Behavioral headache management is central to a comprehensive care plan for children and adolescents with primary headaches. In fact, The American Academy of Neurology and American Headache Society practice guidelines recommend behavioral headache treatment as a first line preventive intervention for pediatric headache. Behavioral treatment goals are numerous, including: reducing the frequency and severity of headache pain; increasing the patient’s sense of control of their headaches; reducing related disability and symptoms; and for some patients, limiting reliance on ineffective, poorly tolerated, and/or unwanted medications.
To support medical providers in securing these valuable services for their patients, this chapter has two primary aims: First, we will overview the evidence-base for integration of four commonly used behavioral headache management interventions (cognitive behavioral therapy, relaxation training, biofeedback, and mindfulness) into a pediatric neurology or primary care practice. Second, we will provide concrete recommendations and resources to support medical providers in making behavioral headache management resources available to this patient population. Notably, in this chapter, neurology and primary care provider (PCP) recommendations will be reviewed simultaneously as there are relatively few differences between these specialties in approaching behavioral headache intervention.
Describing behavioral headache intervention to families
When introducing the concept of behavioral intervention to patients with headache and their families, it is critical to first normalize behavioral strategies as a central, evidence-based component of headache treatment. Optimal headache management occurs when all providers on a team utilize a biopsychosocial model. This model recognizes that biological, psychological, and social/environmental factors all play an interactive role in the trajectory of symptom development, progression, and treatment. Importantly, evidence in broader pediatric pain populations suggests families’ adoption of a biopsychosocial understanding relates to an increased receptivity to behavioral pain management strategies. It is therefore incumbent upon referring providers to foster a biopsychosocial disease model of migraine in patients and their families prior to initiating a referral to behavioral medicine.
Due to negative past experiences (for example, a prior provider not believing the patient’s pain experience) and the invisible nature of headache, when first hearing the terms “behavioral,” “psychology,” or “therapist,” a family may inadvertently internalize the message that their provider views the child’s headache as “psychologically based” or “in their head.” To place behavioral intervention within the framework of treating the patient’s neurological disorder, a referring provider may give an overview of the role of autonomic nervous system dysregulation in headache symptoms. The assumption is not that stress causes symptoms (that is, the child does not have a headache because they are more anxious than their peers). Rather, the experience of chronic headache symptoms inherently places the body in a state of stress, contributing to an overactive sympathetic nervous system, subsequently amplifying the headache problem. Furthermore, typical life stressors (e.g., social and academic stress) can contribute to the child’s physiological arousal, feeding a problematic cycle of physical, cognitive, behavioral, and emotional symptoms. The goal of behavioral headache management is to disrupt this cycle, improving the child’s functioning across the aforementioned domains.
In our conversations with families about the importance of behavioral intervention in pediatric headache management, we typically introduce the role of sympathetic arousal in symptom maintenance through a description of “the fight or flight response.” As a classic example, if the child saw a bear in the forest, the sympathetic response (rapid heart rate, increased respiration, and tightened muscles) would adaptively prepare their body for action, such as to run away or fight the bear. However, when this automatic response is triggered in reaction to day-to-day stressors (for example, when the child is taking a difficult exam or experiencing an aura and thinking about the consequences of their impending headache), the fight or flight response no longer serves a protective function and instead serves as a “false alarm” to the body. This physiological activation can then, problematically, exacerbate or trigger a headache.
When describing these processes, the referring provider is encouraged to emphasize that behavioral headache management does not imply the child’s pain is not real . Instead, these strategies are a standard component of headache treatment: In behavioral headache treatment, the patient will learn how to identify situations where the “false alarm” may be triggered and develop a set of skills they can employ to activate a parasympathetic response or “calm their nervous system.” Importantly, taking the time to teach the patient and their parents these concepts prior to making a therapy referral serves as an intervention in itself, illustrating the ways in which the child does have the ability to control certain aspects of their body in the context of a disorder that often feels scary and outside of their control.
Summary of evidence-base
To date, research has demonstrated Level A evidence (established efficacy with at least two Class I trials) for the following behavioral pediatric headache interventions in preventive headache management: cognitive behavioral therapy (CBT); relaxation training; thermal biofeedback combined with relaxation training; and electromyographic (EMG) biofeedback. Additionally, Level B evidence (probably effective with one Class I or two Class II studies) is established for behavioral therapy combined with preventive drug therapy to achieve additive clinical improvement for migraine. In this chapter, we will overview the above therapies. We will additionally provide information on mindfulness, given the potential benefits of incorporating this intervention to better cope with functional disability (that is, the impact of headache on the child’s day to day functioning) and the popularity/availability of mindfulness-based interventions.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) is a brief (typically 6–8 sessions), skills-based psychotherapy intervention with considerable empirical support in the treatment of children and adolescents with headache. This intervention is also effective in addressing a range of other disorders including anxiety, depression, insomnia, and chronic pain. CBT is built on interrelationships between thoughts, emotions, behaviors, and physiological responses, illustrated in the “CBT cycle” below. As suggested by its name, cognitive behavioral therapy (CBT) includes the instruction of both thought-related “cognitive” strategies (to address anxious, negative thoughts) and action oriented “behavioral” strategies (to address daily stressors and general self-care).
