Cross-Lagged Associations Among Sleep, Headache, and Pain in Pediatric Mild Traumatic Brain Injury: An A-CAP Study.

Objective: To test cross-lagged associations among sleep, headache, and pain in pediatric mild traumatic brain injury (mTBI).

Setting, participants, design: Children and adolescents aged 8.0 to 16.9 years who sustained a mTBI and presented to 1 of 5 pediatric emergency departments across Canada completed assessments at 1-week, 3 months, and 6 months post-injury as part of a larger prospective cohort study.

Main measures: Sleep disturbance was measured using 7 sleep items from the Child Behaviour Checklist. Sleep duration was measured using average weekday and weekend sleep from the Healthy Lifestyle Behaviours Questionnaire. Pain intensity was measured using an 11-point numerical rating scale. Headache severity and associated functional impairment were measured using the Headache Impact Test and 1 item from the Health and Behaviour Inventory. Analyses included trivariate-indicator random-intercept cross-lagged panel models.

Results: Of 633 recruited children, 563 were included in the current study. Headache showed significant within-person, bidirectional, cross-lagged associations with sleep disturbance and duration, as well as with pain intensity. More specifically, worse headache predicted greater sleep disturbance (1-week to 3 months and 3 months to 6 months: Bs = .47, Ps ≤ .013) and shorter sleep duration (1-week to 3 months: B = -.21, P = .006), while greater sleep disturbance predicted worse headache (1-week to 3 months: B = .08, P = .001). Worse headache also predicted higher pain intensity (1-week to 3 months & 3 months to 6 months: Bs ≥ 1.27, P s < .001), while higher pain intensity predicted worse headache (3 months to 6 months: Bs ≥ .03, Ps ≤ .042). No cross-lagged associations involving sleep disturbance or duration with pain intensity were significant.

Conclusions: Significant bi-directional, cross-lagged associations exist between headache and both sleep and pain. The findings suggest that early intervention for headaches may help prevent later sleep disturbance and pain after pediatric mTBI.