Voice-over: Welcome to Spotlight on Migraine: The Professional Series, a podcast hosted by the Association of Migraine Disorders. In the professional series, we dive deeper into migraine-related topics with the help of guests from the medical field. The content of these episodes is intended for medical professionals, but may be useful or interesting for patients as well. This episode is brought to you by our generous sponsor, Teva Pharmaceuticals.
Today we are sharing a presentation by Dr. Kaczynski, associate director of psychology for the pediatric headache program at Boston’s Children Hospital. Dr. Kaczynski reviews psychological approaches for assessing and treating pediatric migraine, discusses the role of a clinical psychologist in the process, explains how to identify psychological factors that contribute to migraine and reviews non-pharmacological interventions for migraine.
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Karen Kaczynski: I hope you are all well and staying healthy wherever you are. My name, again, is Karen Kaczynski, and I am a psychologist at the Pediatric Headache Program at Boston Children’s Hospital, where we treat children and adolescents with chronic headaches, including chronic migraine, in which their migraine or headache has impacted their emotional adjustment and/or functioning. So that will be the population that I’ll focus on in this talk. And I will be talking about psychological approaches to pediatric migraine.
So as many of you in the audience, I’m sure, are aware, migraine is an incredibly common disorder that causes significant disability worldwide. It’s the third most common disease after dental cavities and tension-type headaches, and it’s the seventh leading cause of disability worldwide. Migraine often onsets in adolescence around puberty and frequently persists into adulthood, which makes childhood and adolescence an ideal time to intervene to prevent the development of migraines or at least mitigate the course.
The one-year prevalence of migraine in a school-based sample was 23 to 36 percent, making migraine episodes incredibly common, even in school-based kids in the community. And up to 5 percent of youth experience chronic headache, including migraine; and these, again, is the population that we see in the program where I work.
Migraine is more disruptive to functioning than other headache disorders and even more so than other chronic illnesses such as asthma, diabetes, and cancer. And it’s particularly disruptive to school functioning in children and adolescents.
As with other complex chronic illnesses, the biopsychosocial model applies to pediatric migraine. So this involves an interaction between genetic, biological, psychological, and social factors. I will allow other people in this conference to talk about the genetic and biological components of migraine, and I will be focusing on the psychological and social components of migraine.
So in terms of psychological components, I will talk about psychiatric comorbidity, personality characteristics that are commonly seen in children with chronic migraine, and the role of psychosocial stressors in triggering and maintaining migraine.
So in terms of psychiatric comorbidity, there are high rates of comorbid anxiety and depression in children and adolescents with migraine. Comorbid major depression and generalized anxiety increase the risk of the development of migraine later on and increase the severity of migraines if migraines have already developed.
In our population in the pediatric headache program, again, where we see kids with severe chronic migraines that have impacted their functioning in some way, we found that of our cases with migraine, 89 percent met criteria for a comorbid psychiatric diagnosis. Almost half met criteria for an anxiety disorder, about a quarter met criteria for major depression, and almost 40 percent met criteria for psychological factors affecting medical condition. And that suggests that there were some comorbid symptoms of anxiety and depression which likely contributed to the migraine or the migraine-related disability.
Similar to our population, anxiety disorders are the most frequently found comorbid diagnosis in youth with migraine. Why is this important? It’s important because comorbid anxiety and depression may make kids more susceptible to certain triggers for migraine, such as sleep disruption or stress. They may also cause functional difficulties, such as school difficulties, that contribute to the cycle of migraine and associated disability. Lastly, anxiety and depression may impact the treatment course by making patients less willing to participate in and benefit from their treatment. So it’s very important to address comorbid psychopathology in conjunction with treating patients with migraine in order to have the best treatment response.
There are a variety of personality characteristics that are found to be elevated or frequently found in children and adolescents with migraine, and this is certainly consistent with what we see clinically in our population. So our patients tend to be very highly achievement-oriented, be perfectionistic, have very low tolerance for stress, low tolerance for failure of any sort. Oftentimes, our patients will be used to getting straight 100s on all of their exams, and if they get a 96 or a 97, it’s like the end of the world. And they haven’t really developed effective stress-management skills, so sort of minor daily hassles can really push them over the edge and make them really overwhelmed.
Alexithymia has also been found to be common in children with chronic migraine, so that means that these kids often have difficulty identifying and expressing emotions. It could be that their difficulty expressing and coping with stress and emotional distress in adaptive ways makes it more likely that they’ll express that stress in somatic complaints such as migraine. So helping kids kind of identify and recognize and manage their emotional responses in more healthy, adaptive ways can help them in terms of minimizing the impact of those responses on their migraines. These characteristics can also make treatment much more challenging and complicated, so it’s really important to get a sense of the patient’s personality style because it can inform how you work with them and their family.
