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Cognitive Behavioral Therapy Plus Amitriptyline for Pediatric Chronic Migraine

January 14, 2014

Cognitive Behavioral Therapy Plus Amitriptyline for Pediatric Chronic Migraine

  1. Alain Joffe, MD, MPH, FAAP

This combination was superior to medication plus headache education.

  1. Alain Joffe, MD, MPH, FAAP

Nearly 2% of children and adolescents experience chronic migraine (≥15 headache days/month), but no FDA-approved interventions exist for this condition in youth. Both cognitive behavioral therapy (CBT) and amitriptyline have been shown to be effective as single agents for management of chronic pain and headache. In a randomized trial, researchers examined whether the combination of amitriptyline plus CBT is superior to amitriptyline plus headache education in 135 patients (mean age, 14 years; 79% female) seeking care at an academic medical center headache clinic. Patients had a mean of 21 headache days/month and severe disability on a pediatric migraine disability assessment (mean, 68 on a 0–240 point scale).

All patients received amitriptyline (~1 mg/kg/day) plus either CBT (8 weekly and 5 booster sessions, including biofeedback and coping skills) or a similar number of headache education sessions. At 20 weeks, the CBT group had a significantly greater reduction in headache days/month than the control group (reduced by 11 vs. 7 days) and a significantly greater decrease in mean migraine disability scores (from 68 points at baseline to 15 vs. 29 points). At 12 months, 86% of CBT recipients had ≥50% reduction in headache days versus 69% of controls, and 88% in the CBT group had scores indicating mild-to-no disability versus 76% in the control group. Significantly more adverse events were reported in control group (135 vs. 97).

Comment

This rigorous study indicates that adding cognitive behavioral therapy (CBT) to amitriptyline treatment is more effective than adding headache education for treatment of chronic migraine in children and adolescents. Whether CBT alone would yield similar results is unknown. As noted in an accompanying editorial, the biggest challenge will be getting patients, parents, and payers to commit to and pay for CBT rather than opting solely for a quick-fix prescription.

  • Disclosures for Alain Joffe, MD, MPH, FAAP at time of publication Editorial boards Adolescent Medicine: State of the Art Reviews; JAMA Pediatrics

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