Update on Pediatric Migraine Treatment Focuses on Cognitive Behavioral Therapy

A 2021 update on research progress and needs for pediatric headache disorders highlights recent developments in psychological interventions for this patient population—specifically cognitive behavioral therapy (CBT)—and stresses the importance of improved access and equitability of care.

Writing in Current Pain and Headache Reports, researchers noted that to achieve these goals, “tailoring psychological treatments for patients with varying headache presentations and youth from a variety of cultural, racial, ethnic, and linguistic backgrounds” is warranted.

Migraine affects approximately 10% of school-aged children and 20% of older adolescents, and, according to evidence, pharmacological treatment is not superior to placebo in these patients.

In addition, “given that pill-based therapies can be associated with high rates of adverse events and side effects, the available data suggest that psychological interventions should be a front-of-the-line treatment option for pediatric migraine,” authors said.

CBT, which teaches patients how to use relaxation, behavioral, and other skills to manage pain, is considered the gold standard for treating migraine in youth. It is also the most frequently studied psychological intervention and can help reduce comorbid mental health symptoms, including those of anxiety and depression.

A review conducted in 2018 found that cognitive and/or behavioral interventions significantly reduced headache days and intensity among youth with chronic pain. The review also revealed less, but still positive, evidence on the treatment’s efficacy in headache-related disability.

According to authors, data on why and how CBT serves as a beneficial frontline intervention in this population are just emerging.

One study found the practice led to “pre-to-post-treatment changes in prefrontal cortical (PFC) activity, with concomitant alterations in functional connectivity between the PFC and the amygdala,” in youth with migraine. These findings suggest CBT may produce neural functioning changes in areas of the brain responsible for cognitive control, emotional regulation, and pain modulation. However, the study did not include a control group.

An additional study funded by The National Institute of Neurological Disorders and Stroke and the National Center for Complementary and Integrative Health is currently looking into neural alterations linked with specific components of CBT and a pill placebo. Authors postulate these results, once released, could set the groundwork for development of personalized CBT interventions.

Despite some evidence pointing to the efficacy of pain-focused CBT, “further optimization of available psychological interventions is needed, and focus should be placed on addressing the impact of headaches on the daily functioning and quality of life of children and adolescents,” researchers said.

In cases where comorbid depression or other mental health symptoms are acute and worsen an individual’s pain, authors recommend interventions directly addressing these concerns should be prioritized. Individual migraine characteristics should also be taken into account when developing a treatment plan.

Additional methodologies such as motivational interviewing (MI) can also be utilized in conjunction with CBT or other treatments. “Future research should focus on determining the added benefits of interventions like MI in clinical outcomes when combined with cognitive-behavioral interventions for youth with migraine,” authors wrote.

Mindfulness or acceptance and commitment therapy (ACT) could also be beneficial to those more suited to cognitive pain management strategies. These tactics differ from CBT as they encourage the patient to participate in activities despite the pain, as opposed to working to reduce the pain.

Currently, no clinical trials of mindfulness-based interventions have been carried out in youth migraineurs, while “the evidence base for ACT in the treatment of chronic pain in children and adolescents is growing, suggesting that this intervention may hold promise for use among youth with headache conditions.”

Researchers highlighted that the majority of migraineurs included in clinical trials are White, English-speaking females, creating the opportunity to better diversify enrollees and study populations.

Although this population is reflective of those who seek treatment for migraine, systemic barriers in health care could lead to access disparities that affect recruitment efforts and distort population demographics. Purposefully including individuals from traditionally underrepresented populations would help to increase generalizability of findings.

“Because beliefs about pain and the best ways to manage pain can vary considerably across racial and ethnic groups, taking time to understand how patients view their pain experience will allow providers to share a rationale for treatment that is consistent with these beliefs, and may enhance patient engagement in a psychological intervention,” researchers said.

However, the limited availability of providers with training in behavior change also marks a challenge to equitable migraine care. Some patients may not live close to a hospital to receive CBT; for others, the frequency of sessions can be burdensome.

Telemedicine may help fill some of these access gaps, as digital therapeutic tools have been developed to address these needs, but most pilot studies have been conducted among adult populations.

More research is needed in this area, and authors cautioned rigorous data will be needed for providers to feel confident in “prescribing” an e-health platform as an adjunct to in-person CBT.

Adherence to cognitive-behavioral coping skills among youth with migraine also constitutes a challenge, although group-based interventions may help address this barrier.

Overall, “psychological interventions such as CBT are safe and effective treatments for pediatric pain management and should be considered a frontline treatment for youth with migraine,” researchers said.

“In order to make a broader public health impact, research that includes diverse samples of children and adolescents with headaches will be desperately needed in the coming years to ensure the equitability and accessibility of nonpharmacological interventions to all youth with headache disorders,” they concluded.

Reference:

Knestrick KE, Gibler RC, Reidy BL, Powers SW. Psychological interventions for pediatric headache disorders: a 2021 update on research progress and needs. Curr Pain Headache Rep. Published online February 2, 2022. doi:10.1007/s11916-022-01007-z