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Behavior Modification

DOI: 10.1177/0145445505282164

2006; 30; 93Behav Modif

Frank Andrasik and Mark S. SchwartzBehavioral Assessment and Treatment of Pediatric Headache

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10.1177/0145445505282164BEHAVIOR MODIFICATION/ January 2006Andrasik, Schwartz / PEDIATRIC HEADACHE

Behavioral Assessment and Treatment of

Pediatric Headache

FRANK ANDRASIK

University of West Florida, Pensacola

MARK S. SCHWARTZ

Mayo Clinic, Jacksonville, FL

Headaches are quite common in children and adolescents, and they appear to persist into adult-

hood in a sizable number of individuals. Assessment approaches (interview, pain diaries, andgeneral and specific questionnaires) and behavioral treatment interventions (contingency man-

agement, relaxation, biofeedback, and cognitive behavior therapy) are reviewed, as is the evi-

dencebase for their use. The article concludes with practical suggestions for headache manage-

ment.

Keywords: headache; assessment; treatment; contingency management;

biofeedback; relaxation; cognitive behavior therapy

EPIDEMIOLOGY AND SCOPE OF THE

DISORDER AND/OR PROBLEM

Headachesaresurprisinglycommonin children. Even at theyoung

age of 3 years, headaches are present in 3% to 8% of children. This

increases to about 20% at age 5 years, 37% to 52% at age 7 years, and

57% to 82% from age 7 to 15 years (see Lipton, Maytal, & Winner,

2001, fora review).A U.S. study that included 3,158 children,ages 12

to 17 years, found that 56% of the males and 74% of the females

reported a headache in the past 4 weeks, 27% of the males and 41.4%

of the females reported two or more headaches, and 4.5% of the males

93

AUTHORS’ NOTE: Direct correspondence to Frank Andrasik, Ph.D., Department of Psychol-

ogy, University of West Florida, 11000 University Parkway, Pensacola, FL 32514; e-mail:

[email protected].

BEHAVIOR MODIFICATION, Vol. 30 No. 1, January 2006 93-113DOI: 10.1177/0145445505282164

© 2006 Sage Publications








and 9.4% of the females reported four or more headaches in the

past month (Linet, Stewart,Celentano, Ziegler,& Sprecher, 1989).On

a 1- to 10-point scale, the average intensity was moderate (4.5 males,

4.7 females), and the mean duration was 5 to 6 hours.

Many continue to believe that pediatric headache does not need to

be taken seriouslybecause it will be outgrown with time. Regrettably,

this does nothold true formany childrensoaffected, as revealedby the

longitudinal work of the Swedish pediatrician Bo Bille and others.

Nearly five decades ago (mid-1950s), Bille (1962) began a landmark

studyof about 9,000 Swedish schoolchildren, ranging inagefrom 7 to

15 years, and his first publication told us much about headache occur-

rence across gender and age. Bille was able to follow a subset of thesechildren, all of whom were diagnosed with migraine at a very young

age, for 40 years. The majority continued to be troubled by headaches

at this final follow-up assessment (Bille, 1997). Subsequent work has

confirmed the resilient nature of childhood headaches (e.g., Larsson,

2002; Sillanpää, 1994; Waldie, 2001) and reinforced the importance

of early intervention for ameliorating current symptoms and prevent-

ing adult symptoms (including headaches because of chronic overuse

of medication; Diener & Wilkinson, 1988). Furthermore, there are

indications that headaches have increased in prevalence over the past

decades (Sillanpää & Anttila, 1996).

The pain and suffering children experience can have a significant

impact on every aspect of their daily lives (Bandell-Hoekstra, Abu-Saadm, Passchier, & Knipschild, 2000; Hershey, 2005; Powers,

Patton, Hommel, & Hershey, 2003). Bille’s (1962) initial investiga-

tion, for example, found that sufferers of child headache missed sig-

nificantly more school time than other children. Egermark-Eriksson

(1982) found that approximately 70% of a sample of more than 400

children who missed 4 or more days of school suffered from recurrent

headaches.Finally, childrenwhoconsult a physicianhave beenshown

to incur more school absences (and more nausea) than those who do

not consult (Metsähonkala, Sillanpää, & Tuominen, 1997b). See

Allen, Mathews, and Shriver (1999) for further discussion of the

impact of headache on school performance and achievement.

94 BEHAVIOR MODIFICATION / January 2006








REFERRAL PROCESS/PROCEDURES/PROBLEMS

AND PROSPECTS

Although most headaches in childhood are not because of perma-

nent structural defects or diagnosable physical conditions other than a

primary headache disorder (Rothner, 2001), the prudent nonmedical

practitioner is wise to require a thorough medical evaluation from a

physician experienced with headache prior to accepting a patient for

treatment. It is equally prudent to remember that just because medical

factors are ruled out at the time of initial referral this does not mean

that organic factors cannot come into play at a later date. The practi-

tioner needs to observe for marked changes in presentation and aworsening of symptoms and consider these as indications of a need to

return to a physician. Also, many children will be receiving medica-

tion in addition to behavioral treatment. These concerns argue for a

close and sustained collaboration with medical colleagues when

treating patients with pediatric headache.

Diagnosis and medical evaluation for pediatric headache proceeds

much as it does for adult patients (Holden, Levy, Deichmann, &

Gladstein,1998; Rothner, 2001). Pediatric practitioners and research-

ers note that it can be more difficult to make specific diagnoses for

children because many features depart from those typically seen in

adults (e.g., migraine in children can be more frequent but briefer in

duration, it can be experienced as all encompassing instead of uni-lateral in location, etc.; Silberstein, 1990; Winner, Wasiewski,

Gladstein, & Linder, 1997). Lack of an agreed-onsystemforclassify-

ing and diagnosing headache in children complicates matters. Revi-

sions have been proposed to the system now widely in use with adult

headache patients (Gladstein & Holden, 1996; Winner et al., 1997).

