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

Sleep Symptoms in Migraine

PURPOSE OF REVIEW

To review replicated and highlight novel studies of sleep in children and adults with episodic and chronic migraine.

RECENT FINDINGS

Attack-related sleep symptoms are most common in the prodrome and may represent early activation of the hypothalamus rather than migraine triggers. Interictally, patients with migraine report poor sleep quality and high rates of insomnia symptoms. Cognitive behavioral therapy for insomnia in adults and adolescents with chronic migraine and comorbid insomnia results in significant improvement on their headache burden. Thus far, objective studies report that migraine per se is a not associated with sleep apnea. At the present time, there is minimal evidence that migraine is under circadian influence. The current body of evidence suggests that the insomnia symptoms and poor sleep quality commonly reported by patients with migraine are not attack-related but occur interictally and are a marker of worsening disease. The development of clinical guidelines to approach sleep symptoms and expansion of CBT-I trials in those with episodic migraine would be clinically valuable.

Behavioral therapy in migraine: Expanding the therapeutic arsenal

BACKGROUND AND PURPOSE

The US Headache Consortium developed evidence-based guidelines for the treatment of migraine and found grade A evidence in support of behavior therapy (BT). Understanding the mechanisms of BT may improve the management of migraine and reduce its burden.

METHODS

We performed a narrative review to define the current evidence of BT and determine its usefulness in migraine management.

RESULTS

The information was obtained from 116 publications, with 56 of them retrieved through direct searches in PubMed (2011-2020) and the remainder selected by the authors to complete the content. BT might reduce migraine impact by decreasing the sympathetic nervous system's response to stress and increasing pain tolerance. Acting in headache-related surroundings can be improved, together with headache duration and self-efficacy. Applications such as mobile health and electronic health applications can help to carry out healthier lifestyle patterns. Regarding medication overuse, BT seems to be a good choice, with similar results to pharmacological prophylaxis. Advantages of using BT are the lack of adverse effects and the unrestricted use in children, where BT is postulated to be even more effective than the standardized pharmacopeia.

CONCLUSIONS

BT is an interesting tool that can be used as an add-on therapy in migraine. Through BT, the autonomy and empowerment of migraine patients is enhanced. BT may not cure migraine, but it could help to reduce pain severity perception, disability, and migraine impact, adding an emotive and cognitive approach to the perceptive role of pharmacopeia. Thus, a better approach in migraine, implementing specific therapeutic management, can improve migraine control.

Identifying and Predicting Subgroups of Veterans With Mild Traumatic Brain Injury Based on Distinct Configurations of Postconcussive Symptom Endorsement: A Latent Class Analysis

OBJECTIVE

To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership.

SETTING

Outpatient Veterans Health Administration (VHA).

PARTICIPANTS

Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale.

DESIGN

Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership.

MAIN MEASURES

Latent classes identified using NSI items.

RESULTS

The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood).

CONCLUSION

The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population.

An evaluation of psychosocial sleep interventions for children with chronic health conditions: A systematic review

Chronic health conditions (CHC; e.g., cystic fibrosis, type 1 diabetes) in children are associated with disease-specific physical symptoms that contribute to a high prevalence of sleep problems. Sleep problems exacerbate other health-related sequelae and can impede therapeutic response to health treatments, increasing the overall complexity of symptom management. Psychosocial sleep interventions (PSI) improve sleep in children with typical development and neurodevelopmental conditions. Yet, the effectiveness of PSI for children with CHC has scarcely been investigated. This systematic review appraises the literature examining the effectiveness and acceptability of PSI for children with CHC. A search identified 20 studies that met inclusion criteria. Data related to participant characteristics, sleep targets, research design and methods, measures, sleep outcomes and collateral effects were extracted. Study rigor was then evaluated. Most studies evaluated youth-directed Cognitive Behavioral Therapy for Insomnia or parent-implemented behavioral sleep interventions. Twelve studies demonstrated positive sleep treatment effects and four demonstrated mixed effects. Collateral improvements were reported in child mental health and parental health and well-being, though physical health benefits for children were not consistently reported. One, five and 14 studies were rated as having strong, adequate, and weak methodological rigor respectively. Recommendations for clinical practice and future research are made.

Adolescent Girls' Musculoskeletal Pain is More Affected by Insomnia Than Boys, and Through Different Psychological Pathways

Prior research has established that insomnia is predictive of pain in adolescents and that psychological mechanisms have a crucial role in this relationship. Adolescent girls report more insomnia and pain than boys, yet little is known of gender differences in how insomnia influences pain. This study assessed gender differences in levels and trajectories of insomnia and pain during adolescence, and whether rumination and negative mood mediated the effect of insomnia on pain. Longitudinal survey data measured on 5 annual occasions (Nbaseline = 2,767) were analyzed in a multigroup longitudinal serial mediation model. A final model was generated with insomnia as the predictor, rumination and depressed mood as mediators, pain as the outcome, and gender as the grouping variable. The results showed that insomnia predicted pain in adolescents, with an effect 3.5 times larger in girls than boys. Depressed mood was the main mediator in boys. In girls, rumination was the only significant mediator. There were significant gender differences in the effects of insomnia on rumination and pain, and in the effects of rumination on depressed mood and pain, with stronger effects in girls. These results highlight that girls and boys should be considered separately when studying the relationship between insomnia and pain. PERSPECTIVE: Levels of insomnia and pain are progressively higher in adolescent girls than boys, across adolescence. The predictive strength of insomnia symptoms for future pain is 3.5 times greater in girls, with distinct gender-specific underlying pathways: rumination partially mediates this effect in girls, while depressed mood does so in boys.

