A pilot study of one-session biofeedback training in pediatric headache

Biopsychosocial treatment response among youth with continuous headache: A retrospective, clinic-based study

BACKGROUND

Youth with continuous (always present) headache are vastly understudied; much remains to be understood regarding treatment response in this population.

OBJECTIVE

To describe and explore biopsychosocial factors related to initial clinical outcomes among treatment-seeking youth with continuous headache.

METHODS

This retrospective cohort study extracted data of 782 pediatric patients (i.e., aged <18 years) with continuous headache from a large clinical repository. Youth in this study had experienced continuous headache for ≥1 month before presenting to a multidisciplinary headache specialty clinic appointment. Extracted data from this appointment included patients' headache history, clinical diagnoses, and headache-related disability, as well as information about biopsychosocial factors implicated in headache management and/or maintenance (e.g., healthy lifestyle habits, history of feeling anxious or depressed). Additional data regarding patient headache characteristics, disability, and lifestyle habits were extracted from a subset of 529 youth who returned to clinic 4-16 weeks after their initial follow-up visit. After characterizing initial treatment response, exploratory analyses compared youth with the best and worst treatment outcomes on several potentially influential factors.

RESULTS

Approximately half of youth (280/526; 53.2%) continued to have continuous headache at follow-up, ~20% of youth (51/526) reported a significant (≥50%) reduction in headache frequency. Improvements in average headache severity (e.g., percentage with severe headaches at initial visit: 45.3% [354/771]; percentage with severe headaches at follow-up visit: 29.8% [156/524]) and headache-related disability were also observed (e.g., percentage severe disability at initial visit: 62.9% [490/779]; percentage severe disability at initial follow-up visit: 34.2% [181/529]). Individuals with the worst headache frequency and disability had a longer history of continuous headache (mean difference estimate = 5.76, p = 0.013) and worse initial disability than the best responders (χ2 [3, 264] = 23.49, p < 0.001). They were also more likely to have new daily persistent headache (χ2 [2, 264] = 12.61, p = 0.002), and were more likely to endorse feeling depressed (χ2 [1, 260] = 11.46, p < 0.001).

CONCLUSION

A notable percentage of youth with continuous headache show initial improvements in headache status. Prospective, longitudinal research is needed to rigorously examine factors associated with continuous headache treatment response.

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.

Safety and Tolerability of an Innovative Virtual Reality-Based Deep Breathing Exercise in Concussion Rehabilitation: A Pilot Study

To examine the safety and tolerability of a virtual reality-based deep breathing exercise for children and adolescents who are slow to recover from concussion. Methods: Fifteen participants (ages 11 to 22; mean = 16.9 years) were recruited from a specialty concussion clinic within a tertiary care medical center. Participants completed a 5-min paced deep breathing exercise administered via a virtual reality headset. Results: Nearly all participants (93.3%) reported the experience was either positive or extremely positive. No participants reported significant discomfort or discontinued the exercise. Three participants reported a mild increase in headache, dizziness, or nausea. Participants reported significant decreases in stress (r =.57), tension (r =.73), fatigue (r =.73), and confusion (r =.67), with large effect sizes, following the deep breathing exercise. Conclusion: A brief, virtual reality-based deep breathing exercise is worthy of additional study as a rehabilitation component for children and adolescents with prolonged concussion recoveries.

