A Systematic Review and Meta-Analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine

Non-Pharmacological Treatments in Paediatric Migraine

Psychological, social, and biological aspects contribute synergistically to the maintenance and chronicity of pain in primary headaches. An integrated intervention seems to be the most appropriate in the management of these conditions, taking advantage not only of pharmacological strategies, but also of different approaches according to the global assessment and patient necessities. In this perspective, non-pharmacological treatments are becoming increasingly used to overcome these issues also in paediatric migraine treatment. Particularly, nutraceuticals, non-invasive neuromodulation, and behavioural approaches are well tolerated and of potential interest. This paper aims to present the main approaches reported in the literature in the management of migraine in children and adolescents presenting an up-to-date review of the current literature. We therefore performed a narrative presentation for each of these three categories: nutraceuticals (riboflavin; magnesium; melatonin; vitamin D; coenzyme Q10; and polyunsaturated fatty acid); non-invasive neuromodulation (trigeminal nerve stimulator; non-invasive vagal nerve stimulation; transcranial magnetic stimulation; and remote electrical neuromodulation), and behavioural therapies (biofeedback; cognitive behavioural therapy; and mindfulness-based therapy). These approaches are increasingly seen as a valid treatment option in primary headache management also in paediatrics, avoiding medication overuse and drug treatment contraindications.

An Online Psychological Program for Adolescents and Young Adults With Headaches: Iterative Design and Rapid Usability Testing

BACKGROUND

Headache disorders are common, debilitating health problems. Cognitive-behavioral therapy (CBT) is recommended but rarely easily available. With the use of the internet and communication technologies among youth and young adults, these individuals could be self-trained in CBT skills. There is an increasing number of internet-based interventions for headaches, but there has been little research into the usability of these interventions because evaluating usability across the intervention development life cycle is costly. We developed an internet-based CBT program, the Specialized Program for Headache Reduction (SPHERE). While developing it, we aimed to improve SPHERE through rapid usability testing cycles.

OBJECTIVE

This study aims to presents a rapid and affordable usability testing approach that can be performed throughout the intervention development life cycle. This paper also provides evidence of the usability of SPHERE.

METHODS

We used the "think aloud" usability testing method based on Krug's approach to test user interaction within a lab setting. This was followed by a short posttest interview. We planned to test SPHERE with 3-5 participants testing the same part of the program each cycle. Both the design and development team and the research team actively participated in the usability testing process. Observers independently identified the top 3 usability issues, rated their severity, and conducted debriefing sessions to come to consensus on major issues and generate potential solutions.

RESULTS

The testing process allowed major usability issues to be identified and rectified rapidly before piloting SPHERE in a real-world context. A total of 2 cycles of testing were conducted. Of the usability issues encountered in cycles 1 and 2, a total of 68% (17/25) and 32% (12/38), respectively, were rated as major, discussed, and fixed.

CONCLUSIONS

This study shows that rapid usability testing is an essential part of the design process that improves program functionality and can be easy and inexpensive to undertake.

Cognitive behavioural therapy for functional abdominal pain disorders in children and adolescents: A systematic review of randomized controlled trials

AIM

Although Cognitive behavioural therapy (CBT) potentially holds efficacy in addressing functional abdominal pain disorders (FAPDs) amongst children and adolescents, the persistent efficacy is uncertain.

METHODS

We searched three databases to identify related randomized controlled trials (RCTs). Meta-analysis was performed using RevMan and Stata. Subgroup analyses were mainly conducted based on follow-up time. The GRADE approach was used to evaluate the certainty of the evidence.

RESULTS

A total of 14 RCTs evaluating 858 patients were included. All RCTs were rated as having a high risk of bias. Compared with control groups, CBT was associated with improvement of general functional impairment (standardized mean difference (SMD) = -0.77, 95% CI [-1.12, -0.42], p < 0.05), higher treatment success (relative risk (RR) = 2.35, 95% CI [1.50, 3.69], p < 0.05), improvement of abdominal pain symptoms (SMD = -0.48, 95% CI [-0.73, -0.23], p < 0.05), QoL (SMD = 0.42, 95% CI [0.20, 0.64], p < 0.05), and psychological states (SMD = -0.95, 95% CI [-1.62, -0.27], p < 0.05).

CONCLUSION

This meta-analysis provides low to moderate quality evidence that CBT could significantly improve clinical outcomes and QoL for children and adolescents with FAPDs with improvement persisting until short-term follow-up. However, there were discrepancies regarding CBT's effects at mid- and long-term follow-up across different outcomes. More high-quality and longer-duration studies are thus warranted to explore the effectiveness of CBT in the future.

SYSTEMATIC REVIEW REGISTRATION ON PROSPERO

CRD42022369353.

The effect of virtual reality on women's perceived pain, fear, anxiety, and views about the procedure during hysterosalpingography: A randomized controlled trial

BACKGROUND

Hysterosalpingography is a stressful procedure that causes pain and anxiety. Therefore, measures must be taken to reduce or eliminate the pain and anxiety associated with it.

OBJECTIVES

This paper investigated the effect of virtual reality (VR) during hysterosalpingography on pain, anxiety, fear, physiological parameters, and satisfaction.

METHODS

A randomized controlled trial design was used. Patients were randomized into two groups (VR group = 31, control group = 31). The study was conducted between April 26 and June 30, 2022. Anxiety was evaluated using the State Anxiety Inventory. Pain, fear, and satisfaction were evaluated using the Visual Analogue Scale (VAS). Temperature, pulse, blood pressure, and oxygen saturation were followed up.

RESULTS

There was a significant difference in the mean VAS scores during and 15 min after hysterosalpingography between the VR and control groups. There was no significant difference in the mean SAI scores between the groups. The VR group participants were significantly more satisfied with hysterosalpingography than the control group. There was no significant difference in physiological parameters just before, immediately after, and 15 min after hysterosalpingography between the groups.

CONCLUSION

Virtual reality helps patients experience less pain and fear and makes them more satisfied with hysterosalpingography. However, it does not affect their anxiety and vital signs. Patients are highly satisfied with VR technology.

Cognitive Behavioral Therapy for Children With Headaches: Will an App Do the Trick?

Participants were enrolled into a pilot randomized-controlled 4-week trial comparing the efficacy and feasibility of app-based cognitive behavioral therapy (CBT) to a stretching program. Headache-related disability and quality of life were assessed using the Pediatric Migraine Disability Scale (PedMIDAS), Kidscree27, and Pediatric Quality of Life Inventory. Multivariable regression analysis were performed to assess the group effects in the presence of adherence and other covariates. Twenty participants completed the study. Adherence was significantly higher in the stretching than in the CBT app group (100% vs 54%, P < .034). When controlling for adherence and baseline scores, the stretching group showed greater reduction in PedMIDAS score (average: 29.2, P < .05) as compared to the CBT app group. However, in terms of the Quality-of-Life Indicators, pre- and postintervention raw scores were not significantly different between groups (P > .05). App-based CBT was not superior to a stretching program in reducing headache-related disability in a select population of pediatric headache patients. Future studies should assess if implementing features to the CBT app, like tailoring to pediatric age groups, would improve outcomes.