Temporal Daily Relationships Between Sleep and Pain in Adolescents With Systemic Lupus Erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder characterized by recurrent episodes of pain. This study aimed to describe the temporal daily relationships between sleep and pain in adolescents with SLE.

METHOD

Twenty-three adolescents with SLE recruited from a pediatric hospital wore actigraphy and completed diaries. Generalized estimating equation models were used.

RESULTS

On average, evening pain negatively predicted subsequent sleep quality that night, and, on average, sleep quality negatively predicted morning pain. Shorter total sleep time significantly predicted higher morning pain (95% confidence intervals [CI], -0.38 to -0.03, p = .02), whereas sleep efficiency and sleep quality were not significantly associated with morning pain (95% CI, -0.03 to 0.03; 95% CI, -0.08 to 0.06, respectively). Subsequent evening pain did not predict daily nighttime sleep DISCUSSION: Our findings suggest that sleep is a target for pain interventions to include among adolescents with SLE.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making approach.

Telehealth delivery of adapted CBT-I for insomnia in chronic pain patients: a single arm feasibility study

Objectives

A large proportion of individuals with chronic pain experience insomnia-related symptoms which can be persistent in nature, and negatively impact one's quality of life. This single arm trial aimed to investigate the feasibility and preliminary efficacy of CBT-I, adapted for people with chronic musculoskeletal pain, delivered via telehealth.

Methods

We conducted a single arm feasibility trial in which 10 adult women (M age = 50.76 years, SD = 8.03 years) with self-reported insomnia and a diagnosed chronic musculoskeletal chronic pain received six CBT-I individual treatment sessions over 6-10 weeks. Treatment was delivered via telehealth. Participants completed weekly sleep diaries, and self-reported measures of insomnia, pain, anxiety and depression pre-treatment, post-treatment, and one-month follow-up.

Results

The trial yielded, high levels of compliance with intervention protocols, and affirmative feedback on satisfaction which demonstrated feasibility. The enrolment rate into the study was 37% (27 participants screened, 10 participants enrolled). The intervention was associated with statistically and clinically meaningful improvements in self-reported insomnia severity. There were statistically significant improvements in sleep efficiency, wake after sleep onset, sleep onset latency, anxiety and depression.

Conclusion

Adapted CBT-I delivered via telehealth may be a feasible, acceptable, and efficacious therapeutic approach for individuals with co-existent sleep and chronic pain. Future trials should adopt a randomized design against usual care.

Executive Functioning and Self-Management Processes Mediate the Relationship Between Insomnia and Pain-Related Disability

Insomnia has been identified as a predictor of reduced benefit from cognitive-behavioral treatment (CBT) for adolescent chronic pain; however, it is not well understood how insomnia leads to reduced treatment response. The purpose of this study was to evaluate executive function and self-management processes as 2 potential mediators of the relationship between insomnia symptoms and pain-related disability outcomes from internet-delivered CBT using a single-arm clinical trial design. Eighty-five adolescents with chronic pain (77% female, ages 12-17 years) and their caregiver received an 8-week internet-delivered CBT intervention. Youth completed validated measures of insomnia symptoms, executive function, self-management processes, and pain-related disability at baseline, mid-treatment, immediate post-treatment, and 3-month follow-up. Results from multilevel structural equation modeling indicated that more severe insomnia symptoms were associated with greater problems with executive function, which, in turn, led to lower engagement in self-management processes and less improvement in pain-related disability. These findings identify 2 mediators by which higher insomnia symptoms may lead to reduced benefit from CBT intervention for chronic pain. Research is needed to understand whether psychological treatments for chronic pain may be optimized by strategies targeting insomnia, executive function, and/or engagement in self-management. This trial was registered at clinicaltrials.gov (NCT04043962). PERSPECTIVE: Our study suggests that executive functioning and self-management processes mediate the relationship between insomnia and treatment outcomes for pediatric chronic pain, highlighting the impact of insomnia on youth learning and implementation of self-management strategies and the critical need for targeted sleep interventions in this population.

Sleep Disorders and Chronic Pain Syndromes in the Pediatric Population

Sleep problems are widespread in children and adolescents suffering from chronic pain disorders. Sleep loss intensifies the experience of pain and is detrimental to the budding self-efficacy of a young individual with limitless horizons. Addressing sleep disorders may prevent the chronification of pain and prevent adverse health outcomes, such as functional impairment, psychiatric comorbidities and overall poor quality of life. This review will explore the cyclical nature between sleep, pain and mood, as well as the functional impact of this relationship on children and adolescents. There will be a discussion about sleep assessment and diagnostic testing, followed by a description of sleep disturbances found in specific pain conditions, ranging from headache, musculoskeletal/abdominal pain, to rheumatologic disorders. Finally, there will be a brief review of pharmacologic and behavioral interventions designed to improve sleep quality, and when possible, to alleviate pain.

Focus Groups to Inform User-Centered Development of an eHealth Sleep Intervention for Adolescents: Perspectives of Youth with Insomnia Symptoms, with and without Pain

INTRODUCTION

Adolescence is a developmental stage that often coincides with increasing sleep problems. Focus groups were conducted to inform development of an adolescent eHealth sleep intervention by exploring opinions about (1) healthy sleep practices, and (2) using an eHealth intervention.