These systems seek to distinguish migraine (with and without aura),

tension-type headache, and migraine-tension headaches combined,

the types most commonly seen by behavioral practitioners, from a

host of other headaches that typically do not come to the attention of

behavioral practitioners because they are more organic and less func-

tional in nature. These determinations are quite important for guiding

appropriate pharmacological treatment; however, they are less useful

Andrasik, Schwartz / PEDIATRIC HEADACHE 95








for planning behavioral treatment, where factors revealed during a

functional analysis are of greater benefit. A second approach classi-

fies headaches according to temporal patterns and severity, resulting

in five categories: acute, acute recurrent (usually migraine), chronic

progressive (organic), chronic nonprogresssive (usually tension), and

mixed (migraine and tension; Rothner, 1978).

STANDARDIZED APPROACHES TO ASSESSMENT

The major assessment approaches concern the clinical interview,

pain diary and/or log, general psychological measures, andheadache-specific measures (Andrasik, 2001a, 2001b; Andrasik, Lipchik,

McCrory, & Wittrock, 2005; King, Murphy, Ollendick, & Tonge,

1997; McGrath & Koster, 2001; Powers & Andrasik, 2005).

The interview serves two basic purposes, the first of which is to

assist in arriving at a classification. Here the focus is on headache

symptomatology and characteristic presentation (e.g., location, fre-

quency, duration, onset, accompanying symptoms, etc.). This is fol-

lowedby a careful functional analysis, focusing on headache anteced-

ents and consequences (Lake, 1981) that may potentially be altered

during treatment. It is helpful to interview parents, school personnel,

and sometimes friends and/or siblings.

To minimize recording bias, daily headache diaries or logs are rec-ommended (Andrasik, 2001a; Andrasik, Lipchik, et al., 2005). The

types of pain scales advocated vary as a function of age and interven-

tion intent. For example, McGrath and Koster (2001) listed nearly a

dozen different pain measures. If attempts are made to alter anteced-

ents and consequences as a part of treatment, then these aspects are

typicallymonitoredas well in thediary on a daily basis.These diaries,

thus, canbe used tohelp guide treatmentand assessoutcome,andthey

mayadditionallybe useful for tracking specific headache characteris-

tics when diagnoses are complicated and unclear (Metsähonkala,

Sillanpää, & Tuominen, 1997a).

Committees drafting guidelines for conducting controlled trials

recommend that the following serve as the primary measures of out-come: (a) number of days headache is present in a 4-week period; (b)









severity of attack, rated on either (1) a 4-point scale, where 0 = no

headache, 1 = mild headache (allowing normal activity), 2 = moder-

ate headache (disturbing but not prohibiting normal activity, bed rest

is not necessary), and 3 = severe headache (normal activity has to be

discontinued, bed rest may be necessary) or (2) a visual analogue

scale, wherein one end is anchored as none and the other as very

severe; (c) headache duration in hours; and (d) responder rate, or the

number or percentage of patients achieving a reduction in headache

days or headache duration per day that is equal to or greater than 50%

(see Andrasik,2001a;Andrasik,Lipchik, et al., 2005, fora more com-

plete discussion; Andrasik, Burke, Attanasio, & Rosenblum, 1985;

Labbé, Williamson, & Southard, 1985; Richardson, McGrath,Cunningham, & Humphreys, 1983, for sample diary approaches and

comparisons of various approaches). These guidelines were devel-

oped largely with adult patients in mind; however, they should be

applicable with pediatric headache patients as well.

A number of general measures may be useful depending on the

presence ofcomorbid conditions (suchas anxiety anddepression) and

the goals of treatment (Powers & Andrasik, 2005).

Finally, headache-specific scales are increasingly being developed

for the purposes of assisting in the diagnosis of headache (e.g., Labbé

et al., 1985; McGrath & Koster, 2001; Mindell & Andrasik, 1987),

identifying environmental variables associated with headache (Budd,

Workman, Lemsky, & Quick, 1994), and assessing impact of head-ache on various important life domains (quality of life) and extent of

disability (Andrasik, 2001b; D’Amico et al., 2003; Hershey et al.,

2004; Powers & Andrasik, 2005; Powers, Patton, Hommel, &

Hershey, 2004).

STANDARDIZED TREATMENT PROTOCOLS

When organic causes have been ruled out and assessment informa-

tion has been gathered, Silberstein (1990) suggested reassuring the

familyabout thebenignnatureof theconditionandencouraging regu-

larization of routine activities (consistent bedtime, awake time, andmealtime, avoidance of activity overload). Indeed, interviews con-









ductedwith patients with pediatricheadache at the initial consultation

revealed they most wanted information about the cause of their head-

aches and what would bring relief and reassurance they did not havea

life-threatening illness (Lewis et al., 1996). Treatment begins with

identification and modification of obvious trigger and contributing

factors, such as physical exertion, hunger, noise, traveling, light glare

(Andrasik, Blake, & McCarran, 1986; McGrath & Hillier, 2001), and

diet (Rossi, Bardare, & Brunelli, 2002).

The utility of contingency management alone has been demon-

strated in several case studies. In the first, Yen and McIntire (1971)

successfully reduced the constant headaches in a 14-year-old female

by applying a mild “red tape” response cost contingency (the childwas required to record various parameters about headache and list

activities that might be completed if headache was notpresent prior to

complaining to others or requesting medication). Ramsden, Fried-

man, and Williamson (1983) reduced reports of head pain in a 6-year-

oldby reinforcing well behaviorandpunishingpain behavior. Punish-

ment isunlikely tobeemployedin this era,because of the potential for

abuse and unpleasant emotional side effects and the availability of

many alternative,positivelyorientedprocedures. Finally, Lake(1981)

described an interesting indirect treatment approach that was used

with an 11-year-old migraineur whose headaches resulted in an

exceedinglyhigh rate of schoolabsences (the boyhad attended only ½

dayin theprior month). Treatment involved implementationof a writ-ten contract that provided reinforcement for increasingly sustained

school attendance. As school attendance increased, headache activity

markedlydecreased, andthis improvementwas maintained at a 1-year

follow-up evaluation.

