Distraction

Distraction, as described by limited attentional capacity theory, is the act of redirecting attention away from pain, with the goal of reducing the cognitive resources the child has available for pain perception. This form of active coping encourages a patient to immediately engage in an activity at the onset of a headache to help redirect attention away from presenting symptoms.

Efficacy of distraction in pediatric acute pain

In experimental paradigms, employing distraction strategies during an induced pain episode significantly reduces participants’ reported pain intensity scores. While there is little research specifically looking at the use of distraction during headaches, it is a central component of acute pediatric pain management using a cognitive behavioral (CBT) intervention framework. CBT meets the Chambless criteria for “empirically supported” treatment for acute pediatric procedural pain management. Notably, this mechanism may not be applied as successfully when factors such as pain catastrophizing (worst-case scenario thinking) or clinically significant levels of anxiety co-occur during these episodes.

How to support your patients with distraction

To support children in using distraction during a headache attack, the provider is encouraged to help their patient recall a time when they naturally used distraction to cope with pain. For example, you might ask, “Was there ever a time you were having so much fun playing soccer/laughing with your friends/drawing that maybe your headache did not go away, but you noticed it a little less?” It is possible to use these same skills during a painful headache attack. Anxiety and pain experiences can interfere with memory during a headache attack. Therefore, it is recommended that the child create a list of distraction techniques in advance for use in the moment, during difficult times.

This distraction list may take the form of internal mechanisms or external mechanisms. Internal mechanisms include counting breaths, reciting a song, or imagining the sensory experience of visiting a favorite place (see guided imagery in the preventative behavioral intervention chapter). External mechanisms include accessing a “go to” playlist of music, list of writing topics, or a creative art project. Many patients have also endorsed identifying and downloading phone applications (e.g., mindfulness or relaxation apps with visual images and calming sounds) for easy access during a headache attack as very useful. Encouraging a “go to” positive self-statement or mantra to focus on such as “I can get through this” may also be an effective mechanism to distract from acute symptoms. Some patients may opt for social distraction, reaching out to a friend or family member and asking them to tell a funny story or engage in conversation as a way to redirect attention. All of these methods of engagement, while sounding quite simple, utilize different senses (audio, visual) to redirect attention away from pain, supporting the patient through a headache attack until symptoms stabilize.

Clinical hypnosis

Clinical hypnosis is broadly defined as a narrowing of attention and suspension of critical judgment during a relaxed state through the use of therapeutic suggestions that help the patient shift sensory perceptions and experience of their physiological state. Although many aspects of clinical hypnosis involve relaxation, what makes this intervention unique is the deliberate use of therapeutic suggestions (i.e., “this relaxing place is where you are in control of how you want to feel”) to help the child create their own sensory experience. Working with a trained professional, the child learns how to access their natural ability to use imagery and other senses to elicit a relaxed state and cope through a headache. Through this process, the child maintains a sense of control over how they want to feel in that moment. For example, one child viewed her pain experience as “a roller coaster” and developed her own way of changing this experience by imagining pulling a lever to slow down the pain. Children can be taught how to build this skill independently and use it whenever they experience a headache attack.

Efficacy of hypnosis in pediatric acute pain

Although there are limited studies on the use of hypnosis with a pediatric migraine population, one retrospective record review of children referred for recurrent headaches over a 13-year period revealed that, for 144 patients, those who learned self-hypnosis reported a reduction in headache frequency from an average of 4.5 per week to 1.4 per week, as well as a reduction in intensity and average duration. Study methodology suggests that patients were taught hypnotic suggests for use during a headache and were encouraged to practice regularly. The effectiveness of hypnosis has also been demonstrated in the management of other types of acute pain in children, including post-surgical pain, pain during various dental and medical procedures, and pain associated with oncological treatments. Although headaches can be comprised of a multitude of symptoms, the utilization of this intervention is helpful to reduce acute pain during these episodes. Clinical hypnosis can also be implemented during procedures that elicit acute pain such as Botox or nerve blocks. Anecdotally, patients have verbalized the utility of this intervention during these specific procedures in clinic.

How to support your patients with clinical hypnosis

Hypnosis is a helpful strategy to add to a patient’s repertoire of skills. When describing the benefits of hypnosis, it is recommended to note the importance of this intervention being taught by a provider who has received training in pediatric clinical hypnosis, such as a psychologist, therapist, or primary care physician. Training in pediatric hypnosis can be found through the National Pediatric Hypnosis Training Institute ( https://www.nphti.org/ ).

Relaxation strategies, mindfulness, and biofeedback

In addition to distraction, relaxation, and mindfulness strategies may be implemented during headache attacks to build the child’s parasympathetic response (slowing heart rate, slowing breathing, relaxing muscles), counteracting sympathetic arousal (muscle tension, shallow breathing, increased heart rate) and downregulating their pain experience. Strategies described in more detail in the chapter for preventative headache management ( Chapter 17 ) can be applied during a headache attack as well: mindful breathing/exercises (e.g., “thought bubbles,” “10 breaths”), diaphragmatic breathing, guided imagery, and progressive muscle relaxation.