METHODS

Adolescents 14-18 years old experiencing symptoms of insomnia based on the Insomnia Sleep Index, with and without recurrent pain, and associated stakeholders (i.e., parents, school personnel, and health care providers) were recruited. Across six online focus groups, 24 adolescents with insomnia participated (14 pain-free, 10 with recurrent pain; 10 male, 14 female). Across seven online focus groups, 22 stakeholders participated, including 8 parents, 9 school professionals, and 5 health care providers (10 male, 8 female). Using a content analysis, subthemes were induced from transcripts.

RESULTS

Most healthy sleep practices were perceived as reasonable for adolescents to implement, except avoiding technology before bed and using bedrooms only for sleep. Three primary barriers to sleep practices were identified, including a variable schedule due to lifestyle factors, technology at night, and academics interfering with sleep, and only in the pain group, the barrier related to pain was identified. Content addressing adolescent-specific barriers was considered important to include in a sleep intervention. Desirable eHealth components included interactive features, videos, audio, and pictures to present information. A common barrier to using an eHealth sleep intervention was the program feeling too academic, with accessibility of the sleep information and strategies as a common facilitator.

CONCLUSIONS

This research represents the first step in a user-centered approach to developing an adolescent eHealth sleep intervention. These results provide insights from a range of perspectives on guiding adolescents to follow healthy sleep practices. Next, these findings will be integrated in the development of an eHealth intervention for adolescents with and without recurrent pain.

Sleep Symptoms and Disorders in Episodic Migraine: Assessment and Management

PURPOSE OF REVIEW

We review research on sleep symptoms and disorders in patients with episodic migraine and propose a framework for evaluating sleep symptoms in this patient population.

RECENT FINDINGS

Patients with episodic migraine consistently report poorer sleep on validated self-reports compared to those without migraine. In polysomnographic studies, children with migraine have objectively shorter sleep duration and lower percentage of REM sleep interictally. Prospective actigraphy studies in adults and children suggest that there are no significant changes in sleep duration, efficiency, or quality in the night before or after a migraine attack. The relationship between sleep and migraine is multifaceted. Patients with episodic migraine report poorer sleep and have higher risk of some sleep disorders, including insomnia, sleep-related bruxism, and restless legs syndrome. Sleep screening questions may be incorporated into headache evaluations. Care should be taken to avoid headache medications that may exacerbate sleep symptoms. Evidence-based treatments for insomnia may be initiated while patients await CBT-I. Further studies are needed to assess whether treatment of comorbid sleep disorders results in improvement in migraine-related burden in those with episodic migraine.

Sleep disorders in chronic pain and its neurochemical mechanisms: a narrative review

Chronic pain (CP) is a prevalent problem, and more than half of patients with CP have sleep disorders. CP comorbidity with sleep disorders imposes immense suffering and seriously affects the patient's quality of life, which is a challenging issue encountered by clinicians. Although the reciprocal interactions between pain and sleep have been studied to some degree, there is still a lack of awareness and comprehensive description of CP comorbidity with sleep disorders. In this narrative review article, we summarize the current knowledge about the present estimates of the prevalence of comorbid sleep disorders in CP patients, sleep detection methods, sleep characterization in CP, and the effect of sleep disorders on CP and current therapies. We also summarize current knowledge of the neurochemical mechanisms of CP comorbidity with sleep disorders. In conclusion, insufficient attention has been paid to the role of sleep disorders in CP patients, and CP patients should be screened for sleep disorders in the clinic. Special attention should be given to a possible risk of drug-drug interaction when using two types of drugs targeting pain and sleep simultaneously. The current insight into the neurobiological mechanisms underlying CP comorbidity with sleep disorders is still rather limited.

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.

Mediating Role of Treatment Perceptions in the Relationship Between Individual Characteristics and Engagement With a Digital Psychological Intervention for Pediatric Chronic Pain: Secondary Data Analysis

BACKGROUND

Engagement predicts benefits from self-managed treatments. However, engagement is an important concern in digital interventions, with over 50% of patients being nonadherent to interventions in chronic conditions such as chronic pain. Little is known about the individual characteristics that contribute to engagement with a digital self-management treatment.

OBJECTIVE

This study tested the mediating role of treatment perceptions (difficulty and helpfulness) in the association between individual baseline characteristics (treatment expectancies and readiness to change) and treatment engagement (online and offline) with a digital psychological intervention for adolescents with chronic pain.

METHODS

A secondary data analysis of a single-arm trial of Web-based Management of Adolescent Pain, a self-guided internet intervention developed for the management of chronic pain in adolescents, was conducted. Survey data were collected at baseline (T1), midtreatment (ie, 4 weeks after the treatment started; T2), and post treatment (T3). Online engagement was assessed using back-end information on the number of days adolescents accessed the treatment website, while the offline engagement was assessed with the reported frequency of use of skills (ie, pain management strategies) learned at the end of the treatment. Four parallel multiple mediator linear regression models, using ordinary least square regression incorporating the variables were tested.

RESULTS

In total, 85 adolescents with chronic pain (12-17 years old, 77% female) participated. Several mediation models were significant in predicting online engagement. A significant indirect effect was found for the path expectancies-helpfulness-online engagement (effect 0.125; SE 0.098; 95% CI 0.013-0.389) and for the path precontemplation-helpfulness-online engagement (effect -1.027; SE 0.650; 95% CI -2.518 to -0.054). Fourteen percent of the variance of online engagement was explained by the model including expectancies as a predictor (F₃=3.521; P<.05), whereas 15% was explained by the model where readiness to change was the predictor (F₃=3.934; P<.05). Offline engagement was partially explained in the model including readiness to change as the predictor but with marginal significance (F₃=2.719; R²=0.111; P=.05).

