Published: July 15, 2025
Elizabeth S. Doll, M.D.
Pediatric Neurologist and Headache Medicine Specialist
Norton Children’s Neuroscience Institute
Associate Professor, PediatricsUofL School of Medicine
Rachel L. Evans, M.D.
Assistant Professor, PediatricsUofL School of Medicine
Jessica D. Hatfield, APRN
Pediatric Neurology Nurse Practitioner
Affiliated With the UofL School of Medicine
The patient is a now 13-year-old girl with a history of anxiety and headaches dating back to approximately age 7, although she did not present to neurology until age 9. At that time, she was reporting approximately 15 out of 30 headache days per month and was meeting criteria for chronic migraine without aura, which is 15 days of headache or more for three months or longer, including eight migraine days per month.
The patient was on cyproheptadine for several years, which initially provided some benefit. However, at age 12, she returned to the neurology clinic of Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine, presenting with worsening headaches occurring 12 days per month.
Neuroimaging via MRI was normal. However, migraine is a clinical diagnosis and generally does not require brain imaging. It is estimated that 50% of CT scans are unnecessary, with approximately 1 in 1,000 patients developing cancer related to CT exposure. Unless a patient has acute concerns, MRI is preferred when imaging is indicated.
The SNOOP mnemonic — developed by the American Headache Society — is a helpful tool in assessing headache warning signs. It stands for:
The patient was enrolled in a clinical trial evaluating the efficacy of cognitive behavioral therapy (CBT) alone versus CBT plus amitriptyline. She was randomized to the CBT-alone arm of the study and has experienced significant improvement while enrolled in this trial. She now reports a maximum of four headache days per month, sometimes going weeks without headaches. She also takes magnesium oxide for prevention. The patient reports that CBT has been beneficial in reducing headache frequency and equipping her with life skills and stress management techniques.
Research has shown that amitriptyline plus CBT is superior to amitriptyline treatment alone, but CBT alone has not been studied in isolation as a treatment for migraine. While this study is ongoing, the patient has shown significant improvements in her self-esteem, mood and stress-coping strategies. A comprehensive headache treatment plan should include appropriate acute treatment, preventive treatment if indicated and discussion of lifestyle factors that can contribute to the worsening of the patient’s symptoms. Up to 50% of pediatric patients with migraine have comorbid anxiety or depression, so it is critical for the health care provider to inquire about these symptoms.