Pediatric Primary Headache From A to Z

William T. Basco, Jr., MD, MS


June 24, 2015

In This Article

Behavioral Approaches to Managing Headache

Dr Lisa Giles, a pediatric psychiatrist, detailed behavioral approaches for treating headache in children. She began by emphasizing that there is often a significant overlap between headache and psychological conditions, suggesting that behavioral interventions can help with chronic headache.

Headache is a common presentation of both depression and anxiety. If either anxiety or depression is present, treating the headache is more difficult. The comorbid conditions must be recognized and treated as well.

Screening tools are available for assessing anxiety and depression in patients who present with headache as a chief complaint. Publicly available tools include the nine-item Patient Health Questionnaire (PHQ-9) or the PHQ-A for adolescents to screen for depression, and the seven-item Generalized Anxiety Disorder (GAD-7) screen for anxiety. Both the PHQ-9 and GAD-7 are available in multiple languages.

For treatment of depression, either selective serotonin reuptake inhibitors or tricyclic antidepressants are recommended, although serotonin syndrome is a potential risk with either. Fewer data are available on the effectiveness of serotonin-norepinephrine reuptake inhibitors in children with headache.

Cognitive-Behavioral Therapy. The first part of the behavioral evaluation of headache is to determine whether adverse behaviors (poor sleep hygiene, poor diet, insufficient fluid intake, environmental stress) are leading to headache. These behaviors are difficult for patients to change, so motivational interviewing can be an effective approach. It is important to be supportive of patients and offer to be available to them as they struggle with behavior change to improve headache control.

If lifestyle modifications are insufficient, cognitive-behavioral therapy (CBT) is effective for chronic headache. The premise of CBT is that changing thoughts and behaviors will change how an individual feels. CBT also provides the patient with improved coping skills and gives them the feeling that they have more control over their pain. There is some evidence from functional imaging that CBT can change brain functioning.

The process involves educating the patient about his or her pain, then helping the patient restructure his or her thoughts about pain. Techniques include behavioral imagery, relaxation, and biofeedback. Increased physical activity is also part of a behavioral treatment plan, but patients should be encouraged to pace themselves.

The evidence for CBT is considerable, with many randomized clinical trials in different chronic pain settings suggesting improvement in 50% of patients. Evidence indicates a 30%-70% reduction in headache symptoms, and that patients experience long-term sustained benefit from this approach.

There are also good pediatric data on the ability of CBT to improve headache. In a study from Cincinnati looking at 135 youths in a headache clinic, the combination of CBT and amitriptyline was compared with headache education and amitriptyline. The patients who received CBT had much better functioning at the end of 20 weeks of treatment, experienced fewer side effects associated with amitriptyline, and had a reduction in headache frequency of 12 days per month, compared with a reduction of 7 days per month in the active control group.[20]

Biofeedback. The evidence for biofeedback in headache therapy also shows strong effect sizes. Biofeedback involves using monitors to measure the physiologic effects as patients undergo relaxation self-therapies. The effectiveness of biofeedback is probably related to patients feeling that they have control over their pain. Relaxation techniques include distraction, guided imagery, breathing exercises, and self-hypnosis.

A team-based approach should focus on all aspects that are feeding into the patient's pain experience. It is helpful for the patient to hear consistent messages from all providers involved in headache treatment. Certainly, challenges exist, including whether the appropriate resources are available in certain communities, whether a patient's insurance will cover such adjunct care options as CBT, as well as the need to train more providers in these methods. Headache-specific clinics that include neurologists, pediatricians, and psychologists as part of the evaluation team can help to reduce the stigma patients may otherwise experience.

In summary, CBT, biofeedback, and relaxation approaches have all been demonstrated to be effective in children, and multidisciplinary approaches can result in better outcomes for patients. Providers should focus on an approach in the chronic setting that emphasizes improving function, with less emphasis on degree of headache pain or the frequency of headaches.


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