The Relationship of Tobacco Use and Migraine: A Narrative Review

PURPOSE OF REVIEW

Tobacco use is associated with significant health consequences especially for people with medical conditions. Although lifestyle strategies (e.g., sleep, diet) are commonly recommended as part of migraine treatment, tobacco-related strategies (e.g., smoking cessation) are rarely included. This review is aimed at elucidating what is known about tobacco use and migraine and at identifying gaps in the research.

RECENT FINDINGS

The prevalence of smoking is higher among people with migraine, and people with migraine believe that smoking makes migraine attacks worse. There is also evidence that smoking may exacerbate migraine-related consequences (e.g., stroke). Very few studies have examined other aspects of smoking and migraine or tobacco products other than cigarettes. There are significant gaps in our knowledge of smoking and migraine. More research is needed to understand the relationship of tobacco use to migraine and potential benefits of adding smoking cessation efforts into migraine care.

Fifteen-minute consultation: The dizzy child

Vestibular disorders are often overlooked in children and may cause significant morbidity. About a third of children presenting with problems in balance show a vestibular pathology and the overall prevalence of paediatric vertigo is about 5%. Appropriate diagnosis and holistic management can have a significantly positive impact on a child's quality of life and can be very rewarding. We present a structured approach to the assessment and management of a child presenting with dizziness in a general, non-neurological specialty or community paediatric outpatient setting.

Digital Therapeutics in Migraine Management: A Novel Treatment Option in the COVID-19 Era

Migraine is a chronic and often lifelong disease that directly affects over one billion people globally. Because access to migraine medical services is limited, only a minority of migraine patients are treated adequately. This situation worsened during the COVID-19 pandemic. Digital therapeutics (DTx) is an emerging therapeutic approach that opens up many new possibilities for remote migraine management. For instance, migraine management tools, online migraine diagnosis, guideline-based treatment options, digitally networked patients, and collecting anonymized information about migraine attacks and course parameters for scientific evaluation. Various applications of DTx in migraine management have been studied in recent years, such as the usefulness of digital migraine self-management tools in diagnosing and tracking migraine attacks, and the efficacy and safety of digital cognitive behavioural therapy. However, the development of DTx is still in its infancy and still faces many obstacles. The primary goal of this study is to review the latest research on DTx in migraine management, identify challenges, and outline future trends.

Evidence Mapping Based on Systematic Reviews of Cognitive Behavioral Therapy for Neuropathic Pain

Objective

This evidence mapping is aimed at identifying, summarizing, and analyzing the available evidence on cognitive behavioral therapy (CBT) for neuropathic pain (NP).

Methods

This study was conducted following the methodology of Global Evidence Mapping (GEM). Searches were conducted in PubMed, Embase, the Cochrane Library, and PsycINFO to identify systematic reviews (SRs) with or without meta-analysis published before February 15, 2022. The authors independently assessed eligibility, extracted data, and evaluated the methodological quality of the included SRs using AMSTAR-2. The results were presented in the tables and a bubble plot based on the identified population-intervention-comparison-outcome (PICO) questions.

Results

A total of 34 SRs met the eligibility criteria. According to the AMSTAR-2, 2 SRs were rated "high," 2 SRs were rated "moderate," 6 SRs were rated "low," and 24 SRs were rated "critically low." The most common study design utilized to evaluate the efficacy of CBT for NP was the randomized controlled trial. In total, 24 PICOs were identified. Migraine was the most studied population. CBT for NP usually reaches the "potentially better" result at follow-up.

Conclusions

Evidence mapping is a useful way to present existing evidence. Currently, the existing evidence on CBT for NP is limited. Overall, the methodological quality of the included SRs was low. Further improvements in the methodological quality of SRs and more research on the most efficient CBT formats for NP are recommended in the future.

Child and caregiver perspectives on access to psychosocial and educational support in pediatric chronic kidney disease: a focus group study

BACKGROUND

Children with chronic kidney disease (CKD) generally have worse educational and psychosocial outcomes compared with their healthy peers. This can impair their ability to manage their treatment, which in turn can have long-term health consequences through to adulthood. We attempted to capture the experiences of children with CKD and to describe the perspectives of their parents and caregivers on access to educational and psychosocial support.

METHODS

Children with CKD (n = 34) and their caregivers (n = 62) were sampled via focus groups from pediatric hospitals in Australia, Canada, and the USA. Sixteen focus groups were convened and the transcripts were analyzed thematically.

RESULTS

We identified four themes: disruption to self-esteem and identity (emotional turmoil of adolescence, wrestling with the sick self, powerlessness to alleviate child's suffering, balancing normality and protection); disadvantaged by lack of empathy and acceptance (alienated by ignorance, bearing the burden alone); a hidden and inaccessible support system (excluded from formal psychological support, falling behind due to being denied special considerations); and building resilience (finding partners in the journey, moving towards acceptance of the illness, re-establishing childhood).

CONCLUSIONS

Children with CKD and their caregivers encountered many barriers in accessing psychosocial and educational support and felt extremely disempowered and isolated as a consequence. Improved availability and access to psychosocial and educational interventions are needed to improve the wellbeing and educational advancement of children with CKD. A higher resolution version of the Graphical abstract is available as Supplementary information.

What is new in migraine management in children and young people?

For this narrative review, we found recent publications on the use and effectiveness of old therapies including nutraceuticals, such as riboflavin, vitamin D, magnesium, melatonin and talking therapies. Recent large trials of established conventional pharmaceuticals such as propranolol, pizotifen, topiramate and amitriptyline for childhood migraine have failed, but the use of a quasi-placebo in future trials could help. We reviewed the evidence for angiotensin antagonists including candesartan in adults, but found a lack of evidence for their use in children. There have been new developments in pharmaceuticals recently, including a more selective 5-HT1F agonist, lasmiditan, an effective acute treatment with no vasoconstrictor activity in adults, currently being tested in children. Also, a number of new calcitonin gene-related peptide (CGRP) antibodies and antagonists, with proven efficacy in acute treatment and/or prevention of migraine in adults, are undergoing trials in children. Peripheral nerve blocks and botulinum toxin are gaining popularity in adult practice, but we really need more good quality evidence for their effectiveness in children. Finally, electroceuticals, that is, therapeutic electric devices, are now marketed for acute and or preventative treatment, including an external trigeminal nerve stimulator (e-TNS), a non-invasive vagal nerve stimulator (nVNS), a single-pulse transcranial magnetic stimulator (sTMS) and a remote electrical neuromodulation device (REN). At the moment, evidence for their effectiveness in children is still lacking. So, there has been much progress, but mostly for adults. We are in urgent need of more migraine trials in children.