The most common treatments reported in the literature employ

self-regulation strategies, chief among these being relaxation, bio-

feedback, and cognitive-behavioral therapies. Larsson and Andrasik

(2002) found more than 10 investigations of varied forms of relax-

ation, applied in varied settings (clinics and schools, the locations

where many headaches occur) and by varied personnel (therapists,

teachers, nurses, etc.). Generally positive effects have been obtained

with migraine and tension-type headache, pointing to the robustnessof this approach. These treatments have typically involved the follow-









ing components: discrimination training focusing on identificationof

tense and relaxed larger muscle groups; differential relaxation (some

muscle groups are tensed while other muscles are relaxed); cued

relaxation (pairing breathing to a relaxing word, such as calm, peace,

or relax ); minirelaxation focused on a limited number of muscles in

the head, neck, or shoulder and applied regularly throughout the day

(whenever the watch is looked at, the school bell rings, etc.); and

application of techniques in everyday life (when headaches and feel-

ings of stress tend to occur). Relaxation treatment is typically

delivered over 8 to 10 sessions, administered either individually or in

groups.

Biofeedback constitutes another common approach for pediatricheadache (and this approach is well studied foradultsas well).Histor-

ically, thermal biofeedback has been used most often for migraine

headache and electromyogram (EMG) biofeedback for tension-type

headache (Andrasik, Larsson, & Grazzi, 2002; see Figure 1). See

Andrasik et al. (2002) for details regarding biofeedback treatment.

When used with patients with headache, these procedures likelywork

in a similar manner, by promoting generalized relaxation, and thus

they may be interchangeable (Andrasik & Flor, 2003). Work is only

now beginning to evaluate specific types of biofeedback that directly

target physiology presumed to underlie headaches. This includes

electroencephalogram (EEG) biofeedback (Siniatchkin et al., 2000)

and blood volume pulse biofeedback (Sartory, Müller, Metsch, &Pothmann, 1998).

Cognitive therapy or cognitive stress coping training has been

much less investigated; however, it too has promise. With one excep-

tion (Richter et al., 1986), cognitive approaches have been combined

with other major treatment modalities, and the experimental designs

employedhavenotmade itpossible topartial outthe sourceofeffects.

Researchers have begun to experiment with delivering self-regula-

tory treatments in more economical ways, by limiting individual ther-

apist contact or administering treatments to groups of patients. Pre-

liminary investigations with child migraineurs suggest that

biofeedback may work equally well when delivered in this manner,

with either the child or the parent serving as the main treatment agentfor the home instruction (Allen & McKeen, 1991; Burke & Andrasik,









1989; Guarnieri & Blanchard, 1990; Hermann, Blanchard, & Flor,

1997; see Haddock et al., 1997, for a quantitative review). This

approach increasesthe need forfamilyinvolvement andsupport, lead-


Figure 1. Childreceiving thermal and electromyogram(EMG) biofeedback. (Top Panel)The therapist is explaining the feedback modalities to the child. The verticalbarson either sideof thecomputermonitordisplay EMGactivity from thefore-head and forearm. The circle in the middle and the bar on the bottom of themonitor provide temperature (relative) feedback. Actual temperature valuesare provided digitallyin the middle of the circle. (Bottom Left Panel) A typicalthermistor placement formonitoring surface skin temperature. (Bottom RightPanel) A typical EMG electrode array placement for treatment of tension-typeheadache and generalized relaxation.








ing Guarnieri and Blanchard (1990) to speculate that environmental

factors may be particularly important when employing such limited-

contact treatments (e.g., effects may be lessened when the home is

somewhat chaotic or nonsupportive). This makes sense fora pediatric

population but requires further study. Cautious practitioners will

check thehome environment beforedeciding on this approach in clin-

ical practice (Aromaa, Sillanpää, Rautava, & Helenius, 2000). Data

bearing on this point come from the investigation of Allen and

McKeen (1991). Several of the children who were treated complied

with relaxation; however, their parents did not follow the guidelines

for behavior management that were a part of the treatment package.

These children then gradually worsened over treatment and, subse-quently, did not do as well as the others. At a later follow-up, though,

the initial responders had regressed, and differences were no longer

apparent (Kuhn & Allen, 1993). Most recently, the effectiveness of

single-session behavioral treatmenthasbeen examined (Powers et al.,

2001). Although statistical significance was obtained, percentage

symptom reductions were only 10%, 25%, and 25% for headache

severity, frequency, and duration, respectively, at a modest follow-up

(average of 21 weeks). Thus, more intensive therapeutic effort is

needed.

