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Behavioral therapy may treat migraines in kids, teens

By Andrew M. Seaman

NEW YORK (Reuters Health) - Children and teens with chronic migraines may find headache relief when they pair medication with psychotherapy, according to a new study.

Researchers found that kids who received cognitive behavioral therapy, a type of psychotherapy that teaches relaxation and coping techniques, had significantly fewer days with headaches.

"This is a learning based treatment in a sense that you as a young person can learn skills and apply them to everyday life," Dr. Scott Powers said.

Powers is the study's lead author and co-director of the Headache Center at Cincinnati Children's Hospital Medical Center in Ohio.

Migraines are severe headaches - sometimes accompanied by light sensitivity, visual hallucinations or nausea - that can disable a person for hours or even days at a time. The majority of migraine sufferers are women.

About 2 percent of adults suffer from chronic migraine, which is defined as having the severe headaches for at least 15 days per month. About 1.75 percent of children have the chronic condition, Powers and his colleagues write in JAMA.

Despite the severity of chronic migraine and how common the condition is in children and teens, there are currently no treatments for kids approved by the U.S. Food and Drug Administration.

Instead, the antidepressant amitriptyline (first sold as Elavil by AstraZeneca), which has been found to help prevent migraines, is sometimes prescribed for kids.

Some studies have also suggested that cognitive behavioral therapy (CBT), a form of talk therapy that emphasizes changing one's responses to problems, may help children and teens to manage chronic pain.

To see whether CBT could improve kids' ability to cope with chronic migraine, the researchers randomly assigned 135 chronic migraine sufferers between the ages of 10 and 17 to undergo either CBT or an education program about headaches. All the participants were also taking amitriptyline.

Each child received eight weekly hour-long sessions of either headache education or CBT. That was followed by booster sessions at 12 and 16 weeks, plus three more booster sessions over the next year.

Children in the CBT group received a modified version of a program that teaches coping skills to help control pain. It includes relaxation skills, such as slow and deep breathing exercises, and a biofeedback component to show kids the body's response to the techniques.

The children in the education group discussed headache-related topics and received support from therapists during their sessions.

The study was conducted between October 2006 and September 2012.

At the beginning, the children reported having migraines for an average of 21 out of 28 days. On a scale that measures disability from migraine symptoms, where 50 or above is considered severe, they averaged a disability level of 68.

After 12 months, the number of days with migraines had been cut by at least half in 86 percent of children in the CBT group, compared to only 69 percent of kids in the education group.

"We may not get rid of migraines entirely but we can reduce them significantly," Powers said.

The researchers also found that 88 percent of the CBT group scored below 20 on the disability scale at the end of the study. That compared to 76 percent of the headache education group.

A score below 20 on the disability scale signifies mild or no disability.

In an editorial accompanying the new study, Mark Connelly says there had been some evidence that CBT in addition to medication would be effective as treatment for chronic migraines, but that doesn't mean it will be widely available right away.

"I don't think right off the bat every provider who sees these kids will have access to people who can help," Connelly said. He's co-director of the Comprehensive Headache Clinic at Children's Mercy Hospitals and Clinics in Kansas City, Missouri.

Children and teens may be unlikely to follow through with a doctor's recommendation to see a therapist for chronic migraines, he said, and doctors may not have the time or training to properly explain the rationale for CBT.

Also, insurance companies may not pay for CBT and people would need to be trained in the therapy, he noted.

While Powers and his fellow researchers didn't examine the cost of the program, he said the total cost of treatment may be less than for a typical medical imaging test, such as an MRI.

"You're talking about the potential of cost being under $2,000 to get these types of results," Powers said, adding that the ability to spread this type of therapy would also partially depend on whether insurance companies cover it.

Still, Powers said, people may be able to take advantage of the program used in this study if they ask their doctors about CBT.

Connelly, however, said availability of the treatment will still probably depend on doctors' ability to explain the therapy.

"I think some families will see a summary of the data and potentially pursue it on their own, but more likely it will be providers who need to explain it and push people to do it," he said.

In the future, Powers said, there may be ways to alter the therapy to make it more accessible. For example, they could modify it to be partially delivered by computer or online.

"We think there are ways through the research on how to improve upon what we've done," Powers said.

SOURCE: http://bit.ly/JOTmp1 JAMA, online December 24, 2013.

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