Psychological stress is really important to consider because stress is one of the most common triggers and maintenance factors for migraine across the board, and children and adolescents with migraine do experience a lot of stress. So they frequently experience school disruption, and it may be that they are struggling with school to begin with, and that school stress, then, contributes to the development or persistence of their migraines. It may also be that migraines make it hard for kids to complete their schoolwork, to pay attention in class, or even to attend school. And so then due to that school disruption caused by the migraine, that causes greater school stress, which then feeds back into the migraine cycle.
One study showed that there were increased ED visits for severe migraine in September and January, and that time frame suggests that stress related to the return to school after a vacation likely played a role in triggering more severe migraines requiring ED visits.
Adverse childhood events in general — so these are more severe stressors such as divorce, loss of a parent, experiencing a natural disaster, being abused, being in a severe car accident, or having a severe illness — all of these stressors early on make it more likely that a child will develop migraines in adolescence. So it may be that early stress really primes the pump or kind of contributes to nervous system activation, which makes kids more vulnerable to developing migraine later in life.
There are also social stressors which play a role in the development and persistence of pediatric migraine, and these are important to evaluate and address as well. So in terms of interpersonal stress, children and adolescents with migraine often experience greater peer difficulties. It may be that peer difficulties such as peer conflict or bullying are stressful and that those experiences trigger migraines. It may also be that migraines result in kids withdrawing from peer activities or having difficulties in interactions with peers, which results in greater peer stress, which then feed back in the migraine cycle as well.
Kids with migraine also experience higher rates of divorce, which suggests that they’re exposed to increased family conflict and family tension and stress prior to the divorce and that all of that stress could contribute to their migraines. Migraine is also linked to severe interpersonal stress such as physical and sexual abuse, suggesting that any stressor the child may experience either prior to the development of the migraine or during the course of the migraines could play a role in migraine and associated disability. So it’s really important to evaluate these stressors and address them in treatment.
In terms of other social stressors, psychologists often think about interpersonal dynamics and interactions and how those factors may contribute to a problem. So in the case of migraines, some research has shown that parents of children with migraine are more protective than parents of children with tension-type headache and that these protective parental responses may result in greater school-related disability. So helping parents recognize that their responses, while reasonable, may be feeding into greater disability and teaching parents ways to kind of support their child with migraine while also encouraging the child to function, can be really helpful.
Maternal controlling behavior has also been linked to increased fear of pain and poorer treatment adherence in children with chronic pain, so the more mothers are kind of authoritarian and controlling with their kids, the more children will be fearful of their pain, which results in more activity avoidance and less willing to participate in multidisciplinary treatment.
The response of teachers is really important, and kids are very sensitive to the way their teachers are responding to them, particularly kids with chronic pain. So the way teachers react when kids are saying that they have a migraine can really impact how the child experiences the relationship with that teacher and the school environment as a whole. Adolescents with migraine are thought by teachers to have high academic competence, but they’re also found to have poorer performance. So teachers may be confused or concerned about the discrepancy between their impressions of the child’s abilities and their performance, and that may lead to sort of a negative perception of the child that feeds into the teacher’s response when the child is reporting a migraine.
Teachers also underestimate the prevalence of migraine, and teachers and school nurses are frequently getting reports from kids that they can’t take a test or they can’t complete an assignment because they had a headache. And so I think teachers and nurses are already kind of biased and don’t really necessarily take a complaint of migraine as seriously as they should or could. And that sort of dismissive or critical response that children are experiencing or perceiving from their teachers could feed into a school stress which exacerbates migraines as well.
Peer relationships and reactions are also really important, and as you may remember or know from your own kids, relationships with peers are really primary, particularly in adolescence. And children with migraine have been found to have fewer friends, to experience more bullying, and to be considered less likable by their peers than kids without migraines. And so that suggests that these kids are already struggling in peer interactions or in relationships. They’re already feeling particularly victimized or ignored or avoided by peers, and that in itself is a really stressful experience in childhood and adolescence, which can feed into migraines. Again, then when kids are having migraines that kind of pulls them out of peer relationships and peer activities, that can only heighten those situations.
So what is the psychologist’s role in all of this? So we frequently work in multidisciplinary clinics like the one where I work, where we collaborate with neurologists, pain physicians, nurse practitioners to provide comprehensive multidisciplinary evaluations and treatments for kids with chronic headache and migraine. We conduct comprehensive evaluations of psychosocial factors that contribute to migraine and functional difficulties, as I’ve discussed: comorbid psychiatric disorders, psychosocial stressors, interactions with important people in the child’s life, personality characteristics. And then we provide evidence-based and individualized interventions to address those issues that we’ve assessed.