Digital headache self-management interventions for patients with a primary headache disorder: A systematic review of randomized controlled trials

OBJECTIVE

This article systematically reviews the empirical literature examining the efficacy of digital headache management interventions for patients with a primary headache disorder.

BACKGROUND

Digital headache management interventions provide opportunities to improve access to behavioral headache interventions to underserved groups.

METHODS

A systematic search of PubMed, Scopus, and EBSCO (PsycInfo, Education Research Complete, ERIC, Health Source: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection) and reference review was conducted. Included studies had to recruit a sample with a primary headache diagnosis, be a randomized controlled trial including a digital component, assess a headache outcome (i.e., frequency, duration, severity, intensity, disability) or quality of life, and be published in English. Two authors independently extracted data for included studies. The methodological quality of studies was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

Thirteen studies with unique interventions met inclusion criteria. More than half of the studies were pilots; however, nearly 70% (9/13) demonstrated significant between-group or within-group improvements on one or more headache-related outcomes. All interventions included some form of relaxation training and the majority were delivered via interactive website. While fewer than half the studies report participant race and/or ethnicity, of those that do, 83% (5/6) reported a predominately White/Caucasian sample.

CONCLUSIONS

Efficacy testing of digital headache interventions is in its infancy with the majority of these studies relying on pilot studies with small samples comprised of homogenous patient populations. Interactive websites were the most common digital medium to deliver digital headache management interventions and have demonstrated promising results. Further testing using large-scale randomized controlled trials and exploration of other digital tools is warranted. Future studies with more diverse samples are needed to inform health equity of digital headache interventions.

Cognitive Behavioral Therapy for Chronic Insomnia in Outpatients with Major Depression-A Randomised Controlled Trial

The aim of this randomised controlled assessor-blinded trial was to examine the effect of cognitive behavioural therapy for insomnia on sleep variables and depressive symptomatology in outpatients with comorbid insomnia and moderate to severe depression. Forty-seven participants were randomized to receive one weekly session in 6 weeks of cognitive behavioural therapy for insomnia or treatment as usual. The intervention was a hybrid between individual and group treatment. Sleep scheduling could be especially challenging in a group format as patients with depression may need more support to adhere to the treatment recommendations. The primary outcome measure was the Insomnia Severity Index. Secondary measures were sleep diary data, the Dysfunctional Beliefs and Attitudes about Sleep Questionnaire, the Hamilton Depression Rating Scale, and the World Health Organization Questionnaire for Quality of Life and polysomnography. Compared to treatment as usual, cognitive behavioural therapy significantly reduced the insomnia severity index (mean ISI 20.6 to 12.1, p = 0.001) and wake after sleep onset (mean 54.7 min to 19.0 min, p = 0.003) and increased sleep efficiency (mean SE 71.6 to 83.4, p = 0.006). Total sleep time and sleep onset latency were not significantly changed. The results were supported by analyses of the other rating scales and symptom dimensions. In conclusion, cognitive behavioural therapy for insomnia as add-on to treatment as usual was effective for treating insomnia and depressive symptoms in a small sample of outpatients with insomnia and major depression. ClinicalTrials.gov Identifier: NCT02678702.

Early maladaptive schemas differing according to sex may contribute to migraine among the youth

OBJECTIVE

Despite many diverse findings from studies about the comorbidity of psychiatric disorders and migraine, there are still unknown points. Schemas, which are the basic structures of cognition, are understudied. This study examined the effects of sex on early maladaptive schemas (EMSs) and the clinical characteristics of migraine in adolescents with migraine.

METHODS

The sample comprised 171 adolescents (67.3% females, n = 115) aged 12-18 years. The clinical characteristics of migraine (duration, severity, frequency of headaches, etc.), accompanying symptoms (nausea, vomiting, photophobia, etc.) and EMSs were evaluated depending on sex. Psychopathology and abuse history were analyzed as covariates in this study.

RESULTS

The mean age was 15.4 ± 1.9 among the females and 15.2 ± 2.0 among the males (p = 0.65). There was no difference in terms of migraine characteristics, and except for dizziness and pain relief by massage, all other symptoms were similar between the sexes. Female adolescent migraineurs significantly elevated scores for EMS of emotional deprivation, abandonment/instability, defectiveness/shame (disconnection/rejection domain), dependence/incompetence, vulnerability to harm/illness, failure (in impaired autonomy/performance domain) and negativity/pessimism (in hypervigilance/inhibition domain). On the other hand, male migraineurs had significantly elevated scores only in insufficient self-control/self-discipline (in impaired limits domain). Type of migraine and current psychopathology had no significant effect on the EMS domains, while sexual abuse history significantly affected some EMS.

CONCLUSION

Our study highlights the importance of screening for EMSs among adolescent patients with migraine. Schema therapy and similar therapeutic interventions may be used in the management of migraine in adolescents. Gender may also be important factor the schema therapy in adolescent migraine patients.

From the New Diagnostic Criteria to COVID-19 Pandemic Passing Through the Placebo Effect. What Have We Learned in the Management of Pediatric Migrane Over the Past 5 Years?

In 2018, the Food and Drug Administration (FDA) approval of anti-calcitonin gene-related peptide (CGRP) therapies for the treatment of migraine represented a milestone for the management of the disease in adults. On the contrary, the novelties in the field of pediatric migraine are inserted in a different scenario and still concern: (1) diagnostic criteria of the international classification of headache disorders-3 (ICHD-3) that show numerous limits of applicability in the developmental age; (2) the release of the results of the Childhood and Adolescent Migraine Prevention (CHAMP) study that raised doubts about the usefulness of traditional drugs for the treatment of pediatric migraine; (3) the Coronavirus disease 2019 (COVID-19) pandemic has put the spotlight on the importance of managing the psychological factors associated with the disease. In this mini review we discuss the most relevant news in pediatric migraine over the last 5 years.

Cognitive behavioral therapy for children and adolescents with post-traumatic stress disorder: meta-analysis

BACKGROUND

Children and adolescents who experience traumatic events may develop post-traumatic stress disorder (PTSD), which is often associated with other psychiatric disorders, including depression and anxiety. Cognitive behavioral therapy (CBT) is widely used in psychotherapy to treat PTSD in children and adolescents. This meta-analysis evaluated previous studies on the effectiveness of CBT in the treatment of PTSD in children and adolescents.

