Hybrid Cognitive Behavioral Therapy Acceptable in Patients With Pediatric Migraine, Insomnia

child with headache
child with headache
Investigators sought to determine whether hybrid cognitive behavioral therapy is effective for youths with chronic migraine and insomnia.

A hybrid cognitive behavioral therapy (CBT) protocol composed of sleep hygiene education, sleep restriction, and reassociating the bed with sleep is feasible and acceptable among adolescents with chronic migraine and insomnia, as reported in a recent issue of Headache.

Investigators enrolled 21 adolescent patients with co-occurring chronic migraine and insomnia from a pediatric neurology clinic and a pediatric pain clinic at a single academic center in the Pacific Northwest. Participants underwent 6 sessions of hybrid CBT during a 6- to 12-week period, with a booster session administered 1 month after treatment completion.

The hybrid CBT program consisted of sleep hygiene education (eg, avoiding caffeine), reassociating the bed with sleep, and introducing sleep restriction as a means of reducing the time spent in bed awake. Investigators asked participants to complete a 7-day headache and sleep diary and to report insomnia, sleep quality, sleep habits, and activity limitations at baseline, immediately after therapy, and at 3-month follow-up.

Of 21 patients, 17 adhered to treatment during the entire course of the study, and approximately 75% of participants completed the booster session. Both parents and adolescents reported that the therapy was highly acceptable (mean score of Treatment Evaluation Inventory, Short Form [TEI-SF] for parents=40.67±4.48; mean score of TEI-SF for adolescents=39.13±5.10). Self-reported headache frequency on the prospective 7-day diary was reduced from pretreatment to immediately after therapy (b =−1.91; P =.004; d =0.84), which was maintained at follow-up (b =−2.16; P =.002; d =0.87).

No changes were observed in headache pain intensity; however, from pretreatment to posttreatment (b =0.40; P =.25; d =−0.28) or at follow-up (b =−0.15; P =.68; d =−0.28). Additionally, self-reported insomnia symptoms were reduced from before and immediately after treatment (b =−7.32; P =.001; d =1.31). These findings were maintained at follow-up (b =−7.60; P =.001; d =0.50). Self-reported sleep efficiency also improved from pretreatment to posttreatment (b=9.31; P =.008; d=−0.60); these findings were maintained at 3-month follow-up (b =13.51; P =.001; d =−0.95).

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Limitations of the analysis include its single-arm design, small number of patients, and the reliance of self-reported sleep and migraine measures.

According to the researchers, pediatric pain physicians and neurologists “should be prepared to screen for sleep disturbances in adolescents with chronic headache and consult with sleep medicine specialists when needed.”


Law EF, Wan Tham S, Aaron RV, Dudeney J, Palermo TM. Hybrid cognitive-behavioral therapy intervention for adolescents with co-occurring migraine and insomnia: a single-arm pilot trial. Headache. 2018;58(7):1060-1073.