Biofeedback in pediatric populations: a systematic review and meta-analysis of treatment outcomes

Biofeedback is commonly used for both pediatric and adult patients with a myriad of diagnoses in clinical settings. The majority of previous research has focused on the use of biofeedback in adults, with only a small body of literature examining the usefulness of biofeedback in treating children. The current systematic review and meta-analysis seeks to quantitatively examine the usefulness of biofeedback in addressing pediatric conditions. A systematic review of biofeedback interventions in children was conducted using four databases (Ovid MEDLINE, EMBASE, PsycINFO, and Cochrane CENTRAL). Outcomes included changes in symptoms of associated conditions or changes in physiological functioning. Out of 3,128 identified articles, 23 studies (with 24 effect sizes) were eligible for inclusion in the meta-analysis. Using a random effects model, the overall effect of pediatric biofeedback was statistically significant with a large effect size. Despite the large effect size, general study quality was low, limiting interpretation of findings. Despite widespread clinical use of biofeedback in pediatric populations, research is still limited concerning the efficacy of biofeedback in children. While findings suggest potential positive effects of biofeedback to address pediatric conditions, high-quality studies are necessary to fully support the use of biofeedback in children.

Self‐administered biofeedback treatment app for pediatric migraine: A randomized pilot study

Objective

To investigate the effect size, safety, and tolerability of a therapist‐independent biofeedback treatment app among adolescent with migraine.

Materials and Methods

This was a prospective, 3:1 ratio randomized, sham‐controlled, double‐blind, pilot study with 16 adolescents diagnosed with migraine randomized to eight weeks of biofeedback treatment (n = 12) or sham biofeedback (n = 4), carried out at two university hospitals in Norway. The prespecified and primary objective of the study was to observe changes in outcomes within the active treatment group. The sham control group was included in a minor ratio primarily to evaluate its feasibility. The primary outcome was change in headache frequency. A modified intention to treat analysis was performed, including participants completing at least seven biofeedback sessions in weeks 1–4 (n = 12 vs. n = 4) and weeks 5–8 (n = 7 vs. n = 2).

Results

Adherence was poor with 40% (136/336) of planned biofeedback sessions completed during weeks 5–8. Within the biofeedback group, a not statistically significant reduction in headache frequency was observed at weeks 1–4 (2.92 days/month, 95% CI −1.00 to 6.84, p = .145) and weeks 5–8 (1.85 days/month, 95% CI −2.01 to 5.72, p = .395). The biofeedback group experienced a median of one fewer headache days/month versus sham that did not reach significance (95% CI −4.0 to 9.0, p = .760).

Conclusions

We observed a small reduction in headache frequency in the active treatment group. Findings were likely undermined by low adherence and underpowered analyses but indicate that a therapist‐independent biofeedback treatment app has the potential to be an effective, tolerable, and inexpensive treatment option.

When to Consider Prophylactic Antimigraine Therapy in Children with Migraine

PURPOSE OF REVIEW

Headache is not an uncommon complaint in children, and recognition of migraine is increasing in children and adolescents. Treatment options consist of abortive and preventive medications; however, when to start the preventive treatment is not clear in the pediatric population. This article reviews current guidelines and practices to provide a better clinical approach in the management of migraines in children and adolescents.

RECENT FINDINGS

Currently, the only FDA-approved medical treatment option for preventive therapy in chronic migraine in adolescents is topiramate. However, the Childhood and Adolescent Migraine Prevention Study (CHAMP) did not endorse superiority of topiramate or amitriptyline over placebo. At this time, there is no clear consensus on when to start preventive therapy in children and adolescents with migraines. The decision is multifactorial and should be initiated after a thorough discussion with the patient and caregiver(s) about related risks and benefits of treatment. Education regarding various modalities of treatment and ensuring compliance is essential to treatment success.

Cognitive-Behavioral Therapy: How Medical Providers Can Increase Patient and Family Openness and Access to Evidence-Based Multimodal Therapy for Pediatric Migraine

Although evidence supports the recommendation for cognitive-behavioral therapy (CBT) for pediatric migraine, few children actually receive this evidence-based intervention. In this article, we briefly review the most recent empirical evidence supporting CBT. We then identify both provider- and system-related barriers as well as patient-related barriers. Finally, we provide practical solutions to addressing these barriers in the service of facilitating children receiving optimal comprehensive management of their headaches.

