Jun 8, 2015 — Family history is a factor in more than 80% of children who suffer from chronic headaches. If your child suffers from headaches and migraines, you might want to consider cognitive behavioral therapy. Dr. Jim Bale, a child neurologist at the University of Utah explains cognitive behavioral therapy and its effectiveness. He also compares cognitive behavioral therapy to traditional conventional medication to help parents determine which opinion is best for their child.


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If you have a child that suffers from headaches, you might want to consider cognitive behavioral therapy. We're going to find out more about that right now from Dr. Jim Bale. He's a Professor of Pediatrics and Neurology at University of Utah Healthcare and has been dealing with this sort of thing for 30-plus years. Tell me about this treatment. First of all, how would a parent know if it was right for their child?

Dr. Bale: Well, first off all, it's a complicated answer because it isn't a necessarily the first place we start.

Dr. Miller: Okay.

Dr. Bale: We may start with conventional medications and use these then to see whether they respond. If they respond, then that's what we'll stay with.

Dr. Miller: Why the choice of using medication versus this cognitive treatment?

Dr. Bale: In some ways, they're simpler, they're easier to do and a lot of mild migraines or other headaches respond very effectively to them. However, when they don't respond, and maybe sometimes we should be doing it first anyway, we do then try cognitive behavioral therapy.

Dr. Miller: Okay. So that's kind of a second step if the medications aren't working.

Dr. Bale: Currently it is. I anticipate that over the next perhaps few years it will become a first step or at least offered as a first step as opposed to saying, "Let's try this medicine first."

Dr. Miller: So tell me, what is it?

Dr. Bale: So cognitive behavioral therapy really is a strategy by which we teach individuals to begin to use guided imagery, to think about how, in a way, biofeedback might interact. Although this is different than biofeedback. A bit of it is relaxation distraction approaches, which have been around for a long time. But it's really intense training, how to do it when pain becomes more intense. So that's why I say that it's not as easy as just starting a medication. It requires interaction with a trained individual, usually a psychologist who is very comfortable with this approach. And then it's several sessions, really, of training to make certain that a child begins to incorporate that into their daily routine.

Dr. Miller: That sounds tough for an adult to do let alone a child. There must be some unique challenges.

Dr. Bale: Well, that's why I say sometimes starting a medication, frankly, is easier and if works then you use it. But again, medicines have side effects. We don't think cognitive behavioral therapy really has side effects.

Dr. Miller: How effective is it? It sounds, I don't know, kind of ethereal a little bit.

Dr. Bale: Well, maybe it sounds a little bit like fairy dust, but the reality is when it's been studied, and it's been studied quite well by the individuals at the University of Cincinnati, Cincinnati Children's, when you combine cognitive behavioral therapy with a standard medication known as amitriptyline. In fact, the two together are better than amitriptyline alone.

Dr. Miller: Yeah.

Dr. Bale: What that says to us is that cognitive behavioral therapy is a very effective approach.

Dr. Miller: So it's been researched, it's been proven.

Dr. Bale: Right.

Dr. Miller: Yeah. What else do I need to know if I'm a parent who has a child who suffered from headaches and the medications haven't worked and I'm interested in this therapy?

Dr. Bale: Surely. Well, I think, first of all, is to explore the family history and see if there are migraines in the family history. We believe that about 80%, or maybe all of the children that have chronic headaches, have a migraine predilection, meaning this is why they're predisposed to headaches.

So what we then begin to think about are what are the other alternative and complementary approaches to this. We look, for example, through sleep hygiene. If they are staying up all night or only getting maybe five or six hours of sleep a night, that may be an important factor. If there is stress or anxiety and that has not been approached, then that may be an important factor as well.

And then sometimes we'll use some complementary approaches, like high-dose vitamins. There are certain things like magnesium that can be beneficial. An interesting substance called coenzyme Q10 is another one that's been beneficial. The data on a vitamin called riboflavin maybe is a little less clear, but it's been used and sometimes it's been effective. So we look at those things in part because they can be beneficial. Not for every child, but they can be and they have very few side effects.

Dr. Miller: Yeah. If a physician determines that therapy is a good idea, what would the next step for the parent be and the child?

Dr. Bale: Well, I think the first step is to look at what the therapy is and to put it in the context of what the side effects are, what the child's needs are and what are the other kind of comorbid aspects of this, meaning the things that come along with headaches. For example, if sleep is the problem, maybe a medication that's sedating might be given at bedtime. Amitriptyline is a very good choice for that.

If anxiety is a major part, perhaps, again, cognitive behavioral therapy or other approaches to anxiety may be very important. But anxiety is really not the only and maybe not the most important driver of headaches, it's really the migraine predilection and all of those environmental factors that then influence the prevalence and the occurrence of migraines.

Dr. Miller: Back to cognitive behavioral therapy, do most children figure out how to integrate these things into their daily life fairly easily or is it 50/50 or do we have any idea?

Dr. Bale: Well, I think, first of all, it takes a child of a certain age because obviously cognitive behavioral therapy implies you must have a certain level of cognition.

Dr. Miller: Yeah.

Dr. Bale: So we think that for late childhood adolescence it can be very beneficial. The nice thing about that is that we look at the epidemiology of headache in children. In fact, it's really the adolescence where headaches are most prevalent, not only migraine but another common problem called chronic daily headache. So in a sense, that's the right substrate to try cognitive behavioral therapy because these kids can learn it and respond to it and often respond very well.

Dr. Miller: Is it something that adults can use as well?

Dr. Bale: Absolutely.

Dr. Miller: So you use it for the rest of your life once you learn it.

Dr. Bale: Yeah, in a way. It's a strategy to cope with any kind of pain throughout your life. So a really good strategy is I've got migraines and I sometimes use my own guided imagery. I love to fly fish. Now, this is a kind of simplistic approach to it, but I have a sequence of visions that I create when my headaches occur to take me to my favorite trout stream. I begin to feel the water, I begin to feel the pulse of the fish at the end of my fly line and by then, my headaches are much less of an issue. That's a really simplistic approach to what guided imagery is about, but it's using those kinds of strategies that work on the brain that truly indeed help with headaches.

Dr. Miller: For more information, where would you recommend a parent go?

Dr. Bale: Well, if they're interested, we have an evolving and wonderful headache clinic with several clinicians. Dr. Lynne Kerr is the director of this. She would be a great person to talk with, to talk with our child neurology group, get an appointment and then we'd be happy to see you and happy to help out.

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