Another large scientific article on the benefits of cognitive behavioral therapy (CBT) was just published in the Journal of the American Medical Association. In this study by doctors at the Cincinnati Children’s Hospital led by Dr. Andrew Hershey, CBT was combined with amitriptyline (an antidepressant used for the treatment of pain and headaches) and compared to headache education plus amitriptyline.

They enrolled 135 children (79% girls) aged 10 to 17 years who were diagnosed with chronic migraine (15 days with headaches per month or more) and who had migraine-related disability. The study was conducted between October 2006 and September 2012. An unusually large number of kids completed the trial – 129 completed 20-week follow-up and 124 completed 12-month follow-up.

The treatment consisted of ten CBT or 10 headache education sessions involving equivalent time and therapists’ attention. Each group received the same dose of amitriptyline per pound of weight.

The main end point was days with headache and the secondary end point was the disability score determined at 20 weeks. Durability was examined over the 12-month follow-up period.

The results at the 20-week end point showed that days with headache were reduced by 11.5 for the CBT plus amitriptyline group vs 6.8 for the headache education plus amitriptyline group. The disability score decreased by 53 points for the CBT group vs 39 points for the headache education group. At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education group;

The authors concluded that among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with use of headache education plus amitriptyline. These findings support the efficacy of CBT in the treatment of chronic migraine in children and adolescents.

The accompanying editorial strongly endorsed the results of the study, which is only the last one of many studies showing the benefits of CBT with or without biofeedback in treating headaches in children and adults. The editorial also pointed out several obstacles to the implementation of these findings. First, many doctors do not refer their patients for CBT because they are not aware of these studies or, more often lack the time and the training to explain the benefits of CBT without implying that the headache is a purely psychological problem, which obviously it is not. Secondly, even if they do refer for CBT, less than half of children and adults actually pursue this treatment.

Most doctors usually just prescribe amitriptyline or an epilepsy drug used for chronic migraines. In my experience with adolescents, Botox provides excellent relief for chronic migraines in children as well as it does in adults, although Botox is approved by the FDA only for adults. Botox has far fewer side effects than medications and I find that it is well accepted and tolerated by kids as young as 10. However, I always start with dietary changes, sleep hygiene, exercise, supplements such as magnesium and CoQ10 and CBT, biofeedback or meditation. These measures alone are often sufficient to provide significant relief and in many children there is no need for medications or Botox.

Mindfulness appears to reduce the effect of pain on day-to-day functioning in adolescents, according to a new study published in The Journal of Pain by Canadian researchers. This was a scientifically rigorous study of 198 boys and girls aged 13 to 18 years. The researchers made an effort to recruit some children who meditated and some who did not. They were all subjected to the Child and Adolescent Mindfulness Measure questionnaire and to the Pain Catastrophizing Scale (questions such as “When I have pain I feel I can’t stand it anymore). They were asked about their daily pains, such as headache, stomachache, tooth pain, muscle pain, back pain. They were also subjected to experimental pain, which was produced by submerging their hand into ice cold water. The results showed that mindfulness had a direct effect on pain interference with daily activity and an indirect effect on the experimental pain intensity and tolerance by producing less catastrophizing.

The good news is that mindfulness is something that can be learned by meditation and can be taught as part of a course of cognitive-behavioral therapy. Kids with migraines, headaches, and other pains should be always advised to start with meditation, biofeedback, or cognitive-behavioral therapy.

The risk of dying from a variety of causes can be reduced by exercise, according to a new study published in the British Medical Journal. The effect of exercise was as strong as the effect of drugs for the prevention of diabetes, coronary heart disease, rehabilitation of stroke, and treatment of heart failure. The authors reviewed 305 previous trials that involved almost 340,000 people, making their findings very reliable.

Exercise has been also proven to prevent migraine headaches (see my previous post). This finding was based on a review of over 46,000 patient records, also a very large number that suggests a true effect. Most people don’t need these studies to convince them of the benefits – they know that exercise improves their headaches and makes them feel better. The most common problem is lack of time and motivation. However, headaches also cost time and reduce productivity, so exercising 30 minutes four days a week will save time.

Doctor recommendations often do influence their patients’ behavior and doctors need to remember to emphasize to their patients the importance of exercise, both for headaches and other conditions.

Vitamin D seems to prevent relapses of multiple sclerosis, according to a large study by Dr. Ascherio and his colleagues at the Harvard School of Public Health. My previous posts mentioned that a high proportion of migraine sufferers have low vitamin D levels and that low vitamin D levels have been associated with Alzheimer’s disease, other dementias, and strokes. This latest study of patients with MS indicates that those with higher levels of vitamin D did better than those with lower, even if the lower level was still within normal range. Studies of vitamin D in other conditions also reported similar findings of progressive benefits with increasing levels. Many laboratories consider a level between 30 and 100 to be normal. However, even in the absence of definitive proof of benefit, it is probably prudent to aim for a level of at least 50. Just taking vitamin D, even at doses of 2,000 to 5,000 units a day does not guarantee a good level because many people do not absorb it well. Ideally, you should have your vitamin D level rechecked after taking vitamin D for a few months.