Cognitive CBT strategies
Cognitive CBT strategies teach the child to identify and challenge negative “self-talk” statements, enhance their belief in their own self-efficacy, and build an internal locus of control. For example, a child who is anxious about the onset of a migraine secondary to prolonged focused concentration during an upcoming school examination may generate anxious thoughts such as “I am going to get a headache during my final. I won’t be able to concentrate and will fail.” This thought may serve as a self-fulfilling prophecy, creating an anxious emotional response, triggering sympathetic arousal, and subsequently a migraine, which impairs the child’s test performance just as predicted. Using a strategy called “cognitive reframing” the therapist will help the child learn to shift their focus away from this unhelpful thought to the factors that they can control in the situation. This intervention does not aim to teach the child to be artificially positive (“I will probably never get a headache again!”) or simply to push the thought away, but instead to focus on realistic and helpful ways of thinking. For example, this child may learn to generate the coping statement: “If I use the coping skills I have learned in therapy and take breaks during this test, I can manage a headache and get through this test. I might not do perfect but I do know the material and studied hard so I will probably do OK.” Cognitive reframing improves a child’s self-efficacy in managing anxiety and headache as they choose how to respond to a negative self-talk statement as opposed to automatically reacting to it.
Behavioral CBT strategies
Behavioral CBT strategies in headache treatment may include: identifying behaviors that precipitate, increase, or maintain headaches (including modifying triggers and teaching problem-solving skills to adaptively manage daily stressors such as school stress described in the example above), teaching self-regulation skills that help decrease physiological arousal and increase relaxation and wellbeing (described in detail in the “ Relaxation ” section), and setting up a structured behavioral plan to promote healthy lifestyle habits such as regular sleep, hydration, meals, and exercise (described in detail in other chapters of this book).
Notably, a skilled child and adolescent therapist will adapt CBT strategies to the developmental level of the patient, making this intervention applicable to a wide age range. Parents and school staff will be incorporated in treatment as is appropriate.
Efficacy of CBT in pediatric headache
Numerous meta-analyses demonstrate the benefit of cognitive behavioral therapy in reducing the intensity of pain in pediatric chronic headache. Furthermore, a randomized clinical trial of 135 youth aged 10–17 demonstrated that supplementing amitriptyline with cognitive behavior therapy resulted in a greater reduction in days with headache and headache related disability as compared to a control group of amitriptyline with headache education after 20 weeks (11.5 headache day reduction for CBT supplementation vs 6.8 headache day reduction for headache education supplementation ). This study emphasizes the added benefit of CBT even when children are improving with pharmacotherapy. Prior randomized controlled trials also indicate efficacy of multiple modalities of CBT for headache including therapist-administered group therapy and home-based self-help and a 4-week computerized CBT program as a supplement to medical care. Taken together, these data suggest that specific CBT training can be recommended based on accessibility and individual preference, with the expectation of clinically significant improvement in headache days and disability.
How to support your patients in accessing CBT
Helping your patient access a therapist
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Depending on the volume of headache patients in your clinic it may be warranted to consider pursuing access to funding to integrate a behavioral health specialist into your clinical care team. A neurology provider may argue the evidence-base for cognitive behavioral therapy for headache specifically. There is also a national push for improved access to behavioral health in a primary care setting.
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If you do not have access to an embedded psychology provider, encourage your patients to search for a therapist who (A) has experience working with children and adolescents and (B) is trained in Cognitive Behavioral Therapy (CBT). Expertise in pain management or health psychology specifically is wonderful – however in many locations a pain specialist may not be accessible. A therapist who specializes in anxiety will have an applicable skillset.
Electronic resources
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WebMAP Mobile: a program from Seattle Children’s Hospital designed to help teens cope with chronic pain and increase their ability to do things that are important to them.
Books for interested families
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“Managing Your Child’s Chronic Pain ” by Tonya Palermo, PhD
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“When Your Child Hurts: Effective Strategies to Increase Comfort, Reduce Stress, and Break the Cycle of Chronic Pain” by Rachel Coakley, PhD
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“ The Chronic Pain & Illness Workbook for Teens: CBT & Mindfulness-Based Practices to Turn the Volume Down on Pain ” by Rachel Zoffness, PhD
Relaxation strategies
Relaxation strategies are skills that decrease sympathetic arousal and help the patient gain a sense of efficacy and mastery over a specific aspect of their body’s functioning. As noted above, relaxation strategies are an important component of CBT. These strategies, however, also have a strong evidence-base in preventive headache treatment as an independent intervention. Evidence-based relaxation strategies reviewed in this section include diaphragmatic breathing, progressive muscle relaxation, and guided imagery. Of note, prior research suggests that these strategies work best when practiced daily and proactively (that is, in advance of having a headache), to help initiate the parasympathetic “relaxation response” and maintain autonomic balance. When teaching relaxation strategies to children, it is important to emphasize the active practice of these skills and their benefit compared to simply relaxing passively (that is, watching television or taking a nap is not a relaxation strategy). Reinforcing daily practice is key to building the child’s sense of self-efficacy and allowing these strategies to become automatic and naturally implemented.
Diaphragmatic breathing