METHODS

Randomized controlled trials (RCTs) published before July 25, 2021, were retrieved from seven databases. All RCTs of CBT compared to control, including conventional treatment or other treatments, in children or adolescents with PTSD. Random effect models were employed for all outcomes. Risk of bias was performed by Cochrane Collaboration's tool. The publication bias was evaluated using the Egger's regression analysis.

RESULTS

Nineteen RCTs were included in the meta-analysis. Compared with control, CBT was effective in reducing the symptoms of PTSD in children and adolescents, with a variety of scales used to measure the overall PTSD symptoms: CAPS (SMD = -0.41, 95%CI [-0.71, -0.12]), CPSS (SMD = -0.88, 95%CI [-1.42, -0.34]) and UCLA-PTSD RI (SMD = -1.70, 95%CI [-2.98, -0.42]). Furthermore, CBT also improved the comorbidities of depression (SMD = -0.43, 95%CI [-0.70, -0.17]) and anxiety (SMD = -0.29, 95%CI [-0.56, -0.03]) associated with PTSD. However, CBT was not effective in reducing avoidance symptoms (SMD = 0.38, 95%CI [-0.55, 1.31]).

CONCLUSION

CBT can reduce the severity of PTSD in children and adolescents and improve the symptoms of depression and anxiety, as evident in the treatment of PTSD victims of sexual abuse and war and in patients aged more than 7 years.

The Development and Impact of Anxiety With Migraines: A Narrative Review

Migraine is a chronic, disabling neurological disorder characterized by recurrent episodes of headache. Psychiatric disorders have been reported to arise due to a patient's physical and emotional stress caused by migraine episodes, with anxiety disorders being one of the most commonly associated psychiatric disorder with migraine. This association poses the question of similar or shared pathogenesis between the two disorders and raises a concern for the diagnosis and management of situations when these disorders present together. In this review, we discuss the possible shared mechanism for the development of anxiety disorders in the presence of migraine, such as the vascular, nervous, and genetic factors that might hold the key to their association. We also discuss the number of clinical features shared by these conditions and provide evidence for the higher degree of association between these conditions.

A focused evaluation of anxiety disorders in migraine might benefit patients with earlier diagnoses and improve their quality of life with effective pharmacotherapy and psychotherapy. This review also emphasizes the importance of preventing future migraine episodes with effective prophylactic medications to reduce the risk of developing anxiety disorders, and the need to discuss the medical and psychiatric management of anxiety disorders in patients suffering from migraines on an acute and long-term basis. ​​​​​​

Effects of cognitive-behavioural therapy on psychological, physical and social outcomes of children with cancer: A systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to summarise the effects of cognitive-behavioural therapy on psychological, physical and social outcomes of children with cancer without limitations on publication date.

METHODS

Thirteen English and seven Chinese electronic databases were searched from April to June 2021. Randomised control trials, quasi-experimental studies, pre-test post-test studies with a control group, factorial or cross-over designs that included children ≤18 years old and during various stages of the cancer trajectory, who have received cognitive-behavioural therapy, and reported (anxiety, depression, stress, quality of life, self-efficacy, fatigue, pain, behavioural distress, anger, and/or academic performance) were included.

RESULTS

Eight studies with quality of evidence ranging from low to high risk of bias were included. The results show cognitive-behavioural therapy has favourable effects on anxiety, depression, pain and behavioural distress. The meta-analysis also show that it reduces anxiety (SMD = -0.89, 95% CI (-1.45, -0.32), p < 0.002), depression (SMD = -0.90, 95% CI (-1.40, -0.39), p < 0.0005), and pain (SMD = -0.56, 95% CI (-1.04, -0.08), p < 0.002). It also has a favourable effect on stress, anger and self-efficacy, though the results are drawn from a single study.

CONCLUSION

Cognitive-behavioural therapy has the potential to reduce anxiety, depression and pain for children with cancer. It also shows promise in reducing behavioural distress. Although effects on stress, anger, and self-efficacy have been found to be significant, there have been limited studies on these aspects of functioning and more research is needed. The findings are drawn from heterogeneous participants and interventions, thus emphasising the need to conduct well-designed intervention studies, including cancer survivors.

Cognitive Behavioral Therapy for Migraine Headache: A Systematic Review and Meta-Analysis

Background and Objectives: Migraine headaches are chronic neurological diseases that reduce the quality of life by causing severe headaches and autonomic nervous system dysfunction, such as facial flushing, nasal stuffiness, and sweating. Their major treatment methods include medication and cognitive behavioral therapy (CBT). CBT has been used for pain treatment and various psychogenic neurological diseases by reducing pain, disability, and emotional disorders caused by symptoms of mental illness and improving the understanding of mental health. This study aimed to evaluate the effectiveness and safety of CBT in treating migraines. Materials and Methods: Seven electronic databases were searched from the date of inception to December 2020. Randomized controlled studies (RCTs) using CBT as an intervention for migraine were included. The primary outcome of this study was to determine the frequency of migraines and the intensity of migraines on Visual Analog Scale (VAS), the frequency of drug use, Migraine Disability Assessment (MIDAS), and Headache Impact Test (HIT-6) index. The two authors independently conducted the data extraction and quality assessment of the included RCTs, and conducted meta-analysis with RevMan V.5.4. Results: Among the 373 studies, 11 RCTs were included in this systematic review. Seven out of the 11 RCTs were conducted in the USA, and four were conducted in the UK, Germany, Iran, and Italy, respectively. Headache frequency and MIDAS scores were statistically significant reduced. In the subgroup analysis, headache strength was significantly reduced. Two of the included studies reported adverse effects, including worsening of migraine intensity and frequency, respiratory symptoms, and vivid memory of a traumatic event. Conclusions: CBT for migraine effectively reduced headache frequency and MIDAS score in meta-analysis and headache intensity subgroup analysis, with few adverse events. Additional RCTs with CBT for migraine headaches are needed for a more accurate analysis.

Preference, Knowledge, and Attitudes of Parents Toward Cognitive Behavioral Therapy for Their Children in Riyadh, Saudi Arabia

Introduction: Cognitive behavioral therapy (CBT) for children and adolescents has shown efficacy in treating different psychiatric disorders. It has been added to multiple clinical guidelines as the first-line treatment. However, despite more studies of its efficacy, CBT is underutilized in clinical settings due to a lack of rigorous training programs and qualified CBT therapists. The limited knowledge of parents in this intervention and their negative attitudes toward it have been considered as possible reasons. Methods: This is a cross-sectional survey-based study among 464 Saudi parents living in Riyadh city. We aimed to evaluate the preference, knowledge, and attitudes of Saudi parents toward CBT for their children. We compared the difference in the level of knowledge and attitudes toward CBT in relation to the characteristics of parents. An online questionnaire that included 39 questions was carefully reconstructed from four validated scales, approved by an expert panel, and piloted. Participants were recruited to participate through online social media. Results: Saudi parents had average knowledge about CBT; however, they had positive attitudes toward the therapy itself and its role in treating the behavioral issues of children. Male participants showed better knowledge than female participants. Participants with higher education and those with high income had more favorable attitudes toward CBT than others. Conclusion: The knowledge of parents is considered inadequate and indicated the need for more awareness and perhaps mass education. In contrast, they maintained positive attitudes and were interested in evidence-based treatment, with more preference toward non-psychopharmacological interventions.

