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.