Helping the Child and Adolescent with Headaches: School Absences, Social Concerns, Parents

Transcription

1 Helping the Child and Adolescent with Headaches: School Absences, Social Concerns, Parents Randall Weeks, Ph.D. New England Institute for Behavioral Medicine Stamford, CT HCNE Stowe, VT 2009

2 OUTLINE Overview Assessment Considerations Treatment Rules Treatment Tools In the Trenches

3 Overview Pts. are not miniature adults Greater impact on systems Contextual factors are key Interview pt. alone and with parent(s)

4 Overview Assess pt. & parental needs/goals Assess systems issues re: impact of pain Set up clearly defined Rx strategy At all costs,, limit disability

5 New Daily Persistent Headache May present a greater Rx challenge in this population Likely to become a family issue Need to use all available resources LIMIT DISABILITY

6 Three Dimensions of Headache Impact Pain Disability Affective distress Holroyd K et al. Pain. 1999; 83:

7 Pain and Learning Operant conditioning - pain behavior is affected by its consequences reinforcement (secondary gain) avoidance learning Classical conditioning - biological reactions can be conditioned to associated stimuli fear reactions avoidance learning

8 It Exists at Different Ages

9 Psychobiological Model As a headache disorder becomes more severe and chronic, faulty learning and behavior become important maintenance factors.

10 Assessment Considerations

11 Assessment Considerations Frequency/Quality/Severity of headache (operational definition) Associated Symptoms/Family History Behavioral Assessment (Habits, Sleep, Triggers, etc.) Degree of Disability Impact on Systems

12 Assessment Considerations Assess Rx, OTC, and caffeine- containing agents When does patient medicate? How long over-medicating? Previous failed treatments during rebound? Assess pt. attitude about not medicating Is pt. medicating underlying affective issues?

13 Assessment Considerations Pt s s and family s s expectation re: improvement How is pain dealt with in the family, school, and with peers??? If appropriate, How was pain dealt with in parents lives, historically??? What is the school s s policy re: pain???

14 Treatment Rules

15 Treatment Rules Freq. contact indicated early on Biofeedback treatment may be used to engage pt. re: assmt of psych/behavioral/social issues Pt. must keep own calendars Behavioral mgmt. re: sick role beh, sleep hygiene, computer time, etc Inpatient option remains

16 Treatment Rules Avoid/limit triggers Lifestyle management/self-regulation Evaluate relevant co-morbid issues Optimize treatment of acute attacks Assess need for preventive therapy Flexible plan with periodic reassessment

17 Truth about M Triggers No single entity, however classic (red wine, chocolate, stress) acts as a trigger for all M pts. In the individual migraineur,, rarely does a trigger consistently provoke an attack. Simultaneous exposure to two or more triggers may be required to provoke an attack What serves as a trigger may also serve as a treatment (e.g., caffeine) Rothrock JF. Headache,, 2008:48(3),

18 Components of Treatment (6 E s) E 1. Engage patient (family/school???) in treatment process 2. Educate regarding process of treatment 3. Evaluate pt s/ s/fam s needs/concerns 4. Eliminate offending agents 5. Enact pharmacological and behavioral Rx 6. Establish long-term treatment plan

19 1. Engage Pt. in Treatment Pt. must buy in to the process of treatment Define as a collaborative effort Frequent contact may be necessary early in the process Support from family members/sig sig.. others will be necessary Explain that Pharmacological and Behavioral Rx s s will be offered (COMPLIANCE is essential)

20 2. Education Basic understanding of symptoms and Rx Review anticipated treatment course (detox( schedules, time lag before benefits of new medications fully realized, etc.) Discuss genetic issues/ pain vs. suffering model If appropriate, review potential side-effects effects from medications Avoid/Limit triggers; Introduce Self- Regulation KEEP HEADACHE CALENDAR

21 3. Evaluate Pt s/parent s/parent s Needs/Concerns Address concerns regarding illness Assess parent s s attitudes re: pt s absences from school Assess teachers /school /school s attitude toward pt s s status Assess peer/social concerns

