Behavioral Management of Chronic Daily Headache
Todd A. Smitherman, PhD, FAHSUniversity of Mississippi
Scott W. Powers, PhD, ABPP, FAHSUniversity of Cincinnati College of Medicine
Cincinnati Children’s Hospital
Learning Objectives
• By the end of this course attendees will be able to…
• Summarize recent advances in behavioral treatments for CDH. • Select evidence‐based interventions for patients with CM, CM with comorbid insomnia, or MOH.
• Implement (or refer for) cost‐efficient behavioral management strategies in conjunction with pharmacotherapy.
Behavioral Treatment of CDH in Adults:Novel Applications
Todd A. Smitherman, PhD
Associate Professor of PsychologyDirector, Center for Behavioral Medicine
University of Mississippi, Oxford MS
None relevant for commercial interests
Funding:Migraine Research Foundation University of Mississippi
Disclosures for Dr. Smitherman
Novel applications: Adapted delivery formats Treating comorbidities to reduce headache Interventions targeting disability (vs
headache reduction)
Behavioral Treatment of CDH in Adults
Cost-effective vs even inexpensive preventive medications
Adapted Delivery Formats
Schafer et al., 2011
38% of migraineurs sleep <6 hours/night vs 10% of general population
Take twice as long to fall asleep
Majority of headache clinic patients have insomnia 68-84% of patients with CM have insomnia Often on a daily basis
Insomnia as an Exemplar Comorbidity
Calhoun et al., 2006; Kelman & Rains, 2005Maizels & Burchette, 2004; Sancisi et al., 2010
American College of Physicians’ Guideline
“ACP recommends that all adult patients receive CBT for insomnia (CBT-I) as the initial treatment for
chronic insomnia”
Qaseem et al, 2016
Treating Comorbid Insomnia Improves CM
Smitherman et al. (2016), follow-up to Calhoun (2007) 31 adults with CM and insomnia ( M = 21 days/month) 3-session CBTi vs sham Daily headache diaries plus actigraphy MOH excluded (vs overused meds discontinued)
Treating Comorbid Insomnia Improves CMI At follow-up odds of headache were 60% less for BT group 48.9% frequency reduction from baseline vs 25% for control
PSQI changes: r = .54 (p =.002) w/ HA probability and r = .46 (p = .018) with HIT-6 changes
Smitherman et al., 2016
Case-Based Application: Assessment Diagnostic Criteria:
Insufficient sleep despite opportunity: <6 hours/night or ≥30 mins to fall/stay asleep
Daytime impairment
REST mnemonic Restorative nature of sleep Excessive daytime sleepiness or fatigue Presence of habitual Snoring Total sleep time
PSQIAmerican Academy of Sleep Medicine; Rains & Poceta, 2006
Case-Based Application: Self-Monitoring
Case-Based Application: Management Stimulus control: Help patient re-associate bed with sleep
Eliminate naps (except those required for migraine relief)
Get out of bed if you can’t sleep within 20-30 mins Use bed only for sleep Keep consistent bedtime and wake time
Case-Based Application: Management Sleep restriction:
Limit time in bed to time spent sleeping
Use daily sleep diaries: calculate average total sleep time and time in bed Sleep efficiency: Total sleep time / Time in bed
Prescribe new bed schedule = avg sleep time + 30 min Increase 20-30min as sleep efficiency reaches 85%
Cautions: Do not restrict anyone to< 5 hours Do not use with bipolar patients (PMR instead)
One’s responses to pain are as important as pain itself
Focus on building “psychological flexibility”: Acceptance, valued action
Target disability more than pain
Acceptance and Commitment Therapy For CDH
145 total RCTs across various conditions Grade A evidence for chronic pain Promising results from 2 headache trials
CTTH/CM: Mo’tamedi et al., 2012 Migraine w/ MDD: Dindo et al., 2012, 2014) Case-based application: post-traumatic headache
Psychological flexibility accounts for 20% of variance in MIDAS scores after controlling for gender and headache severity