Prophylaxis of migraine in children and adolescents

While it has been established that headaches in the pediatric age group are relatively common, the characterization of headache disorders and their treatment in this group has historically been limited. Due to the paucity of controlled studies on prophylaxis of the primary headache disorders in children, the diagnosis of migraine often rests on criteria similar to those used in adults. Data from adult studies are often extrapolated and applied to the pediatric patient. Although it appears that many prophylactic agents are safe, well tolerated and efficacious in children, currently only topiramate is FDA-approved for use in patients 12 years and over. As a result, despite often experiencing significant disability, many children who present to their physician with migraines do not receive preventive therapy. One-third of adolescents meet the criteria for warranting prophylactic therapy, yet few are offered a preventative medication. Moreover, controlled clinical trials investigating the use of both abortive and prophylactic medications in children have suffered from high placebo response rates. A diverse group of medications are used to prevent migraine attacks, including antidepressants, antiepileptics, antihistamines and antihypertensive agents, yet there still remains a serious lack of controlled studies on the pharmacological treatment of pediatric migraine.

Use of Complementary and Alternative Medical Therapies in a Pediatric Neurology Clinic

Background:

Complementary and alternative medicine (CAM) is increasingly used in adults and children. Studies on CAM in neurological disorders have focused on the adult population and its use among pediatric neurology patients has not been well characterized.

Objectives:

The purpose of this study was: 1) To characterize the prevalence of CAM in pediatric neurology patients; 2) To determine the perceived effectiveness of CAM in these children; 3) To compare the cost of CAM with conventional therapies; and 4) To describe caregiver or patient-related variables associated with the use of CAM.

Methods:

This was a cross-sectional survey of patients and families attending the Alberta Children's Hospital neurology clinic between February and May 2004. Patients were considered eligible if they were between two and 18 years of age and had a known history of neurological disorders. Caregivers completed several self-administered questionnaires regarding their socio-demographic profile, their child's neurological illness, and their experience with CAM. Caregivers also rated their child's quality of life using the Pediatric Quality of Life Inventory.

Results:

One hundred and five of 228 (46%) families completed the survey. The mean age of the neurology patients was 9.8 ± 4.5 years. Forty-six (44%) out of 105 patients received one or more types of CAM, with the most common types being chiropractic manipulations (15%), dietary therapy (12%), herbal remedies (8%), homeopathy (8%), and prayer/faith healing (8%). Caregivers' sociodemographic variables or pediatric health-related quality of life were not significantly associated with the use of CAM. Fifty-nine percent of CAM users reported benefits, and only one patient experienced side effects. There was no significant difference in the total median cost of CAM compared to conventional therapies ($31.70 vs. $50.00 per month). Caregivers' personal experience or success stories from friends and media were common reasons for trying CAM.

Conclusions:

The use of CAM was common among pediatric neurology patients. Over half of the families reported benefits with CAM, and side effects were perceived to be few. Physicians should initiate discussion on CAM during clinic visits so that the families and patients can make informed decisions about using CAM. Further studies should address the specific role of CAM in children with neurological disorders, and to determine the potential interactions between CAM and conventional therapies in these patients.

Single-session biofeedback-assisted relaxation training in children with sickle cell disease

Sickle cell disease (SCD) pain remains difficult to manage. This pilot study evaluated single-session biofeedback-assisted relaxation training (BART) for SCD pain in children. Ten participants (mean = 12.1 y) completed a 1-hour BART session using thermal biofeedback and home practice. Participants demonstrated changes in peripheral body temperature after the training session (d = 1.08) and at 6-week follow-up (d = 0.97) relative to their baseline visit. Reductions in patient-reported pain frequency were found after completing BART. Health-related quality of life and pain-related disability improvements were observed; however, effect sizes were small to minimal. Single-session BART may be a promising, complementary approach to medical management of pediatric SCD pain.

