Stress and Primary Headache: Review of the Research and Clinical Management

A regression model on work-related musculoskeletal disorders and associated risk factors among radiographers

Objectives. This study aimed to develop a predictive model for work-related musculoskeletal disorders (WRMSDs) among radiographers. Methods. A survey was conducted in seven hospitals in two cities with radiographers using the ergonomic assessment for radiographers questionnaire. Logistic regression, confirmatory factor analysis and structural equation modelling (SEM) were utilized to establish statistical relationships between independent factors and musculoskeletal complaints. Results. Of 165 respondents, 75.2% reported musculoskeletal pain in the past 12 months, with lower back pain the most prevalent (58.8%). Adjusting for covariates, musculoskeletal pain significantly correlated with body mass index < 23 (odds ratio [OR] 0.06, 95% confidence interval [CI] [0.005, 0.914]), smoking status (OR 0.274, 95% CI [0.751, 6.195]), fixed work break schedule (OR 2.839, 95% CI [1.123, 7.176]), sustained posture (OR 4.854, 95% CI [1.203,19.594]) and prolonged standing or walking (OR 7.499, 95% CI [1.086, 51.753]). The fit measures indicate a moderately good fit of the proposed model to the observed data. However, latent variables did not exhibit significant associations with WRMSD in SEM. Conclusions. The model suggests that WRMSDs among radiographers moderately correlate with underweight, smoking status, fixed work breaks, sustained posture and extended periods of standing or walking. The absence of significant associations between latent variables and WRMSDs suggests the presence of unexplored factors influencing the outcome.Trial registration: Clinical Trials Registry India identifier: CTRI/2021/09/036992.

Higher Risk of Many Physical Health Conditions in Sexual Minority Men: Comprehensive Systematic Review and Meta-Analysis in Gay- and Bisexual-Identified Compared with Heterosexual-Identified Men

Purpose: The purpose of this study was to provide a systematic review and, where possible, meta-analysis on the prevalence of physical health conditions in sexual minority men (SMM, i.e., gay- and bisexual-identified men) compared with heterosexual-identified men. Methods: A systematic literature search in the databases MEDLINE, Embase, CENTRAL, CINAHL, and Web of Science was conducted on epidemiological studies on physical health conditions, classified in the Global Burden of Disease project and published between 2000 and 2021. Meta-analyses comparing odds ratios were calculated. Results: In total, 23,649 abstracts were screened, and 32 studies were included in the systematic review. Main findings were that (1) Largest differences in prevalence by sexual identity were found for chronic respiratory diseases, particularly asthma: overall, SMM were significantly almost 50% more likely to suffer from asthma than heterosexual men. (2) Evidence of higher prevalence was also found for chronic kidney diseases and headache disorders in gay men and for hepatitis B/C in both gay and bisexual men. (3) We found an overall trend that bisexual men were more affected by some of the physical health conditions compared with gay men (e.g., cardiovascular diseases, asthma). However, regarding cancer, headache disorders, and hepatitis, gay men were more affected. Conclusion: We found evidence of physical health disparities by sexual identity, suggesting more health issues in SMM. Since some of these findings rely on few comparisons or small samples of SMM only, this review is intended to be a vehement plea for routinely including sexual identity assessment in health research and clinical practice.

Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial

BACKGROUND

Primary headaches, including migraine and tension-type headaches, are widespread and have a social, physical, mental, and economic impact. Among the key components of treatment are behavior interventions such as lifestyle modification. Scalable conversational agents (CAs) have the potential to deliver behavior interventions at a low threshold. To our knowledge, there is no evidence of behavioral interventions delivered by CAs for the treatment of headaches.

OBJECTIVE

This study has 2 aims. The first aim was to develop and test a smartphone-based coaching intervention (BalanceUP) for people experiencing frequent headaches, delivered by a CA and designed to improve mental well-being using various behavior change techniques. The second aim was to evaluate the effectiveness of BalanceUP by comparing the intervention and waitlist control groups and assess the engagement and acceptance of participants using BalanceUP.

