behavioral management of chronic daily headache · • summarize recent advances in behavioral...

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? tasmithe@olemiss.edu

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.