Psychological interventions for headache in children and adolescents

Headache in children and adolescents represents a number of complex and multifaceted pain syndromes that can benefit from psychological intervention. There is good evidence for the efficacy of cognitive behavioral therapy, relaxation training, and biofeedback. The choice of intervention is influenced by patients' age, sex, family and cultural background, as well as the nature of stressors and comorbid psychiatric symptoms. Management must always be family-centered. Psychological treatments are essential elements of the multidisciplinary, biopsychosocial management of primary headache disorders, particularly for those with frequent or chronic headache, a high level of headache-related disability, medication overuse, or comorbid psychiatric symptoms. Future studies of efficacy and effectiveness of psychological treatment should use the International Headache Society's definition and classification of headache disorders, and stratify results by headache type, associated conditions, and treatment modality.

Pediatric migraine

Migraine is the most common cause of acute recurrent headaches in children. The pathophysiological concepts have evolved from a purely vascular etiology to a neuroinflammatory process. Clinical evaluation is the mainstay of diagnosis and should also include family history. Investigations help to rule out secondary causes. The role of new drugs in treatment of migraine is discussed and trials are quoted from literature. Indications for starting prophylaxis should be evaluated based on frequency of attacks and influence on quality of life. For management of acute attacks of migraine both acetaminophen and ibuprofen are recommended for use in children. Many drugs like antiepileptic drugs (AED), calcium channel blockers, and antidepressants have been used for prophylaxis of migraine in children. The data for use of newer drugs for migraine in children is limited, though AEDs are emerging a popular choice. Biofeedback and other nonmedicinal therapies are being used with promising results.

The effectiveness of non-pharmacological pain management in relieving chronic pain for children and adolescents

BACKGROUND

There is accumulating evidence that recurring pain symptoms in children are becoming a serious health concern. Children and adolescents who suffer from ongoing pain have negative outcomes not only to their physical health, but also to their emotional and spiritual health. Furthermore, recurrent pain in children may also cause a number of other negative consequences to the child, the family and society. Thus, a non-pharmacological approach to reduce the pain is vital to help children having better quality of life.

OBJECTIVES

The objective of this review is to determine the best available evidence on the effectiveness of non-pharmacological pain management in relieving chronic pain for children and adolescents.

SEARCH STRATEGY

The search strategy aimed to find published studies, between 1956 and 2008 and limited to the English or Chinese languages. Reference lists of studies that met the inclusion criteria were searched for additional studies.

TYPES OF STUDIES

This review included any systematic reviews, randomized controlled trials and quasi-experimental design that explored the effectiveness of non-pharmacological intervention for chronic pain in children and adolescents.

TYPES OF PARTICIPANTS

Children and adolescents with cancer pain, Juvenile chronic arthritis, sickle cell disease, burn pain, chronic or recurrent abdominal pain, headache and aged 18 years old or less and suffering with pain for at least one month.

TYPES OF INTERVENTIONS

The review considered studies that examined non-pharmacological interventions in relieving chronic pain for children and adolescents that included heat wrap therapy, massage, chiropractic spinal manipulative therapy, cognitive-behavioral therapy (distraction & guided imagery), meditation, progressive muscle relaxation, self-hypnosis, biofeedback, music therapy, and dance training.

TYPES OF OUTCOME MEASURES

The primary outcome measures included: (1) Behavioral variables, such as pain behavior, cognitive coping and appraisal, psychiatric reaction (anxiety and depression), and social activities, (2) Quality of life scores and (3) Pain scores.

TYPES OF SETTING

The review focuses on studies that operated either at a hospital or in a community setting.

DATA COLLECTION AND ANALYSIS

Meta-analysis was used to pool the data from studies to determine the effectiveness of the intervention. The Comprehensive Meta Analysis V2 was used to manage the data.