22 4. Eliminate Offending Agents Outpatient Rx vs. Inpatient Rx

23 INPATIENT TREATMENT DHE has been found to be effective in treating/aborting an episode of status M in children & adolescents (Kabbouche MA et al. Headache, 2009;49; ). 109). Inpatient programs may offer benefit (allows changes re: family dynamics)

24 5. Enact Pharmacological Rx Should target reduction of duration, frequency, & intensity of head pain Should address co-morbid issues (look for therapeutic two-fors ) Options should include failed treatments when pt was experiencing MOH Referral for psychopharmacology consultation (if indicated)

25 Likely Will Need More than Pharmacotherapy

26 Cherry-flavored sugar pill Dietary supplement Launched June, 2008 in England Can stimulate the body s s ability to repair itself and the miracle power of the brain

27 oopdoo TM because not all boo- boos bleed

28 5. Enact Non-Pharmacological Rx Elimination diet (if indicated) Maintain consistency in dietary & sleep habits Increase exercise and physical activity Adhere to limits re: abortive meds, caffeine, etc

29 Sleep Found support for a relationship between headache and sleep disturbance in adolescents with primary HA (Gilman DK et al. Headache 2008;47: ). 1194). In a recent study with women with transformed M, a targeted behavioral sleep intervention was assoc. with improvement with HA freq., HA index, and with reversion to episodic M (Calhoun AC, Ford S. Headache 2008;47: ). 1183). Episodic morning M assoc with insomnia (Alstadhaug K et al. Headache 2008;47: ).

30 Enact Non-Pharmacological Treatment Introduce/encourage the use of biofeedback strategies, yoga, acupuncture and other pain mgmt strategies Use cognitive/behavioral pain mgmt strategies (e.g., develop action plans ) Limit time on computer, isolation, etc. If indicated, refer for psychotherapy

31 Behavioral Treatment for Migraine- Evidence Grade A Evidence Relaxation training (RLX) Thermal biofeedback (TBF) with RLX EMG biofeedback (EMG BF) Cognitive-behavioral therapy (CBT) Grade B Evidence Behavioral + pharmacologic offer additive improvement Grade C Evidence Recommendations not possible for hypnosis, acupuncture, TENS, cervical manipulation, occlusional adjustment, and hyperbaric oxygen Campbell, Penzien & Wall (2000) Evidence-based guidelines for migraine headaches: Behavioral and physical treatments. AAN Website

32 Behavioral Treatment for Migraine & TTHA-- Evidence Migraine Headache RLX, TBF, TBF+RLX, EMG BF, CBT and CBT+TBF were superior to controls Tension-type Headache RLX, EMG BF, EMG BF+RLX, and CBT were superior to controls. F Andrasik. Neurol Sci 2007;28:S70-S77. S77.

33 What is Biofeedback? Goal is to overlearn adaptive responses/decondition bracing responses Address anticipatory behavior/decrease pain behavior Generalization is essential Usually is part of an overall behavioral strategy Is not a panacea

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36 Cognitive-Behavior Therapy Attempt to foster an internal locus of control and modify distress-related related thoughts Reestablish identity as person not patient Recognize triggers for symptoms Accurately interpret body signals Develop action plans Reduce anxiety and helplessness

37 Cognitive-Behavior Therapy (Action Plans) Preparing for a headache Confronting and handling pain Coping with the feeling of being overwhelmed Reinforcing self-statements statements

38 Behavioral Strategies Decrease Sick Role Behavior Decrease Behavioral Isolation Increase Exercise/Activity Increase Pleasurable Activities Set Up Reasonable Program for Studies/Homework

39 System(s) ) Intervention Family School Social????

40 6. Establish Long-Term Treatment Plan Chronic HA & Migraine is managed not cured MOH occurs in migraine patients Periodic follow-up visits with pts with a history complicated HA, MOH, etc

41 Practice in the Trenches Pt. can t t get up in the morning for school Pt. can t t stay at school Behavioral contracting with pt. School issues re: pt absences Validity of Sx s Making up assignments Homebound tutoring

42 Invitation HCNE would like to invite everyone to our upcoming meeting November 14, 2009 Boston, MA

43 Thank you for your kind attention