Notably, it is important for the child to develop and practice these strategies outside of acute episodes in order to better access these skills quickly and competently when needed. As with preventative treatment, practice of these skills can be reinforced through biofeedback-assisted therapy. As discussed under “ Distraction ” section, it is useful to encourage the patient to identify a “relaxation list” that can easily be referenced in times of acute need.

Cognitive reframing

Cognitive reframing is another skill that children will learn as a part of cognitive behavioral therapy for preventative headache management that can also be applied during a headache attack. Given the role of anxious thoughts in perpetuating autonomic arousal and the pain-stress cycle, the development of this skillset to identify and reframe unhelpful thoughts is vital in increasing self-efficacy and interrupting this unhelpful cycle.

Efficacy of cognitive reframing in acute pain episodes

Prior research has demonstrated a child’s cognitions about the pain experience directly influences his or her experience of pain. Cognitive reframing is a central component of CBT, which as previously mentioned, is an evidence-based intervention for both acute and chronic pain.

How to support your patients with cognitive reframing

When referring your patient for cognitive behavioral treatment, it is useful to describe the types of cognitive skills they will be learning. In brief, typical thoughts during acute pain episodes tend to, understandably, be catastrophic in nature, such as, “It will never stop” or “It’s going to keep getting worse and worse and I’ll never feel better.” These thoughts can directly magnify negative emotions, increase focus on pain, and due to the aforementioned pain-stress cycle, enhance the child’s pain experience. This cycle serves to magnify the response to an acute episode and anticipation of these symptoms can trigger the same sympathetic response that pain triggers. Learning ways to stop, breathe and reframe these thoughts (e.g., “Is there another way to look at this?” “Is this thought helping me?” “Have I been able to get through these episodes in the past?”) with the help of positive self-statements increases the child’s sense of autonomy and allows them to work towards increased coping in moments that might feel impossible to bear.

Parent education and family interactions

Pediatric headache not only affects the child but the entire family system. Parents often endorse elevations in anxiety and frustration during these episodes, wanting to understandably “take their child’s pain away” but feel helpless in their efforts. Parental education, therefore, is a key component in treating pediatric headache. During a headache attack, parents are encouraged to validate their child’s experience and reinforce active versus passive coping strategies.

Efficacy of parental education

The literature in pediatric pain indicates parental emotional and behavioral responses to their child’s symptoms can play a role in their child’s experience of pain. Specifically, parenting behaviors such as solicitous responses (i.e., frequently attending to pain symptoms), catastrophic thinking regarding their child’s pain as well as highly protective behaviors are related to increased disability in children with pain. Therefore, parents are encouraged to identify their own response during these stressful times and find ways to modify their behavior to disrupt the cycle of anxiety and pain during a headache attack.

In a Cochrane review looking at problem-solving skills training for parents of children with chronic conditions, this intervention was found to be effective in decreasing distress when parenting a child with a chronic illness. Therefore, incorporating parent education is vital to treating pediatric headache.

How to support families helping their child

Scott Powers has identified parent guidelines to help encourage parents to respond adaptively to their child’s pain. These include encouraging your child to manage their pain independently and engage in normal daily activities, as well as eliminating status checks to help reduce the focus on pain. Parenting guidelines can be found at: https://www.cincinnatichildrens.org/research/divisions/b/psychology/labs/powers .

These recommendations are often a counterintuitive and challenging shift in perspective and behavior for parents. We encourage the provider to educate parents on the long-term benefits of reinforcing active and independent coping of headaches, building the child’s sense of confidence in managing their own symptoms and promoting healthy identity development. The parent praising their child’s efforts regardless of pain reduction shifts the focus from the headache itself to the implementation of a proactive behavior, reducing helplessness for both the child and parent.

Lastly, encouraging the patient to verbalize how their parent can best help them during a headache attack supports improved communication, identifies the child as the lead of their own headache coping plan, provides the parent concrete strategies to assist their child, and aims to allow the family working together to move through a headache attack successfully.

Conclusion

In summary, a patient’s utilization of independent, active coping skills can feel difficult in the moment of a headache attack but sets a precedent for long-term benefit and increased self-efficacy. Active headache coping skills include distraction techniques, mindfulness exercises, clinical hypnosis, diaphragmatic breathing, imagery, progressive muscle relaxation, and cognitive reframing. Encouraging parents to reinforce active coping and to focus on what their child can control including other aspects of who they are (e.g., being a good friend, extacurricular interests) promote healthy identity development and positive coping behaviors. In your role as the patient’s healthcare provider, you have the potential to positively influence patients and their families to develop an adaptive coping approach to managing acute headaches.