ARTICLE IN BRIEF
Investigators reported that children who had chronic migraine fared better (experiencing fewer headaches each month) after cognitive behavioral therapy — a ten-week course teaching them relaxation and pain management exercises.
Cognitive behavioral therapy combined with amitriptyline appears to reduce the number of headaches experienced each month by children and adolescents with chronic migraine, according to the first prospective, randomized clinical trial.
Researchers at Cincinnati Children's Hospital Medical Center compared cognitive behavioral therapy (CBT) or education classes in children and adolescents taking the tricyclic antidepressant and found that a ten-week, one-hour course of CBT — generally teaching them relaxation and pain management exercises — resulted in 4.7 fewer monthly headache days when compared with a similar group of treated children receiving education only, a two-thirds reduction.
The findings were reported in the Dec. 25, 2013 edition of the Journal of the American Medical Association.
“Children can have migraines as severe as adults, and I think we need to take a multimodal approach with them by adding CBT to the treatment approach,” said lead author Scott W. Powers, PhD, a professor of pediatrics and co-director of the headache center at Cincinnati Children's Hospital Medical Center.
The researchers randomized 135 children and adolescents between the ages of 10 and 17 years into CBT or education classes and used days without headache and the Pediatric Migraine Disability Assessment Score (PedMIDAS) as endpoints, with follow-up visits at 3, 6, 9, and 12 months to assess treatment durability.
The researchers only included children with a diagnosis of chronic migraine by a certified headache specialist using the International Classification of Headache Disorders-11 criteria — five or more days with headache per month measured by a prospective 28-day headache diary, and a PedMIDAS Score of greater than 20 points, indicating at least moderate disability.
All patients were also given 1 mg/kg daily of amitriptyline. A total of 129 children completed a 20-week follow-up assessment period and 124 continued to be seen for one full year. At the study's outset, the subjects experienced 15 or more days per month with a migraine.
A 50 percent or greater reduction in headache days was used as a marker of clinical significance, with a PedMIDAS disability score in the mild to none range. PedMIDAS assigns a 0–240 value to disability; 0-10 for little to none, 11-30 for mild, 31-50 for moderate, and greater than 50 for severe problems.
The mean number of headache days per month at the study's outset was 21, plus or minus five, and the mean PedMIDAS score was 32 points. After 20 weeks, however, the patients who had CBT plus amitriptyline had 11.5 fewer headache days compared with 6.8 fewer headache days in the education group. PedMIDAS scores decreased by 52.7 points in the CBT group, and 66 percent had 50 percent or greater reduction in headache days. In the education group PedMIDAS scores fell 38.6 points, and 36 percent of the children had fewer headache days.
After one year, 86 percent of CBT participants had a 50 percent or greater reduction in headache days compared with 69 percent in the other children, while 88 percent had PedMIDAS scores under 20 versus 76 percent in the latter group.
“The efficacy of CBT in helping children with migraine is clear and it should be routinely offered as a first-line treatment along with medications, and not only as an add-on if medications are not found to be sufficiently effective,” Dr. Powers told Neurology Today in a telephone interview.
“Our retention rate was very high in the CBT group. Once patients and their families made the commitment, they got a lot out of them and most stuck with it. The challenge is training enough clinicians in CBT for migraine and getting insurers to cover therapy.”
He also said testing of alternate formats for delivery like online therapy and mobile apps should be developed to overcome barriers to face-to-face therapy.
To facilitate training, he and his colleagues are in the process of preparing a website CBT training module for clinicians, along with summaries of treatment manuals, he told Neurology Today.
BARRIERS AND LIMITATIONS
In an accompanying editorial, Mark Connelly, PhD, the acting director of integrative pain management at Children's Mercy Hospital in Kansas City, MO, said that while the findings are encouraging, applying them in the clinical setting might be challenging.
He noted that meta-analyses of relaxation strategies like CBT in chronic pain management have shown an approximately three-fold greater likelihood of clinically significant improvements, however patient, clinician, and system variables may limit application of the findings.
One important limitation is that evidence indicates that adolescents may not follow recommendations for CBT.
“Youth seeking care for headaches are unlikely to follow advice to see a therapist no matter the evidence,” he wrote. “Estimates suggest less than half of pediatric patients with a chronic pain condition will follow through with a physician's recommendation to pursue CBT.”
Moreover, many primary care clinicians lack the time, training, or both, necessary to adequately explain the rationale for CBT for headache management to families and their children. “Unless communicated carefully, suggesting a child see a therapist for headache treatment could inadvertently imply that the origin of chronic migraine is psychological. In response, families may paradoxically increase efforts to find a medical solution elsewhere,” he said.
Barriers within the health care system may also limit the implementation of CBT as a first-line treatment for pediatric migraine, he wrote, noting that insurance reimbursement for the codes used for headache management CBT vary widely, even within states, so therapy may require out-of-pocket expenses that are prohibitive for some families.
David Rothner, MD, chairman emeritus of child neurology at Cleveland Clinic, and director of the Pediatric/Adolescent Headache Program in the Center for Pediatric Neurology, told Neurology Today in a telephone interview that the study's authors are among the top headache experts in the country at one of the leading migraine research centers, both of which lend credence to the study's findings.
“There is no question that CBT adds value to the mix of multimodal treatment options that should be made available to children with chronic migraine, but only those with frequent migraine episodes such as those included in the study. A number of younger kids only have a migraine every two weeks or so, but those of us who work in this field know that children with chronic migraines — and that means 15 of more episodes every month — are the most difficult to treat.”
Two factors that are often overlooked when treating such cases are the overuse of over-the-counter pain medications and the large number of days of school these children typically miss, he added, noting that one of his patients has missed almost three weeks of school since September.
“These are much tougher patients, but the tougher they are, I believe the more they need CBT. Children with occasional migraines do not need it.”
Although it is unknown why children with chronic migraine benefit from CBT, Dr. Rothner said one factor appears to be difficulties in their home life, as well as comorbid psychological conditions including depression, bipolar disorder, and attention-deficit hyperactivity disorder.
Dr. Rothner and his colleagues have recently started a rehabilitation facility, which uses a multimodal approach to pediatric patients with different types of chronic pain, including those with chronic migraines. The program involves two weeks of in-patient care and one of outpatient care; the results, he told Neurology Today, are very encouraging.
“So far, 70 percent of the children are back in school.”
•. Powers SW, Kashikar-Zuck SM, Hershey AD, et al. Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: A randomized clinical trial. JAMA. 2013; 310:2622–2630.
•. Connelly M. Cognitive behavioral therapy for treatment of pediatric chronic migraine. JAMA. 2013; 310:2617–2618.
•. Eccleston C, Palermo TM, de C, Williams AC, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2012; 12:CD003968.
•. Simons LE, Logan DE, Chastain L, Cerullo M. Engagement in multidisciplinary interventions for pediatric chronic pain: parental expectations, barriers, and child outcomes. Clin J Pain. 2010; 26:291–299.