METHODS

In an unblinded randomized controlled trial, adults with frequent headaches were recruited on the web and in collaboration with experts and allocated to either a CA intervention (BalanceUP) or a control condition. The effects of the treatment on changes in the primary outcome of the study, that is, mental well-being (as measured by the Patient Health Questionnaire Anxiety and Depression Scale), and secondary outcomes (eg, psychosomatic symptoms, stress, headache-related self-efficacy, intention to change behavior, presenteeism and absenteeism, and pain coping) were analyzed using linear mixed models and Cohen d. Primary and secondary outcomes were self-assessed before and after the intervention, and acceptance was assessed after the intervention. Engagement was measured during the intervention using self-reports and usage data.

RESULTS

A total of 198 participants (mean age 38.7, SD 12.14 y; n=172, 86.9% women) participated in the study (intervention group: n=110; waitlist control group: n=88). After the intervention, the intention-to-treat analysis revealed evidence for improved well-being (treatment: β estimate=-3.28, 95% CI -5.07 to -1.48) with moderate between-group effects (Cohen d=-0.66, 95% CI -0.99 to -0.33) in favor of the intervention group. We also found evidence of reduced somatic symptoms, perceived stress, and absenteeism and presenteeism, as well as improved headache management self-efficacy, application of behavior change techniques, and pain coping skills, with effects ranging from medium to large (Cohen d=0.43-1.05). Overall, 64.8% (118/182) of the participants used coaching as intended by engaging throughout the coaching and completing the outro.

CONCLUSIONS

BalanceUP was well accepted, and the results suggest that coaching delivered by a CA can be effective in reducing the burden of people who experience headaches by improving their well-being.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017422; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00017422.

Rising trends in the burden of migraine and tension-type headache among adolescents and young adults globally, 1990 to 2019

BACKGROUND

Headache disorders are major contributors to disability in adolescents and young adults worldwide. We aimed to analyze global trends in the burden of migraine and tension-type headache in 10 to 24-year-olds from 1990 to 2019.

METHODS

Data were obtained from the Global Burden of Disease Study (GBD) 2019 to examine trends in incidence, prevalence, and disability-adjusted life years (DALYs) for migraine and tension-type headache in adolescents and young adults by location, age, sex and sociodemographic index (SDI). Joinpoint regression analyzed trends and identified years of significant change.

RESULTS

Globally, migraine and tension-type headache incidence, prevalence, and DALYs increased from 1990 to 2019, though with some fluctuations. The highest growth in migraine incidence occurred in males and individuals aged 10-14, while for tension-type headache incidence, it was observed in males and individuals aged 20-24. Prevalence and DALYs were highest for both disorders in females and those aged 20-24 years. Incidence increased fastest in East Asia for migraine and tension-type headache. For migraine, Tropical Latin America had the fastest increase in prevalence and DALYs. East Asia had the fastest increase in prevalence of tension-type headache, while North Africa and the Middle East had the highest growth in DALYs. Some high-income countries such as Singapore, Norway, and Iran (Islamic Republic of) demonstrated fast increases, while a few countries including Qatar, Thailand and Ethiopia decreased.

CONCLUSIONS

The incidence, prevalence and disability from migraine and tension-type headache are rising in adolescents and young adults, especially in males, older youth and middle SDI populations. The increasing trends highlight the need for targeted interventions focused on prevention and control in priority populations. Continued monitoring of trends can help identify strategies to promote headache health and reduce the life-course impacts of headache disorders globally.

