Article published online: 2021-12-14

Original Article 221

Headache in Children and Adolescents: The

Association between Screen Time and Headache
within a Clinical Headache Population
Josefine Lund1 Amalie Berring-Uldum1 Merve Colak1 Nanette Marinette Monique Debes1

1 Department of Pediatrics, Herlev University Hospital, Copenhagen, Address for correspondence Josefine Lund, MD, Department of
Denmark Pediatrics, Herlev University Hospital, Borgmester Ib Juuls Vej 1,
Herlev, 2730, Denmark (e-mail: Josefi[email protected]).
Neuropediatrics 2022;53:221–226.

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Abstract Background More than half of children and adolescents have experienced headache
within the last 3 months. Several risk factors for headache have been identified,
including obesity and lack of sleep. The association between screen time and headache
in children and adolescents is sparsely investigated. The aim of this study was to assess
this association and evaluate if it varied according to headache diagnosis.
Method This cross-sectional study was performed at the tertiary pediatric outpatient
clinic for headache at Herlev University Hospital. A total of 139 participants who
answered a questionnaire on lifestyle factors and their daily living were included.
Diagnoses of migraine and tension-type headache (TTH) were made according to the
International Classification of Headache Disorders-3. Children with both migraine and
TTH were allocated to a mixed headache group. We differentiated between total,
leisure, and school-related screen time.
Results The mean age was 13.20
3.38 years and 53.2% were girls. Note that 25.2%
were diagnosed with migraine without aura, 23.0% migraine with aura, 28.1% TTH,
15.8% mixed headache, and 7.9% had an unclassified headache diagnosis at the time of
Keywords inclusion. There was no statistically significant difference in screen time across the five
► headache headache groups. An association between screen time and headache frequency was
► migraine found in children with migraine with aura.
► tension-type Conclusion In this study, we investigated the association between screen time and
headache headache in children and adolescents. More screen time was associated with more
► risk factor frequent headaches in children with migraine with aura. Future prospective studies are
► screen time needed to determine the causality of this association.

Introduction all children and adolescents, 7.7 to 9.1% are diagnosed with
migraine and 31% suffer from TTH.4,5
Headache is a common complaint across the world. In
Europe, lifetime prevalence of headache is 91.3%.1 Of chil- Risk Factors for Headache in Children and Adolescents
dren and adolescents, 58.4% have experienced at least one Numerous risk factors for migraine in children have been
headache episode within a 3-month period.2 Migraine with identified including obesity, alimentation, and lack of sleep.6
and without aura and tension-type headache (TTH) are the Several studies have found an association between obesity
most prevalent primary headache diagnoses in children.3 Of and migraine in both adults and children, where a body mass

received © 2021. Thieme. All rights reserved. DOI https://doi.org/

July 15, 2021 Georg Thieme Verlag KG, 10.1055/s-0041-1740550.
accepted after revision Rüdigerstraße 14, ISSN 0174-304X.
November 10, 2021 70469 Stuttgart, Germany
published online
December 14, 2021
222 The Association between Screen Time and Headache Lund et al.

index over 30 increases the risk of having migraine compared Methods

with those of normal weight. Although this association has
been acknowledged, its nature is still discussed.7–10 Regard- The study was located at the tertiary pediatric outpatient
ing alimentation, studies show that 12 to 44% of both clinic (POC) for headache at Herlev University Hospital,
children and adults with migraine are triggered by a partic- Denmark.
ular food or drink.11–14 The most common food triggers are
chocolate, cheese, and citrus fruit.14,15 Although an associa- Inclusion of Participants
tion between certain foods and migraine has been estab- From April 2019 till April 2021, all patients aged 5 to 18 years
lished, it is still discussed whether it should be seen as a in the POC were asked to participate in the project. All
trigger or a premonitory symptom.16 Caffeine, smoking, and questionnaires were in Danish, therefore children who had
alcohol are also well-known to induce headaches in adoles- never attended a Danish institution or school were excluded
cents.17–19 Sleep is thought to have great impact on head- to avoid a language barrier.
aches as well as health in general. Studies show that children
with migraine or TTH on average tend to sleep less and have a The Questionnaire