CONCLUSIONS

Treatment perception, specifically, perceived helpfulness, was a mediator of the pathway between both treatment expectancies and readiness to change and online engagement with a digital psychological intervention for chronic pain. Assessing these variables at baseline and midtreatment may help to determine the risk of nonadherence. Further work is needed to confirm these mediation pathways in larger samples.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04043962; https://clinicaltrials.gov/ct2/show/NCT04043962.

Insomnia and Migraine: A Review of Evidence-Based, Biobehavioral Interventions

PURPOSE OF REVIEW

The purpose of this review is to discuss the current evidence for Cognitive Behavioral Therapy for Insomnia (CBT-I) for patients with migraine and comorbid insomnia. In this article, we provide a narrative review of the literature on CBT-I and migraine, highlighting recent advances in research into this topic. Finally, we propose a way for clinicians to integrate CBT-I into clinical practice.

RECENT FINDINGS

Multiple studies support CBT-I as a validated modality for the treatment of insomnia in migraine. CBT-I is used to treat insomnia and should be offered as first line therapy. Clinicians should screen for insomnia in all patients with headache, especially in those with migraine, to best manage this condition through the implementation of specific insomnia treatment.

Intervention for Sleep and Pain in Youth (ISPY-RCT): protocol for a two-phase randomized controlled trial of sequenced cognitive-behavioral therapy for insomnia and pain management in adolescents with migraine

BACKGROUND

Migraine is a major pediatric health problem impacting 10-12% of youth. About 1 in 3 youth with migraine are diagnosed with insomnia. Sleep and migraine share a cyclical relationship, and data indicate that insomnia symptoms increase migraine severity. CBT for insomnia (CBT-I) has demonstrated efficacy for improving insomnia in adults with migraine and other pain conditions; however, effects in youth have not been evaluated. Moreover, in adults, there is some indication that CBT-I may lead to changes in pain after there are sustained improvements in sleep, but this has never been empirically tested. Cognitive-behavioral therapy for pain management (CBT-Pain) is an established treatment approach for youth with migraine, leading to reductions in headache frequency and disability. In the proposed study, we will address these gaps in knowledge by using an innovative two-phase trial design to (1) test the efficacy of Internet-delivered CBT-I intervention for youth with migraine and comorbid insomnia compared to Internet-delivered sleep education for modifying sleep and (2) investigate how changes in sleep may modify the response to Internet-delivered CBT-Pain intervention.

METHODS

We will study a cohort of 180 adolescents, ages 11-17 years, with migraine (with or without aura, chronic migraine) and comorbid insomnia. In phase 1, youth will be randomly assigned to receive Internet-delivered CBT-I intervention or Internet sleep education control. In phase 2, all youth will receive Internet-delivered CBT-Pain intervention. Assessments will occur at baseline, immediately after phase 1 intervention, immediately after phase 2 intervention, and 6 months post-intervention. We will use a comprehensive multidimensional assessment of sleep and headache including self-report questionnaires, ambulatory actigraphy monitoring, and 14-day daily diaries.

DISCUSSION

Given the high prevalence of insomnia in adolescents with migraine, an extension of CBT-I intervention to this population will address an important gap in clinical practice and in conceptual understanding of the relationship between sleep and migraine. By testing a separate CBT-I intervention, we will be able to apply this treatment in the future to other pediatric populations (e.g., cancer, arthritis) who commonly experience comorbid insomnia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04936321. Registered on June 23, 2021.

Pain Widespreadedness, and Not Primary Pain Location, is Associated With Comorbid Symptoms in Children With Chronic Pain

OBJECTIVES

Pediatric chronic pain represents heterogeneous diagnoses; often, primary pain location informs research classifications and treatment. In contrast, recent research has highlighted the role of widespread pain and this perspective has been adopted in assessments in specialty pediatric pain clinics. The lack of direct comparison between these 2 methods of categorizing pediatric chronic pain may hinder the adoption of evidence-based practices across the spectrum of care. Therefore, this study aimed to compare whether primary pain location or pain widespreadedness is more informative for pain-related symptoms in pediatric chronic pain.

METHODS

Youth (n=223) between the ages of 8 to 23 years (M=15.93, SD=2.11, 83% female) completed surveys upon intake at the pediatric chronic pain clinic. Free-text entries of primary pain location were coded into categories: headache, abdominal pain, and musculoskeletal pain. Additional domains assessed included widespread pain, pain interference, kinesiophobia, catastrophizing, anxiety, depression, sleep, and fatigue.

RESULTS

Differences based on primary pain location only emerged for kinesiophobia, F(2150)=8.20, P<0.001, with the highest scores among those with musculoskeletal pain. In contrast, controlling for sex, age, and pain intensity, pain widespreadedness was associated with pain interference, pain catastrophizing, fatigue, anxiety, and depression (P<0.05).

DISCUSSION

Pain widespreadedness was more consistently associated with pain-related outcomes among pediatric chronic pain patients than primary pain location, and body maps may be useful in determining a nociplastic pain mechanism to inform treatment. Improved assessment of pediatric pain mechanisms may help advance more precise treatment delivery.

Headache in the Pediatric Population: Focus on Migraine

Pediatric headache is a common condition with significant impact on quality of life and ability to function in academic, social, and extracurricular activities. Most pediatric patients seen in primary care and neurology clinics with headache have primary headache disorders. Diagnosis is largely based on clinical history. Imaging is rarely needed in the absence of red flag features. Careful diagnosis is important to guide appropriate treatment. Treatment focuses on a biopsychosocial model integrating lifestyle, pharmacologic and nonpharmacologic treatment modalities. As few therapies are approved in the pediatric population, treatments are often used off-label based on evidence extrapolated from adult studies. Outcomes vary over time but are generally favorable when headache disorders are diagnosed promptly and managed in a multidisciplinary setting.