Prolactin and pain of endometriosis

Women experience chronic pain more often than men with some pain conditions being specific to women while others are more prevalent in women. Prolactin, a neuropeptide hormone with higher serum levels in women, has recently been demonstrated in preclinical studies to sensitize nociceptive sensory neurons in a sexually dimorphic manner. Dysregulation of prolactin and prolactin receptors may be responsible for increased pain especially in female predominant conditions such as migraine, fibromyalgia, and pelvic pain. In this review, we focus on the role of prolactin in endometriosis, a condition characterized by pelvic pain and infertility that affects a large proportion of women during their reproductive age. We discuss the symptoms and pathology of endometriosis and discuss how different sources of prolactin secretion may contribute to this disease. We highlight our current understanding of prolactin-mediated mechanisms of nociceptor sensitization in females and how this mechanism may apply to endometriosis. Lastly, we report the results of a systematic review of clinical studies conducted by searching the PubMed and EMBASE databases to identify association between endometriosis and blood levels of prolactin. The results of this search strongly indicate that serum prolactin levels are increased in patients with endometriosis and support the possibility that high levels of prolactin may promote pelvic pain in these patients and increase vulnerability to other comorbid pain conditions likely by dysregulating prolactin receptor expression. Targeting of prolactin and prolactin receptors may improve management of pain associated with endometriosis.

[Fear of migraine attacks: diagnosis and treatment]

In the field of headache disorders, the term "fear of attacks" refers to the fear of a headache attack occurring. Excessive fear of attacks may worsen the course of a migraine and lead to an increase in migraine activity. In the assessment of attack-related fear, a categorical (fear of attacks as a specific phobia) and a dimensional approach (measuring the extent of fear using a questionnaire) are available. The 29-item Fear of Attacks in Migraine Inventory (FAMI) is an economic self-report questionnaire for the assessment of attack-related fear, and it has good psychometric properties. The treatment of attack-related fear includes behavioral interventions as well as pharmacological therapy. Behavioral interventions have few side effects and are based on the treatment of common anxiety disorders (e.g., agoraphobia). Although the evidence of existing treatments is sparse, attack-related fear should be considered in routine care.

Intensive Mindfulness Meditation Reduces Frequency and Burden of Migraine: An Unblinded Single-Arm Trial

Objectives

Preventing migraine headaches and improving the quality of life for patients with migraine remains a challenge. We hypothesized intensive meditation training would reduce the disease burden of migraine.

Method

An unblinded trial was analyzed as a single cohort exposed to a silent 10-day Vipassana meditation retreat that included 100 hr of sitting meditation. Participants with chronic or episodic migraine were enrolled and followed for 1 year. The primary outcome was a change in mean monthly migraine days at 12 months from baseline. Secondary outcomes included headache frequency and intensity, acute medication use, work days missed, home meditation, sleep quality, general health, quality of life, migraine impact, positive and negative affect, perceived stress, mindfulness, and pain catastrophizing.

Results

Three hundred people were screened and 58 (19%) agreed to participate and enrolled in the intensive meditation training. Forty-six participants with chronic migraine (≥ 15 headaches/month of which ≥ 8 were migraines) and 12 with episodic migraine (< 15 and ≥ 4 migraines/month) attended and 45 (78%) completed the retreat. At 12 months, the average migraine frequency was reduced by 2.7 days (from 16.6 at baseline) per 28 days (95%CI - 4.3, - 1.3) and headaches by 3.4 (20.1 at baseline) per 28 days (- 4.9, - 1.9). Fifty percent responder rate was 29% for migraine. Acute medication use dropped by an average of 2.2 days (- 3.9, - 0.5) per 28 days, and participants reported 2.3 fewer days (- 4.0, - 0.5) on which they reduced their activity due to migraines. The most striking and promising effects were in several secondary outcomes, including migraine-specific quality of life, pain catastrophizing, and perceived stress. The significant improvements observed immediately following the intervention were sustained at 12 months follow-up.

Conclusions

Training in Vipassana meditation via a 10-day retreat may reduce the frequency and burden of migraine.

Preregistration

ClinicalTrials.gov: NCT00663585.

The impact of the COVID-19 pandemic on patients with migraine

Objectives

The aim of our work was to assess the impact of the COVID-19 pandemic and quarantine measures on migraine patients in regards to the activity of the disease, the psycho-emotional background of the patients and their quality of life.

