Cognitive Behavioral Therapy for Treatment of Pediatric Chronic Migraine

Abstract

Headaches that occur more days than not are prevalent in youth, affecting asmanyas 1 in60childrenandadolescents.1,2 Chronic migraine is defined as frequently recurring episodes of severe pulsating headaches with features such as nausea, vomiting, and sensitivity to light and sound that occur along with daily or near-daily milder headaches.3 The majority of childrenwith this disorder experience substantial impairment in their ability to function at school and to participate in typical physical and social activities.1,4 Yet rarelydo childrenwithchronicmigraineseek treatment.1 If theydid,historically most clinicians had little treatment to offer because of insufficient training inheadachemanagement,5 lackof preventive medications approved by the US Food and Drug Administration for this condition, and limiteddata fromplacebocontrolled randomized trials to guide treatment.6 In this issueof JAMA, the reportbyPowersandcolleagues7 of their randomizedclinical trialofcognitivebehavioral therapy (CBT) for chronic migraine in children and adolescents enhances the evidence on which to base clinical treatment decisions for this population. The investigators randomly assigned 135 children and adolescents (aged 10-17 years; 79% female) having a diagnosis of chronic migraine (based on the criteria of the International Classification of Headache Disorders, 2nd Edition) and a Pediatric Migraine Disability AssessmentScore (PedMIDAS)ofgreater than20points to receiveCBT (n = 64) or headache education (control group; n = 71). Participants in both groups also received standardized dosing of amitriptyline for headache prevention. Of the enrolled patients, 129 completed the 20-week follow-up and 124 completed 12-month follow-up. At the 20week endpoint, therewere significantly greater reductions in days with headache per month in the CBT group (reduced by 11.5 days) compared with the control group (reduced by 6.8 days) and in the PedMIDAS (decreased by 52.7 points for the CBT group vs 38.6 points for the control group). Among children in theCBTgroup, 66%hada clinically significant (≥50%) reduction inheadachedays comparedwith 36%of children in thecontrolgroup.Theauthorsconcludethat their findingssupport the efficacy of CBT in the treatment of chronic migraine in children and adolescents. The study by Powers et al7 is unique in rigor among behavioral intervention trials forpediatric chronicheadache.The study is well described, sufficiently powered, conservatively controlledwitha crediblebehavioral “placebo”condition, and of sufficient duration with atypically excellent participant retention8 to validly judge theprimary findings. Although the contribution of the studymedication amitriptyline to the observed outcomes could not be determined due to the selected researchdesign, the trial quality lends confidence in asserting that superior outcomes inpain anddisability are likely to be observed with CBT (vs only extra headache education) whenused in conjunctionwith a prophylacticmedication for pediatric chronic migraine. Psychological therapies similar in content to the approach investigated in the study by Powers et al7 have a long history of demonstrated efficacy in the treatment of pediatric headache. Meta-analyses of interventions that CBT comprises, suchas instruction in relaxationstrategies (withorwithout biofeedback assistance) and cognitive pain coping skills, have reported an approximately 3-fold greater likelihood of clinically significant improvement inheadache relative to control conditions.9 As such, the suggestion by Powers et al7 that CBT along with medications be considered a first-line treatment for children with chronic migraine has scientific precedents. Firmempirical evidenceof interventionefficacy,however, is rarely sufficient for translation into clinical practice. Whereasprescribing amitriptyline as aprophylactic agent for pediatric chronic migraine is relatively straightforward to implement, a number of patient, clinician, and system variables may limit successful application of the findings of Powers et al7 into practice. First, youth seeking care for headaches are unlikely to follow advice to see a therapist no matter the evidence. Estimates suggest less than half of pediatric patientswithachronicpainconditionwill followthroughwith a physician’s recommendation to pursue CBT.10 Perhaps coincidentally, less than half of the patients assessed for eligibility agreed to participate in the trial by Powers et al,7 with common reasons including distance, time commitment, and preference formedicationmanagement. Adherence in implementing the skills learned in CBT also is necessary for optimal outcomes, yet may be subpar in children and teens11; no dataonpatient adherence inuseof the skills acquired through CBT were included in the results of the trial by Powers et al.7 Second, primary care clinicians may lack the time,12 training,5 or both, necessary to adequately explain the rationale for CBT for headache management to families and their childrenmeeting diagnostic criteria for chronicmigraine. Yet it is unlikely that familieswill pursue anevidence-based treatment without the recommendation by a trusted pediatrician or pediatric neurologist. Unless communicated carefully, suggesting a child see a therapist for headache treatment could inadvertently imply that the origin of chronicmigraine is psyRelated article page 2622 Opinion