Cognitive behavioral therapy (CBT) is an effective nonpharmacologic treatment that should be considered as a first-line therapy for pediatric migraine, according to a large systematic review and meta-analysis reported in Headache.1
An international group of investigators led by Qin Xiang Ng, MBBS, from the Yong Loo Lin School of Medicine in Singapore, conducted a systematic review of 3841 articles published between 1980 and 2016 that reported on CBT for migraine or headache, and identified 14 randomized control trials that evaluated its efficacy in pediatric or adolescent patients.2-15 The studies included in the analysis were all head-to-head comparisons of CBT with wait-list control, placebo, or standard pharmacotherapy (including amitriptyline, nonsteroidal anti-inflammatory drugs, and triptans).
Using a primary pain outcome of 50% or greater reduction of headache activity, they found an odds ratio (OR) for clinical improvement that strongly supported the use of CBT in patients younger than 19 years both immediately posttreatment and at 3-month follow-up (OR, 9.11 [95% CI, 5.01-16.58; P <.01] vs OR, 9.18 [95% CI, 5.69-14.81; P <.001], respectively). In addition, the investigators found a stable duration of response of up to 1 year across all the studies.
Previous reviews have shown a very high incidence of headache (both primary and secondary) among children; a 1996 review compiled a worldwide estimate of 75% among children up to 15 years old, whereas a 2010 review of 50 population-based studies reported estimates of 60%.16,17 Multiple studies have indicated a pattern of increasing headache prevalence with age, ranging from 47.2% among children aged 7 to 9 years to 69.5% among those aged 13 to 15 years.18-21 Migraine, a type of primary headache associated with a significant effect on quality of life, showed a prevalence of 9.1% overall among children.22-24
Treatment of migraine in pediatric patients, however, is complicated and somewhat limited compared with adults, consisting mainly of acetaminophen and nonsteroidal anti-inflammatory drugs and the use of sumatriptan nasal spray as a first- or second-line therapy for adolescents aged 12 to 17 years.25-32 Preventive therapies may include tricyclic antidepressants, anticonvulsants, and antiserotonergic therapies.7,8 Dr Ng and colleagues pointed out that use of these therapies in children is often considered “off-label,” and therefore is not well documented. They recommend CBT as a first-line therapy and also reported on 1 study that showed it was effective as an add-on in improving response to amitriptyline.28
The benefits to CBT go beyond the significant reduction of migraine pain and disability, the authors concluded, as relief is achieved without the potential adverse effects that accompany traditional medications, a factor that may significantly enhance adherence to therapy as well.32 They reported that the ability to self-administer CBT “presumably helps to alter a child’s experience of migraine,” and that distance training appeared to be equally effective as in-person training.33,34 The 1 caveat they identified for the use of CBT was that it requires a certain level of cognition, which may limit its effectiveness in younger children.
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