Baseline Sleep Disturbances Modify Outcome Trajectories in Adolescents With Chronic Pain Receiving Internet-Delivered Psychological Treatment

Over 50% of adolescents with chronic pain report comorbid sleep disturbances (eg, difficulties with falling asleep), which is associated with increased pain-related disability and poorer quality of life. However, limited longitudinal data are available to understand how sleep disturbance may impact response to psychological treatment. Our primary hypothesis was that baseline sleep disturbances would significantly modify how adolescents responded to an internet-delivered psychological intervention for chronic pain in terms of outcome trajectories. The sample included 85 adolescents, 12 to 17 years, with chronic pain recruited from a multidisciplinary pain clinic and headache clinic who received access to an internet-delivered psychological intervention for chronic pain. Baseline sleep assessment included actigraphy monitoring for 7 days and survey measures. Outcomes were assessed at baseline, 8 weeks, and 3 months including core pain-related outcomes, executive functioning, fatigue, positive and negative affect. Results demonstrated that greater baseline insomnia and poorer sleep quality was associated with worse outcome trajectories for pain-related disability, depression, anxiety, fatigue, negative affect, and executive functioning. Findings extend the limited studies that examine how sleep disturbance may modify effectiveness of psychological treatments for adolescent chronic pain and emphasize the importance of treating comorbid sleep disturbance. This trial was registered at clinicaltrials.gov (NCT04043962). PERSPECTIVE: Our study suggests that sleep deficiency, in particular insomnia and poor sleep quality, may modify the effectiveness of psychological treatments for chronic pain, highlighting the urgent need to screen youth for sleep problems prior to initiating treatment, and to consider implementation of sleep-specific treatments such as cognitive-behavioral therapy for insomnia.

Efficacy of a digital cognitive behavioral therapy for insomnia in people with low back pain: a feasibility randomized co-twin and singleton-controlled trial

Background

Digital cognitive behavioral therapy for insomnia (CBT-i) in people with low back pain (LBP) may be efficacious in improving both sleep and pain; and twin trial designs provide greater precision of treatment effects by accounting for genetic and early environmental factors. We aimed to determine the feasibility of a trial investigating the efficacy of a digital CBT-i program in people with comorbid symptoms of insomnia and LBP, in twins and people from the general community (singletons).

Methods

Thirty-two twins (16 pairs) and 66 singletons with comorbid symptoms of insomnia and LBP (> 6 weeks duration) were randomized to digital CBT-i (intervention) or educational program (control) for 6 weeks. The digital CBT-I, Sleepio (developed by Big Health Inc.), was an online interactive, automated, personalized course comprising of six sessions, once a week. The education program was six emails with general sleep information, once a week. Participants were blinded to their group allocation and offered the alternative intervention at the completion of the study. Feasibility outcomes included recruitment and follow-up rates, data collection and outcome measure completion, contamination (communication about trial interventions), acceptability (adherence), credibility, and participants’ experience of the intervention.

Results

Sixteen out of 722 contacted twin pairs were recruited (recruitment rate = 2.2%). Twins were recruited between September 2015 and August 2018 (35 months) and singletons between October 2017 and Aug 2018 (10 months). Follow-up rates for post-intervention and 3-month follow-up were 81% and 72% for twins and 82% and 78% for singletons respectively. Adherence rates (percentage of sessions completed out of six) for the digital CBT-i were 63% for twins and 55% for singletons. Contamination (speaking about the study to each other) was present in two twin pairs (13%). Written or verbal feedback (n = 21) regarding the digital CBT-i intervention from participants were positive (n = 11), neutral (n = 5), or negative (n = 6).

Conclusions

Online CBT-i was received favorably with people with comorbid symptoms of insomnia and LBP. While the online data collection was successful, strategies need to be implemented to improve adherence, follow-up, control group credibility (for digital CBT-i), and twin recruitment rates (for twin trials).

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12615000672550). Registered 29 June 2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01087-z.

Sleep Health Assessment and Treatment in Children and Adolescents with Chronic Pain: State of the Art and Future Directions

Sleep is interrelated with the experience of chronic pain and represents a modifiable lifestyle factor that may play an important role in the treatment of children and adolescents with chronic pain. This is a topical review of assessment and treatment approaches to promote sleep health in children and adolescents with chronic pain, which summarizes: relevant and recent systematic reviews, meta-analyses, and methodologically sound prospective studies and clinical trials. Recommendations are provided for best practices in the clinical assessment and treatment of sleep health in youth with chronic pain. This overview can also provide researchers with foundational knowledge to build upon the best evidence for future prospective studies, assessment and intervention development, and novel clinical trials.

