Headache diagnosis in children and adolescents: validation of the Italian version of the HARDSHIP questionnaire

Background: Headache disorders are common in children and adolescents, significantly affecting quality of life and academic performance. Despite their high prevalence, they remain underdiagnosed and undertreated. The Child and Adolescents HARDSHIP questionnaire, developed by the Global Campaign Against Headache, has been widely used in adult epidemiological studies but lacks validation in the Italian pediatric population. Methods: The study was conducted within the Epidemiologic Registry of Child and Adolescents Headaches - Registro Epidemiologico delle Cefalee in età evolutiva (REPICEF), a population-based registry on pediatric headache epidemiology in L'Aquila, Italy. The Italian version of the HARDSHIP questionnaire was adapted using the TRAPD method, ensuring linguistic and conceptual accuracy. Validation was performed by comparing questionnaire-based diagnoses with clinical diagnoses attributed by expert neurologists assumed as gold standard. We computed the sensitivity, specificity, positive and negative predictive values. Results: Out of 858 screened children and adolescents, the first 535 (62.4%) were selected for the validation questionnaire. Based on the HARDSHIP questionnaire, the most common diagnoses were probable Migraine (pMig) in 175 (20.7%), probable Tension-Type Headache (pTTH) in 144 (16.7%), Undifferentiated Headache (UDH) in 105 (12.2%), Tension-Type Headache (TTH) in 86 (10.0%), migraine in 68 (7.9%) children and adolescents. The agreement between questionnaire-based and clinical diagnoses was for migraine k = 0.432, for TTH k = 0.327, for pMOH k = 0.214. Conclusions: The validated Italian version of the HARDSHIP questionnaire provides a useful instrument for epidemiological research and for the improvement in diagnosis of pediatric headache disorders.