Psychological issues in the evaluation and treatment of tension-type headache

Individual endogenous pain modulation profiles within a multidimensional context of people with cervicogenic headache - A retrospective exploratory study

BACKGROUND

One in four individuals with cervicogenic headache (CeH) are unresponsive to therapy. Such therapy involves predominantly biomedical interventions targeting the upper-cervical spine. A recurring theme within musculoskeletal practice is the multidimensional nature and substantial heterogeneity of the condition. Such heterogeneity might be a reason for failure of a biomedical approach. Therefore, future studies investigating efficacy of managing CeH should ideally be based on identification, and better understanding of the heterogeneity of this population based on a comprehensive evaluation of clinically relevant contributing factors.

OBJECTIVES

The objective was to map profiles of individuals with CeH based on pain modulation within a multidimensional context.

DESIGN

Pain Modulation Profiles (PMPs) of 18 adults (29-51 years) with CeH were mapped retrospectively.

METHOD

The PMPs consisted of a Pain-Profile (bilateral suboccipital, erector spinae, anterior tibialis pressure pain thresholds), a Psycho-Social-Lifestyle-Profile (Depression, Anxiety, Stress Scale, Headache Impact test, Pittsburgh Sleep Quality Index), or a combination of both. Individual results were compared to normative data. Two Pain-Profiles were defined: normal or altered. Psycho-Social-Lifestyle-Profiles were categorized based on the number of altered psycho-social-lifestyle factors (range 0-5).

RESULTS

Mapping PMPs in individuals with CeH resulted in 50% presenting with a dominant altered Pain-Profile, 16.7% with a dominant altered Psycho-Social-Lifestyle-Profile, and 5.6% with dominant alterations in both Pain-Profile and Psycho-Social-Lifestyle-Profile.

CONCLUSION

Our results indicate heterogeneity of PMPs within the CeH population. Replication of these results is needed through dynamic assessment of the Pain-Profile before evaluating if these profiles can help patient-stratification.

Relationship between Self-Efficacy and Headache Impact, Anxiety, and Physical Activity Levels in Patients with Chronic Tension-Type Headache: An Observational Study

Background

Chronic tension-type headache is the primary headache with the highest prevalence. The present study is aimed at analyzing the associations between patient self-efficacy and headache impact with pain characteristics, kinesiophobia, anxiety sensitivity, and physical activity levels in subjects with chronic tension-type headache.

Materials and Methods

An observational descriptive study was carried out. A total sample of 42 participants was recruited at university environment with diagnosis of tension-type headache. Headache characteristics (frequency, intensity, and duration), physical activity levels, pain related-self-efficacy, kinesiophobia, anxiety sensitivity, and headache impact were measured.

Results

The HIT-6 (61.05 ± 6.38) score showed significant moderate positive correlations with the ASI-3 score (17.64 ± 16.22; r = 0.47) and moderate negative correlations with the self-efficacy in the domains of pain management (31.9 ± 10.28; r = −0.43) and coping with symptoms (53.81 ± 14.19; r = −0.47). ASI-3 score had a negative large correlation with self-efficacy in the domains of pain management (r = −0.59), physical function (53.36 ± 7.99; r = −0.55), and coping with symptoms (r = −0.68). Physical activity levels showed positive moderate correlations with the self-efficacy in the domain of physical function (r = 0.41). Linear regression models determined that the self-efficacy and anxiety sensitivity with showed a significant relationship with the HIT-6 score (R² = 0.262; p = 0.008) and with the ASI-3 score (R² = 0.565; p < 0.001). In addition, no correlations were found between pain intensity, duration or frecuency with psychosocial factors, or headache impact.

Conclusions

The present study showed that patients with chronic tension-type headache had a great negative impact on daily tasks and physical activity levels, which were associated with higher anxiety levels and lower self-efficacy.

Assessment of Pain Modulatory and Somatosensory Profiles in Chronic Tension-Type Headache Patients

Objective

The aim of this study was to thoroughly phenotype a group of chronic tension-type headache (CTTH) patients.

Methods

Fifteen CTTH patients diagnosed according to the International Classification of Headache Disorders–3 and 15 healthy controls were included in this study. Furthermore, 70 healthy controls were included to establish normative values. Quantitative sensory testing (QST), including temporal summation of pain (TSP), conditioned pain modulation (CPM), and psychological and sleep variables, was assessed in a single session. TSP and CPM were then combined to build pain modulation profiles (PMP) for each individual.

Results

No difference was found between groups for PMP, TSP, and CPM. However, 10 CTTH patients showed a pronociceptive PMP, with 8 related to a deficient CPM and 2 to both a deficient CPM and increased TSP. Increased cold detection thresholds were the most common sensory disturbance found in CTTH patients. Significant differences were seen between groups for pain catastrophizing, depression, and sleep quality although not all patient’s scores were above the clinically meaningful cutoffs.

Conclusions

In summary, CTTH patients presented with different PMP. These PMP may be related to increased TSP, deficient CPM, alterations in thermal detection that may be related to autonomic dysregulation, or a combination of all three. Overall, this suggests that due to their heterogeneous pathophysiology, CTTH patients should be managed according to their underlying pathophysiology and not with a one-size-fits-all approach.