Methods

his study included 133 patients with established diagnosis of migraine. All study participants were divided into two clinical groups: A-patients with chronic and episodic forms of migraine, who had a history of positive PCR test for COVID-19, and B-patients with chronic and episodic forms of migraine who did not have a history of coronavirus disease.

Results

We detected increase in the number of antimigraine medication (p = 0.04), frequency of headache attacks (p = 0.01), and the psycho-emotional state deterioration (increase in the Hamilton anxiety scale score) (p = 0.002) in patients after recovery from the coronavirus disease. There was no significant difference in the headache's intensity according to the VAS scale (p = 0.51) as well as in the dynamics of the Beck depression scale score (p = 0.09) before and after the COVID-19 infection.

Conclusion

Patients with a history of migraine who recovered from COVID-19 showed increased frequency of migraine headache attacks and anxiety.

Comprehensive systematic review and meta-analysis on physical health conditions in lesbian- and bisexual-identified women compared with heterosexual-identified women

BACKGROUND

Sexual minority individuals experience discrimination, leading to mental health disparities. Physical health disparities have not been examined to the same extent in systematic reviews so far.

OBJECTIVES

To provide a systematic review and, where possible, meta-analyses on the prevalence of physical health conditions in sexual minority women (i.e. lesbian- and bisexual-identified women) compared to heterosexual-identified women.

DESIGN

The study design is a systematic review with meta-analyses.

DATA SOURCES AND METHODS

A systematic literature search in MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science databases was conducted on epidemiologic studies on physical health conditions, classified in the Global Burden of Disease project, published between 2000 and 2021. Meta-analyses pooling odds ratios were calculated.

RESULTS

In total, 23,649 abstracts were screened and 44 studies were included in the systematic review. Meta-analyses were run for arthritis, asthma, back pain, cancer, chronic kidney diseases, diabetes, headache disorders, heart attacks, hepatitis, hypertension, and stroke. Most significant differences in prevalence by sexual identity were found for chronic respiratory conditions, especially asthma. Overall, sexual minority women were significantly 1.5-2 times more likely to have asthma than heterosexual women. Furthermore, evidence of higher prevalence in sexual minority compared to heterosexual women was found for back pain, headaches/migraines, hepatitis B/C, periodontitis, urinary tract infections, and acne. In contrast, bisexual women had lower cancer rates. Overall, sexual minority women had lower odds of heart attacks, diabetes, and hypertension than heterosexual women (in terms of diabetes and hypertension possibly due to non-consideration of pregnancy-related conditions).

CONCLUSION

We found evidence for physical health disparities by sexual identity. Since some of these findings rely on few comparisons only, this review emphasizes the need for routinely including sexual identity assessment in health research and clinical practice. Providing a more detailed picture of the prevalence of physical health conditions in sexual minority women may ultimately contribute to reducing health disparities.

Graphene-Based Sensor for the Detection of Cortisol for Stress Level Monitoring and Diagnostics

In this work, we study the sensing properties of multi-layer graphene combined with pyrrole in order to elaborate low-cost, high-sensitive material for cortisol detection. Graphene nanoplatelets and pyrrole were dispersed in a solution containing 1M HNO3 by using a powerful ultrasound probe for 10 min, then centrifuged for 30 min at 4000 rpm; polymerization was performed by cyclic voltammetry. The graphene-pyrrole composite was tested to ultra-low levels of cortisol in artificial saliva, consistent to the levels excreted in human salivary samples. The composite was further investigated by Raman spectroscopy and we modeled the interaction between the sensitive layer and cortisol using MarvinBeans software. It shows a good sensitivity for salivary values of cortisol cyclic voltammetry being able to detect a level down to 0.5 ng/mL cortisol.

Sex and gender differences in migraines: a narrative review

Introduction

Gender medicine is a new medical approach aimed at the study of the differences between women and men in terms of prevention, diagnosis, and the outcome of all diseases. Migraines are among these. They represent the most common neurological illness; they are most prevalent in adults between 20 and 50 years of age and are three to four times more frequent in woman than in men. Affecting people in working age, migraines are a problem that strongly impacts the psychophysical health and productivity of workers, regardless of the specific job task they have.