Another approach to cost containment concerns group administra-

tion. This approach has been used regularly by Larsson and col-

leagues with relaxation approaches administered in school settings(see Larsson & Andrasik, 2002). Preliminary evidence supports the

utility of a brief group behavioral treatment that is designed to be eas-

ily administered by a neurologist and place minimal demands on pro-

vider and patient, such that it could be applied in various day-to-day

medical practice settings. In this investigation (Andrasiket al., 2003),

34 children (from age 9 to 16 years) with episodic tension-type head-

ache were seen in small groups (three to five individuals, based on

similar ages), once per week for 8 weeks, with sessions limited to a

maximum of 30 minutes. Each session followed the same format:

practice of progressive muscle relaxation training with eight muscle

groups (lower arms, upper arms, legs, abdomen, chest, shoulders,

eyes,andforehead)anddiscussion ofways to apply relaxation to copewith headache and headache-related distress. A tape recording of the









first session was provided to guide home practice. Patients were

instructed to practice with the tape once per day during treatment and

twice perweek thereafter. A neurologist, whoconferredwith a behav-

ioralpsychologist,provided treatment. Statistically significant effects

were found for several variables (except analgesic tablets), and most

of these changes were clinically meaningful as well (≥ 50%). The

improvements noted at the end of treatment held throughout the 1-

year of follow-up. Although the reduction in analgesic tablet con-

sumption was not statistically significant, it was sizable from a clini-

cal perspective (exceeded 50%). Even though this investigation was

uncontrolled, the magnitude of effects rivaled those of typical, more

effort-intensive behavioral treatments and surpassed those that aretypical for placebo effects (Hermann, Kim, & Blanchard, 1995).

Further research on this type of approach, with larger samples,

appears warranted.

Prudent practitioners will consider medications based partlyon the

frequency of the headaches, the severity and durations of the head-

aches, and the effectiveness of simple analgesics for the child. Pro-

phylacticmedications areuseful forsome children with chronic head-

aches, especially those who have “severe, frequent attacks” and those

“complicated by neurological symptoms” (Silberstein, 1990). See

Damen,Bruijn, Verhagen, et al. (2005), Levin (2001), Lewis, Yonker,

Winner, and Sowell (2005), Pothmann (2002), and Winner (2001) for

a more complete discussion of medication approaches.

SUMMARY OF TREATMENT EFFICACY

Several major literature reviews have been conducted since the

mid-1990s. The first (Hermann et al., 1995) culled all available drug

andnondrug studies forchildhoodmigraine that hadappeared prior to

early 1993. A meta-analysis was then conducted on the 17 behavioral

and 24 pharmacological studies that met explicit design criteria to

ensure that adequate designs and sample sizes were employed, dupli-

cation of participants, and repetition of findings were avoided,

and samples were not specially selected. The results from that meta-analysis are presented graphically in Figure 2, which lists the results









in decreasing order of obtained effects sizes (outliers excluded).

These findings provide support for various behavioral approaches,

reveal similar levels of effectiveness for these approaches when com-

pared to medication, and indicate that effects are larger than those

obtained for variousplacebo conditions. An updated meta-analysis bythese same authors revealed essentially the same findings (Hermann

& Blanchard,2002). A meta-analysiscompletedby another investiga-

tive team found similar support forbehavioral approaches (Eccleston,

Morley, Williams, Yorke, & Mastroyannopoulou, 2002).

The second major investigation (Holden, Deichmann, & Levy,

1999) examined 31 behavioral studies and determined the extent to

which they met what have become fairly standard criteria for deter-

mining efficacy of psychologically based interventions, based on the

seminal work by the Task Force on Promotion and Dissemination of

Psychological Procedures launched by Division 12 of the American

Psychological Association, the Society of Clinical Psychology. On

completion of their review, Holdenet al. (1999)rated theefficacy baseas follows: Evidence for relaxation and/or self-hypnosis was “well-

established”; thermal biofeedback was “probably efficacious”; and


0

0.5

1

1.5

2

2.5

3

3.5

Treatment Condition

Thermal Biofeedback

Thermal BFB+Relaxation

Propranolol

Ergotamine

Clonidine

Relaxation

Dopaminergic

Multicomponent

Serotonergic

Calcium Blocker

Medication Placebo

Psychological Placebo

WaitList Control

Figure 2 Within-group effect size values for behavioral and pharmacological treatmentforchildhood migraine. (Data derivedfrom Hermannet al.,1995).Forthis typeof effect size, values greater than 1 reflect medium to large effects.








cognitive behavior therapy was “promising” interventions. It was a

lack of available research rather than thepresence of negative findings

that resulted in the later two treatments’ not receiving higher status

ratings.

Another exhaustive efficacy review of treatments for pediatric

headache included a number of complementary and alternative medi-

cine approaches as well (McGrath, Stewart, & Koster, 2001). Seven

different electronic databases were searched; Internet sites and study

registries (Cochrane, National Institutes of Health [NIH],andDARE)

were examined; manual searches were conducted for recent books,

journals, conference proceedings, retried bibliographies, and so on;

and pertinent associations were contacted. Studies were rated withrespect to type andconsistency of evidence. Table 1 lists thecognitive

and behavioral treatments that employed randomized trials and

yielded consistent evidence, while Table 2 summarizes findings for

physical and complementary treatments. Obviously, work is just

beginning to scratch thesurface for these latter approaches. Andrasik,

Powers, and McGrath (2005) provided helpful guidelines for

improving clinical trials conductedwithpediatricheadachepatients.

Several investigations have revealed reasonable maintenance

effects over time (Grazzi et al., 2001; see studies reviewed in Larsson

& Andrasik, 2002), whereas at least one has been less positive (Kuhn

& Allen, 1993). It is unfortunate to note, minimal attention has been

devoted to identifying predictors of initial and enduring responses totreatment. A meta-analysis revealed that thermal and EMG biofeed-

back treatments led to greater clinical outcomes when used with chil-

dren than when applied with adults (for thermal biofeedback, child

headache sufferers improved by 62.3% whereas adult headache suf-

ferers improved by 33.9%; for EMG biofeedback, improvement rates

were 80.8% for children and 50.0% for adults), although no differ-

ences occurred for abilities to regulate physiology (Sarafino &

Goehring,2000).This supported thenotion that children maybe espe-

cially good candidates for biofeedback and related self-regulatory

treatments (Attanasio et al., 1985). Children appear to display a

greater placebo response (Bussone, Grazzi, D’Amico, Leone, &









PRACTICE RECOMMENDATIONS

On working with a number of children and adolescents, ranging

from age 6 to 17 years, Attanasio et al. (1985) identified a number of advantages in working with younger individuals, which may help

account for their enhanced treatment response (see Table 3). Certain

difficulties were encountered as well (see Table 3); however, these

potentialproblems areeasilyaddressedby tailoring language andtak-

ing the time to ensureoptimal understanding, decreasing the lengthof

treatment trials, adding rest periods, and employing contingency

managementstrategies to sustainperformance whenmotivation lags.