Pain Diagnosis, Pain Coping, and Function in Individuals with Chronic Musculoskeletal Pain

Purpose

Research supports a role for coping responses in adjustment to chronic pain. However, it is likely that some coping responses play a larger role in adjustment to pain for some individuals than others. The identification of the factors that moderate the association between coping responses and pain-related outcomes has important clinical implications. This study sought to determine if musculoskeletal pain diagnosis moderates the associations between eight pain-coping responses and both pain and function.

Patients and Methods

A non-probabilistic sample of 323 persons with different chronic musculoskeletal pain conditions completed measures of pain intensity, physical function, psychological function, and pain-coping responses.

Results

With only one exception, the frequency of use of pain-coping responses was not associated with pain diagnosis. Statistically significant moderation effects of pain diagnosis on the association between coping and pain outcomes were found for two coping responses: 1) support seeking when predicting pain intensity, and 2) resting when predicting both physical and psychological function.

Conclusion

The findings indicate that coping responses tend to play a similar role in patients' pain and function across different musculoskeletal pain conditions, with some important exceptions. If the findings are found to replicate in other samples, they would have important implications for determining when psychosocial pain treatments might (and when they might not) need to be adapted for specific diagnostic groups.

Preclinical Signs of a Temporomandibular Disorder in Female Patients With Episodic Cervicogenic Headache Versus Asymptomatic Controls: A Cross-Sectional Study

BACKGROUND

The International Classification of Headache Disorders, 3rd Edition, accepted "headache attributed to temporomandibular disorders" as a valid headache. The neurophysiologic interplay between cervical structures and the temporomandibular joint, however, might also suggest that a temporomandibular disorder could develop in patients with cervicogenic headache.

OBJECTIVE

To compare the presence of preclinical temporomandibular signs between female patients with episodic cervicogenic headache and a control group.

DESIGN

Case-controlled cross-sectional design.

SETTING

Institutional setting: Hasselt University.

PARTICIPANTS

Twenty-two women (mean age ± SD: 20.7 ± 2.5 years) with episodic cervicogenic headache, without temporomandibular signs and 22 matched (gender, age, level of education, occupation) asymptomatic controls (21 ± 2.3 years).

METHODS

(Un)assisted temporomandibular range of motion, pressure pain thresholds, painful palpations were examined and the level of perceived stress was measured.

MAIN OUTCOME MEASUREMENTS

Temporomandibular range of motion (mm), pressure pain thresholds (kPa/cm²), painful palpations (yes/no), and level of perceived stress (Perceived Stress Scale).

RESULTS

Maximal mouth-opening was significantly smaller in the headache group (P <.05; effect size [ES] -0.45). Palpation of the masseter resulted in significantly more positive pain responses in the headache group at the left (P = .009; ES ∞) and right (P = .002;ES 17.5) origin, left (P = .004; ES 14.54) and right (P = .03; ES 5.71) body and left (P < .001; ES 12) insertion. Significantly lower pressure pain thresholds on the left and right anterior (P = .03; ES -0.33 resp. P = .02; ES -0.35), central (P = .003; ES 1.02 resp. P = .02; ES 0.79) and right posterior (P = .03; ES 0.62) temporalis and right tibialis anterior (P = .03; ES -0.33) were measured in the headache group. The level of perceived stress was significantly higher (P = .02) in the headache group.

CONCLUSIONS

Patients with episodic cervicogenic headache present with signs of a preclinical temporomandibular disorder and sensitization. The smaller range of motion, lower pressure pain thresholds, and higher levels of stress accentuate the multidimensionality of the problem.

LEVEL OF EVIDENCE

IV.

Cognitive impairment in patients with migraine: causes, principles of effective prevention and treatment

Cognitive impairment (CI) is common in patients with migraine; its causes and pathogenesis continue to be discussed. Some authors consider that migraine proper does not lead to decreased cognitive functions, neuroimaging changes in the brain white matter are asymptomatic in migraine; and CI in patients with this condition is caused by comorbidities (depression, anxiety disorder) and/or concurrent cerebrovascular and neurodegenerative diseases. Other authors report the pathogenetic role of migraine in the development of CI and the importance of the frequency of headache attacks and neuroimaging changes in the brain matter in migraine. The paper reviews clinical trials dealing with the prevalence, causes, and pathogenesis of CI in patients with migraine. It sets forth the current principles of prevention and treatment of CI in patients with this condition.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

Headache and facial pain: differential diagnosis and treatment

Headaches affect 90% of the population sometime during their life. Most are benign and fleeting, some are serious and life-threatening, and others require ongoing medical consultation and treatment. A careful history and physical is necessary to establish a differential diagnosis and to guide the choice of testing to make an accurate diagnosis. The most common types of headaches are discussed in this review. They are divided into primary and secondary headache disorders as classified by the International Headache Society. Primary headache disorders include migraine without and with aura, cluster and tension-type headaches. Secondary headaches are those that occur as a result of some other disorder and include brain tumors, rhinosinusitis, diseases of intracranial and extracranial vasculature, and temporomandibular joint disease.