Kids With Chronic Migraines: Medication Alone May Not Be the Best Treatment

Chalanda Jones, MD

Cognitive behavioral therapy combined with traditional pharmacotherapy knocked down children’s chronic migraine better than medications alone.

Chronic migraine—at least 15 days per month of headache with migrainous features—has a prevalence as high as 1.75% in children and adolescents.1 The mainstay treatment for migraine headache has been primarily pharmacologic. Cognitive behavioral therapy (CBT), focusing on coping skills and biofeedback-assisted relaxation training, has been explored in the adult population as a viable treatment plan.

The authors of a recent study found that among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reduction in days with headache and migraine-related disability compared with the use of headache education plus amitriptyline. These data support that CBT is efficacious in the treatment of chronic migraine in children and adolescents.

Participants were patients 11 years of age and older treated at the Headache Center at Cincinnati Children’s Hospital between October 2006 and September 2012. Inclusion criteria included a diagnosis of chronic migraine by a board-certified specialist, 15 or more days with headache per month documented in a 28-day headache diary, and a Pediatric Migraine Disability Assessment Score (PedMIDAS) of greater than 20 points, indicating as least moderate disability.1

Participants were randomly assigned to the treatment group or control group and remained blinded to their assignment throughout the study. The treatment group was treated with CBT plus amitriptyline; the control group was treated with headache education plus amitriptyline. Both groups received 8 weekly, 1-hour individual sessions, followed by monthly booster sessions at weeks 12 and 16, and at 3-, 6-, and 9-month follow-up assessments. Participants were followed up to the 12-month assessment.

At baseline, the children and adolescents in both study groups had a mean (SD) of 21 (5) days with headache per 28 days, and a mean (SD) PedMIDAS of 68 (32) points. At 20 weeks, the participants treated with CBT plus amitriptyline had a reduction of 11.5 days with headache versus a reduction of 6.8 days with headache in the education plus amitriptyline group.

At 12-month follow-up, 86% of CBT participants had a 50% or greater reduction in days with headache versus 69% of the headache education participants. Of the CBT participants, 88% had a PedMIDAS of less than 20 points versus 76% of the headache education group.

The authors propose that these findings indicate that CBT, when combined with medication, is an active change agent for youth with chronic migraine, and that the treatment effects are durable throughout at least 1 year.

Among the study’s limitations are that it did not include a group with treatment focused solely on the effect of CBT. Therefore, it is unknown whether CBT plus amitriptyline is superior to CBT alone for the management of chronic pediatric migraine. Nevertheless, this study does provide support for CBT as a part of the headache management armamentarium. The authors suggest that CBT should be offered routinely along with medications as a first-line treatment for chronic migraine; they further note that CBT should be made more accessible to patients through inclusion as a covered service in health insurance plans, as well as be offered in various formats, including online and mobile access.


1.Powers SW, Kashikar-Zuck SM, Allen JR, et al. Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: a randomized clinical trial. JAMA. 2013;310(24): 2622-2630.

Dr Jones is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD––Series Editor:Dr Pohl is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson College in Philadelphia, Pennsylvania.