Methods

A narrative review was performed, searching for the most relevant articles describing gender differences in people suffering from migraines, and particularly in workers.

Results

Migraine global prevalence is 20.7% in women and 9.7% in men whereas prevalence in Italy is 32.9% for women and only 13.0% for men. This difference is partly explained by hormonal differences, as well as by differences in brain structure, genetic polymorphisms and neuronal pathways. Sex differences may also play a role in the progression from episodic to chronic migraine. In workers, migraines are mostly associated with strenuous physical work in men, whilst migraines triggered by night shifts, lack of sleep, or irregular sleep patterns are more common in women.

Conclusions

To this day, the reasons of sex/gender disparity for migraine are still obscure. However, migraines, chronic migraine in particular, have a negative impact on the lives of all individuals affected by this disease, but particularly in women in which family cares and working activity are often superimposed. Migraine prevention strategies should be planned in workers through the occupational health physician.

Psychological Disorders, Adverse Childhood Experiences and Parental Psychiatric Disorders in Children Affected by Headache: A Systematic Review

BACKGROUND

Pediatric headaches have been linked to adverse life events or psychological factors in children and their families, with a complex and bidirectional association. Moreover, it is well-known that psychological stress can trigger headaches.

METHODS

We searched three databases for studies focusing on headaches and adverse events or psychological factors in children up to 12 years old or in their caregivers.

RESULTS

We included 28 studies. Child psychological factors, including internal and external symptoms, were commonly associated with all types of headaches. Sleep disturbances showed a positive association with headaches in 3 out of 5 studies. Family conflict and unhappiness were frequently found in children suffering with headaches, while single-parent families and divorce were not associated. Stressful environments and adverse life events, particularly bullying, were also found to be linked with headaches.

CONCLUSIONS

Childhood headaches represent an alarm bell for clinicians to investigate and treat psychological or psychiatric disorders in children and their family. Further studies are needed to elucidate the role of early-life adverse events in children and their families.

Efficacy of Cognitive-Behavioral Therapy for the Prophylaxis of Migraine in Adults: A Three-Armed Randomized Controlled Trial

Background

Behavioral approaches are central to the preventive treatment of migraine but empirical evidence regarding efficacy and effectiveness is still sparse. This study aimed to evaluate the efficacy of a newly developed migraine-specific, integrative cognitive-behavioral therapy program (miCBT) combining several approaches (trigger and stress management, coping with fear of attacks, relaxation training) by comparing it with a single behavioral approach (relaxation training, RLX) as an active control group and a waiting-list control group (WLC).

Methods

In a three-armed open-label randomized controlled trial, 121 adults with migraine were assigned to either miCBT, RLX or WLC. The outpatient group therapy (miCBT or RLX) consisted of seven sessions each 90 min. Participants who completed the WLC were subsequently randomized to one of the two treatment groups. Primary outcomes were headache days, headache-related disability, emotional distress, and self-efficacy. The baseline was compared to post-treatment, and followed by assessments 4- and 12-months post-treatment to compare miCBT and RLX.

Results

Mixed-model analyses (intention-to-treat sample, 106 participants) showed significantly stronger pre-post improvements in self-efficacy (assessed by the Headache Management Self-Efficacy Scale, HMSE-G-SF) in both treatment groups compared to the WLC (mean difference at post; miCBT: 4.67 [0.55–8.78], p = 0.027; RLX: 4.42 [0.38 to 8.46], p = 0.032), whereas no other significant between-group differences were observed. The follow-up analyses revealed significant within-group improvements from baseline to 12-month follow-up in all four primary outcomes for both treatments. However, between-group effects (miCBT vs. RLX) were not significant at follow-up.

Conclusion

The miCBT has no better treatment effects compared to RLX in migraine-prophylaxis. Both treatments effectively increase patients' self-efficacy.

Trial Registration

German Clinical Trials Register (www.drks.de; DRKS-ID: DRKS00011111).