The effectiveness of intervention with cognitive behavioral therapy on pornography: A systematic review protocol of randomized clinical trial studies

BACKGROUND

The increasing rate of problematic pornography use (PPU) among the general population has risen. There are limited data on the efficacy of Cognitive Behavioral Therapy (CBT) on online pornographic addiction; therefore, this study aimed at investigating the issue.

METHODS

SCOPUS, PubMed, PubPsych, WOS (Web of Science), Cochrane Central Register of Controlled Trials, Google Scholar, Scientific Information Database (SID) & Iranmedex, and other databases (for gray literature) (eg, conference papers, key journals) will be systematically reviewed. Preliminary search strategies were started on March 2, 2019, and will be updated in April 2021. Eligibility criteria were having PPU, with designs of interest including randomized trials with three or more months of follow-up with CBT intervention. Two authors will independently conduct data extraction and quality assessment. A modified Verhagen checklist for clinical trial studies will be used for quality assessment. Pooled measures of association will be computed using random-effects model meta-analyses. Between-study heterogeneity will be assessed using the I2 statistic and the Cochrane χ2 statistic. Minor study effects will be evaluated for meta-analyses with sufficient studies using funnel plots and Egger's test. If a meta-analysis is appropriate, quantitative data will be pooled using the comprehensive meta-analysis software.

DISCUSSION

The evidence obtained in this meta-analysis will help to determine whether CBT can decrease PPU severity, anxiety, depression, and compulsive sexual behavior. In addition, due to the comprehensive view on CBT effects on PPU patients, which was not clarified before, we can expect that the results of this study will benefit psychiatrists.

Migraine attacks as a result of hypothalamic loss of control

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Hypothalamo-limbic connectivity reflects the cyclic nature of migraine.

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Hypothalamo-limbic connectivity is largest just before the attack.

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Hypothalamo-limbic connectivity is collapsing during the attack.

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Limbic perfusion is increasing and has a maximum during the attack.

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The disrupted connectivity allows high limbic perfusion, resulting in migraine attack.

Migraine is a complex neurological disorder affecting approximately 12% of the population. The pathophysiology is not yet fully understood, however the clinical features of the disease, such as the cyclic behaviour of attacks and vegetative symptoms, suggest a prominent role of the hypothalamus. Previous research has observed neuronal alterations at different time points during the migraine interval, specifically just before the headache is initiated. We therefore aimed to assess the trajectory of migraineurs’ brain activity over an entire migraine cycle.

Using functional magnetic resonance imaging (fMRI) with pseudo-continuous arterial spin labelling (ASL), we designed a longitudinal intra-individual study to detect the rhythmicity of (1) the cerebral perfusion and (2) the hypothalamic connectivity over an entire migraine cycle. Twelve episodic migraine patients were examined in 82 sessions during spontaneous headache attacks with follow-up recordings towards the next attack.

We detected cyclic changes of brain perfusion in the limbic circuit (insula and nucleus accumbens), with the highest perfusion during the headache attack. In addition, we found an increase of hypothalamic connectivity to the limbic system over the interictal interval towards the attack, then collapsing during the headache phase.

The present data provide strong evidence for the predominant role of the hypothalamus in generating migraine attacks. Due to a genetically-determined cortical hyperexcitability, migraineurs are most likely characterised by an increased susceptibility of limbic neurons to the known migraine trigger. The hypothalamus as a metronome of internal processes is suggested to control these limbic circuits: migraine attacks may occur as a result of the hypothalamus losing control over the limbic system. Repetitive psychosocial stress, one of the leading trigger factors reported by patients, might make the limbic system even more vulnerable and lead to a premature triggering of a migraine attack. Potential therapeutic interventions are therefore suggested to strengthen limbic circuits with dedicated medication or psychological approaches.

Effects of Mindfulness-Based Cognitive Therapy for Chronic Pain: A Multicenter Study

The prevalence of chronic pain in Spain is 15%. The objective of this study was to evaluate the efficacy of mindfulness-based cognitive therapy on patients with chronic pain. A quasi-experimental design of repeated measures pre- and post-test (N = 57) was carried out at three hospitals from the province of Alicante. Self-reported assessment measurements of pain intensity, anxiety-depression symptoms, perception of health status, interference of pain on sleep, self-efficacy in pain, acceptance, and mindfulness attitude were included. The T-test indicates significant differences in intensity of present pain, mental quality of life, and depression (medium effect sizes), as well as in self-efficacy: total score, symptom management and pain control (medium effect sizes), sleep disturbances and quantity of sleep (large effect sizes). MBCT is effective in reducing many symptoms in patients with chronic pain, although its maintenance needs to be further investigated.

Approach to Pediatric Intractable Migraine

PURPOSE OF REVIEW

Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus.

RECENT FINDINGS

A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.

A Randomized Controlled Trial of a Cognitive Behavior Therapy Program for Children with Clinical Anxiety Symptoms

High anxiety and anxiety disorders are among the most prevalent mental health problems in children and lead to significant interference with children’s daily functioning. Most empirical evaluations of treatment come from English-language countries. The aim of the present study was to evaluate and replicate the effectiveness of a cognitive-behavioral intervention program to manage anxiety in children among children from Greece. Forty-one children–parent(s) dyads participated in the study. Children were 9–12 years old, with clinically elevated symptoms of anxiety, and they were assigned to either the standard group treatment (cognitive behavior therapy (CBT)) or to a waitlist group (WL). Both children and their parents in the CBT group reported statistically significant reductions in children’s anxiety symptoms at post-intervention and at the 6-month follow-up. A significant reduction was also found in life interference due to anxiety according to both child and parent reports. In contrast, no significant changes in anxiety symptoms or life interference were reported among the WL. The current results support the effectiveness of a CBT program for anxious children from a non-clinic, non-school setting in Greece.

Nutraceuticals and Behavioral Therapy for Headache

PURPOSE OF REVIEW

Headache affects and disables at least 1 billion people worldwide. Patients and providers seek new therapies to relieve headache without the side effects and financial burden of current treatments. This narrative review highlights recent treatment advances in integrative headache medicine: nutraceuticals and behavioral therapies.

