Impact of psychiatric comorbidity, resilience and executive function on childhood and adolescent headaches: A narrative review

Background The impact of psychiatric comorbidities in children and adolescents with headache disorders can be more comprehensively understood through a biopsychosocial perspective, which examines the dynamic interplay of factors beyond headache attacks. Resilience and executive function emerge within this framework, playing a central role in development psychopathology and other critical domains. Methods This narrative review aimed to examine the impact of psychiatric comorbidity on migraine and/or high-frequency headaches (HFH) in children and adolescents through a biopsychosocial perspective centered on the role of resilience and executive function (EF), exploring their potential clinical implications. PubMed was searched for English language articles of human participants, from birth to 18 years, published up to 10 April 2025. Results Clinical and population-based studies suggest that children and adolescents with migraine and/or HFH are at an increased risk of low resilience and EF impairments. Preliminary interaction and multivariate analyses suggest that high vulnerability (the counterpart to resilience) exerts a moderating role in the psychiatric comorbidity of migraine, as well as a mediating effect in the association of HFH with psychiatric symptoms and disorders. Candidate predictors of psychiatric comorbidity in youths with migraine and/or HFH include EF impairment, high vulnerability, female sex, low socioeconomic status, prenatal exposure to tobacco, poor academic performance and headache attacks accompanied by nausea and vomiting. Conclusions The multidimensional impact of psychiatric comorbidities on children and adolescents with headache disorders is clearly demonstrated by consistent evidence of their adverse effects on headache severity and chronification, as well as negative outcomes in quality of life, cognitive performance, academic achievement and overall patient well-being, leading to long-term continuity across childhood, adolescence and adulthood. Most of this impact is probably due to the interactions between reduced resilience, increased vulnerability and EF impairment. This narrative review underscore the relevance of routinely assessing psychiatric symptoms, resilience, executive function skills and school functioning in children and adolescents with headache disorders. Future studies should examine whether early interventions focused on resilience, vulnerability and EF can prevent psychiatric comorbidities and improve headache outcomes in children and adolescents with migraine and/or HFH.