By Ethan Benore, PhD; Gerard Banez, PhD; and A. David Rothner, MD
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The literature supporting rehabilitation for children with chronic pain and functional disability has begun to specifically demonstrate utility for children with chronic daily headache with migraine. Rehabilitation seems most appropriate for severely affected children and adolescents with headache who have not responded well to outpatient therapies and medications and who require a multidisciplinary setting that addresses medical, psychological, environmental and lifestyle factors concurrently and intensively.1,2 A recent review found that children with chronic migraine reported less pain and improved mood following pediatric rehabilitation.3
These findings align with our experience treating chronic daily headache with migraine in Cleveland Clinic Children’s Pediatric Pain Rehabilitation Program. Here we present encouraging outcomes from 111 children with chronic daily headache with migraine treated in our program during the past seven years.
The program in brief
At Cleveland Clinic Children’s, we evaluate approximately 350 children each year with a diagnosis of chronic daily headache with migraine. Approximately 20 are treated each year in our multidisciplinary Pediatric Pain Rehabilitation Program, an intensive program designed to improve the functional quality of life of children and their families. Ours is the nation’s only pediatric specialty interdisciplinary pain rehabilitation program to be accredited by the Commission on Accreditation of Rehabilitation Facilities.
The program supports children with chronic daily headache with migraine by:
- Increasing strength and endurance
- Assisting a return to daily life activities
- Using appropriate self-directed coping and pain management skills
Children are typically enrolled for three weeks — two weeks of inpatient care and one week of daytime hospital care. The program blends rehabilitation therapies (physical, occupational and recreational therapy), psychological services, medical subspecialty care, alternative therapies (aromatherapy, acupuncture, biofeedback and reiki) and school. On average, patients spend seven to eight hours in treatment each day, with services scheduled hourly from 8 a.m. to 5 p.m.
Rehabilitation therapy takes place in groups and individually, using both land-based and aquatic forms of therapy three hours per day. Patients receive three individual/family psychological treatment sessions per week, on average, and take part in a cognitive-behavioral skills training group three times weekly. They participate in a school program one to two hours each day and in recreation or music therapy groups at least one hour daily.
Since severe pediatric headache typically affects the patient’s whole family, parents are involved in a separate part of the program focused on parent support and wellness, and parents and siblings participate in recreational therapy.
Outcomes show improvements across multiple measures
Our Pediatric Pain Rehabilitation Program has demonstrated clinically significant improvements in the lives of the 111 children with chronic daily headache with migraine (and their families) who have completed the program over the past seven years. These patients’ mean pre-enrollment duration of headache was three years.
Child quality of life. As shown in Figure 1, children and parents both report a sharp improvement in the child’s quality of life that continues through 12 months of postdischarge monitoring. Scores at 12 months are close to a previously reported average for “healthy children”4 (Cleveland Clinic child report = 73.9; healthy child report = 83.84) (Cleveland Clinic parent-proxy report = 64.2; healthy child parent-proxy report = 82.7).
Figure 1. Self-reported headache pain rating (0-10) and child quality of life as rated by PedsQL™ child and parent-proxy reports.
Pain. Interestingly, but not unexpectedly, pain level is reduced but not eliminated during the 12 months following discharge (Figure 1). This is consistent with our program’s philosophy and with findings in related literature — that the primary goal for chronic pain management in these families is to increase independent functioning despite pain. At each time point, between 4 and 11 percent of children reported no pain that day.
Emotional functioning. Given the link between pain and emotional functioning, we also report notable reductions in both anxiety and depressed mood in children and their parents following the program (Figure 2). Scores are reported as a percentage of total symptom severity for the respective scales. This result underscores the link between emotional and physical functioning, providing further support for an interdisciplinary approach addressing the spectrum of a child’s well-being.
Figure 2. Raw symptom scores of parent depression and anxiety rated on the Bath Adolescent Pain–Parent Impact Questionnaire, and raw symptom scores of child depression and anxiety rated on the Bath Adolescent Pain Questionnaire. Scores are reported as a percentage of total symptom severity.
Absenteeism. Finally, outcomes from the program translate into reduced school and work absences related to the child’s headache (Figure 3). When children are physically conditioned and learn coping skills to maintain high levels of functioning despite the presence of headache, they are less likely to miss school (due to headache or doctor appointments). In turn, their parents can return to a regular workweek. These outcomes are a marker for the impact of chronic pain and the benefit of intensive multidisciplinary rehabilitation.5
Figure 3. Rates of child absences from school (per month) and parent absences from work (per month) related to the child’s chronic daily headache with migraine.
An additional outcome: Hope
Chronic daily headache with migraine poses a serious threat to a child’s well-being and profoundly impacts his or her family. Our Pediatric Pain Rehabilitation Program is measurably improving the lives of these children, and our updated outcome results provide hope for patients and families alike.
Dr. Benore is a pediatric psychologist and associate staff member in the Center for Pediatric Behavioral Health in Cleveland Clinic Children’s Hospital for Rehabilitation.
Dr. Banez is a pediatric psychologist and Clinical Director of Cleveland Clinic Children’s Pediatric Pain Rehabilitation Program.
Dr. Rothner is a pediatric neurologist, Chairman Emeritus of the Section of Child Neurology and Director of Cleveland Clinic Children’s Pediatric/Adolescent Headache Program.
- Sieberg CB, Huguet A, von Baeyer CL, Seshia S. Psychological interventions for headache in children and adolescents. Can J Neurol Sci. 2012;39(1):26-34.
- Pistoia F, Sacco S, Carolei A. Behavioral therapy for chronic migraine. Curr Pain Headache Rep. 2013;17(1):304.
- Eccleston C, Palermo TM, de C Williams AC, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2012;12:CD003968.
- Varni JW, Limbers CA, Burwinkle TM. Impaired health-related quality of life in children and adolescents with chronic conditions: a comparative analysis of 10 disease clusters and 33 disease categories/severities utilizing the PedsQL 4.0 Generic Core Scales. Health Qual Life Outcomes. 2007;5:43.
- McGrath PJ, Walco GA, Turk DC, et al. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain. 2008;9(9):771-783.