RECENT FINDINGS

Growing use of complementary and alternative medicine (CAM) therapies for headache (riboflavin, coenzyme Q10, magnesium, vitamin D, melatonin) alongside mainstream treatments is increasing with improving evidence of quality, safety, and tolerability. Increasing interest in medical cannabis is tempered by lack of evidence regarding safety and efficacy. Behavioral therapies including cognitive behavioral therapy (CBT), biofeedback, mindfulness-based stress reduction (MBSR), and acceptance and commitment therapy (ACT) improve patient resiliency and self-efficacy outcomes and reduce disability. The body of evidence for nutraceutical and behavioral CAM interventions for headache continues to grow and improve in quality. Providers and patients should educate themselves regarding CAM therapies as part of integrative headache management. Future studies should examine combinatorial trials of CAM therapies against current standards of headache care.

Nonpharmacological Interventions for Pediatric Migraine: A Network Meta-analysis

CONTEXT

Migraine is a common neurologic disorder in children and adolescents. However, a comparison of multiple nonpharmacological treatments is lacking.

OBJECTIVE

To examine whether nonpharmacological treatments are more effective than waiting list and whether there are differences between interventions regarding efficacy.

DATA SOURCES

Systematic review and network meta-analysis of studies in Medline, Cochrane, Embase, and PsycINFO published through August 5, 2019.

STUDY SELECTION

Randomized controlled trials of nonpharmacological treatments in children and adolescents diagnosed with episodic migraine.

DATA EXTRACTION

Effect sizes, calculated as standardized mean differences (SMDs) for the primary outcome efficacy, were assessed in a random-effects model.

RESULTS

Twelve studies (N = 576) were included. When interventions were classified into groups on the basis of similarity of treatment components, self-administered treatments, biofeedback, relaxation, psychological treatments, and psychological placebos were significantly more effective than waiting list with effect sizes ranging between SMD = 1.14 (95% confidence interval, 0.09 to 2.19) for long-term psychological placebos to SMD = 1.44 (95% confidence interval, 0.26 to 2.62) for short-term self-administered treatments. However, when all interventions were examined individually (ie, 1 node per intervention), none were significantly more effective compared with waiting list, mainly because of lack of statistical power.

LIMITATIONS

Because of our focus on pediatric migraine, only a small number of studies could be included.

CONCLUSIONS

Our findings reveal that components of nonpharmacological interventions are effective in treating pediatric migraine. Some effects have to be interpreted carefully because they are based on small studies. Future researchers should identify factors associated with individual responses in large, multicentered studies.

Identification of neural and psychophysical predictors of headache reduction after cognitive behavioral therapy in adolescents with migraine

ABSTRACT

Cognitive behavioral therapy (CBT) is a psychological intervention that involves development of coping strategies to reduce the experience of pain. Although CBT is a promising intervention to reduce headache days in patients with migraine, it may not be effective for all patients. Thus, there is a need to identify markers that could predict which patients will respond to CBT. We aimed to determine whether baseline brain function and amygdalar connectivity, assessed by functional magnetic resonance imaging, or pain modulation capacities, assessed by the conditioned pain modulation (CPM) response, can predict a reduction in headache days after CBT in adolescents with migraine. Patients with migraine (n = 20; age range 10-17 years) completed 8 weekly CBT sessions. The CPM response was examined in the trapezius and the leg. Headache days significantly decreased after CBT (P < 0.001). Greater functional connectivity before CBT between the right amygdala and frontal gyrus, anterior cingulate cortex, and precentral gyrus was related to greater headache reduction after CBT. Greater reduction in headache days after CBT was related with less efficient CPM response before CBT at the trapezius (r = -0.492, P = 0.028) but not at the leg. This study found that headache reduction after CBT was related to right amygdala connectivity with frontal and sensorimotor regions at baseline as well as baseline pain modulation capacities. These findings suggest that individual differences in brain function and pain modulation can be associated with clinical improvements and help with determination of CBT responsiveness.

A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education

Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.

Migraine Symptoms Improvement During the COVID-19 Lockdown in a Cohort of Children and Adolescents

Background: Pediatric migraine is among the most common primary or comorbid neurologic disorders in children. Psychological stressors are widely acknowledged as potential triggers involved in recurring episodes of pediatric migraine. As the COVID-19 emergency may have affected the levels of stress perceived by children and adolescents with migraine, the present study was aimed to understand the effect of COVID-19 emergency on symptoms intensity and frequency in pediatric patients.

Methods: A cohort of 142 child and adolescent patients with a diagnosis of migraine was enrolled at the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia (Italy). Socio-demographic and clinical characteristics were obtained from medical records. An on-line survey was used to collect information on COVID-19 exposure, stress response to the lockdown period, anxious symptoms during COVID-19 emergency, as well as migraine symptoms intensity and frequency before and during the lockdown.

Results: The great majority were outpatients (n = 125, 88.0%), 52 (36.6%) had migraine with aura, whereas, 90 (63.4%) had migraine without aura. All the patients reporting worsening symptoms progression before COVID-19, had reduced intensity during the lockdown (χ² = 31.05, p < 0.0001). Symptoms frequency reduction was observed in 50% of patients presenting worsening symptoms before the lockdown, 45% of those who were stable, and 12% of those who were already improving. All patients who had resolved symptoms before COVID-19 were stable during the lockdown (χ² = 38.66, p < 0.0001). Anxious symptomatology was significantly associated with greater migraine symptoms frequency (χ² = 19.69, p < 0.001). Repeating the analysis separately for individuals with and without aura did not affect the findings and significant associations were confirmed for both the patients' subgroups.

Discussion: A significant reduction of migraine symptoms intensity and frequency was observed in pediatric patients during the COVID-19 lockdown phase in northern Italy. The improvement in both intensity and frequency of the migraine symptoms was especially significant in patients who were stable or worsening before the lockdown. The reduction of symptoms severity during a period of reduced environmental challenges and pressures further highlights the need of providing effective training in stress regulation and coping for these patients.

Mapping the evidence and gaps of interventions for pediatric chronic pain to inform policy, research, and practice: A systematic review and quality assessment of systematic reviews

Background: Reviews in pediatric chronic pain often focus on only one intervention or population, making it difficult for policymakers and decision makers to quickly synthesize knowledge to inform larger-scale policy and funding priorities. Aims: The aims of this study were to (1) create an evidence and gap map of interventions for pediatric chronic pain and (2) identify gaps between existing evidence and recently identified patient-oriented research priorities. Methods: We performed a systematic review of English-language peer-reviewed systematic reviews or clinical practice guidelines of pediatric chronic pain intervention published in the past 20 years. Database searches of Medline, Embase, PsycINFO, Web of Science, CINAHL, and SCOPUS were conducted inclusive to June 3, 2019. Review quality was assessed using the AMSTAR-2. Results: Of 4168 unique abstracts, 50 systematic reviews (including 2 clinical practice guidelines) crossing diverse pediatric chronic pain populations and intervention settings were included. One third were rated high quality, with half rated low to critically low quality. The largest proportion of reviews addressed psychological and pharmacological interventions, followed by interdisciplinary, other (e.g., dietary), and physical interventions. Most common outcomes included pain, physical, emotional, and role functioning and quality of life. Treatment satisfaction and adverse events were less common, with minimal report of sleep or economic factors. Most patient-oriented research priorities had not been investigated. Conclusions: Sufficient quality evidence is available to guide evidence-informed policies in pediatric chronic pain, most notably regarding psychological and pharmacological interventions. Numerous evidence gaps in patient-oriented research priorities and treatment outcomes should guide prioritization of research funds, as well as study aims and design.