And the treatment may include education for the patient and family on how migraine works, how to treat it using multidisciplinary interventions. It may include teaching pain-coping skills such as relaxation strategies to the patient and sometimes to their parent as well. We address comorbid psychiatric issues such as anxiety and depression within the context of an overall cognitive behavioral treatment approach, which I will discuss in detail.
We help kids manage psychosocial stressors by using better coping strategies and working with people in the child’s environment, such as their teachers and guidance counselors to help reduce the impact of stressors on these kids. We also help kids improve their functioning even with migraine, so help them gradually return to activities that are important to them or figure out ways to maintain their participation in activities that they enjoy even if they’re having migraines.
So cognitive behavioral therapy is generally the approach that psychologists use. And many of you have probably heard this term, cognitive behavioral therapy, or CBT, but you may not know exactly what it means. And I thought the best way to explain it would be to provide an example and sort of talk you through how a CBT therapist would intervene with this specific example.
So the overview is that in CBT, we look at an event or a situation and we try to break it down into its component parts. So we always start by looking at the antecedent, so what preceded the event, which may or may not have triggered it. It may just have preceded it in time, but it’s always important to kind of look at what came first or what happened before.
We then look at an event, which may be a migraine. It may be a depressive episode. It may be a conflict with a parent. And we break that event down into thoughts, feelings, and actions. The idea in CBT is that these components of an event can be separated. They are all interrelated, and they all influence each other, certainly. But we want to tease them apart because the way we intervene is by trying to change the cycle of thoughts, feelings, and actions by either changing the actions or changing the thoughts. And by changing one of those components, we hope that we can change the entire cycle.
Lastly, we look at consequences, so what is the outcome, what is the response of others, what happens after the event that may contribute to the event being more likely or less likely to occur again.
So in the example that I want to talk through, the antecedent is a math test. So this is a frequent stressor for children and adolescents. A lot of kids struggle with math and feel really stressed about math. So the reaction or the thought that a child may have in response to having a math test is, “I’m going to fail. I can’t do it. Math is hard. I’m really stressed.” So that thought then leads to a feeling, which is stressed, anxious, worried, overwhelmed, any of those types of feelings. And that stressed feeling may lead to an action, which is to stay up all night studying for a test.
So this combination of negative thoughts, feeling really stressed, and then disrupting sleep by staying up all night to study may trigger a migraine. The consequence of that cycle of events is that the child stays home from school due to the migraine, misses the test, falls behind in school, and then experiences greater school stress, which then is more likely to trigger another stressful cycle that triggers another migraine.
So again, this cycle can develop in which there is increasing pattern of school stress, migraine, school avoidance, which kind of intensifies and increases, and the child can get stuck and have a hard time getting out of the cycle. We often see cases like this in our program, and I imagine many of you have seen this as well, where the child just feels so stuck in a cycle of chronic migraine and school absence and school disability that they just can’t themselves out of it.
So again, we’re looking at the cycle of negative thoughts, “I’m going to fail”; negative emotional responses, stress; and then an action in response, which is studying all night. And again, this cycle of events results in increased stress and sleep disruption, which triggers a migraine.
So how do we address it? Again, in CBT, we want to try to change the child’s behaviors or change their thoughts. So to change their behaviors, one intervention that we might try is to work on activity pacing. So rather than staying up all night to study, in which you’re expending a lot of time and energy but probably not learning the material very efficiently, we may encourage kids to study in shorter periods of time in which they’re much more focused on the material and then take breaks in between, and then to work on discontinuing or stopping studying an hour before bedtime so that they’ve got time to practice some good sleep hygiene, some good relaxation strategies, some good kind of rest, relaxation before getting into bed so that they can get a good night of sleep, because that’s probably going to be more important to their performance on the test than excessive studying. And of course, adequate sleep is really important for migraine management as well.
We would also work on teaching the child relaxation skills. So rather than staying up all night and stressing out about the test, we would encourage them, again, to take breaks from studying to practice strategies such as deep breathing; progressive muscle relaxation, which involves gradually tensing and relaxing various muscle groups; visual imagery or self-hypnosis, which is really focused relaxation that can elicit a very calming, relaxing response; and even biofeedback-assisted relaxation training, which has been found to be particularly helpful for migraine.
