Cognitive Behavioral Therapy plus Amitriptyline for Children and Adolescents with Chronic Migraine Reduces Headache Days to ≤4 Per Month

Authors

  • John W. Kroner MS,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Andrew D. Hershey MD, PhD, FAHS,

    1. Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Headache Center, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Susmita M. Kashikar-Zuck PhD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Susan L. LeCates MSN,

    1. Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Headache Center, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Janelle R. Allen MS,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Headache Center, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Shalonda K. Slater PhD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Marium Zafar PsyD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Marielle A. Kabbouche MD, FAHS,

    1. Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Headache Center, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Hope L. O'Brien MD,

    1. Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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  • Chad E. Shenk PhD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Joseph R. Rausch PhD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Ashley M. Kroon Van Diest PhD,

    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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  • Scott W. Powers PhD, ABPP, FAHS

    Corresponding author
    1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    2. Headache Center, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    • Address all correspondence to S.W. Powers, Division of Behavioral Medicine and Clinical Psychology, Cinncinati Children's Hospital Medical Center, 3333 Burnet Ave ML: 3015, Cincinnati, OH 45229-3039, USA, email: Scott.Powers@cchmc.org

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  • Conflict of Interest: The authors report no relevant conflicts of interest.

Abstract

Objective

The objective of this secondary analysis of results from a previously published trial (Clinical Trials Registration Number: NCT00389038) in chronic migraine in children and adolescents was to examine if participants who received cognitive behavioral therapy and amitriptyline reached a greater level of reduction in headache frequency that no longer indicated a recommendation for preventive treatment as compared to those who received headache education and amitriptyline.

Background

Chronic migraine negatively affects children's home, school, and social activities. Preventive medication therapy is suggested for 5 or more headaches per month. Reduction to one headache day per week or less may suggest that preventive treatment is no longer indicated and provide a clinically relevant outcome for treatment efficacy and patient care.

Methods

Randomized study participants (N = 135) kept a daily record of their headache frequency during 20 weeks of treatment and during a 1 year follow-up period. Baseline headache frequency was determined at the end of a 28 day screening period. Post treatment frequency was determined at 20 weeks (N = 128 completed) and post treatment follow-up was measured 12 months later (N = 124 completed). A chi-square test of independence was conducted by treatment group and by time point to determine group differences in the proportion of headache days experienced.

Results

At 20 weeks (post treatment), 47% of the cognitive behavioral therapy plus amitriptyline group had ≤4 headache days per month compared to 20% of the headache education plus amitriptyline group, (P = .0011), and 32% of the cognitive behavioral therapy plus amitriptyline group had ≤3 headache days per month at 20 weeks compared to 16% of the headache education plus amitriptyline group, (P = .0304). At the month 12 follow-up, 72% of the cognitive behavioral therapy plus amitriptyline group had ≤4 headache days per month compared to 52% of the headache education plus amitriptyline group, (P = .0249), and 61% of the cognitive behavioral therapy plus amitriptyline group had ≤3 headache days per month at their month 12 follow-up compared to 40% of the headache education plus amitriptyline group, (P = .0192).

Conclusions

Participants who received cognitive behavioral therapy and amitriptyline were more likely than participants who received headache education plus amitriptyline to reach the clinically meaningful outcome of less than or equal to 4 headache days per month at both time points. These results may help inform what treatment outcomes are possible for children and adolescents suffering from chronic migraine and provides further evidence for behavioral treatment to be considered as a key part of a first line treatment regimen.

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