The Rorschach Test Evaluation in Chronic Childhood Migraine: A Preliminary Multicenter Case–Control Study

Object About 1.2–3.2% of children at 7 years of age with increasing age up to 4–19% in adolescents are suffering from migraine without aura (MwA). The aim of the present study is investigating the personality style associated with children and adolescents affected by MwA, administrating the Rorschach test, and comparing with typical developing healthy controls (TD). Methods 137 patients (74 males), aged 7.3–17.4 years (mean age 11.4, SD 3.02 years), affected by MwA according to the IHs-3 criteria. The Rorschach variables were treated as numerical variables and statistically tested with t-Student’s analysis. Results No statistical differences were found between the MwA and TD for age (p = 0.55), and gender (p = 0.804). From the comparison between the two samples, MwA group shows lower W responses (p < 0.001), good quality W responses (p < 0.001), high frequency of detailed responses (p < 0.001), the presence of even minor form of good quality responses (p < 0.001), increased presence of animals answers (A%) (p < 0.001), more frequent trivial answers (Ban%) (p < 0.001). Discussion Rorschach interpretation pinpointed many interesting and, perhaps, peculiar aspects in our MwA population such as a trend predisposition for: analytical reasoning rather than synthetic, ease/practicality rather than creativity, oppositionality rather than external adaptation to the environment that may be interpreted as effect of general maladaptivity.

In this light, MwA should be considered as disabling condi tion in pediatric age, particularly for the high risk of chroni city in adolescents and adults, despite of treatment (17,18). In gen eral, MwA is also considered an important cause for school absenteeism, poor quality of life, and social skills with peers, mainly during childhood and adolescence (19,20). In the last decades, many studies reported the high prevalence of psychiatric comorbidity in children and adolescents affected by primary headache and MwA to be considered mandatory in the correct therapeutic and assessment management. Despite all, few studies about the chronological relationship between MwA and psycho logical stressors are reported. Mood alteration such as alertness (21,22), emotional tension (22), depressive tendency (23), con stant irritability, chronic fatigue (24) often tend to precede the migraine attacks. Migraine may be considered also related to anxious symptoms (25) and stress and mood changes could be related to MwA, although is not well known how MwA and mood may interact.
Many reports through last decades have identified the major triggers for migraine attacks (26,27) in stressor factors. In fact, physiological response to stress tend to activate the hypothala mus-pituitary-adrenal and sympathetic nervous system, with subjective feeling of external or internal restlessness and worry (28). On the other hand, the autonomic/vegetative response intensity is related directly to frequency, duration, intensity of stress, and subjective state health traits (29). In this light, psy chological stress may play a relevant role not only in prodromal migraine phases (30,31) but also for painful attacks frequency (32,33), and for symptoms maintaining, and for shifting from painful episodic to chronic symptoms (34).
Moreover, the role of putative personality peculiar traits in migraineurs is still discussed and debated, mainly considering that MwA patients tend to show an increase in neurotic and anxious personality traits (35,36), also due to life events (37,38).
Particularly referring to Rorschach test (RT) evaluation among children and adolescents with MwA, this topic is not completely new as research object because, in 1986, Guidetti et al. (38) exam ining 46 subjects of mean age, 10.4 highlighted no differences in children with migraine.
The hypothesis in the present Italian multicenter report was the identification of peculiar personality organization among children and adolescents affected by MwA evaluated on the projective RT respect of typical developing healthy controls (TD). The large number of recruited MwA children and adolescents and healthy control subjects can be considered the novelty and the strength of the present study.

MaTerials anD MeThODs
137 Caucasian patients (74 males and 63 females), between 7.3 and 17.4 years (mean age 11.4, SD 3.02 years), diagnosed by MwA according to the IHs3 criteria were consecutively recruited in each pediatric headache center or neuropsychiatric clinic partici pating to the study, between January 2010 and December 2014.
200 TD Caucasian subjects (112 males and 88 females, between 7.1 and 17.3 years, mean age 11.6, SD 3.01 years) were randomly recruited from primary and secondary school in Sicily, Calabria, and Umbria Regions.
Exclusion criteria were neurological or psychiatric diagnosed illness and headaches different from MwA.
Parents of children and adolescents of both groups gave writ ten consent and the study design and protocol was approved by Departmental ethics committees at the University of Palermo, Perugia and Catanzaro (EUDract 201000045340).

