Chronic migraines are on the rise in children, with nearly two percent experiencing these headaches at least 15 days a month. Along with this rise has been an increasing reliance on chronic medications -- like the antidepressant amitriptyline -- to prevent migraines. But these drugs often don’t work well, and doctors worry about the long term side effects of giving them to kids and continuing them throughout adulthood.
Many parents may want to consider trying a behavioral therapy that teaches kids to manage their pain since a new clinical trial published in the prestigious Journal of the American Medical Association found that it works in conjunction with amitriptyline to reduce the frequency of these headaches.
Researchers at Cincinnati Children’s Hospital Medical Center tested the approach, called cognitive behavioral therapy, on 135 children ages 10 to 17, and found that those who took amitriptyline and had eight weekly sessions of the therapy with a psychologist experienced 12 fewer headache days per month compared to seven fewer days a month for those in a placebo group who took amitriptyline and went to headache education sessions.
“Cognitive behavioral therapy can teach kids to have some control over how their body reacts to pain,” said Dr. Elizabeth Loder, a Brigham and Women’s Hospital internist and president of the American Headache Society. Instead of allowing pain to trigger anxiety that, in turn, can worsen a headache, CBT teaches them to relax and cope.
The therapy involves a combination of teaching migraine sufferers to think differently about their head pain -- to challenge negative thoughts that may pop into their head the moment they feel the first dull ache. “Instead of thinking that the headache will go on forever or that the last time the medications didn’t work, they’re taught to think that they can get control over their pain and that sometimes treatments do work,” Loder said. “It’s about changing cognition.”
It also has a biofeedback component where practitioners attach sensors to monitor blood pressure, breathing rate, and pulse in order to teach children to induce a sense of relaxation, to help reduce their pain and manage it better.
“It provides people with a way of intervening themselves -- instead of depending on a pill or needing someone to do something for them -- which can be very therapeutic,” said Loder, who often refers her adult migraine patients for the therapy. Headache specialists at Boston Children’s Hospital treat pediatric migraine sufferers with CBT as well.
While Loder pointed out that CBT might have worked synergistically with amitriptyline, she said the therapy alone would likely have reduced the headaches nearly as well.
“There’s a tremendous interest among headache specialists to use non-drug interventions especially in children and teens,” Loder said. Many will have to deal with migraines for their entire lives, and doctors don’t know the long term side effects of being on preventive medications for decades.
But -- and this is a biggie -- parents and kids need to be willing to invest the time and effort in the treatment, which usually involves hour-long sessions for six to eight weeks in addition to several followup appointments throughout the year. Insurance coverage has been spotty in Massachusetts often requiring doctors to push managed care companies to pay. Parents who pay on their own may wind up shelling out hundreds of dollars for the therapy.
Even the study researchers, who offered free treatment at a world class headache center, had a hard time recruiting families to join their study because, well, people often prefer the simpler approach to pain management: filling a prescription.