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longer sleep latency compared with healthy controls.20,21 The structured questionnaire “You and your daily life” (“Dig
Despite numerous well-studied risk factors, screen time’s og din hverdag”) consists of general questions about the
effect on headache is yet to be fully understood. child, for example, date of birth, gender, and school level,
No clear definition of screen time, or which devices it followed by questions on their headache, diet, smoking,
includes, is found in existing studies and literature, but the alcohol, drugs, exercise, screen time (see definition below),
common denominator is time spent on screen-based elec- sleep, stress, vision, hearing, dental status, and family.
tronics.22–25 According to a large study including 2,000
young Americans in 2010, the average 8- to 10-year-old Definition of Screen Time
spent nearly 5.5 hours a day in front of a screen, 11- to 14- In this study, screen time is defined as time spent in front of a
year-olds spent > 8 hours a day while 15- to 18-year-olds screen, for example, television, computer, tablet, smart-
spent > 6 hours daily.26 American Academy of Pediatrics phone, and/or video game console. A distinction between
(AAP) recommends that the child’s total entertainment “school-related screen time” and “leisure screen time” has
screen time is limited to a maximum of 2 hours per day.27 been made. “School-related screen time” is defined as screen
Both the World Health Organization and AAP do not recom- time in relation to school classes and homework, while
mend any screen time at all for children under the age of “leisure screen time” is defined as screen time for personal
2 years.27,28 entertainment.
Several studies have shown that increased screen time has
a negative effect on weight, mental health, and sleep.23,29,30 Classification of Headache
The number of studies on screen time and headache is sparse, To compare the different headache diagnoses, medical jour-
but the existing studies have shown an association in healthy nals of the participants were examined. Classification of the
children, adolescents, and young adults, where headache headaches was done by experienced neuropediatricians as
became more frequent with increased screen time.25,31–33 A part of the care pathway at the POC. Classification was done
cross-sectional study on young adults, 18 years and older, according to the International Classification of Headache
found an association between increased screen time and Disorders (ICHD)-3.34 Depending on the diagnosis, the par-
migraine. When divided into migraine with and without ticipants were grouped in five categories: migraine without
aura, the significant association between screen time and aura, migraine with aura, TTH, mixed headache, and unclas-
migraine with aura disappeared.22 sified headache. The unclassified headache group consisted
Two potential hypotheses have been raised to explain how of children in whom the headache was not classified yet.
screen time may interact with the migraine pathophysiolo- Children with both migraine and TTH were allocated to the
gy: (1) The luminosity or frequency of screen band light may mixed headache group.
directly trigger a migraine attack, and (2) increasing screen
time exposure may reduce the threshold for migraine cas- Statistical Methods
cade that is induced by other factors.22 Descriptive statistics were calculated for the sample, accord-
Overall, the evidence on how screen time affects head- ing to headache diagnosis. Chi-square, one-way analysis of
ache in both adults and children is scarce. To provide more variance, and Kruskal–Wallis test were used to assess differ-
knowledge on the probable correlation between screen ences between headache diagnoses. Mann–Whitney’s test
time and headache in children, we have performed a was used to assess the differences between those who had
cross-sectional study on a clinical headache population of headache at least once a week, versus less than once a week,
children and adolescents. The hypotheses were that (1) in relation to screen time (total, leisure, and school-related)
there is an exposure–response relationship between the and physical activity. When relevant, adjustment for con-
number of hours spent in front of a screen and the frequen- founders such as age, gender, physical activity, and healthy
cy of headache, and (2) the association of screen time and eating was made. The confounders were included based on
headache frequency varies depending on the headache existing literature.14–31 The statistical analyses were per-
diagnosis. formed using SPSS statistics software (version 26; IBM Corp.,

Neuropediatrics Vol. 53 No. 4/2022 © 2021. Thieme. All rights reserved.

 The Association between Screen Time and Headache Lund et al. 223

Table 1 Sample characteristics, headache frequency, dietary habits, time spent on physical exercise, and screen time (school-
related, leisure screen time, and total screen time) stratified by headache diagnosis (N ¼ 139)

Characteristics Migraine Migraine Tension-type Mixed Unclassified p

without aura with aura headache headache headache
N ¼ 35 N ¼ 32 N ¼ 39 N ¼ 22 N ¼ 11
Gender
Boys (%) 57.14 68.75 17.95 40.91 63.64 < 0.001a
Age (mean
SD) 12.41
3.73 12.28
3.04 14.57
2.88 13.65
3.32 12.57
3.78 0.019b
Headache frequency < 0.001a
Daily (%) 8.58  61.54 45.45 27.27
Weekly (%) 11.43 53.13 30.77 36.36 36.36
Monthly (%) 65.71 40.63 7.69 13.64 27.27

