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Cognitive Behavioral Therapy for Treatment of Pediatric Chronic Migraine

Article  in  JAMA The Journal of the American Medical Association · December 2013


DOI: 10.1001/jama.2013.282534 · Source: PubMed

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Opinion

Editorials represent the opinions of the authors and JAMA


EDITORIAL and not those of the American Medical Association.

Cognitive Behavioral Therapy for Treatment


of Pediatric Chronic Migraine
Mark Connelly, PhD

Headaches that occur more days than not are prevalent in retention8 to validly judge the primary findings. Although the
youth, affecting as many as 1 in 60 children and adolescents.1,2 contribution of the study medication amitriptyline to the ob-
Chronic migraine is defined as frequently recurring episodes served outcomes could not be determined due to the se-
of severe pulsating head- lected research design, the trial quality lends confidence in as-
aches with features such as serting that superior outcomes in pain and disability are likely
Related article page 2622 nausea, vomiting, and sensi- to be observed with CBT (vs only extra headache education)
tivity to light and sound that when used in conjunction with a prophylactic medication for
occur along with daily or near-daily milder headaches.3 The pediatric chronic migraine.
majority of children with this disorder experience substantial Psychological therapies similar in content to the ap-
impairment in their ability to function at school and to par- proach investigated in the study by Powers et al7 have a long
ticipate in typical physical and social activities.1,4 Yet rarely do history of demonstrated efficacy in the treatment of pediat-
children with chronic migraine seek treatment.1 If they did, his- ric headache. Meta-analyses of interventions that CBT com-
torically most clinicians had little treatment to offer because prises, such as instruction in relaxation strategies (with or with-
of insufficient training in headache management,5 lack of pre- out biofeedback assistance) and cognitive pain coping skills,
ventive medications approved by the US Food and Drug Ad- have reported an approximately 3-fold greater likelihood of
ministration for this condition, and limited data from placebo- clinically significant improvement in headache relative to con-
controlled randomized trials to guide treatment.6 trol conditions.9 As such, the suggestion by Powers et al7 that
In this issue of JAMA, the report by Powers and colleagues7 CBT along with medications be considered a first-line treat-
of their randomized clinical trial of cognitive behavioral therapy ment for children with chronic migraine has scientific prec-
(CBT) for chronic migraine in children and adolescents en- edents. Firm empirical evidence of intervention efficacy, how-
hances the evidence on which to base clinical treatment de- ever, is rarely sufficient for translation into clinical practice.
cisions for this population. The investigators randomly as- Whereas prescribing amitriptyline as a prophylactic agent
signed 135 children and adolescents (aged 10-17 years; 79% for pediatric chronic migraine is relatively straightforward to
female) having a diagnosis of chronic migraine (based on the implement, a number of patient, clinician, and system vari-
criteria of the International Classification of Headache Disor- ables may limit successful application of the findings of
ders, 2nd Edition) and a Pediatric Migraine Disability Assess- Powers et al7 into practice. First, youth seeking care for head-
ment Score (PedMIDAS) of greater than 20 points to receive CBT aches are unlikely to follow advice to see a therapist no mat-
(n = 64) or headache education (control group; n = 71). Par- ter the evidence. Estimates suggest less than half of pediatric
ticipants in both groups also received standardized dosing of patients with a chronic pain condition will follow through with
amitriptyline for headache prevention. a physician’s recommendation to pursue CBT.10 Perhaps co-
Of the enrolled patients, 129 completed the 20-week fol- incidentally, less than half of the patients assessed for eligi-
low-up and 124 completed 12-month follow-up. At the 20- bility agreed to participate in the trial by Powers et al,7 with
week end point, there were significantly greater reductions in common reasons including distance, time commitment, and
days with headache per month in the CBT group (reduced by preference for medication management. Adherence in imple-
11.5 days) compared with the control group (reduced by 6.8 menting the skills learned in CBT also is necessary for opti-
days) and in the PedMIDAS (decreased by 52.7 points for the mal outcomes, yet may be subpar in children and teens11; no
CBT group vs 38.6 points for the control group). Among chil- data on patient adherence in use of the skills acquired through
dren in the CBT group, 66% had a clinically significant (≥50%) CBT were included in the results of the trial by Powers et al.7
reduction in headache days compared with 36% of children in Second, primary care clinicians may lack the time, 12
the control group. The authors conclude that their findings sup- training,5 or both, necessary to adequately explain the ratio-
port the efficacy of CBT in the treatment of chronic migraine nale for CBT for headache management to families and their
in children and adolescents. children meeting diagnostic criteria for chronic migraine. Yet
The study by Powers et al7 is unique in rigor among be- it is unlikely that families will pursue an evidence-based treat-
havioral intervention trials for pediatric chronic headache. The ment without the recommendation by a trusted pediatrician
study is well described, sufficiently powered, conservatively or pediatric neurologist. Unless communicated carefully, sug-
controlled with a credible behavioral “placebo” condition, and gesting a child see a therapist for headache treatment could
of sufficient duration with atypically excellent participant inadvertently imply that the origin of chronic migraine is psy-

