Pediatric Migraine: Evidence-Based Alternative Management

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The episodic and unpredictable nature of the disease makes it particularly difficult to manage acute migraine attacks in childhood and adolescence.
The episodic and unpredictable nature of the disease makes it particularly difficult to manage acute migraine attacks in childhood and adolescence.

Migraine is a prevalent episodic neurologic disease in pediatric populations, affecting approximately 8% of children and adolescents.1 In young children, prevalence is slightly higher in boys compared with girls; however, with the onset of puberty, migraine incidence increases more rapidly in girls, resulting in a higher prevalence in adolescent girls compared with boys.2 For many children and adolescents with migraine, the disease significantly affects quality of life and contributes to reduced functioning at school, at home, and in relationships with peers.3,4

The episodic and unpredictable nature of the disease makes it particularly difficult to manage acute migraine attacks in childhood and adolescence,5 as children and adolescents have limited control over their own schedules, including bedtime, naptime, and when they can (and cannot) eat snacks, drink water, or take acute medications. Providers, family members, and teachers should strive to work together to optimize a child's acute management of migraine attacks. However, these challenges to acute management highlight the need for effective preventive therapies for pediatric migraine.

Unfortunately, recent high-quality clinical trial evidence has demonstrated that medications commonly prescribed for migraine prevention in pediatric patients (amitriptyline and topiramate) were not superior to placebo for reduction of headache days or headache disability in children and adolescents.6 In this trial, all groups experienced reductions in migraine frequency (50% reduction in headache days observed in 52% of the amitriptyline group, 55% of the topiramate group, and 61% of the placebo group), which raises important questions about the mechanisms of preventive migraine medications in pediatric patients. These results also emphasize the importance of interdisciplinary care to reduce migraine frequency in children and adolescents with migraine.

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a core feature of evidence-based interdisciplinary care for pediatric migraine. A recent systematic review of 14 randomized clinical trials found a pooled odds ratio of 9.11 (95% CI, 5.01-16.58) for a clinically significant improvement (reduction of 50% or more in headache activity) at posttreatment points compared with wait list, placebo, or standard medication.7 For example, a recent high-quality clinical trial found that cognitive behavioral therapy plus amitriptyline was superior to headache education plus amitriptyline in reducing headache days and migraine disability in youths (aged 10-17 years) with chronic migraine.8

Relaxation Training

Relaxation training is a core coping skill gained in any cognitive behavioral therapy for pediatric migraine protocol.1 Relaxation training involves systematically instructing children on techniques to volitionally reduce sympathetic activation, including deep breathing, muscle relaxations, various cue-controlled relaxation strategies, and imagery. These skills are practiced on a daily basis to reduce overall sympathetic activation and increase self-efficacy to manage migraine in the moment. Biofeedback is sometimes used to strengthen the connection between using relaxation techniques and the body's reaction. In certain children and adolescents, biofeedback can increase buy-in because the patient can actually see the changes happening in their body when they use relaxation techniques; increase the efficiency of learning relaxation techniques, as they can see when the techniques are working; and "gamify" the regular practice of relaxation techniques, helping the patient incorporate them into their daily routine. Alone, as well as in broader cognitive-behavioral therapy treatment protocols, relaxation and biofeedback-assisted relaxation have demonstrated efficacy to reduce headache frequency in pediatric migraine.7

Mindfulness

Mindfulness is an attention control technique in which one pays attention to the present moment without making judgments. Mindfulness has been practiced for thousands of years in a religious context, and has recently been adapted for stress management, wellness, and mental health applications. Mindfulness is often practiced through meditation, which includes paying attention to the breath and other sensory or cognitive experiences without judging, although mindfulness can also be practiced within other contexts. Mindfulness is not necessarily relaxation. Some people may choose to practice mindful awareness while engaging in relaxation exercises such as deep breathing and muscle scanning; however, practice of mindfulness does not necessarily induce relaxation. In adults, mindfulness-based interventions have demonstrated efficacy for a variety of important endpoints, including psychiatric symptoms9 and weight loss.10

