In kids,cognitive therapy with medicine is better than medicine alone and is possibly better than Botox and other drugs

Half of the kids seen by pediatric headache specialists suffer from chronic migraines. Dr. Hershey and his colleagues at the Cincinnati Children’s Hospital presented results of a study that compared cognitive behavioral treatment combined with amitriptyline (an antidepressant used to treat migraine and other pains) with amitriptyline alone in children aged 10 to 17 who suffered from chronic migraines. This was a first randomized clinical trial in childred with chronic migraines. Combined psychological & pharmacological treatment has been reported to be effective in adults and children with chronic pain other than migraine. Psychological intervention was cognitive behavioral therapy (including biofeedback); pharmacological intervention was amitriptyline (goal dose of 1 mg/kg/day). The control group was taught attention control with equal to psychological intervention in terms of contact frequency and face-to-face time, and involved education and support. They enrolled 135 children with mean age of 14 years; 15% minority; 79% female. Mean baseline headache frequency was 21 days and mean baseline disability score was 68 (severe disability grade). There were no differences between groups at baseline.

For the combined group, a greater than 50% headache frequency reduction was seen in 66% at post-treatment (20 weeks later), 86% at 12-month follow-up. And most impressively, 71% no longer had chronic migraines at the end of treatment and 88% were not chronic at 12-month follow-up. The disability score dropped to below 20 (mild to no disability) in 75% at post-treatment and 88% at 12-month follow-up. These results were significantly better than in the control group of children. The authors concluded that the combined psychological and medication treatment in youth with chronic migraine shows clinically significant reductions in headache frequency and migraine-related disability. At 12-month follow-up, almost 9 out of 10 children no longer had chronic migraines and were mild to no disability grade. They also felt that the results of this study should immediately impact practice of headache medicine in children. However, they could be wrong speculating that based on the published studies in adults, cognitive-behavioral therapy with amitriptyline may be better than other medications and Botox injections. In order to prove this, they need to do a study directly comparing Botox injections with cognitive-behavioral therapy and amitriptyline. One other factor that is not mentioned by the authors is that chronic migraines often subside on their own, which was shown in a study of 122 Taiwanese adolescents.

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