RESULTS

The search process identified 43,100 studies that addressed the objectives of the review protocol. Fifty-four articles were selected for critical appraisal. Finally, 31 trials were considered to be eligible for the present review and 5 articles were excluded. Data was pooled together from eight articles using meta-analysis to examine the effectiveness of relaxation training of the pre-test and post-test of headache intensity. The findings show that the effective size was 0.323 with significant difference. Two of the articles evaluate the effectiveness of relaxation training for releasing the recurrent headaches for adolescents and the post-test data were collected over the following six months. The findings show that there is a statistically significance difference. Another two articles examined the effectiveness of a relaxation training program in reducing the sum of medication used of adolescents with recurrent headaches. The findings show that there is no statistical significance. Furthermore, the findings show that biofeedback treatment could improve the outcome of children and adolescents' headache, especially at 6 and 12 months after the treatment. In terms of psychosocial treatment, five articles examined the effectiveness of behavioral treatment, relaxation training program, cognitive behavior therapy, and acupuncture/ hypnosis intervention to reduce anxiety of children and adolescent with chronic pain. The various outcomes measures among the five studies.

CONCLUSIONS

This review has provided an evidence-based guide to future priorities for clinical practice. Relaxation programs could reduce recurrent headache and pain intensity in children and adolescents in the short term as well as lasting for three and six months. Furthermore, biofeedback treatment could reduce recurrent headache of pain intensity in children and adolescents in the short term and last for as long as six months.

Chronic daily headaches in children

Chronic daily headache (CDH) is increasingly recognized as a problem in pediatrics and tertiary pediatric headache care. It is estimated that up to 4% of the adult population has CDH. Many of these are chronic migraine (CM). The fraction of the pediatric population with CDH appears to be lower, although the prevalence has not been adequately determined. The simplest definition of CDH is more than 15 headache days per month. In the International Classification of Headache Disorders, Second Edition (ICHD-II), several types of CDH have been identified. These criteria have been contrasted with the Silberstein-Lipton criteria, with revisions suggested. The diagnosis of CDH is further complicated and may be initiated by the overuse of analgesic medications (medication overuse headache) and requires the resolution of this issue before a final diagnosis can be established. In children, most CDH appears to have migraine features, although it may not completely meet the ICHD-II criteria for migraine or CM. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the secondary headaches or headaches directly attributed to a secondary cause. Treatment and management involve a multidisciplinary approach, including acute therapy for when the headache severity increases (while avoiding medication overuse), preventative therapy to reduce the frequency and impact of the CDH, and biobehavioral therapy to assist with long-term outcome.

Behavioral assessment and treatment of pediatric headache

Headaches are quite common in children and adolescents, and they appear to persist into adulthood in a sizable number of individuals. Assessment approaches (interview, pain diaries, and general and specific questionnaires) and behavioral treatment interventions (contingency management, relaxation, biofeedback, and cognitive behavior therapy) are reviewed, as is the evidence base for their use. The article concludes with practical suggestions for headache management.

Outcome of a Multidisciplinary Approach to Pediatric Migraine at 1, 2, and 5 years

OBJECTIVE

To assess the long-term effectiveness and outcome of multidisciplinary treatment of childhood headaches 1, 2, and 5 years after initial treatment.

BACKGROUND

Headaches are a common problem for children and adolescents and for many patients continue into adulthood. Outcome research for pediatric migraine headaches is limited, thus restricting knowledge of the effectiveness of long-term management and outcome.

METHODS

Headache characteristics were assessed at the initial visit and were reevaluated 1, 2, and 5 years later in independent sub-groups of consecutive patients. These characteristics included headache frequency, severity, average duration, school absences, and overall perceived response to treatment.

