The Complex Interplay Between Metacognition and Headache in Children

young woman holding her head
young woman holding her head
Researchers find that adults who had headaches as children, cognitive and psychomotor ability are compromised. Metacognitive skills, anxiety, depression, motivation, academic performance, human social interactions, and stress symptoms are common headache triggers that may be controlled and monitored by patients.

Recurrent headache in children is common; migraine is the most frequent pediatric headache type, reported in up to 60% of children and adolescents worldwide.1 Because headache has a significant impact on a child’s quality of life, affecting school performance and physical and social activities, recent investigations have begun to question the potential interaction with metacognitive processes that are developing during this same period.

In 1979, Flavell of Stanford University in California first described metacognition, including the cognitive processes, beliefs, and knowledge that combine to allow for understanding that one’s thoughts are unique, facilitate strategic planning and goal-setting, and the ability to read and assess one’s own mental state.2

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Metacognition develops throughout childhood to create evolving awareness of a child’s own thoughts, beliefs, and emotions, along with a sense that they can monitor and control these processes. He elaborated on this concept with theory of mind (ToM), which described the further development of this ability to empathetically apply self-knowledge to someone else’s state of mind in order to understand and predict their behavior. These are 2 critical developmental abilities that color a child’s perception of themselves and the world, but also influence their experience of that world, including pain.

Recent evidence has pointed to potential impairment of both metacognitive processes and ToM being associated with migraine in children. Patterns of impaired ToM have been seen with epilepsy, and in 1 study that evaluated children with headache and epilepsy.Various studies have shown that neurophysiologic functions including psychomotor ability and cognitive domains of information processing and attention are compromised in adults with headache.4

A number of independent studies have indicated some involvement of organizational thinking related to metacognition in various neurologic conditions. A parental report on 75 children with Chiari malformation type 1, a developmental structural abnormality of the cerebellum in which brain tissue from the back of the brain protrudes into the spinal canal, found that 69% of pediatric patients had headaches as a complication. An overlapping one-third of participants in the study also demonstrated higher than normal impairment of executive function, particularly with regard to working memory.3

Metacognition is strongly influenced by psychological factors, and chronic pain disorders are often accompanied by comorbid medical and psychological conditions. Children with headache can have comorbidities ranging from allergies, asthma, and sleep disorders to anxiety and depression.1 A large-scale Norwegian population-based study conducted in nearly 5000 adolescents from 1995 to 1997 found a higher incidence of anxiety and depression in participants with headache than participants without.5 The same study also reported a greater degree of attention deficits associated with migraine and nonclassifiable headache in patients aged 15 to 17 years.5

Despite the overlaps that occur during this developmental period between headache and metacognition, direct evidence of a link has been lacking. Metacognitive processes and particularly ToM have been evaluated in many psychiatric diseases, but rarely in relation to migraine, and not at all in children.

Costa-Silva, of the Federal University of Minas Gerais, Belo Horizonte, Brazil, et al6 reported in 2016 that cognitive dysfunction is common in adolescents with headache, particularly adolescents with migraine. They found that adolescents with a migraine diagnosis were more readily distracted from learning tasks and demonstrated greater impairment of verbal memory, recognition, and recall than a control group without headache (n=28 and n=26, respectively).6 “Since the cognitive deficits found in adolescents with migraine are similar to those reported in adults with migraine, cognitive impairment seems to persist throughout life,” they concluded.

Executive function and other facets of metacognition develop throughout childhood and this process continues into early adulthood. Mahy, of the University of Oregon in Eugene, and colleagues,7 proposed that maturity of the brain in the development of executive function is “predicted to influence ToM maturity.” A similar evaluation by Luna, of the University of Pittsburgh in Pennsylvania, et al8 suggested that they are linked and vulnerable during the same adolescent life stage, particularly to the onset of mental conditions, such as depression and anxiety.

As tenuous connections have been made between migraine, depression, and anxiety in adolescents, researchers have also focused their investigations on the impact of pain on metacognition. “Their results suggest that psychological suffering due to body sickness can affect some mental representation and way to think,” according to a 2017 review by Faedda, a mood disorders specialist,  and colleagues.1 The investigators suggested that the combined elements of headache and psychiatric and neurologic comorbidities may influence the ongoing development of metacognitive processes. They also theorized that mindfulness and cognitive behavioral therapy may significantly improve headaches and reduce the risks for psychiatric or behavioral comorbidities that often accompany chronic headache in children.

The Faedda review pointed to cognitive behavioral therapies as promoting improved metacognition by reducing rumination and worry, while biofeedback and relaxation skills have demonstrated reductions in headache frequency and pain.1  Studies of pain acceptance and pain self-efficacy in children have demonstrated direct correlations with depression, disability, and school functionality. Improvement in these features was associated with better quality of life and recovery from pain.


1. Faedda N, Natalucci G, Calderoni D, et al.  Metacognition and headache: Which is the role in childhood and adolescence? Front Neurol 2017;8:650.

2. Flavell JH. Metacognition and cognitive monitoring: a new area of cognitive developmental inquiry. Amer Psychol  1979;34:906-911.

3. Lacy M, Ellefson SE, DeDios-Stern S, Frim DM. Parent-reported executive dysfunction in children and adolescents with Chiari malformation type 1. Abstract. Pediatr Neurosurg 2016;51:236-243.

4. Esposito M, Pascotto A, Gallai B, et al. Can headache impair intellectual abilities in children? An observational study. Neuropsychiatr Dis Treat 2012;8:509-513.

5. Blaauw BA, Dyb G, Hagen K, et al. Anxiety, depression and behavioral problems among adolescents with recurrent headache: the Young-HUNT study. J Headache Pain. 2014;15:38.

6. Costa-Silva MA, Prado ACA, de Souza LC, Gomez RS, Teixeira AL. Cognitive functioning in adolescents with migraine. Dement Neuropsychol. 2016;10:47-51.

7. Mahy CE, Moses LJ, Pfeifer JH. How and where: theory-of-mind in the brain. Dev Cogn Neurosci. 2014;9:68-81.

8. Luna B, Padmanabhan A, O’Hearn K. What has fMRI told us about the development of cognitive control through adolescence? Brain Cogn. 2010;72:101-113.