Green (1983) provided a number of very helpful suggestions and

verbatim scripts to use when teaching self-regulatory skills to very

young children. She recommended inviting the family unit to the ini-

tial session to prevent the child from being singled out as the problem

or “sick one.” When employing biofeedback, she recommended thatthe therapist be introduced as a “biofeedback teacher,” someone who

teaches ideas and skills, who likes to be asked questions, and who in


TABLE 3

Advantages and Disadvantages When Treating Children by Biofeed-back (from Attanasio et al., 1985)

Advantages

• Increased enthusiasm

• Quicker rate of learning

• Less skeptical about self-control procedures

• Greater confidence in special abilities

• Increased psychophysiological lability

• Few previous failure experiences with treatment

• Increased enjoyment when practicing

• Increased reliability of symptom monitoring

Disadvantages

• Briefer attention span

• Off-task behaviors during session• Fear and apprehension about equipment

• Intolerant of minor discomfort in removing sensors

• Emotional and psychological problems can complicate treatment

• Reduced ability to comprehend treatment rationale and procedures

• Scheduling can be complicated

• Lack of standardized electrode placements








turn likes to askquestions. Shesuggested that a demonstration be pro-

videdwith a response that iseasilycontrolled or produces a quick,dis-

cernible response (EMG from the forearm, electrodermal response

while playing a guessing game).Shemakes frequent useof adjunctive

techniques, such as belly or diaphragmatic breathing, body scanning,

and imagery involving a “limp rag doll.”

Although fairly straightforward translations of biofeedback and

related treatments, developed with adult patients,havemetwith much

success, it is likely that addinga developmental perspective to evalua-

tion and treatment could enhance effects further, as this is rarely

reported as being done in theliterature. MarconandLabbé (1990)dis-

cussed cognitive, self-regulation, psychosocial factors, and issues thatarise at various stages of development. Some of the examples

reviewed concern conceptualizationsof pain; differences in language,

time perception, and approaches to tasks; and varied abilities to com-

prehend the notion of severity. They also pointed to the importance of

considering environmental influences on headache, specifically

attention from family members and teachers.

AllenandShriver (1998)provideda concrete illustrationof this last

point. They randomly assigned child and adolescent migraineurs,

ages 7 to 18 years, to either standard thermal biofeedback or biofeed-

back combined with “pain behavior management” training for par-

ents. Parents assigned to the latter condition were instructed to mini-

mize reactions to pain behavior displays, insist on participation innormal, planned activities to the extent possible, and praise and sup-

port biofeedback practice (see Table 4). Thermal biofeedback led to

significant improvement, as expected; however, the addition of parent

training added a further significant increment to treatment. The com-

binedtreatmentgroupobtained greater overall reductions in headache

frequency, had a larger percentage of patients displaying clinically

significant improvements (reductions greater than50%), and revealed

better adaptive functioning (i.e., pain led to less interference in daily

activities). Benefits from theaddition of parent behaviormanagement

training have not met with uniform success, however (Kröner-

Herwig, Mohn, & Pothmann, 1998).

A reduced contact approach appears to work well with pediatricpatients.This approach increases theneed forfamily involvement and









support. The home environment needs careful consideration before

deciding on this approach.

REFERENCES

Allen, K.D.,Mathews, J. R.,& Shriver, M.D. (1999).Childrenandrecurrentheadaches:Assess-

ment and treatment implications for school psychologists. School Psychology Review, 28,

266-279.

Allen, K. D., & McKeen, L. R. (1991). Home-based multicomponent treatment of pediatric

migraine. Headache, 31, 467-472.

Allen, K. D., & Shriver, M. D. (1997). Enhanced performance feedback to strengthen biofeed-

back treatment outcome with childhood migraine. Headache, 37 , 169-173.Allen, K. D.,& Shriver, M. D. (1998).Role of parent-mediatedpain behaviormanagement strat-

egies in biofeedback treatment of childhood migraines. Behavior Therapy, 29, 477-490.


TABLE 4

Pain Behavior Management Guidelines for Parents (re-printed from Allen & Shriver, 1998, with permission of the Associa-

tion for Advancement of Behavior Therapy)

1. Encourage independent management of pain: Praise and publicly ac-knowledge practice of self-regulation skills during pain-free episodes.If pain is reported, issue a single prompt to practice self-regulationskills. Praise and reward normal activity when report of pain has beenmade.

2. Encourage normal activity during pain episodes: Insist on attendanceat school, maintenance of daily chores and responsibilities, participa-tion in regular activities (lessons, practices, clubs).

3. Eliminate status checks: No questions about whether there is pain or

how much it hurts.4. Reduce response to pain behavior : No effort should be made to assist

the child in coping. Do not offer assistance or suggestions for coping.Do not offer medications.

5. Reduce pharmacological dependence: If medication is requested,deliver only as prescribed (i.e., follow directed time table).

6. Recruit others to follow same guidelines: School personnel should notsend child home; child shouldbe encouraged andpermitted to practiceself-regulation skills in the classroom, workload should not bemodified.

7. Treat pain requiring a reduction in activity as illness: If school, activi-ties, chores, or responsibilities are missed, the child should be treatedas ill and sent to bed for the remainder of the day, even if pain isresolved. Do not permitwatching television, playing games,or special

treatment.