Examining the Interplay of Smartphone Use Disorder, Mental Health, and Physical Symptoms

The current study examined antecedents and possible consequences of smartphone use disorder (SmUD). In particular, we aimed to increase the understanding of the interplay of SmUD, mental health, and physical symptoms. Studies found that SmUD is associated with diverse psychological and physical health impairments, ranging from depression and anxiety to headaches and sleep disturbances. Based on existing works, we assumed that mental problems mediate the relationship between SmUD and bodily problems. We conducted a cross-sectional random-quota online survey among 938 German smartphone owners aged 14 to 64 years. An instrument based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was used to measure SmUD severity. The data was analyzed using structural equation modeling. We identified a rate of 4.0% potentially disordered users. Males and younger participants showed more signs of SmUD. As expected, SmUD severity was found to be associated with physical (more frequent headaches, sleep disturbances, gastrointestinal problems) as well as psychological (higher levels of loneliness, stress, depression/anxiety) health impairments. Investigating the interplay of these variables showed that depression and anxiety, and stress partially mediated the relationship between SmUD severity and physical symptoms. Taken together, our results confirm that increased SmUD severity is associated with mental problems as well as with somatic symptoms. We assume complex (and presumably circular) relationships, which future studies should examine in more detail. SmUD prevention and intervention programs should follow a broad approach that considers decreases in physical and mental health, possibly causing or resulting from SmUD.

Epidemiological and clinical characteristics of headache among medical students in Palestine: a cross sectional study

BACKGROUND

Headache is one of the most disturbing complaints worldwide, negatively impacting social and regular life activities. In the background of stressful life in medical schools, adding to the stressful situation in Palestine, a developing country under occupation, this study investigated the prevalence and clinical characteristics of migraines and tension- type headaches among medical students from the Palestinian Universities in West Bank and Gaza.

METHODS

A questionnaire-based cross-sectional study was conducted on all Palestinian Medical Students. Students were diagnosed based on ICHD-3 criteria. Demographic characteristics were compared by gender for each type of headache. Frequency, percentage, and mean ± SD. Pearson's chi-squared test, independent t-test, and one-way ANOVA were used where needed. P-value < 0.05 was considered significant.

RESULTS

The study included 806 medical students; 476 (59.0%) of them were female. TTH and migraine's prevalence was 59.8 and 22%, respectively, with a higher prevalence among basic year students. The female to male ratio was 1:0.6 for both types of headaches. Sleep deprivation, physical activities, and altered sleep patterns were reported as the top triggering factors.

CONCLUSIONS

The results demonstrate that the prevalence of both subtypes' primary headache is high among Palestinian medical students, with a higher prevalence among basic year students. The study also showed that these findings are higher than other studies among medical students in other countries.

Exploring the Impact of the COVID-19 Quarantine on the Severity of Headache, Migraine, and Stress in Saudi Arabia

Purpose

This cross-sectional study aimed to investigate the impact of COVID-19 quarantine on the severity of migraine symptoms and stress among adults in Saudi Arabia.

Patients and Methods

Between December 2020 and February 2021, 1212 participants aged 18–65 years completed an online self-administered questionnaire that covered sociodemographic data, self-administered questions, the ID migraine screener, numeric pain rating scale, and the perceived stress scale. Statistical analyses were performed using SPSS. Student’s t-test, paired t-test, and analysis of variance were used to compare quantitative variables, while the chi-square test was used to compare qualitative variables.

Results

After removing ineligible and incomplete responses, we analyzed data obtained from 1111 participants. The mean age of the participants was approximately 29 years old (± 11.2 years); moreover, 87% were females. Headache severity during the COVID-19 quarantine was significantly lower than that during the last 3 months, with a difference of only 0.41 on the 1–10 pain severity scale. There was a significantly increased stress prevalence during the COVID-19 quarantine. During the COVID-19 quarantine, 49%, 56%, and 62% of patients without migraine, patients with possible migraine, and patients with diagnosed migraine, respectively, reported worsening of their perceived stress. There was a weak positive correlation between the severity of migraine symptoms and stress during COVID-19 quarantine. Moreover, headache severity was positively affected by the history of COVID-19 infections.