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Less than monthly (%) 14.29 6.25  4.55 9.09
Healthy eating 0.395a
Yes (%) 85.71 84.38 87.18 68.18 81.82
No (%) 14.29 15.63 12.82 31.82 18.18
Weekly exercise
0 h (%) 37.14 25.00 38.46 40.91 36.36
1–5 h (%) 20.00 46.88 48.72 31.82 27.27
5–10 h (%) 40.00 21.88 7.69 22.73 36.36
More than 10 h (%) 2.86 6.25 5.13 4.55 
Average (mean
SD) 3.31
3.28 3.53
3.09 2.54
3.28 2.86
3.14 3.00
3.26 0.549c
School-related screen time
0–2 h daily (%) 45.71 37.50 41.03 36.36 54.55
2–4 h daily (%) 28.57 28.13 23.08 9.10 27.27
4–6 h daily (%) 8.57 18.75 23.08 27.27 10.00
6–8 h daily (%) 14.29 15.63 12.82 22.73 18.18
More than 8 h (%) 2.86   4.55 
Average (mean
SD) 3.40
2.52 3.56
2.36 3.51
2.22 4.45
2.54 2.82
1.99 0.363c
Leisure screen time
0–2 h daily (%) 31.43 37.50 30.77 22.73 54.55
2–4 h daily (%) 40.00 37.50 51.28 50.00 36.36
4–6 h daily (%) 28.57 18.75 17.95 22.73 9.09
6–8 h daily (%)  3.13   
More than 8 h (%)  3.13  4.55 
Average (mean
SD) 3.43
1.48 3.53
1.98 3.31
1.32 3.77
1.77 2.55
1.37 0.333b
Total screen time
0–4 h daily (%) 31.43 25.00 17.95 4.55 45.45
4–8 h daily (%) 40.00 43.75 56.41 54.55 45.45
8–12 h daily (%) 20.00 21.88 25.64 31.82 9.09
More than 12 h daily (%) 8.57 9.38  9.10 
Average (mean
SD) 6.83
3.48 7.09
3.81 6.82
2.46 8.23
3.25 5.36
2.92 0.178b

Abbreviations: ANOVA, analysis of variance; SD, standard deviation.

Note: Significant estimates (p < 0.05) in bold.
a
Tested by chi-square.
b
Tested by ANOVA one-way.
c
Tested by Kruskal–Wallis test.

Neuropediatrics Vol. 53 No. 4/2022 © 2021. Thieme. All rights reserved.

224 The Association between Screen Time and Headache Lund et al.

Armonk, New York, United States). The level of significance To examine the association of headache frequency and
was set at 0.05. screen time across headache diagnoses, we compared life-
style factors (exercise hours, dietary habits) and screen time
Ethics Statement among those with a headache frequency of less than once a
The project was approved by the Danish Scientific Ethical week and those with a frequency of at least once a week. No
Committee (reference number: H-19003374) and Danish statistically significant differences in screen time or lifestyle
Data Protection Agency (reference number: VD-2019–222). factors were found between the two frequency groups, even
after correction of the possible confounders (exercise, age,
gender, dietary habits).
Results
A total of 139 participants (65 boys and 74 girls) were
Discussion
included in this study. The mean age of the participants
was 13.20
3.38 years and their mean total screen time was In this clinical cross-sectional study, we wanted to eluci-
6.99
3.22 hours per day, of which the mean leisure screen date the association between screen time and headache

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time accounted for 3.40
1.61 hours. in children. An exposure–response relationship between
Sample characteristics, including headache frequency, the number of hours spent in front of a screen and
dietary habits, time spent on physical exercise, and screen frequency of headache was found in children with mi-
time (school-related, leisure screen time, and total screen graine with aura. Children with more frequent headaches
time), was stratified by headache diagnosis (►Table 1). It had higher total screen time than those with less frequent
shows that there was a significant difference in gender, age, headaches.
and headache frequency between the headache groups,
whereas no difference was found in screen time, dietary Headache Diagnosis
habits, and physical activity. Even after adjusting for possible This study found no significant differences in total, leisure, or
confounders (age, gender, physical activity, and dietary school-related screen time across the five headache diagno-
habits) no significant difference in screen time (total, leisure, ses (migraine without aura, migraine with aura, TTH, mixed
school-related) was found. ►Fig. 1 illustrates the differences headache, and unclassified), even after adjusting for head-
in screen time across the five groups. ache frequency and possible confounders.
Participants with migraine with aura and headache at
least once a week had a significantly higher total screen time Headache Frequency
than those with headache less than once a week (p ¼ 0.04) Total screen time and headache frequency was found to be
(►Table 2). No significant association between total screen associated in children with migraine with aura only. In the
time and headache frequency was found in the other head- migraine with aura group, it was found that children with
ache groups (►Table 2). more frequent headaches had over 2.5 hours more total

Fig. 1 Mean screen time in hours per day (total, leisure, and school-related screen time) within the five headache diagnoses.