rT coding and evaluation
In order to investigate personality profile of children affected by MwA, the projective RT has been administered to MwA and TD subjects. RT is a personality projective evaluation based on subject's interpretations of 10 standard inkblot tables, in order to measure emotional, cognitive, and integration functioning (39).
In our multicenter research study, we scored the RT evaluation according to criteria reported by Balottin et al. (39). The Passi Tognazzo method was used to code RT protocols, independently (40), by expert scorers, blinded to the subjects' diagnoses.
As reported by Balottin et al. in 2009 (39), the numerical data obtained from the coding of the RT were replaced as numerical variables in order to be quantified and compared between MwA and TD groups. Mainly, the RT variables with normative data (R, W%, D%, F%, F+%, M, FM, FC, CF, C, sum of the color responses, sum of the shading responses, A%, H%, Ban%) ( Table 1) were transformed into dichotomous variables (normal or pathological) and their frequency of distribution was compared among the groups (Mwa and healthy controls).

statistical analysis
The Student's ttest analysis was used to compare within the two groups (MwA and TD) RT variables (R, W%, W+%, D%, Rorschach Table 1).
From the comparison between the two samples, MwA group shows lower W responses (p < 0.001), good quality W responses (p < 0.001), high frequency among detailed responses (p < 0.001), the presence of even minor form of good quality responses (p < 0.001), increased presence of animals' answers (A%) (p < 0.001), more frequent trivial answers (Ban%) (p < 0.001) (Figure 1).

DiscUssiOn
Migraine is primary headache affecting about 7.8 million children in the European Union Countries (40). MwA is complex disease considered a continuum of events involving the CNS includ ing painful sensation, cardiovascular changes, immunological changes (41)(42)(43)(44).
Migraine without aura may be also interpreted as a maladap tive psychobiological disorder in which genetic predisposition interplays with a number of other factors, external or internal, including climatic, dietary, hormonal, psychological, and emo tional factors (43).
In this light, MwA could be identified as the final effect of the loss of the ability to arrange homoeostatic changes against different multiple stressors (45) independently by age and gender.
Conversely, the Rorschach interpretation pinpointed many interesting and, perhaps, peculiar aspects in our MwA population such as a trend predisposition for: analytical reasoning rather than synthetic, ease/practicality rather than creativity, oppositionality rather than external adaptation to the environment that may be interpreted as effect of general maladaptivity. This aspect of environmental pathology (relational aspects after the 1 year of life; scholastic adaptation of child, his habits, and his/her family) are more evident than those regarding the primary mother-child relationship. According to the psychosomatic theory, we would have expected, instead, a prominent involvement of early diadic relationship.
Other findings such as stereotyped thought, conformism, hard reality testing, and psychological immaturity may be intended as effects of wellknown specific cognitive ability.
In resting state, functional connectivity studies among adoles cents undergoing social stress has been identified as the connec tion between stress and medial prefrontal cortical regions, with cortisol activation related to anterior insula and medial prefrontal cortex regions also known as the "salience" network specifically involved in processing negative emotion such as anxiety and depression (59). This specific network is also involved in MwA complex pathogenesis (60,61).
On the other hand, we have to take into account limita tions of the present study: (1) the lack of followup study in order to verify the effects of psychotherapy and/or pharma cotherapy in these subjects; (2) the small number of recruited subjects.
In the light of all these considerations, further studies will be needed to better understand how personality aspects affect the symptoms of migraine, and how these aspects are related to each other and to the neurobiological bases of migraine in order to improve the management of migraine and of its associated disability.

eThics sTaTeMenT
Parents of children and adolescents of both groups gave written consent and Departmental ethics committees at the University of Palermo, Perugia and Catanzaro approved the study protocol (EUDract 201000045340).
aUThOr cOnTriBUTiOns ME, AM, VM, IB, FS, FP, MR, BG, RT: conceived the study, participated in its design. SP, TS, AG, RM, SML, FL, AgMa con tributed to the conception and design. ME, AM, LP, MS, GT, MC wrote manuscript. LP, MS, BG, MiRo, GT, DB, drafted the article and revised it critically for important intellectual content. GM and MC: final approval of the version to be published. All authors read and approved the final manuscript.