Andrasik,F.(2001a).Assessmentof patients with headache.In D. C. Turk& R. Melzack (Eds.),

Handbook of pain assessment (2nd ed., pp. 454-474). New York: Guilford.

Andrasik, F. (2001b). Migraine and quality of life: Psychological considerations. Journal of

Headache and Pain, 2, S1-S9.

Andrasik, F., Blake, D. D., & McCarran, M. S. (1985). A biobehavioral analysis of pediatric

headache.InN.A.Krasnegor,J.D.Arasteh,&M.F.Cataldo(Eds.), Childhealthbehavior:A

behavioral pediatrics perspective (pp. 394-434). New York: John Wiley.

Andrasik,F.,Burke,E. J.,Attanasio, V., & Rosenblum,E. L. (1985).Child,parent,and physician

reportsof a child’sheadachepain:Relationships prior toandfollowingtreatment. Headache,

25, 421-425.

Andrasik,F.,& Flor, H. (2003).Biofeedback.In H. Breivik,W.Campbell, & C.Eccleston(Eds.),

Clinical pain management: Practical applications and procedures (pp. 121-133). London:

Arnold.

Andrasik, F., Grazzi, L., Usai, S., D’Amico, D., Leone, M., & Bussone, G. (2003). Brief

neurologist-administered behavioral treatment of pediatric episodic tension-type headache.

Neurology, 60, 1215-1216.Andrasik,F., Larsson, B., & Grazzi, L. (2002).Biofeedback treatment of recurrentheadaches in

childrenandadolescents. In V. Guidetti, G. Russell,M. Sillanpää, & P. Winner (Eds.), Head-

ache and migraine in childhood and adolescence (pp. 317-332). London: Martin Dunitz.

Andrasik, F., Lipchik, G. L., McCrory, D. C., & Wittrock, D. A. (2005). Outcome measurement

in behavioral headache research: Headache parameters and psychosocial outcomes. Head-

ache, 45, 429-437.

Andrasik,F.,Powers,S. W., & McGrath,P. J. (2005). Methodological considerationsin research

with special populations: Children and adolescents. Headache, 45, 520-525.

Aromaa, M.,Sillanpää, M.,Rautava,P., & Helenius,H. (2000).Pain experienceof childrenwith

headache and their families: A controlled study. Pediatrics, 106 , 270-275.

Attanasio, V., Andrasik, F., Burke, E. J., Blake, D. D., Kabela, E., & McCarran, M. S. (1985).

Clinical issues in utilizing biofeedback with children. Clinical Biofeedback and Health, 8,

134-141.

Bandell-Hoekstra, I., Abu-Saadm, H. H., Passchier, J., & Knipschild, P. (2000).Recurrenthead-

ache, coping, and quality of life in children: A review. Headache, 40, 357-370.Bille, B. (1962). Migraine in school children. Acta Paediatrica Scandinavica, 51, 1-151.

Bille, B. (1997). A 40-year follow-up of school children with migraine. Cephalalgia, 17 , 488-

491.

Budd, K. S.,Workman,D. E.,Lemsky, C. M.,& Quick,D. M. (1994). TheChildren’s Headache

AssessmentScale (CHAS): Factor structureand psychometricproperties. Journalof Behav-

ioral Medicine, 17 , 159-179.

Burke, E. J., & Andrasik, F. (1989). Home- vs. clinic-based biofeedbacktreatment for pediatric

migraine: Results of treatment through one-year follow-up. Headache, 29, 434-440.

Bussone, G., Grazzi, L., D’Amico, D., Leone,M., & Andrasik, F. (1998). Biofeedback-assisted

relaxation training for young adolescents with tension-type headache: A controlled study.

Cephalalgia, 18, 463-467.

D’Amico, D., Grazzi, L., Usai, S., Andrasik, F., Leone, M., Rigamonti, A., et al. (2003). Use of

the Migraine Disability Assessment Questionnaire in children and adolescents with head-

ache: An Italian pilot study. Headache, 43, 767-773.

Damen, L., Bruijn, J. K., Verhagen, A. P., Berger, M. Y., Passchier, J., and Koes, B. W. (2005).Symptomatic treatment of migraine in children: A systematic review of medication trials.

Pediatrics, 116 , 295-302.









Diener, H. C., & Wilkinson, M. (1988). Drug-induced headache. Berlin, Germany: Springer-

Verlag.

Eccleston,C., Morley, S.,Williams, A.,Yorke,L., & Mastroyannopoulou,K. (2002).Systematic

review of randomised controlled trials of psychological therapy for chronic pain in children

and adolescents, with a subset meta-analysis of pain relief. Pain, 99, 157-165.

Egermark-Eriksson, I. (1982). Prevalence of headache in Swedish school-children. Acta

Paeditrica Scandinavica, 71, 135-140.

Gladstein, J.,& Holden, E. W. (1996). Chronic daily headache in children andadolescents: A 2-

year prospective study. Headache, 36 , 349-351.

Grazzi, L., Andrasik, F., D’Amico, D., Leone, M., Moschiano, F., & Bussone, G. (2001).

Electromyographic biofeedback-assisted relaxation training in juvenile episodic tension-

type headache: Clinical outcome at three year follow-up. Cephalalgia, 21, 798-803.

Green, J. A. (1983). Biofeedback therapy with children. In W. H. Rickles, J. H. Sandweiss,

D. Jacobs, & R. N. Grove (Eds.), Biofeedback and family practice medicine (pp. 121-144).

New York: Plenum.

Guarnieri, P., & Blanchard, E. B. (1990). Evaluation of home-based thermal biofeedback treat-ment of pediatric migraine headache. Biofeedback and Self-Regulation, 15, 179-184.