Longitudinal, bidirectional relationships of insomnia symptoms and musculoskeletal pain across adolescence: the mediating role of mood

ABSTRACT

Previous studies have established a bidirectional relationship between sleep and pain, and mood has been proposed as a mediator of this relationship. There are only a limited number of longitudinal studies examining the mediational role of mood, and the directionality of effects between sleep, pain, and mood is uncertain. In addition, despite the high prevalence of pain and sleep problems during adolescence, these relationships have rarely been examined in a longitudinal sample of adolescents. Here, longitudinal survey data with 5 yearly measurements were used to examine the bidirectional relationship between insomnia symptoms and pain across adolescence (Mbaseline age = 13.65 years, Nbaseline = 2767). We also explored if depressed mood, positive affect, and anxious mood are mediators in both directions of the sleep-pain relationship. Using latent variables for insomnia, pain, and mood at multiple time points, the data were analyzed with cross-lagged panel models for longitudinal data with structural equation modeling. Current results confirmed a bidirectional relationship between insomnia symptoms and pain, where the effect of insomnia symptoms on pain was stronger than vice versa. Depressed mood and anxious mood mediated the effect of insomnia symptoms on pain, but not the reverse effect of pain on insomnia symptoms. Positive affect did not serve as a mediator in either direction. These findings add novel insights into the temporal directionality of sleep, pain, and mood during adolescence, suggesting a temporal path from sleep to pain, through mood, rather than a reciprocal relationship between the constructs.

Headache and Sleep Disturbances in the Pediatric Population

The relationship between sleep disturbances and headaches in the pediatric population is bidirectional. Common underlying molecular mechanisms of sleep and headaches have been speculated to explain the clinical connection. We will summarize various sleep disturbances and their known relationships to headache, focusing on the pediatric population. Careful recognition and assessment of sleep disturbances in patients with headache is critical and may help guide treatment. First line therapies for sleep disturbances consist of behavioral approaches, though surgical and pharmacologic strategies are utilized in particular circumstances.

Psychological Interventions for Parents of Youth With Chronic Pain: A Scoping Review

OBJECTIVE

Parents are integral to their youth's chronic pain experiences, and intervening with parents may improve parent and youth functioning. Existing systematic reviews are not specific to pain or do not systematically report critical aspects to facilitate implementation of parent interventions in diverse settings. Thus, this scoping review aimed to map published parent interventions for pediatric chronic pain to summarize the participant and intervention characteristics, treatment components, methods, outcomes, feasibility, and acceptability, as well as identify gaps for future research.

METHODS

Four databases were searched (PubMed, PsycINFO, CINAHL, and Google Scholar). Studies of any design reporting psychological interventions including parents of youth (0 to 18 y) with chronic pain were included. Data on study characteristics, treatment components, effectiveness, and feasibility/acceptability were extracted.

RESULTS

Fifty-four studies met inclusion criteria from 9312 unique titles. The majority were nonrandomized cognitive-behavioral therapy interventions delivered individually. The degree of parent participation ranged from 17% to 100%; the average enrollment rate was 68%. Reported parent and youth outcomes were variable; 26% of studies did not include any parent-related outcomes.

DISCUSSION

Parent interventions may be a helpful and feasible way to support parents and youth with chronic pain. There is variability across study characteristics, treatment content/aims, parent participation, and parent/youth outcomes.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Sleep Deficiency and Pediatric Chronic Pain

Sleep deficiency in children is a public health concern, and it is highly comorbid in pediatric chronic pain conditions. Children may be particularly vulnerable to the deleterious effects of sleep deficiency, because comorbid sleep deficiency in chronic pain may further exacerbate already existent symptoms of pain, anxiety, depressions, daytime function, and increase health care use. Sleep deficiency is modifiable and integrating human-centered approaches into the development of sleep interventions is a pragmatic approach to partner with parents and children to provide them with the knowledge, motivation, and skills for setting and achieving goals, adapting to setbacks, and problem solving.

A Qualitative Exploration of Sleep Habits and Intervention Needs Among Youth with Cystic Fibrosis

Evidence suggests that individuals with Cystic Fibrosis (CF) experience difficulties with sleep architecture and hygiene, although research is limited. There are currently no behavioral sleep interventions for youth with CF. The current study used qualitative methods to understand sleep needs and concerns among youth with CF, as well as to obtain feedback about potentially useful behavioral sleep intervention strategies. Semi-structured interviews were conducted with youth with CF between the ages of 11-17 and their parents. Themes were extracted from the data and will be used to inform the development of a brief behavioral sleep intervention for youth with CF. Youth and their parents described several CF-specific sleep concerns, often related to respiratory symptoms, and a number of strategies used to manage these concerns. They also described concerns that apply to the general population, including pervasive use of technology around bedtime. Many evidence-based behavioral sleep intervention strategies are acceptable to youth with CF, although modifications are appropriate to reduce time burden and address CF-specific needs. Youth with CF experience a number of disease-specific and more generalized sleep concerns which are likely amenable to behavioral intervention. Results from this study will be used to inform the development of a brief behavioral sleep intervention for youth with CF.

The Role of Sleep in the Transition from Acute to Chronic Musculoskeletal Pain in Youth-A Narrative Review

Musculoskeletal pain is common in the general pediatric population and is a challenge to youth, their parents, and society. The majority of children experiencing musculoskeletal pain will recover; however, a small subgroup of youth develops chronic pain. There is limited understanding of the factors that affect the transition from acute to chronic pain in youth. This review introduces sleep deficiency in the acute to chronic pain transition, exploring the potential mediational or mechanistic role and pathways of sleep in this process, including the interaction with sensory, psychological, and social components of pain and highlighting new avenues for treatment. Biological mechanisms include the increased production of inflammatory mediators and the effect on the hypothalamus-pituitary-adrenal (HPA) axis and on the dopaminergic signaling. Psychological and social components include the effect of sleep on the emotional-affective and behavioral components of pain, the negative impact on daily and social activities and coping strategies and on the reward system, increased pain catastrophizing, fear of pain, pain-related anxiety, hypervigilance, and social isolation. Future longitudinal studies are needed to elucidate these mechanistic pathways of the effect of sleep on the transition from acute to chronic pain, which may lead to the development of new treatment targets to prevent this transition.