Neuropediatrics Vol. 53 No. 4/2022 © 2021. Thieme. All rights reserved.

 The Association between Screen Time and Headache Lund et al. 225

screen time, than those with less frequent headaches. The

0. 788
0.648

0.230

0.315
school-related and leisure screen time were not associated
p with headache frequency in any of the headache diagnosis
once a week groups.
5.00
2.00

3.25
1.26

1.75
0.96

2.76
4.27
Less than

Comparison with Other Studies

Our findings are in line with the existing
once a week

research,22,24,25,31–33 where increased screen time is associ-

Unclassified

5.57
2.57

2.14
1.35

3.43
2.23

3.14
2.91
At least

ated with more frequent headaches. Two studies have found

an increased screen time in the children with migraine
compared with healthy controls.22,24 No differences in
0.324

0.652

0.386

0.081

screen time was found between patients with migraine

p

with aura and patients with migraine without aura, but

once a week

participants with migraine without aura had a statistically

6.75
2.36

3.25
0.96

3.50
2.38

6.00
4.32

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Less than

significant higher screen time than healthy controls.22

In this study, we only found an association between
Mixed headache

screen time and headache frequency in patients with mi-

once a week

graine with aura.

8.56
3.38

3.89
1.91

4.67
2.59

2.17
2.46

Note: Tested by Mann–Whitney. The values presented are means and standard deviation (mean
SD). Significant estimates (p < 0.05) in bold.
At least

The definition of the duration of screen time in this

Table 2 Bivariate analyses between screen time, physical activity, and headache frequency within the five headache groups

study was different from the study of Attygalle et al.24

They distinguished between “an hour or less” and “more
0.346

0.599

0.173

0.746

than one hour” of screen time, while this study includes 1-

p

hour intervals of screen time from 0 to “more than

Less than once

8 hours.” This provides a more accurate estimate of the

8.00
1.00

3.00
1.73

5.00
1.00

1.67
1.53

association.
a week

As described, two potential hypotheses on how screen

time might interact with the migraine pathophysiology has
been raised.22 Although this might explain why previous
At least once

6.72
2.52

3.33
1.31

3.39
2.26

2.61
3.39

studies have found that migraine patients have a higher

a week

screen time than healthy controls, this cannot explain our

TTH

finding that total screen time was associated with frequent

headaches in patients with migraine with aura, but not in
0.123

0.069

0.390
0.04

those without aura. Further studies are needed to examine

p

this further.
once a week

5.67
3.27

2.87
1.51

2.80
2.31

4.27
3.81
Less than

Strengths and Limitations

Migraine with aura

This study has several strengths. The diagnoses in this study

were verified by neuropediatricians using the ICHD-3, which
once a week

8.35
3.89

4.12
2.21

4.24
2.25

2.88
2.21

contributes to correct classification of headaches.

At least

Approximately 25% of the time children and adolescents

use more than one media (TV, computer, smartphone, etc.)
concurrently. This phenomenon has been defined as, “Media
0.586

0.588

0.762

0.158

multitasking.”35 An overestimation of screen time can there-

p

by occur in studies, where screen time is summed per device.

Less than once

One study suggested that the association between screen

6.68
3.51

3.36
1.55

3.32
2.50

2.93
3.27

time and headache might be more related to duration than

a week

Abbreviation: TTH, tension-type headache.

Migraine without aura

the type of screen time.31 In this study, the overestimation of

screen time was avoided by asking the participants of their
At least once

total screen time and using this number instead of summing

7.43
3.55

3.71
1.25

3.71
2.81

4.86
3.08

all their screen time per device.

a week

Limitations of this study include the cross-sectional de-

sign, which precludes any inference about causality. It is
Total screen time (h/d)

therefore not possible to determine whether the migraine

School-related screen
Headache frequency

Leisure screen time

with aura group with frequent headaches had more total

Physical exercise

screen time because they had frequent headaches or if they

time (h/d)

had more frequents headaches due to more total screen time.

(h/wk)
(h/d)

Furthermore, the used questionnaire has not been validated

and the self-reported screen time might introduce recall

Neuropediatrics Vol. 53 No. 4/2022 © 2021. Thieme. All rights reserved.

226 The Association between Screen Time and Headache Lund et al.

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None declared. between migraine, tension headache, and healthy children. Iran J

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