initial evaluation (p � 0.0001). Com-
paring the first follow-up evaluation, the improvement was
significant in all but the fourth evaluation (p � 0.05).
December (1 of 2) 2001 NEUROLOGY 57 2037

naire, however, was developed to assess disability in
20- to 50-year-old patients.
The PedMIDAS ques-
tionnaire was designed to be developmentally appro-
priate and specific to child and adolescent lifestyles.
The development of the adult MIDAS was par-
tially based on the Headache Impact Question-
and the weighting of work, household
chores, and nonwork activity.
Emphasis is placed on
work and household responsibilities, accounting for
80% of the questionnaire. For children and adoles-
cents, school and extracurricular activities, including
both organized activities and less organized leisure
time, make up a major component of a child’s daily
life. The MIDAS domains were therefore modified to
account for this difference. Absenteeism from school
can be assessed by a complete absence, partial day
absence, or a decrease in functioning while at school.
The original MIDAS did not account for the partial
day absence. This, however, is a common problem for
children with headaches. The parents may allow the
student to go to school late or be picked up from
school early. Schools may also contact parents to
take a sick child home from school. Many students
report being unable to complete assignments during
school or spend much of the day in the school nurse’s
office because of headaches. Although this does not
count as an absence, it does impact a student’s
school performance and contribute to headache
Multiple reliability and validity assessments have
demonstrated that the PedMIDAS questionnaire is
useful in determining headache disability in chil-
dren. The internal consistency of this tool was docu-
mented with the Cronbach’s coefficient �. This
suggests that the six items in PedMIDAS measure
the same characteristic—headache disability. The
stability of this questionnaire was demonstrated
with the 2-week test/retest assessment. These re-
sults may have been impacted by the effects of the
initial evaluation and treatment plan. The impact of
the 3-month recall period for the assessment should
minimize this effect and, in fact, the retest scores
were slightly higher, although not significantly dif-
ferent. This high degree of correlation supports the
reliability of the instrument, as well as its usefulness
over time. This degree of correlation also supports its
ease of use and understandability by the patient and
parent. This should make the tool easily expandable
to a much broader, multi-site assessment. Further
evaluation of this tool using multiple sites should
confirm its reliability.
The PedMIDAS’s criterion validity supports its
role as a component of assessing the impact of head-
aches on a child’s life. The positive, yet moderate,
correlations with headache parameters, such as fre-
quency, intensity, and duration, suggest that this
tool makes up for the deficiency of assessing disabil-
ity by these features alone. These validity findings,
in addition to the sensitivity of the PedMIDAS to
treatment response, demonstrates its ability to fill in
the gaps left by these clinical symptoms. Studying
individual patients over long-term treatment should
further help define the importance of assessing head-
ache disability as a key outcome measure for chil-
dren with headaches.
The proportion of the PedMIDAS score that ac-
counts for direct school-related issues (Q1, Q2, and
Q3) accounts for over one-third of the score, whereas
a slightly greater portion of the score is accounted for
by social/extracurricular activities (Q5 and Q6). Chil-
dren are often internally or externally driven to par-
ticipate in extracurricular activities. These are often
physical activities that may trigger or aggravate an
ongoing headache. A child’s unwillingness to partici-
pate in these activities is clearly notable by the par-
ents. Oftentimes, however, it is believed that
children are simply complaining of headaches to get
out of school, yet they continue to participate in “fun”
activities. The PedMIDAS scores demonstrate that
this is not the case. In fact the disability reported is
slightly greater for the two questions related to these
extracurricular activities than for the school activi-
ties. This correlates well with the percent functional
ability that the children report and assists with val-
idating the significance of headache disability in
It has been suggested that MIDAS be used to as-
sess treatment response.
It has also been used to
assess treatment outcome in a randomized trial com-
paring clinical treatment strategies.
We were able
to demonstrate the sensitivity of PedMIDAS to treat-
ment effects both cross-sectionally as well as longitu-
dinally. Children in this study showed a mean
reduction of 22.3 points in their PedMIDAS score,
indicating a reduction of nearly half of their disabil-
ity due to headaches with treatment. This reduction
occurred whether analysis of groups was performed
(i.e., all initial patients compared with all first
follow-up patients) or whether individual patients
were followed longitudinally. Further development of
this tool should greatly enhance the ability to detect
treatment response in children and to help develop
new treatment techniques. The usefulness of this
tool for assessment of long-term treatment in chil-
dren needs further study, including the influence of
treatment strategies and clinical compliance.
With successive treatment it can also be seen that
the PedMIDAS score levels off at a score near 10
(figure 2). This is consistent with the goal of treat-
ment in that migraines can become a controllable
illness—not necessarily curable. Using a hypotheti-
cal goal of one headache per month, a PedMIDAS
score near 10 is reasonable. This would account for 1
day per month where the patient may function at
less than half his or her ability at school, at home,
and in social activities without missing out on these
activities (i.e., a score of three per month times 3
months would yield a total score of nine).
In this article, we show that modification of the
adult migraine disability assessment for children can
prove to be a useful tool to assess the impact of
migraines on children’s day-to-day activities. This
2038 NEUROLOGY 57 December (1 of 2) 2001

tool has been shown to be reliable and valid for as-
sessing disability in children and adolescents and
was found to be easy to complete and use within an
active clinical setting. It should provide the founda-
tion for further assessment of the impact of mi-
graines on a child’s day-to-day activity and overall
quality of life. Further examination of this tool
across multiple sites, including headache specialty
and general pediatric clinics, should strengthen its
widespread usefulness. The instrument also provides
a useful tool to assess treatment outcomes and com-
pare responses to individual therapies.
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