ACT Efficacy and Processes
Foote et al., 2016; McCracken & Vowles, 2014; Veehof et al., 2011
Acknowledgments
Migraine Research Foundation
Drs. Brooke Walters, Carrie Ambrose, Rachel Davis
Drs. Jeanetta Rains, Tim Houle, Don Penzien
Dr. Malcolm Roland
QUESTIONS? [email protected]
CCRF Endowed ChairProfessor of Pediatrics and Psychology, University of Cincinnati College of MedicineDirector of Clinical and Translational Research, Cincinnati Children’s Research Foundation
Co-Director, Headache Center, Cincinnati Children’s HospitalDivision of Behavioral Medicine and Clinical Psychology
Funding: NIH:NINDS/NICHD Grants: R01NS050536; U01NS076788; U01NS077108;Migraine Research Foundation; Society of Developmental and Behavioral Pediatrics;Cincinnati Children’s Research Foundation
Disclosures for Dr. PowersFunding:
• NIH:NINDS/NICHD Grants: R01NS050536; U01NS076788; U01NS077108;
• Migraine Research Foundation; • Society of Developmental and Behavioral Pediatrics;• Cincinnati Children’s Research Foundation
• Headache Management Principles
• Biofeedback‐Assisted Relaxation Training
• Activity Pacing
• Recognizing Negative Thoughts and Using Calming Statements
• Problem‐Solving Skills
• Parent Coaching & Reinforcement of Coping
• Medical & Psychosocial Assessment and Diagnosis
• Headache Diary (28 days)
• Randomization
• Treatment Phase (Total of 20 weeks)
• Weekly for 8 weeks• Monthly for 3 months
• Follow‐Up Phase (Total of 12 months)
• Every 3 months
(N=64) (N=71)
Age: 14.4 ± 1.9 14.4 ± 2.1
Gender: 79.7% female 79% female
HA Days: 21.4 ± 5.4 21.2 ± 5.1
Disability 67.3 ± 29.8 69.2 ± 33.8(PedMIDAS): (Severe Grade) (Severe Grade)
• Avg. Tolerated Dose of Amitriptyline = 1.01 ± 0.02 mg/kg/day
• No Serious Adverse Events (Related & Unexpected)
• Total # of Adverse Events = 199 (Context: Total of 2,160 visits)
• Treatment Credibility and Integrity (Both arms had high levels of credibility to participants and parents; CBT & ATT delivered by same therapists who adhered to Tx manuals demonstrating measured integrity – AHS Behavioral Trial Guidelines)
≥ 50% Reduction in Headache Days
At 20 weeks:
ATT+A = 36% of participants
(PedMIDAS < 20)
At 20 weeks:
ATT+A = 56% of participants
At 12 month F/Up for CBT+A Participants:
What are the recent findings from the Cognitive Behavioral Therapy + Amitriptyline Trial?
Trajectory of Improvement in Children and Adolescents with Chronic Migraine: Results from the Cognitive Behavioral Therapy and Amitriptyline TrialJohn W. Kroner, MS1; James Peugh, PhD1,4; Susmita M. Kashikar‐Zuck, PhD1,4; Susan L. LeCates, MSN2,3;
Janelle R. Allen, MS1,3; Shalonda K. Slater, PhD1,3,4; Marium Zafar, PsyD1; Marielle A. Kabbouche, MD, FAHS2,3,4; Hope L. O’Brien, MD, FAHS2,3,4; Chad E. Shenk, PhD1,4; Ashley M. Kroon Van Diest, PhD1; Andrew D. Hershey, MD, PhD, FAHS 2,3,4, Scott W. Powers, PhD, ABPP, FAHS1,3,4
(In press, Journal of Pain)
Month 1 Month 2 Month 3 Month 4 Month 5
HE+ACBT+A
Pro
portion
010
%20
%30
%40
%50
%60
%70
%80
%90
%10
0%
Proportion of patients with 50% or greater reduction in headache days for each month of the 5-month trial
A significantly higher proportion of the CBT+A group had a ≥50% reduction in headache days for months 2 through 5 (Month 2: CBT+A 36%, HE+A 17% p=0.0117; Month 3: CBT+A 48%, HE+A 30% p=0.0245; Month 4: CBT+A 64%, HE+A 41% p=0.0070; Month 5: CBT+A 69%, HE+A 45% p=0.0.0056).
Published online 10/27/2016
What are the implications of the CHAMPTrial and CBT+A Trial for clinical care now?
In pediatric headache clinic next week
• Expect and measure for effect in first 8 weeks
• Take a team approach and use your skills to increase expectation of improvement
If preventive medication, once a day dosing, low dose to prevent side effects. Optimally, combine with CBT.