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Alterations in Brain Function After Cognitive Behavioral Therapy for Migraine in Children and Adolescents, 2020, Nahman-Averbuch et al
- Thread starter Andy
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So a range of coping skills and kids being told to think less about the pain, and to use medication. Given that the duration of headache for some of the kids was only an hour or two anyway, I wonder how many underreported their headaches after the CBT.
No control group, perhaps doing just the relaxation and pacing without the cognitive restructuring etc.
I can't comment on the brain scan section, as I have no idea of the significance clinically of the findings.
Migraines are horrible, and anything that genuinely helps is a good thing, but this research is surely only preliminary - a very small sample and a short time span.
Potential problems with the headache diaries
So, in some cases, and possibly most cases, parents were the ones filling out the headache diary. 76 days is a long time to be diligent about recording headaches, especially on behalf of someone else. And the study tells us that there were some missing fields, even after they were handed over for checking. I expect there were plenty more missing fields that were hurriedly filled in with something just prior to the checking.
Furthermore, parents were told to not reinforce the idea of migraines - they were specifically instructed to avoid asking their child about pain. That seems to run counter to accurate recording of migraine frequency and intensity.
I think we can be pretty sure that the data was confounded by waning interest in capturing every short migraine or mild headache that might be a migraine as time went on, particularly with both parent and young person being subjected to CBT sessions suggesting that focusing on the pain was part of the migraine pathology. The clear message was that diligently applying what was learned would be reflected in the success of fewer migraines.
Non-CBT controls might have controlled for part of this bias, but of course there weren't any.
So, in some cases, and possibly most cases, parents were the ones filling out the headache diary. 76 days is a long time to be diligent about recording headaches, especially on behalf of someone else. And the study tells us that there were some missing fields, even after they were handed over for checking. I expect there were plenty more missing fields that were hurriedly filled in with something just prior to the checking.
Furthermore, parents were told to not reinforce the idea of migraines - they were specifically instructed to avoid asking their child about pain. That seems to run counter to accurate recording of migraine frequency and intensity.
I think we can be pretty sure that the data was confounded by waning interest in capturing every short migraine or mild headache that might be a migraine as time went on, particularly with both parent and young person being subjected to CBT sessions suggesting that focusing on the pain was part of the migraine pathology. The clear message was that diligently applying what was learned would be reflected in the success of fewer migraines.
Non-CBT controls might have controlled for part of this bias, but of course there weren't any.
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not to say great things about Cochrane or anything, but for what it's worth a 2019 review wasn't impressed with the studies of CBT for migraines at least in adults:
https://pubmed.ncbi.nlm.nih.gov/31264211/
https://pubmed.ncbi.nlm.nih.gov/31264211/
Potential problems with the scanning results
fMRIs are notorious for allowing whatever conclusion you want to make to be made.
One problem is that the changes in functional connectivity that were found might just be a response to the very unusual circumstances of being in a confined tube, unable to move and listening to various loud machine noises. At least two of the participants found it stressful; one was eliminated from the study because they couldn't tolerate the scanning and, for another,
To me, it is likely that any connectivity between the amygdala (which the paper suggests is the region for nociceptive processing) and any of the parts of the brain involving more conscious thought found on the second scanning is due to an increased familiarity with MRIs. I would expect there would be plenty of thoughts of 'yeah, lying in this tiny tube with the loud noises isn't normal or pleasant, but I've done this before and it's actually fine'. It seems a much stronger story than '8 sessions of being encouraged to ignore the pain of migraines has materially changed the way the brain works during an MRI'. But, of course, with no non-CBT controls, the scope for story-telling is so much wider.
The results are actually quite confused and don't seem to tie up with results from studies in disorders that you might expect CBT to work similarly on (that is, other studies found decreased connectivity between the amygdala and higher parts of the brain after CBT rather than increased connectivity). Also, there was not good concordance between the functional connectivity changes that were observed over the period of the study and the functional connectivity changes that seemed to be associated with headache reduction.
fMRIs are notorious for allowing whatever conclusion you want to make to be made.
One problem is that the changes in functional connectivity that were found might just be a response to the very unusual circumstances of being in a confined tube, unable to move and listening to various loud machine noises. At least two of the participants found it stressful; one was eliminated from the study because they couldn't tolerate the scanning and, for another,
I think anyone who has had an MRI would agree that it is somewhat stressful the first time. Of course, having done one with nothing bad happening and knowing what to expect, the second one is a lot less bother.
To me, it is likely that any connectivity between the amygdala (which the paper suggests is the region for nociceptive processing) and any of the parts of the brain involving more conscious thought found on the second scanning is due to an increased familiarity with MRIs. I would expect there would be plenty of thoughts of 'yeah, lying in this tiny tube with the loud noises isn't normal or pleasant, but I've done this before and it's actually fine'. It seems a much stronger story than '8 sessions of being encouraged to ignore the pain of migraines has materially changed the way the brain works during an MRI'. But, of course, with no non-CBT controls, the scope for story-telling is so much wider.
The results are actually quite confused and don't seem to tie up with results from studies in disorders that you might expect CBT to work similarly on (that is, other studies found decreased connectivity between the amygdala and higher parts of the brain after CBT rather than increased connectivity). Also, there was not good concordance between the functional connectivity changes that were observed over the period of the study and the functional connectivity changes that seemed to be associated with headache reduction.
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Here's the conclusion from the Cochrane report that Dave linked above. It's great to see a Cochrane review with good rigour.
Authors' conclusions: This review identified 21 studies of psychological interventions for the management of migraine. We did not find evidence that psychological interventions affected migraine frequency, a result based on four studies of primarily brief treatments. Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low-quality evidence and there was no evidence of an effect of psychological intervention compared to control at follow-up.
There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term.
In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence.
High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.
There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term.
In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence.
High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.
Maybe the structural changes reflected nothing more than changes in questionnaire scoring behaviour, independent of any actual practical therapeutic benefit.
Gross incompetence, or straight fraud?
rvallee
Senior Member (Voting Rights)
It means that one: "lies, damned lies and statistics". Statistical significance on a guesstimate is a sure sign of making stuff up. No better than a physics experiment testing a magical device that creates heat from the vacuum of space and relies on a touch rating from "warm, very warm, hot, very hot" and slaps a fake statistical certainty to it. "Ooooh, I can feel it warming up in my hands!"
Cancel all of it. Fire everyone involved. Retract everything and study this as the highest form of failure. Enough.