The German version of the revised Adolescent Sleep-Wake Scale (rASWS) - A validation study in pediatric pain patients and school children

OBJECTIVE

Sleep problems are common in children and adolescents with chronic pain. The revised Adolescent Sleep-Wake Scale (rASWS) is an internationally well-established instrument to assess sleep quality in adolescents. So far, no German version is available. The study aimed to provide a validated German version of the rASWS, specifically for use in children and adolescents with chronic pain.

METHODS

The translated questionnaire was validated in a sample of N = 159 pediatric outpatients with chronic pain (8-17 years; 65.4% female), who presented to a specialized pediatric pain center. For cross-validation a community sample of N = 1348 school children was analyzed.

RESULTS

Confirmatory factor analysis was conducted to examine the factor structure of the original 10-item 3-factor model in the sample of children and adolescents with chronic pain, which showed poor model fit. Model modifications were carried out by deleting 3 items with low factor loadings stepwise. The overall model fit of the final 3-factor model containing 7 items was excellent. Cronbach's α of the derived scales ranged from 0.74 to 0.86. Cross-validation in a community sample of school children confirmed the superiority of the 7-item model. The convergent validity of the measure was proved by moderate correlations between the rASWS and self-reported sleep problems. Associations with chronic pain characteristics were evident for pain-related disability.

CONCLUSIONS

The use of the 7-item version of the rASWS for German-speaking children and adolescents with and without chronic pain is recommended as a self-report measure of sleep quality.

Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia

Pediatric insomnia is common, impacting up to a third of typically-developing, healthy children, and over 80% of children with neurodevelopmental disorders or chronic medical conditions. Previous reviews of behavioral interventions for pediatric insomnia have had a limited focus on a single age group, a specific population, and/or only randomized controlled trials. Furthermore, few reviews have considered non-sleep outcomes of both children and their parents. This scoping review provides a broader context, including studies regardless of research design or population, along with sleep and non-sleep study outcomes. Clear gaps in the literature were identified, highlighting the need for additional research in different populations, including school-age children and adolescents, racial/ethnic groups around the world, as well as youth with medical or psychiatric disorders. In addition, more research is needed on different features of treatment, including the delivery mode, involvement of all family members, non-sleep outcomes, and long-term follow-up.

Migraine and Sleep in Children: A Bidirectional Relationship

Migraine and sleep disorders in children exhibit a bidirectional relationship. This relationship is based on shared pathophysiology. Migraine involves activation of the trigeminal vascular system. Nociceptive neurons that innervate the dura release various vasoactive peptides. Calcitonin gene-related peptide is the most active of these peptides. Neural pathways that are involved in sleep generation are divided into those responsible for circadian rhythm, wake promotion, non-rapid eye movement, and rapid eye movement sleep activation. Sleep state switches are a critical component of these systems. The cerebral structures, networks, and neurochemical systems that are involved in migraine align closely with those responsible for the regulation of sleep. Neurochemical systems that are involved with both the pathogenesis of migraine and regulation of sleep include adenosine, melatonin, orexin, and calcitonin gene-related peptide. Sleep disorders represent the most common comorbidity with migraine in childhood. The prevalence of parasomnias, obstructive sleep apnea, and sleep-related movement disorders is significantly greater in children migraineurs. Infantile colic is a precursor of childhood migraine. Treatment of comorbid sleep disorders is important for the appropriate management of children with migraine. Sleep-based behavioral interventions can be of substantial benefit. These interventions are particularly important in children due to limited evidence for effective migraine pharmacotherapy.

The Impact of Sleep on Disability and School Functioning: Results From a Tertiary Pediatric Headache Center

Pediatric headache patients often experience significant sleep disturbance, which may be a risk factor for poor physical, academic, and emotional functioning, including increased anxiety/fear. The current retrospective cohort study of a clinical sample of youth with persistent headache aimed to examine the impact of sleep on functional outcomes and to explore pain-related fear as a mediator of the association between sleep problems and functioning. A total of 109 youth (aged 7-17 years) with persistent headache presenting to a tertiary pediatric headache center (and their parents) completed measures of sleep problems, fear of pain, functional disability, and school functioning at the time of an initial evaluation and 6 months later. After controlling for age and headache frequency and severity, linear regression analyses indicated that increased sleep problems at baseline were associated with increased functional disability and poorer school functioning at baseline (β = 0.28, P = .01; β = -0.42, P < .001, respectively). Poor sleep at baseline was associated with poorer school functioning (but not functional disability) at follow-up (β = -0.25, P = .02). Mediation models demonstrated an indirect mediating effect of pain-related fear on the association between baseline sleep problems and follow-up functional disability (β = 0.06, 95% confidence interval 0.01, 0.15) and between baseline sleep problems and follow-up school functioning (β = -0.06, 95% confidence interval -0.13, -0.004). Sleep disturbance in youth with headache may be a risk factor for poor functional outcomes, both concurrently and over time, and may be explained partially through pain-related fear. Given the frequency with which pediatric headache patients experience co-occurring sleep problems, sleep should be thoroughly assessed and considered as a potential early treatment target.