Conclusion

The headache severity in patients with migraine decreased during COVID-19 quarantine compared with that during the last 3 months. Additionally, patients with diagnosed migraine had significantly higher scores on the perceived stress scale than patients without migraine.

Is there a causal relationship between stress and migraine? Current evidence and implications for management

BACKGROUND

The purpose of this narrative review is to examine the literature investigating a causal relationship between stress and migraine and evaluate its implications for managing migraine.

METHODS

PubMed, PsycINFO and CINAHL were searched from 1988 to August 2021, identifying 2223 records evaluating the relationship between stress and migraine. Records were systematically screened. All potentially relevant records were thematically categorized into six mechanistic groups. Within each group the most recent reports providing new insights were cited.

RESULTS

First, studies have demonstrated an association of uncertain causality between high stress loads from stressful life events, daily hassles or other sources, and the incidence of new-onset migraine. Second, major stressful life events seem to precede the transformation from episodic to chronic migraine. Third, there is some evidence for changes in levels of stress as a risk factor for migraine attacks. Research also suggests there may be a reversed causality or that stress-trigger patterns are too individually heterogeneous for any generalized causality. Fourth, migraine symptom burden seems to increase in a setting of stress, partially driven by psychiatric comorbidity. Fifth, stress may induce sensitization and altered cortical excitability, partially explaining attack triggering, development of chronic migraine, and increased symptom burden including interictal symptom burden such as allodynia, photophobia or anxiety. Finally, behavioral interventions and forecasting models including stress variables seem to be useful in managing migraine.

CONCLUSION

The exact causal relationships in which stress causes incidence, chronification, migraine attacks, or increased burden of migraine remains unclear. Several individuals benefit from stress-oriented therapies, and such therapies should be offered as an adjuvant to conventional treatment and to those with a preference. Further understanding the relationship between stress, migraine and effective therapeutic options is likely to be improved by characterizing individual patterns of stress and migraine, and may in turn improve therapeutics.

Sexual dimorphism in functional pain syndromes

Injury-free pain conditions, defined as functional pain syndromes, are more prevalent and more disabling in women. Mechanisms of sexual dimorphism in functional pain are now emerging from preclinical studies, suggesting an opportunity to advance the development of sex-specific therapies that may improve treatment of pain in women.

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

Background: Pandemic of COVID-19, the potentially fatal disease caused by SARS-CoV-2, had caused intangible consequences on global health systems, economy, daily life, education, travel, leisure, work, and mental health. Its impact on mental and physical health, especially in health professionals, has been described. Objective: This study aimed to review and discuss the published evidence regarding the presence of headache on COVID-19 healthcare workers. Methods: In this review, we searched for all articles published in various data bases including PubMed / Medline, Scopus, and Web of Science and all original research studies, letters to editor, case reports, commentaries and reviews published in English, Portuguese or Spanish were searched. Two researchers independently analyzed published articles in order to include/exclude based on inclusion or exclusion criteria.  Results: Thirteen articles were included.  All studies included in this review were observational; eleven were cross-sectional studies, one was a prospective/cohort and one was a retrospective. Two studies evaluated psychological outcomes, mental health disorders and associated factors, one study investigated symptoms and causes of somatic symptom disorder and all other studies evaluated headaches associated with Personal Protective Equipment (PPI). Conclusions: The present review shows that COVID-19 pandemic has negative impact on physical and mental health in healthcare workers and headache has been associated to psychological stress and work overload during pandemic.  Further studies are necessary to better investigate COVID-19 pandemic effects on headaches and other neurological conditions.

Disability and Economic Loss Caused by Headache among Information Technology Workers in Korea

Background and Purpose

Headache disorders are a leading cause of disability globally. However, there is inadequate information available about these disorders and the related economic loss in the workplace in Asian countries. Information technology (IT) jobs are intellectually and cognitively challenging, and hence IT workers are a suitable population for assessing headache disorders and related economic loss.

