Pediatric Migraines: Cognitive Therapy Plus Amitriptyline

Scott W. Powers, PhD APBB Division of Behavioral Medicine and Clinical Psychology and Division of Neurology, Cincinnati Children’s Hospital Medical Center Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OhioMedicalResearch.com Interview with:
Scott W. Powers, PhD APBB
Division of Behavioral Medicine and Clinical Psychology and
Division of Neurology, Cincinnati Children’s Hospital Medical Center Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio

MedicalResearch.com: What are the main findings of the study?

Dr. Powers: Cognitive behavioral therapy plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with the use of headache education plus amitriptyline.  Children and adolescents with chronic migraine began the study with an average of 21 days with headache per 28 days and disability measured in the severe range.  After 20 weeks of treatment, 2 out of 3 participants in the CBT group had a 50% or greater reduction in headache days and 3 out of 4 had a reduction in disability to the mild to none range.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Powers: Cognitive behavioral therapy works, children and adolescents like it and stick with it, and the impact of treatment is durable.  CBT should be discussed with families at the time a diagnosis of chronic migraine is made.  It is helpful to describe the treatment in a way that focuses on the active, coaching in coping skills nature of CBT and how it is based on a biopsychosocial model and when used along with preventive medication, may change the neurobiological mechanisms that generate and maintain chronic migraine.  Because of the clinically meaningful impact we demonstrated in our trial, CBT should now be recommended as a first line treatment for chronic migraine in youth along with medication from the onset of an initial treatment plan and not as as add-on therapy once medication is found to be less than optimally effective.  The major transformation of practice would be to incorporate into treatment from the time of diagnosis and advocate for access, reimbursement, and training of health care providers in this specific form of biopsychosocial treatment.

MedicalResearch.com: Do you have recommendations for future research based upon your trial?

Dr. Powers: First off, migraines need to be recognized, treated, and considered a neurological disorder that has a major impact on the lives of children, adolescents, and adults.  To help patients, we need to now take evidence from rigorous randomized clinical trials, and translate the treatments into practice.  Also, more research focused on determining the efficacy of medication and behavioral treatments for migraines in youth is needed.  Our team at the Cincinnati Children’s Headache Center is leading a US based effort to test amitriptyline, topiramate, and placebo in pediatric migraine.  The CHAMP Study (Childhood and Adolescent Migraine Prevention Trial) is funded by the National Institute of Neurological Disorders and Stroke and involves up to 40 sites across the country.  Currently enrolling, this trial will be the first to compare the effectiveness of these two medications and to compare both to a placebo pill in a group of children and adolescents ages 8 to 17 that are representative of those families that seek care for migraines. The University of Iowa is the data coordinating center.  For chronic migraine, we need to conduct health outcomes research to demonstrate the effectiveness of CBT in the clinical care setting and to innovate in terms of refining the treatment so it is more accessible for the most number of families possible.  We also need to conduct longitudinal research to examine how durable the impact of CBT is as the youth move into adulthood.  If early intervention can be shown to change a life-long trajectory of outcomes for people who have migraines, then the public health impact of CBT and active treatment of youth with migraine and chronic migraine could be quite remarkable.

Citation:
Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents :A Randomized Clinical Trial

Powers SW, Kashikar-Zuck SM, Allen JR, et al. Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents: A Randomized Clinical Trial. JAMA. 2013;310(24):2622-2630. doi:10.1001/jama.2013.282533.