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Opinion Editorial

chological. In response, families may paradoxically increase adolescents with chronic migraine ultimately adhere to the rec-
efforts to find a medical solution elsewhere. However, intro- ommendation of completing CBT, the addition of 11.5 days/
ducing the patient to a biopsychosocial model13 and explain- month of headache freedom and the substantial gain in days
ing how coaching in cognitive and behavioral pain coping skills for which functioning in school, home, play, and social activi-
along with medication management can help change the neu- ties is restored could appreciably improve the lives of many
robiological mechanisms that generate and maintain chronic children and their families. To overcome system barriers, data
migraine could yield a greater chance that the family will pur- from Powers et al7 may be considered in discussions to im-
sue CBT. prove third-party reimbursement of CBT as an efficacious head-
In addition, system barriers may affect the likelihood of ache treatment.
CBT being implemented as a first-line treatment for pediatric Creative means of delivering CBT for pediatric chronic mi-
chronic migraine. Insurance reimbursement for the codes used graine (eg, via telehealth or Internet-based programs, using be-
for CBT or biofeedback for headache management vary widely havioral health consultants in primary care offices) will be nec-
within and across states. 14 Whereas CBT in the trial by essary for reducing current access and referral barriers that
Powers et al7 was provided without charge in the context of could be encountered by many families and physicians. Wid-
research, CBT as an initial treatment for chronic migraine in ening the availability of interdisciplinary models of training
practice may require out-of-pocket expenses that are prohibi- and treatment delivery also will be important for helping en-
tive for some families. Moreover, the success of CBT arguably sure that children with chronic migraine routinely receive com-
depends on the training and quality of the treating clinician. bination therapies rather than being referred for psychologi-
In the study by Powers et al,7 the therapists had specialty train- cal therapy only after other approaches fail.
ing in CBT for pain management and were supervised by ex- Ideally with the efforts of the health care community and
perts. By contrast, access in the community to pediatric be- other relevant stakeholders, the suggestion by Powers et al7
havioral therapists trained to implement CBT protocols for pain to consider CBT along with medication as a first-line treat-
management is limited. Most therapists with such specialty ment for chronic migraine in children will be implemented into
training are affiliated with academic medical centers or pedi- practice well before the typical translation gap.16 Additional
atric pain clinics, of which there are approximately 1 for every studies are warranted, however, to identify methods of pre-
2 states.15 venting chronic migraine development and to determine the
Most of these barriers may be surmountable, and the re- medications and combination therapies that further maxi-
sults of the clinical trial by Powers et al7 provide a compelling mize improvements in health and quality of life outcomes for
impetus to try. For instance, even if only half of children and children and adolescents with chronic migraine.

ARTICLE INFORMATION from the American Migraine Prevalence and 11. Gearing RE, Schwalbe CS, Dweck P, Berkowitz J.
Author Affiliations: Children’s Mercy Hospitals and Prevention study. Headache. 2012;52(1):3-17. Investigating adherence promoters in
Clinics, Kansas City, Missouri; University of Missouri 5. Gallagher RM, Alam R, Shah S, Mueller L, Rogers evidence-based mental health interventions
School of Medicine, Kansas City. JJ. Headache in medical education: medical with children and adolescents. Community Ment
schools, neurology and family practice residencies. Health J. 2012;48(1):63-70.
Corresponding Author: Mark Connelly, PhD,
Children’s Mercy Hospitals and Clinics, 2401 Gillham Headache. 2005;45(7):866-873. 12. Mechanic D, McAlpine DD, Rosenthal M. Are
Rd, Kansas City, MO 64108 (mconnelly1@cmh.edu). 6. El-Chammas K, Keyes J, Thompson N, patients’ office visits with physicians getting
Vijayakumar J, Becher D, Jackson JL. Pharmacologic shorter? N Engl J Med. 2001;344(3):198-204.
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for treatment of pediatric headaches: a meta-analysis. 13. Seshia SS, Phillips DF, von Baeyer CL. Childhood
Disclosure of Potential Conflicts of Interest and JAMA Pediatr. 2013;167(3):250-258. chronic daily headache: a biopsychosocial
none were reported. 7. Powers SW, Kashikar-Zuck SM, Allen JR, et al. perspective. Dev Med Child Neurol.
Cognitive behavioral therapy plus amitriptyline for 2008;50(7):541-545.

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