Haddock, C. K.,Rowan, A. B.,Andrasik, F., Wilson, P. G.,Talcott, G. W., & Stein,R. J. (1997).

Home-based behavioral treatments for chronic benign headache: A meta-analysis of con-

trolled trials. Cephalalgia, 17 , 113-118.

Hermann, C., & Blanchard, E. B. (2002). Biofeedback in the treatment of headache and other

childhood pain. Applied Psychophysiology and Biofeedback , 27 , 143-162.

Hermann,C., Blanchard, E. B.,& Flor, H. (1997).Biofeedback treatmentfor pediatricmigraine:

Prediction of treatment outcome. Journal of Consulting and Clinical Psychology, 85, 611-

616.

Hermann, C., Kim, M., & Blanchard, E. B. (1995). Behavioral and prophylactic pharmacologi-

cal intervention studies of pediatric migraine: An exploratory meta-analysis. Pain, 20, 239-

256.

Hershey, A. D. (2005). What is the impact, prevalence, disability, andquality of life of pediatric

headache? Current Pain Headache Reports, 9, 341-344.

Hershey, A. D., Powers, S. W., Vockell, A. L., LeCates, S. L., Segers, A., & Kabbouche, M. A.(2004). Development of a patient-based grading scale for PeedMIDAS. Cephalalgia, 24,

844-849.

Holden, E. W., Deichmann, M. M., & Levy, J. D. (1999). Empirically supported treatments in

pediatric psychology: Recurrent pediatric headache. Journal of Pediatric Psychology, 24,

91-109.

Holden,E. W., Levy, J. D.,Deichmann,M. M.,& Gladstein, J. (1998).Recurrentpediatric head-

aches: Assessment and intervention. Journal of Developmental and Behavioral Pediatrics,

19, 109-116.

King, N. J., Murphy, G. C., Ollendick, T. H., & Tonge, B. J. (1997). Childhood headaches:

Behavioral assessmentand treatment. International Journalof Rehabilitation and Health, 3,

71-87.

Kröner-Herwig, B., Mohn, U., & Pothmann, R. (1998). Comparison of biofeedback and relax-

ation in the treatment of pediatric headache and the influence of parent involvement on out-

come. Applied Psychophysiology and Biofeedback , 23, 143-157.

Kuhn, B. R., & Allen, K. D. (1993, November). Long-term follow-up of a home-based multicomponent treatment for pediatric migraine. Poster presented at the 27th annual meet-

ing of the Association for Advancement of Behavior Therapy, Atlanta, GA.









Labbé,E. E.,Williamson, D. A.,& Southard,D. R. (1985). Reliability andvalidity of children’s

reports of migraine headache symptoms. Journal of Psychopathology and Behavioral

Assessment , 7 , 375-383.

Lake, A. E. (1981). Behavioral assessment considerations in the management of headache.

Headache, 21, 170-178.

Larsson, B. (2002). Prognosis of recurrent headaches in childhood and adolescence. In

V. Guidetti, G. Russell, M. Sillanpää, & P. Winner (Eds.), Headache and migraine in child-

hood and adolescence (pp. 203-214). London: Martin Dunitz.

Larsson, B., & Andrasik,F. (2002).Relaxationtreatment of recurrent headaches in childrenand

adolescents. In V. Guidetti, G. Russell, M. Sillanpää, & P. Winner (Eds.), Headache and

migraine in childhood and adolescence (pp. 307-316). London: Martin Dunitz.

Levin,S.D. (2001).Drug therapiesfor childhoodheadache.In P. McGrath& L. M.Hillier(Eds.),

The child with headache: Diagnosis and treatment (pp. 109-127). Seattle: IASP Press.

Lewis, D. W., Middlebrook, M. T., Mehallick, L., Rauch, T. M., Deline, C., & Thomas, E. F.

(1996). Pediatric headaches: What do the children want? Headache, 36 , 224-230.

Lewis, D. W., Yonker,M., Winner, P., & Sowell,M. (2005).The treatmentof pediatricmigraine.Pedriatric Annals, 34, 448-460.

Linet, M. S., Stewart, W. F., Celentano, D. D., Ziegler, D., & Sprecher, M. (1989). An

epidemiologicstudyof headacheamongadolescentsand youngadults. Journalof the Ameri-

can Medical Association, 261, 2211-2216.

Lipton, R. B., Maytal, J., & Winner, P. (2001). Epidemiology and classification of headache. In

P. Winner & A. D. Rothner (Eds.), Headache in childrenand adolescents (pp.1-19). Hamil-

ton, Canada: BC Decker.

Marcon, R. A.,& Labbé,E. E. (1990). Assessment andtreatment of children’s headachesfroma

developmental perspective. Headache, 30, 586-592.

McGrath, P. A., & Hillier, L.M. (2001).Recurrent headache: Triggers, causes, and contributing

factors. In P. A. McGrath & L. M. Hillier (Eds.), The child with headache: Diagnosis and

treatment (pp. 77-107). Seattle: IASP Press.

McGrath, P. A., & Koster, A. L. (2001). Headache measures for children: A practical approach.

In P. A. McGrath & L. M. Hillier (Eds.), The child with headache: Diagnosis and treatment

(pp. 29-56). Seattle: IASP Press.McGrath,P. A., Stewart,D., & Koster, A. L. (2001).Nondrugtherapiesfor childhoodheadache.

In P. A. McGrath & L. M. Hillier (Eds.), The child with headache: Diagnosis and treatment

(pp. 129-158). Seattle: IASP Press.

Metsähonkala,L., Sillanpää, M., & Tuominen, J. (1997a).Headache diaryin diagnosisof child-

hood migraine. Headache, 37 , 240-244.

