Adding CBT Improves School Function in Kids With Migraine

Pauline Anderson

June 26, 2014

LOS ANGELES — Combining cognitive-behavioral therapy (CBT) with amitriptyline improves school performance and quality of life in adolescents with chronic migraines, a new analysis has shown.

The results suggest that physicians should prescribe CBT along with drug therapy for youngsters with chronic migraines, said lead author Scott W. Powers, PhD, professor of pediatrics and psychology, University of Cincinnati, and co-director, Headache Center, Cincinnati Children's Hospital, Ohio.

"Migraine is a lifelong disorder, so young people who develop migraine often continue to have this condition as adults," Dr. Powers told Medscape Medical News. "It's very important to catch this chronic illness early, so they're not spending 20 or 30 years trying to cope without effective skills."

The findings will be presented here at the American Headache Society (AHS) 56th Annual Scientific Meeting.

Quality of Life

The study was a secondary analysis of a randomized clinical trial showing that CBT plus amitriptyline reduced headache frequency compared with the drug plus headache education. The study was published in JAMA and reported by Medscape Medical News at that time.

Investigators were interested to see whether this headache improvement affected quality of life and school functioning.

The study included 135 youths aged 10 to 17 years (mean age, 14.4 years; almost 80% female) diagnosed with chronic migraine (at least 15 days with headache a month) and a score of more than 20 points on the Pediatric Migraine Disability Assessment Score (PedMIDAS).

The children completed the PedsQL, a 23-item assessment of health and activities, feelings, and problems getting along with others, with higher scores indicating better quality of life. Researchers also examined the School Functioning Subscale of the PedsQL.

At baseline, the groups together had a mean of 21.3 headache days a month and a PedMIDAS severity score of 68.3.

The children were assigned to the CBT plus amitriptyline group (n = 64) or to headache education plus amitriptyline group (n = 71). Amitriptyline was titrated to a goal dose of 1 mg/kg per day.

The CBT intervention included weekly sessions for 8 weeks, then monthly sessions for a total of 20 weeks. The package included 3 components: biofeedback-assisted relaxation using deep breathing, muscle relaxation, and guided imagery; education on how pain can be influenced by behavior, emotions, and thoughts; and coping skills. Parents were encouraged to support their child and reinforce his or her coping behaviors.

The educational group had regular discussions on headache-related topics.

In the previously reported results, the CBT intervention resulted in a decrease at 20 weeks of 11.5 headache days vs 6.8 days for the headache education group, a significant difference of 4.7 days (95% confidence interval [CI], 1.7 - 7.7 days; P = .002).

The PedMIDAS score decreased by 52.7 points with CBT compared with 38.6 points with education (difference, 14.1; 95% CI, 3.3 - 24.9 points; P = .01).

In addition, at 12 months, 86% of the CBT group and 69% of the education group had a 50% or greater reduction in headache days — a clinically meaningful benchmark — and 88% of the CBT group and 76% of the education group had a PedMIDAS of less than 20 points.

School Functioning

In this new analysis, both groups improved on the PedsQL total score at both 20 weeks and 12 months. School functioning improved more in the CBT group than the education group (72.3 vs 65.7; P < .05 at 20 weeks; 80.3 vs 73.9; P < .05 at 12 months).

New headache frequency analysis showed headache days were reduced to about 1 per week or less for almost 80% of the children who received CBT.

The combined CBT plus drug therapy not only reduced the frequency of headaches, making it "a lot more fun to go to school," but it also allowed kids to cope better on days when they do get a headache, commented Dr. Powers.

The idea is that kids can use the coping skills they learn throughout their life. "It's not like these young people are never going to have headaches again," said Dr. Powers. "So what we teach them — to understand their body, to use relaxation when a headache starts, to adhere to an acute medicine regimen when a headache starts — allows them to cope better if they do have a headache."

CBT has very few adverse effects, so it would be appropriate for most adolescents. However, there is 1 "clinical caveat," said Dr. Powers. "For youngsters with dissociative disorder or a significant and severe history of abuse or neglect, you might be a little careful about creating a relaxation state without that being coupled with helping them with a trauma-based type of therapy."

Amitriptyline, a drug developed to treat depression, may or may not be the best drug to pair with CBT, he noted. Another study, which is using amitriptyline, topiramate, and placebo and is being carried out at 40 sites in the United States, will help answer that question, said Dr. Powers.

Not a "Wasteland"

Asked to comment on the study, Peter Goadsby, MD, PhD, director, Headache Center, University of California, San Francisco, said it illustrates that "the treatment of pediatric and adolescent headache is not a wasteland," and that it's possible to diagnose and treat children who have chronic migraine.

"The message for me is that children with headache shouldn't be consigned to a pat on the head but should be diagnosed and managed properly," he told Medscape Medical News.

That CBT added to amitriptyline worked in kids with migraine makes sense because a 2-pronged approach typically provides better results than a single approach, said Dr. Goadsby.

He also believes the study drives home a point about the need for accessible resources.

"Life is tricky, life is busy, the child with migraine might not be the only child in family," and it might be difficult for parents to find the time to take one of their children to CBT, said Dr. Goadsby. "The data challenge health care providers at all levels to think about how to better deliver services to children and families."

The study was funded by the National Institutes of Health.

American Headache Society (AHS) 56th Annual Scientific Meeting. Abstract 1963990.

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