RESULTS

At 1 year, 96 patients were evaluated (mean age = 11.0 +/- 3.4, 59% females), 69 patients at 2 years (mean age = 10.6 +/- 3.4, 48% females), and 32 at 5 years (mean age = 10.5 +/- 3.9, 66% females). The headaches were reported as better in 94% at 1 year, 85% at 2 years, and 94% at 5 years. The initial frequency was at 13.4 +/- 10.8 headaches per month, 4.9 +/- 7.0 at 1 year (P < .001), 4.7 +/- 7.6 at 2 years (P < .001), and 4.5 +/- 7.5 at 5 years (P < .001). The severity decreased from 6.8 +/- 1.8 to 5.1 +/- 2.3 at 1 year (P < .001), to 5.0 +/- 2.4 at 2 years (P < .001), and to 4.6 +/- 2.5 at 5 years (P < .01). The school days missed per month showed a marked decrease from 4.5 +/- 9.5 at initial visit to 1.55 +/- 2.8 at 5 years (P < .001). Patients that were only seen at their initial visit and did not choose to return for follow-up had less frequent and shorter duration headaches on initial visit when compared with the rest of the sample and continued to be doing well at the 1-, 2-, and 5-year assessments.

CONCLUSIONS

Multidisciplinary treatment was found to be effective for children and adolescents with improvement of multiple outcome variants of pediatric migraine care, including frequency, severity, and school days missed. Patients who did not return to follow-up evaluation were more likely to have less frequent and shorter duration headaches at initial presentation. Regular follow-up care is needed for those children with more severe initial headache presentation.

Methodological considerations in research with special populations: children and adolescents

Headache occurs across the lifespan, but limited attention has been devoted to children and adolescents. This article discusses pertinent methodological considerations when conducting behavioral research with pediatric populations. Issues needing special consideration when working with children and adolescents involve ethics, sample characterization, headache diagnosis, treatment administration, and outcome measurement. Available literature is reviewed and specific recommendations are offered when possible.

Biobehavioral treatment, disability, and psychological effects of pediatric headache

Headache is a common condition among children and adolescents, and it can result in considerable pain, distress, and functional disability. Lacking proper care, many children will continue to experience headaches into adulthood. These considerations point to the importance of prompt, effective, and early intervention for pediatric headache. Biobehavioral treatments are central to such intervention. From promotion of adherence to optimal use of abortive and prophylactic medications to health behaviors that reduce headache activity to biofeedback-assisted relaxation training, the addition of biobehavioral treatment components to a comprehensive pediatric headache care plan can lead to better initial clinical outcomes, may lessen the need for medication, and may help maintain effects over the long term. Attention to the effects of headache and the accompanying psychological distress is an equally important part of treatment. Indeed, outcomes should be measured in terms of pain parameters (headache frequency, duration, severity) and effect on functional disability and quality of life (school absences, mood, satisfaction with pain relief). Optimal care for children and adolescents with headache can be realized with collaboration among primary care practitioners and headache specialists such as child neurologists and pediatric behavioral medicine experts. Biobehavioral treatment is a foundation for provision of such care.

Pain management in children: developmental considerations and mind-body therapies

One of the most challenging roles of medical providers serving children is to appropriately assess and treat their pain. Pain is one of the most misunderstood, underdiagnosed, and undertreated/ untreated medical problems, particularly in children. New JCAHO regulations regard pain as "the fifth vital sign" and require caregivers to regularly assess and address pain. This review focuses on the clinical assessment of pain, based on a developmental model and addresses common beliefs and myths that affect the management of pain in children. We provide a review of the pain literature that focuses on the integration of mind-body therapies into the management of procedure-related pain, headache, and recurrent abdominal pain in children.

Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses

OBJECTIVE

Despite the high prevalence of headaches in youths, quality of life (QOL) has not been well examined. We examined QOL in a clinical sample of children with headaches and compared it with children with other chronic diseases.

METHODS

A survey study was conducted of 572 consecutive patients (mean age, 11.4 +/- 3.6 years) who presented with headaches to a children's headache center. Children and parents completed the Pediatric Quality of Life Inventory, Version 4.0 and a standardized headache assessment. Results were compared with established norms for healthy and chronically ill children.