Metsähonkala, L., Sillanpää, M., & Tuominen, J. (1997b). Outcome of early school-age

migraine. Cephalalgia, 17 , 662-665.

Mindell,J. A.,& Andrasik,F.(1987).Headacheclassification andfactoranalysiswitha pediatric

population. Headache, 27 , 96-101.

Pothmann,R. (2002).Medical prophylaxis in childhood migraine.In V. Guidetti,G. Russell,M.

Sillanpää, & P. Winner (Eds.), Headache and migraine in childhood and adolescence

(pp. 251-256). London: Martin Dunitz.

Powers, S. W., & Andrasik, F. (2005). Biobehavioral treatment, disability, and psychological

effects of pediatric headache. Pediatric Annals, 34, 461-465.

Powers, S. W., Mitchell, M. J., Byars, K. C., Bentti, A. L., LeCates, S. L., & Hershey, A. D.(2001). A pilot study of one-session biofeedback training in pediatric headache. Neurology,

56 , 133.









Powers, S. W., Patton, S. R., Hommel, K. A., & Hershey, A. D. (2003). Quality of life in child-

hood migraines: Clinical impact and comparison to other chronic illnesses. Pediatrics, 112,

e1-e5.

Powers, S. W., Patton, S. R.,Hommel,K. A.,& Hershey, A. D. (2004). Quality oflife inpaediat-

ricmigraine:Characterizationof age-related effectsusingPedsQL4.0 Cephalalgia, 24, 120-

127.

Ramsden, R., Friedman,B., & Williamson,D. (1983).Treatment of childhoodheadachereports

with contingency management procedures. Journal of Clinical Child Psychology, 12, 202-

206.

Richardson, G. M., McGrath, P. J., Cunningham, S. J., & Humphreys, P. (1983). Validity of the

headache diary for children. Headache, 23, 184-187.

Richter, J. C., McGrath, P. J., Humphreys, P. J., Goodman, J. T., Firestone, P., & Keene, D.

(1986). Cognitive and relaxation treatment of pediatric migraine. Pain, 25, 195-203.

Rossi, L., Bardare, M., & Brunelli, G. (2002). Migraine and diet. In V. Guidetti, G. Russell, M.

Sillanpää, & P. Winner (Eds.), Headache and migraine in childhood and adolescence

(pp. 237-250). London: Martin Dunitz.Rothner, A. D. (1978). Headaches in children: A review. Headache, 18, 169-175.

Rothner, A. D. (2001). Differential diagnosis of headache in children and adolescents. In P. A.

McGrath & L. M. Hillier (Eds.), The childwith headache: Diagnosisand treatment (pp. 57-

76). Seattle: IASP Press.

Sarafino, E. P., & Goehring, P. (2000). Age comparisons in acquiring biofeedback control and

success in reducing headache pain. Annals of Behavioral Medicine, 22, 10-16.

Sartory, G., Müller, B., Metsch, J., & Pothmann,R. (1998).A comparisonof psychological and

pharmacological treatment of pediatric migraine. Behaviour Research and Therapy, 36 ,

1155-1170.

Silberstein, S. D. (1990).Twentyquestions aboutheadaches in children and adolescents. Head-

ache, 30, 716-724.

Sillanpää, M. (1994). Headache in children.In J. Olesen (Ed.), Headacheclassification and epi-

demiology (pp. 273-281). New York: Raven.

Sillanpää, M., & Anttila, P. (1996). Increasing prevalence of headachein 7-year-old schoolchil-

dren. Headache, 36 , 466-470.Siniatchkin, M., Hierundar, A., Kropp, P., Kuhnert, R., Gerber, W. D., & Stephani, U. (2000).

Self-regulation of slow cortical potentials in children with migraine: An exploratory study.

Applied Psychophysiology and Biofeedback , 25, 13-32.

Waldie, K. (2001). Childhood headache, stress in adolescence, and primary headache in young

adulthood: A longitudinal cohort study. Headache, 41, 1-10.

Winner, P. (2001). Triptans in childhood and adolescence. Seminars in Pediatric Neurology, 8,

22-26.

Winner, P. K.,Wasiewski, W., Gladstein, J.,& Linder,S. (1997).Multicenterprospective evalua-

tion of proposed pediatric migraine revisions to the IHS criteria. Headache, 37 , 545-548.

Yen, S., & McIntire, R. W. (1971). Operant therapy for constant headache complaint: A simple

response-cost approach. Psychological Reports, 28, 267-270.

FrankAndrasik is a professor in theDepartment of Psychology at the Universityof West Florida and a senior research scientist at the Florida Institute for Human and Machine

Cognition in Pensacola. He has a long-standing interest in biofeedback and behavioral

assessment and treatment of recurrent pain and stress disorders, with most of this work









concentrating on headache. He received the Distinguished Scientist Award from the

Association for Applied Psychophysiologyand Biofeedback in 2002 for his researchwith

headache disorders.He presentlyserves as editor-in-chiefof AppliedPsychophysiology

and Biofeedback and held this same position for Behavior Therapy in the past.

Mark S. Schwartz has been on the staff of Mayo Clinics since 1967, including 21 years in

Rochester, MN, and 15 years at the Mayo Clinic in Jacksonville, FL, where he remains at

present. He has a long-standing interest in biofeedback and related procedures, having

served as chair of the Biofeedback Certification Institute of America Board for 2 years

from its inception in 1981 and as president of the Biofeedback Society of America from

March1987 to March1988 just beforethis organizationchanged its name to the Associa-

tion for Applied Psychophysiologyand Biofeedback. His publicationsinclude Biofeed-

back 4: Theory and Practice (with M. Shark, 2002) and Biofeedback: A Practitioner’s

Guide (with F. Andrasik, 2003).


behavioral assessment and treatment of pediatric headache

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