Pediatric medical psychology

Paediatric medical psychology is a specialised field within clinical health psychology focussed on the behavioural, developmental, and psychological needs of children, adolescents, and families in healthcare contexts. Paediatric medical psychologists address a myriad of problems by employing evidence-based evaluations and interventions in order to support the well-being of paediatric patients and their families. In this paper, we provide an overview of paediatric medical psychology including the education and training required to be a paediatric psychologist followed by common problems addressed by paediatric psychology, the settings paediatric psychologists work in, and the services they provide. Discussion concludes with future application of integrating paediatric psychology throughout the continuum of care to optimise adjustment and health of paediatric patients.

Headache Hygiene in Pediatrics: Brushing Up on the Basics

Headache hygiene refers to self-management behaviors and practices aimed at reducing headache-related disability and improving self-efficacy. Although self-management interventions have an established place in the management of a wide range of chronic conditions, there is still not a standardized approach to this in pediatric headache. In this article, we focus on headache hygiene approaches including education, lifestyle interventions, and psychologic interventions. We also present our center's resource compilation, made available to patients by quick response code technology, as an example of a structured approach to headache hygiene. Further work should explore a standardized approach to headache hygiene and strategies to support adherence, including the use of technology as an innovative health care delivery pathway.

Effect of cognitive behavior therapy combined with exercise intervention on the cognitive bias and coping styles of diarrhea-predominant irritable bowel syndrome patients

BACKGROUND

Irritable bowel syndrome (IBS) is a common digestive system disease with a high incidence rate and is common in women. The cause of IBS remains unclear. Some studies have shown that mental and psychological diseases are independent risk factors for IBS. At present, the treatment of IBS is mainly symptomatic treatment. Clinically, doctors also use cognitive behavioral therapy to improve patients' cognitive ability to diseases and clinical symptoms. In recent years, exercise therapy has attracted more and more attention from scholars. Improving the symptoms of IBS patients through psychosomatic treatment strategy may be a good treatment method.

AIM

To explore the effects of an intervention of cognitive behavioral therapy combined with exercise (CBT+E) on the cognitive bias and coping styles of patients with diarrhea-predominant irritable bowel syndrome (IBS-D); and to provide a theoretical reference for the management of IBS.

METHODS

Sixty IBS-D patients and thirty healthy subjects were selected. The 60 IBS-D patients were randomly divided into experimental and control groups. The experimental group was treated with the CBT+E intervention, while the control group was treated with conventional drugs without any additional intervention. The cognitive bias and coping styles of the participants were evaluated at baseline and after 6 wk, 12 wk and 24 wk using the Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale (DAS) and Pain Coping Style Questionnaire (CSQ) instruments, and the intervention effect was analyzed using SPSS 17.0 statistical software.

RESULTS

At baseline, the scores on the various scales showed that all subjects had cognitive bias and adverse coping styles. The IBS Symptom Severity Scale (IBS-SSS) scores, ATQ total scores, DAS scores and CSQ scores of the two groups were not significantly different (P > 0.05). Compared with baseline, after 6 wk of the CBT+E intervention, there were significant differences in the ATQ scores, the dependence and total scores on the DAS, and the catastrophization, distraction and prayer scores on the CSQ (P < 0.05). After 12 wk, there were significant differences in the scores for perfectionism on the DAS and in the scores for reinterpretation, neglect and pain behavior on the CSQ in the experimental group (P < 0.05). After 24 wk, there were significant differences in the vulnerability, dependence, perfectionism, and total scores on the DAS and in the catastrophization, distraction and prayer scores on the CSQ in the experimental group (P < 0.01). The IBS-SSS scores were negatively correlated with the ATQ and DAS total scores (P < 0.05) but were positively correlated with the CSQ total score (P < 0.05).

CONCLUSION

Intervention consisting of CBT+E can correct the cognitive bias of IBS-D patients and eliminate their adverse coping conditions. CBT+E should be promoted for IBS and psychosomatic diseases.

Survey of Child Neurologists on Management of Pediatric Post-traumatic Headache

Traumatic brain injury causes significant morbidity in youth, and headache is the most common postconcussive symptom. No established guidelines exist for pediatric post-traumatic headache management. We aimed to characterize common clinical practices of child neurologists. Of 95 practitioners who completed our survey, most evaluate <50 pediatric concussion patients per year, and 38.9% of practitioners consistently use International Classification of Headache Disorders criteria to diagnose post-traumatic headache. Most recommend nonsteroidal anti-inflammatory drugs as abortive therapy, though timing after injury and frequency of use varies, as does the time when providers begin prophylactic medications. Amitriptyline, topiramate, and vitamins/supplements are most commonly used for prophylaxis. Approach to rest and return to activities varies; one-third recommend rest for 1 to 3 days and then progressive return, consistent with current best practice. With no established guidelines for pediatric post-traumatic headache management, it is not surprising that practices vary considerably. Further studies are needed to define the best, evidence-based management for pediatric post-traumatic headache.

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society

OBJECTIVE

To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population.

METHODS

The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended.

RESULTS

Fifteen Class I-III studies on migraine prevention in children and adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine, or flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency.

RECOMMENDATIONS

The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision-making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Hybrid Cognitive-Behavioral Therapy Intervention for Adolescents With Co-Occurring Migraine and Insomnia: A Single-Arm Pilot Trial

OBJECTIVE

This study aimed to evaluate feasibility and acceptability of a hybrid cognitive-behavioral therapy intervention for adolescents with co-occurring migraine and insomnia.

BACKGROUND

Many youth with chronic migraine have co-occurring insomnia. Little research has been conducted to evaluate behavioral treatments for insomnia in youth with migraine.

DESIGN AND METHODS

We conducted a single-arm pilot trial to evaluate the feasibility and acceptability of delivering cognitive-behavioral therapy for insomnia to 21 youth (mean age 15.5, standard deviation 1.6) with co-occurring chronic migraine and insomnia. Adolescents completed up to 6 individual treatment sessions over 6 to 12 weeks, and 1 booster session 1 month later. Assessments included a prospective 7-day headache and sleep diary, and self-report measures of insomnia, sleep quality, sleep habits, and activity limitations at pre-treatment, immediate post-treatment, and 3-month follow-up.