Very little research has evaluated mindfulness in children and adolescents. Because attention control is an executive function that develops throughout adolescence, it may be more challenging for children and adolescents to practice mindfulness compared with adults. The majority of research on mindfulness in children and adolescents has been conducted in schools with nonclinical populations. As of 2017, only 8 studies had evaluated mindfulness in any pediatric chronic illness population.11 All but 1 study had 20 participants or fewer. The single randomized trial reported had an n of 6, with only 2 participants randomly assigned to treatment. Only half the studies (4/8) adapted the treatment for age, and only 2/8 adapted it for diagnosis. The single study available in headache is a single-group pilot of a Mindful Schools group protocol adapted for adolescents (aged 11-16 years) and adapted for recurrent headache.12 This study's sample size was small (n=20), precluding inferences based on the data; however, participants did not report any meaningful reductions in headache frequency, severity, or disability. Another pilot study currently underway is evaluating a 45-minute group-based mindfulness treatment including mindfulness meditation along with muscle and breath-focused relaxations in an adolescent (aged 12-17 years) migraine sample13; however, outcome data are not yet available.

Therefore, we currently have no evidence that mindfulness meditation has efficacy for pediatric migraine at this time, and very limited evidence that mindfulness-based interventions are feasible in this group.

When pediatric headache providers are building their interdisciplinary treatment plans for children and adolescents with migraine, it is important to keep in mind the level of evidence for available treatment modalities. Not all therapies that include "meditation" components are alike. Cognitive behavioral therapy, including relaxation and biofeedback, is an evidence-based treatment for pediatric migraine. Providers who commonly treat pediatric migraine are encouraged to cultivate an interdisciplinary referral network to incorporate evidence-based cognitive behavioral therapy techniques, including relaxation training, into their routine practice. Providers can search the American Psychological Association website (https://locator.apa.org/) for licensed psychologists who have expertise in pediatrics and pain, health, and/or cognitive behavioral therapy.

References

  1. Orr SL, Kabbouche MA, O'Brien HL, Kacperski J, Powers SW, Hershey AD. Paediatric migraine: evidence-based management and future directions. Nature Rev Neurol. 2018;14(9):515-527.
  2. Stewart WF, Wood C, Reed ML, Roy J, Lipton RB. Cumulative lifetime migraine incidence in women and men. Cephalalgia. 2008;28(11):1170-1178.
  3. Hershey A, Powers S, Vockell A, LeCates S, Kabbouche M, Maynard M. PedMIDAS: Development of a questionnaire to assess disability of migraines in children. Neurology. 2001;57(1):2034-2039.
  4. Kröner-Herwig B, Heinrich M, Vath N. The assessment of disability in children and adolescents with headache: Adopting PedMIDAS in an epidemiological study. Euro J Pain. 2010;14:951-958.
  5. Ramsey RR, Ryan JL, Hershey AD, Powers SW, Aylward BS, Hommel KA. Treatment adherence in patients with headache: a systematic review. Headache. 2014;54(5):795-816.
  6. Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2017;376(2):115-124.
  7. Ng QX, Venkatanarayanan N, Kumar L. A systematic review and meta-analysis of the efficacy of cognitive behavioral therapy for the management of pediatric migraine. Headache. 2017;57(3):349-362.
  8. 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.
  9. Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52-60.
  10. Carriere K, Khoury B, Gunak MM, Knauper B. Mindfulness-based interventions for weight loss: a systematic review and meta-analysis. Obes Rev. 2018;19(2):164-177.
  11. Ahola Kohut S, Stinson J, Davies-Chalmers C, Ruskin D, van Wyk M. Mindfulness-based interventions in clinical samples of adolescents with chronic illness: a systematic review. J Altern Complement Med. 2017;23(8):581-589.
  12. Hesse T, Holmes LG, Kennedy-Overfelt V, Kerr LM, Giles LL. Mindfulness-based intervention for adolescents with recurrent headaches: a pilot feasibility study. J Evid Based Complementary Altern Med. 2015;508958.
  13. Sansone E, Raggi A, Grignani E, et al. Mindfulness meditation for chronic migraine in pediatric population: a pilot study. Neurol Sci. 2018;39(Suppl 1):111-113.
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