Neuroimaging Study Explores the Value of CBT in Treating Migraine

When a 31-center clinical trial led by Scott Powers, PhD, and Andrew Hershey, MD, PhD, of Cincinnati Children’s revealed that the two most commonly prescribed medications for preventing migraines in teens are no more effective than placebo, the obvious question became, “Now what?” Early results from a neuroimaging study at Cincinnati Children’s may provide evidence pointing to cognitive behavioral therapy (CBT) as an effective therapy.

“Results from the Childhood and Adolescent Migraine Prevention (CHAMP) study showed that neither topiramate or amitriptyline were superior to placebo, and both drugs showed side effects not present in the placebo group,” says Robert C. Coghill, PhD, director of research for the Department of Anesthesiology at Cincinnati Children’s. “With these results in mind, we decided to switch gears and take a deeper look at CBT, in part because of a 2013 study here, which found higher success rates for controlling chronic migraine when children participate in CBT and receive amitriptyline compared to receiving the medication alone. We wondered whether CBT alone could alter brain activity.”

Before-and-After Images Reveal Clues Coghill, who has been researching individual differences in patient experiences with pain and pain relief for almost 25 years, came to Cincinnati Children’s in 2015, around the time that study results from CHAMP were coming into focus. He began using magnetic resonance imaging (MRI) techniques to study changes in the brains of adolescents who are undergoing cognitive behavioral therapy as part of their migraine care. The study includes 21 patients ages 12-17 who suffer from migraines but have few, if any, comorbidities. Before and after eight weeks of CBT, each patient underwent:

• Functional MRI with blood oxygenation level-dependent contrast (BOLD) to measure functional connectivity between different areas of the brain
• Functional MRI with arterial spin labeling to obtain a quantitative analysis of cerebral blood flow when the brain is at rest

“Preliminary results from BOLD MRI indicate impressive changes in connectivity between the amygdala and other brain structures after CBT, and these changes correlate to a reduction in migraine days,” Coghill says. “This change in functional connectivity may reflect an alteration in the transfer of information from the amygdala to other brain regions – in other words, a reduction in the dissemination of fear and anxiety.”

Data from MRI scans with arterial spin labeling suggest changes in default mode activity pre- and post CBT. “Default mode is associated with mind wandering, a state in which people are more likely to dwell on anxieties,” Coghill says. “It is possible that CBT helps these kids direct their attention away from anxious thoughts. These changes in default mode brain activity also correlate to treatment efficacy.”

Training the Brain to Process Pain Differently Coghill hypothesizes that CBT may help the brain control how pain is elaborated into a conscious experience. “It is possible that the therapy teaches skills that change some of those processes, offering significant benefit without the side effects associated with pharmacologic therapy,” he says. ”We are still analyzing the data, but preliminary results are exciting. If we can identify the brain mechanisms that are associated with CBT and its relief of migraines, we may be able to provide patients, families, doctors and payers with objective evidence that CBT is an effective therapy.”

2018 Neurosurgery Conference for Advanced Practice Providers

The Cincinnati Children's Division of Neurosurgery will host its fifth annual Advanced Practice Provider Neurosurgery Conference April 19-20, 2018, at the medical center. The conference will feature presentations by faculty and advanced practice providers, who will share cutting-edge practices within pediatric neurosurgery.

To learn more, contact Allie.Mains@cchmc.org.