So in this case, we use sensors that we attach to the child to evaluate their physiological stress response, such as heart rate, breathing rate, skin conductance, muscle tension. And then we help the kids learn relaxation strategies while they’re witnessing on the computer screen how their body is responding to those relaxation strategies. This can be really helpful for buy-in for psychological- and brain-based strategies for pain coping, and it can really help kids learn how to do these strategies in an effective way when they’re struggling with that skill.
So whereas many kids may respond to migraines with rest and activity avoidance, the benefit of these strategies is that they’re proactive and they build self-confidence and self-efficacy. And these skills are really important for kids with chronic illnesses in which they often feel very little control or efficacy in managing their illness. So that is an additional benefit of these skills.
In terms of thoughts, children with migraine often show elevated pain catastrophizing. So this means that they engage in negative thoughts about their migraine in which they tend to focus on negative outcomes, often the worst-case scenario. Catastrophic thoughts such as this contribute to increased stress, pain, and avoidance of activities, which again feeds that cycle of stress, migraine, and functional disability that we’re trying to avoid.
So psychologists will often identify, challenge, and modify those thoughts with more helpful and realistic thoughts. So in our example, the child’s negative thought is that “I’m going to fail the math test!” And that triggers this whole cycle of sort of stress and excessive studying, which results in a migraine episode. So we’ll challenge that thought and replace it with a thought, “I will study and do my best. One test will not define me.” And most kids can recognize that that thought is more realistic than their initial thought that they’re going to fail.
Another example is that many kids may think, “My migraines will never go away!” And whereas it’s sort of understandable that kids may have that thought, we challenge that by saying, “Nobody can predict the future. Nobody knows how things are going to go in the future, and we really don’t know what’s going to happen. But what we do know is that you’ve survived migraines in the past and you can do it again.” And children are often, again, very receptive to that reframing because they recognize that that is more accurate than their initial negative thought.
So as you can see, we’ve intervened in order to alter the impact of the antecedent, which is the math test, by changing the child’s thoughts to more realistic and positive thoughts, changing their behavior by helping them increase pacing and practice relaxation skills, and then helping them remain calm and under control in preparing for the math test so that they don’t trigger a migraine episode and they’re able to go to school the next day and take the test and conquer the anxiety and stress related to that.
So what does CBT look like in practice? We frequently see patients once a week or once every other week for 50-minutes sessions. Often those sessions are one on one with a psychologist, but some psychologists involve parents in sessions as well, depending on the child’s age and specific needs. For really straightforward pain-coping cases, 8 to 10 sessions may be adequate, but many of our cases are more challenging and complicated than that, particularly in multidisciplinary programs where we’re seeing kids with chronic headaches, so longer treatment may be required.
We have very clearly defined goals such as improving pain coping, addressing comorbid anxiety, increasing school functioning. And we work with patients and families to develop skills that will help them accomplish the goals that they have for themselves. Those skills often need to be practiced in order to be most effective, such as relaxation strategies.
Psychologists often use handouts to teach their concepts and their skills to patients and families. And treatment may be manualized, but often is not, and it’s not standardized. So whereas all CBT therapists are using the same framework and the same kind of assortment of interventions and ways of thinking about problems, we’re not all treating kids in the same ways. We all have our own individual style, background, education, and we also individualize treatment to the needs of each patient that we’re seeing.
Again, parent education is often included so that parents can be informed about their child’s treatment and also provide guidance and support to their child, since a lot of the work happens outside of the therapy sessions, where kids have to practice the skills. And therapists frequently collaborate with other important people in the child’s life, such as guidance counselors, school nurses, and other providers, to make sure that everyone’s on the same page, addressing any of the psychosocial factors that may be contributing to the child’s migraine so that we can get the best outcome.
And there’s really strong evidence for CBT in treating pediatric migraine. So one meta-analysis comparing CBT with wait-list, placebo, and standard medication showed that CBT was nine times more likely to elicit a clinically significant improvement than any of the other groups. So clinically significant improvement means greater than or equal to 50 percent reduction in migraine frequency. So that is a astonishing result and really strong evidence for the benefit of CBT.
Another study looking at CBT plus amitriptyline compared with education plus amitriptyline showed that the CBT group had significantly greater reductions in headache frequency and headache-related disability. So consistently research is showing that CBT can be really helpful in addressing pediatric migraine and associated disability.
So in conclusion, psychological and social factors contribute to pediatric migraine and associated disability in complex ways, and these factors need to be evaluated and addressed in order to optimize treatment. Psychologists can provide in-depth assessment of psychological and psychosocial functioning and individualized cognitive behavioral interventions to help address those issues. Lastly, research strongly supports CBT for pediatric migraine, and the best thing is that there’s no negative side effects. There’s no interactions.
Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.
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*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.