RESULTS

Most patients (99%) had a clinical diagnosis of migraine: 85% met the International Headache Society migraine criteria, and 40% had chronic daily headaches. Total Pediatric Quality of Life Inventory, Version 4.0 score was lower for the entire group (73.1 +/- 14.4) compared with healthy norms (83.0 +/- 14.8) and lowest for children with chronic daily headaches (70.5 +/- 15.5). The impact on QOL of children with migraine was similar to that of children with arthritis and cancer.

CONCLUSIONS

QOL of children with headaches is significantly affected by their health condition. The impact of headaches on QOL is similar to that found for other chronic illness conditions, with impairments in school and emotional functioning being the most prominent.

Carnitine palmityltransferase II (CPT2) deficiency and migraine headache: two case reports

BACKGROUND

Migraine headache is common and has multiple etiologies. A number of mitochondrial anomalies have been described for migraine, and mitochondrial dysfunction has been implicated as one potential pathophysiological mechanism. Carnitine is used by mitochondria for fatty acid transportation; its deficiency, however, has not been implicated in migraine pathophysiology.

METHODS AND RESULTS

Two adolescent girls presented to the Headache Center at Cincinnati Children's Hospital Medical Center with frequent headaches and were diagnosed with migraine by the International Headache Society (IHS) criteria. Both girls had a history of recurrent fatigue, muscle cramps, and multiple side effects from their prophylactic treatment. Carnitine levels were measured and found to be low. Carnitine supplementation was initiated. Both patients had a reduction in headache frequency, as well as an improvement in their associated symptoms and other complaints. A skin and muscle biopsy obtained from one patient revealed a partial carnitine palmityltransferase II deficiency in the muscle only.

CONCLUSIONS

Carnitine palmityltransferase II deficiency may represent another etiology for migraine headache, and may be useful in further defining the pathophysiology of migraine. When properly recognized, supplementation with carnitine may improve the outcome of the migraine as well as the carnitine-associated symptoms.

Behavioral treatment of migraine in children and adolescents

Behavioral interventions, particularly biofeedback and relaxation therapy, have demonstrated their effectiveness in the treatment of both adults and older children with migraine in controlled trials. The physiological basis for their effectiveness is unclear, but data from one trial suggest that levels of plasma beta-endorphin can be altered by relaxation and biofeedback therapies. The data supporting the effectiveness of behavioral therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. This is due in part to methodological issues, especially the lack of a specific test for migraine, which has hampered research and helped lead to an inappropriate de-emphasis on care for childhood headache. In addition, migraine headaches in children are often briefer and have a higher rate of spontaneous remission than those experienced by adults, making it difficult to separate effective from ineffective treatments. While it is widely believed that stress is a major factor in childhood migraine, well-designed studies have had difficulty developing data to support this viewpoint. Many clinicians utilize 'confident reassurance', reassuring the family that the child is not seriously ill, in the belief that having migraine headaches can be stressful. They also modify behaviors that are believed to trigger migraine headaches, such as poor sleep habits or irregular meal times. Relaxation therapies use techniques such as progressive relaxation, self-hypnosis, and guided imagery. Several studies have found relaxation therapies to be as effective, or more effective, in reducing the frequency of migraine headaches than modest doses of a beta-blockade medication, although one study found relaxation therapy to be no more effective than a control program. Several studies have demonstrated that these therapies can be taught to children in a low cost but effective manner. Biofeedback therapies commonly use an apparatus to demonstrate a physiological effect. Most commonly in pediatrics, children are taught to raise the temperature of one of their fingers. This can be done with or without a thermometer. Several groups have shown that these techniques can be taught to children and that their use is associated with fewer and briefer migraine headaches. People who experience migraines can also experience episodic headaches throughout life. An important consideration is preparing children to deal with future headaches, allowing them to feel in control of their health. Behavioral therapies have the potential to do this, giving the child access to a technique that can be easily resumed without a medical visit or prescription.