RESULTS

Adolescents demonstrated good treatment adherence and families rated the intervention as highly acceptable. Preliminary analyses indicated improvements from pre-treatment to post-treatment in primary outcomes of headache days (M = 4.7, SD = 2.1 vs M = 2.8, SD = 2.7) and insomnia symptoms (M = 16.9, SD = 5.2 vs M = 9.5, SD = 6.2), which were maintained at 3-month follow-up (M = 2.7, SD = 2.8; M = 9.3, SD = 5.0, respectively). We also found improvements in secondary outcomes of pain-related activity limitations as well as sleep quality, sleep hygiene, and sleep patterns.

CONCLUSIONS

These preliminary data indicate that hybrid cognitive-behavioral therapy is feasible and acceptable for youth with co-occurring chronic migraine and insomnia. Future randomized controlled trials are needed to test treatment efficacy on migraine, sleep, and functional outcomes. ClinicalTrials.gov Identifier: NCT03137147.

Integrative Management of Pediatric Primary Headaches

Pediatric primary headache disorders are best treated using a comprehensive and integrative approach, due to the complex interactions between psychosocial and biological processes. Although more quality research is needed for treatment approaches to pediatric headaches, current practice management includes both pharmaceutical and nonpharmaceutical management. This article describes the integrative treatments used in a large regional pediatric headache program. Lifestyle approaches, nutraceuticals and dietary supplements, acupuncture, transcutaneous neurostimulation, relaxation, clinical hypnosis, biofeedback, and psychological services are discussed in detail for clinicians who may consider applying to their practice. [Pediatr Ann. 2019;48(6):e231-e235.].

Relaxation training for management of paediatric headache: A rapid review

The objective of this review was to assess the evidence on relaxation training for management of paediatric headaches. Our methodology was a rapid review of English-language peer reviewed published literature focused on studies evaluating relaxation training as a primary or adjunct management option for headache in a paediatric population (0 to 18 years of age). Seven studies involving 571 children were included in the review. The quality of evidence was very low using GRADE criteria. Headache frequency, duration, and intensity were the primary outcomes in the included studies. Results for the effects of relaxation training for paediatric headache are inconsistent. Four of the seven studies reported decreased headache frequency, two of the five studies reported decreased headache duration, and two of the six studies reported decreased headache intensity following relaxation training. No adverse events were reported. The current state of the evidence for relaxation training for management of paediatric headache is both inconsistent and of very low quality. High-quality research evaluating the effects of relaxation training for paediatric headaches is required to advance the field.

An open/pilot trial of cognitive behavioral therapy in Turkish patients with refractory chronic migraine

Cognitive behavioral therapy (CBT) for pain management is a therapy that aims to modify thoughts and behavior to be more realistic and balanced. There are limited number of studies to assess the efficacy of CBT for patients with pharmacotherapy-resistant chronic migraine in our population. We aimed to invstigate the effects of CBT for patients with refractory chronic migraine on pain attack frequency, disability, severity, anxiety and depression. Fourteen patients with refractory chronic migraine who were referred from the headache clinic to the psychiatry department and regularly attended CBT sessions at least once every 2 weeks for at least 6 months, were included in the study. After 2 sessions of psychiatric evaluation, the subjects had 12 40-min CBT sessions and were given relaxation exercises. The Hamilton depression and anxiety inventories, visual analogue scale for assessing the severity of pain, and the Migraine disability assessment (MIDAS) test were used before and after CBT. The mean Hamilton depression scores before and after CBT were 29.07 ± 7.74 and 14.21 ± 7.7, respectively (p < 0.0001). The mean Hamilton anxiety scores before and after CBT were 26.8 ± 11.7 and 11.7 ± 2.6, respectively (p < 0.0001). The mean VAS scores before and after CBT were 8.07 ± 0.91 and 3.71 ± 1.32, respectively (p < 0.0001). The mean MIDAS scores before and after CBT were 55.5 ± 20.4 and 20.12 ± 16.6, respectively (p < 0.0001). Our results showed that CBT had made a statistically significant difference on pain severity, number of migraine attacks and disability in patients with refractory chronic migraine. CBT should be considered in this patient group.

Relating Photophobia, Visual Aura, and Visual Triggers of Headache and Migraine

OBJECTIVE

This study investigated a potential association between visual factors and symptoms related to migraine. It was predicted that photophobia and visual aura would be positively associated with interictal light sensitivity and visual headache triggers (flicker, glare, and eyestrain), and that these 2 visual symptoms would also be associated.

BACKGROUND

Previous studies have found independent neurophysiological associations between several visual factors and symptoms related to headache disorders. Many of these connections appear to be associated with increased cortical hypersensitivity, a phenomenon that might be in part due to repeated avoidance and reduced tolerance to triggers. If true, and if associations between visual factors and symptoms can be established, this may have implications for an exposure-based treatment for migraine symptoms.

METHODS

Four hundred and ninety-one participants (411 female, 80 male) were recruited through Griffith University (AUS), Headache Australia, Pain Australia, and through social media. Participants were grouped based on the presence of headache disorder symptoms and the presence or absence of photophobia and/or visual aura. A cross-sectional online survey design was utilized to gather information pertaining to interictal light sensitivity, visual triggers, and visual symptoms.

RESULTS

With respect to interictal light sensitivity and photophobia, a significant difference (P < .001, eta squared [η² ] = 0.084) was found between the 3 groups, where headache disorder participants with photophobia (group A1; mean [M] = 2.5, standard deviation [SD] = 0.97) reported significantly greater light sensitivity than participants with headache disorder and no photophobia (A2; M = 1.68, SD = 0.62) and control group participants (A3; M = 1.82, SD = 0.85). This pattern was repeated for participants reporting flicker as a headache trigger (P < .001, η² = 0.061), with group A1 (M = 2.45, SD = 1.24) significantly higher than groups A2 (M = 1.68, SD = 0.83) and A3 (M = 1.68, SD = 0.89), and was also seen for glare as a headache trigger (P < .001, η² = 0.092), with group A1 (M = 2.92, SD = 0.96) significantly higher than A2 (M = 2.31, SD = 0.89) and A3 (M = 2.09, SD = 0.93). This pattern of results was not replicated for headache disorder participants with and without visual aura. A significant association (P < .001) was found between photophobia and visual aura in headache disorder participants based on a chi-square test of independence, with 86/136 participants reporting either both or neither visual symptom.

CONCLUSIONS

This study supports a link between certain visual phenomena in headache disorder populations, and supports future research into exposure-based treatments for migraine symptoms.