Complementary Parent Components for Pediatric Pain Families: Innovations in Treatment

For families with a child with chronic pain, the home environment is the context in which adaptive or maladaptive illness behaviors are developed. Supporting families to effectively cope with their child’s chronic pain is a critical need. This work analyzes intervention approaches from emerging treatment programs to support families coping with pediatric pain that diverge from traditional treatment models by specifically targeting parents. Two novel parent intervention programs are presented that consider caregiver needs in both outpatient and inpatient pain treatment settings: Parents as Coping Coaches and Putting Parents FIRST. These programs are evaluated through comparing parental training components across different stages of treatment. Additionally, the efficacy of Putting Parents FIRST in promoting maintenance of children’s functional gains achieved in intensive interdisciplinary pain treatment is presented, and compared to previous results of the efficacy of Putting Parents FIRST. Specifically, outcomes of 36 children whose parents received the intervention in Putting Parents FIRST were compared to a matched control sample of children whose parents did not receive the parent intervention. Similar to the findings from Parents as Coping Coaches, results indicated that patients whose parents received the intervention maintained/improved program gains in disability, coping, and pain significantly more than patients whose parents did not receive the intervention. Implications for parent-focused intervention development efforts targeting parent and youth functioning in the context of pediatric chronic pain are considered.

A review of psychological treatments for vomiting associated with paediatric functional gastrointestinal disorders

PURPOSE OF REVIEW

Vomiting can be a primary symptom or associated with various other functional gastrointestinal disorders (FGIDs). The purpose of this review was to discuss the evidence for psychological treatments for vomiting in pediatric FGID.

RECENT FINDINGS

Vomiting of functional origin is an increasingly recognized symptom among children and adolescents. It is highly aversive and associated with disability and poor quality of life. Cognitive behavioral therapy, lifestyle modification (especially sleep), diaphragmatic breathing, and hypnosis can be helpful in preventing vomiting episodes and reducing disability. However, no randomized clinical trials have been performed. An evidence base for psychological treatments in children with vomiting of functional origin is highly needed.

SUMMARY

Increased evidence is demonstrating value and efficacy of incorporating psychogastroenterology practices into ongoing treatment plans for digestive conditions. Current psychological treatments are focused on prevention of vomiting through stress reduction and lifestyle modification, reduction of disability by limiting avoidance behaviours, as well as counteracting biological factors. However, psychological treatments have not been shown to be helpful during an acute vomiting episode. More research is needed to build an evidence base for psychological treatments in vomiting disorders.

The role of sleep deficiency in the trajectory of postconcussive symptoms in adolescents

Objective: To investigate the trajectory of sleep deficiency after concussion and examine its role as a predictor of postconcussive symptoms (PCS) over 3 weeks and at 3 months post-concussion. Design: This was a prospective pilot study of 29 adolescents recruited from a pediatric Emergency Department (69% female, mean age = 14.0 years, SD = 1.8) following a concussion. Methods: Adolescents completed questionnaire assessments at baseline, Weeks 1, 2, and 3 on PCS and sleep patterns. Concurrently, adolescents also completed a daily diary and wore an actigraph continuously to monitor sleep activity. At 3 months post-concussion, adolescents repeated questionnaire measures. Results: At enrollment, 53.6% reported severe PCS, and 12% maintained severe symptoms at 3 months. Over the first 3 weeks, sleep duration and daytime sleepiness gradually declined; however, insomnia symptoms remained unchanged. After accounting for age, sex and time since concussion, greater insomnia symptoms at enrollment were associated with more severe PCS at 3 weeks and 3 months (β = 1.17, p < .001). In contrast, sleep duration, efficiency, and waketime after sleep onset were not predictors. Conclusions: Study findings suggest that insomnia symptoms after concussion may provide a target for early intervention to reduce prolonged severity and duration of PCS.

Psychological Sleep Interventions for Migraine and Tension-Type Headache: A Systematic Review and Meta-Analysis

Disordered sleep, poor sleep quality, and insufficient or excessive sleep duration are known triggers of primary and secondary headaches. Given this, it is plausible that improving sleep will subsequently reduce headache activity. We report a systematic review of the literature, examining studies utilising psychological sleep interventions for the treatment of migraine and tension-type headache. PubMed, EMBASE, CINAHL, PsycINFO, and Cochrane Central were searched, using terms pertaining to psychological sleep interventions and headaches. Meta-analysis was performed for two outcome measures; headache frequency, and headache intensity. 103 studies were retrieved, of which 55 were duplicates. After completing reviews, three studies were retained. An additional eligible study was published after the initial search, and was found via monthly update searches, resulting in a total of four included studies. The effects of psychological sleep interventions (and in one study, combined with drug therapy) significantly reduced headache frequency and headache intensity. Three studies improved various sleep outcomes such as duration, efficiency, and excessive sleepiness. Psychological sleep interventions improve headache frequency and sleep, however there is conflicting evidence for the effect on headache intensity between studies. Limitations include the small number of studies conducted to date. Despite this, the notable improvements in headaches and sleep achieved after psychological sleep interventions indicates further research on this promising topic is warranted.

The Interrelationship between Sleep and Chronic Pain in Adolescents

Over half of youth with chronic pain report sleep deficiency including difficulties falling asleep, maintaining sleep, feeling unrested, and experiencing short sleep duration. Sleep deficiency has been shown to play a causal role in the development or worsening of chronic pain, and is associated with a variety of negative consequences for youth with chronic pain. The purpose of this review is to provide a summary of the literature on the interrelationship of sleep and chronic pain in adolescents. We review the impact and prevalence of sleep disturbances, conceptual models of the interrelationship of sleep and pain, biobehavioral mechanisms and risk factors, sleep assessment, and treatment of sleep deficiency and chronic pain in adolescents. Our recommendations for future research include understanding biobehavioral mechanisms that underlie the link between chronic pain and sleep deficiency to help guide development and testing of treatments for co-occurring pain and sleep disturbance in adolescents.