Methods

We sent invitation emails to all employees of selected IT companies. A comprehensive Web-based questionnaire regarding headache characteristics, disability, quality of life, and economic loss was completed by 522 participants from 8 companies.

Results

The participants included 450 (86.2%) who had experienced headache more than once during the previous year. The frequencies of migraine, probable migraine (PM), and tension-type headache (TTH) were 18.2%, 21.1%, and 37.0%, respectively. The Migraine Disability Assessment score was higher for participants with migraine [median and interquartile range, 3.0 (0.0–6.0)] than for those with PM [0.0 (0.0–2.0), p<0.001] and TTH [0.0 (0.0–1.0), p<0.001]. The estimated annual economic losses caused by migraine per person associated with absenteeism and presenteeism were USD 197.5±686.1 and USD 837.7±22.04 (mean±standard deviation), respectively. The total annual economic loss per person caused by migraine (USD 1,023.3±1,972.7) was higher than those caused by PM (USD 424.8±1,209.1, p<0.001) and TTH (USD 197.6±636.4, p<0.001).

Conclusions

Migraine, PM, and TTH were found to be prevalent among IT workers in Korea. Disability and economic loss were significantly greater in participants with migraine than in those with PM or TTH.

The Influence of the COVID-19 Pandemic on the Stress Levels and Occurrence of Stomatoghnatic System Disorders (SSDs) among Physiotherapy Students in Poland

BACKGROUND

This study is a quantitative analysis examining the impact of the COVID-19 pandemic on the occurrence of stress and stomatognathic system disorders (SSDs) among students of physiotherapy.

OBJECTIVE

To assess stress severity, strategies of coping with stress and the presence of type D personality among physiotherapy students including those with symptoms of stomatognathic system disorders.

MATERIAL AND METHODS

The research was conducted from October to December 2020 on a sample of 188 students of physiotherapy. The data were collected using a survey form related to the occurrence of SS disorders symptoms and standardized psychological questionnaires, such as the Perceived Stress Scale (PSS)-10, Mini-Cope, and the type-D Scale (DS14), developed for the purpose of this study.

RESULTS

Women experiencing at least one of the SS disorder-related symptoms were characterized by a significantly higher level of stress and a type D personality (p < 0.05). Among men, these differences were not statistically significant (p > 0.05). On the basis of the strategies of coping with stress, i.e., positive self-reevaluation, discharging and blaming oneself, and taking psychoactive substances, it is possible to predict the intensity of stress during the pandemic in the group of the examined students. Among the reported symptoms of SS, headache was a significant predictor of stress, which was accompanied by an increase in the intensity of stress by nearly 0.2 measurement points. Students with higher levels of stress showed more symptoms of type D personality, and those with more severe symptoms of SS showed higher levels of stress.

CONCLUSIONS

People prone to stress and having type D personality traits should be assessed for the presence of SS disorders.

The Relationship between Stress and Masticatory Muscle Activity in Female Students

The aim of the study was to analyze the relationship between stress measured by the perceived stress scale (PSS-10) questionnaire and masticatory muscle activity. Experimental design assumed the study of healthy young women without temporomandibular disorders, dividing them into three groups depending on the result of the stress level and then comparing these groups in terms of bioelectrical activity of the masticatory muscles. After the exclusion criteria were applied, 63 female students (mean age: 22.3 ± 2.4 years) from Medical University of Lublin were included in the study. The subjects were then divided into 3 groups: with low (n = 18), medium (n = 18) and high stress level (n = 27), according to PSS-10 results. Resting and functional activity of temporalis anterior (TA) and masseter (MM) muscles were measured by electromyograph BioEMG III. There were statistically significant effects of group on the absolute value of asymmetry index (AsI) of TA and MM during maximum voluntary clenching on dental cotton rollers (both p = 0.02). Post hoc analysis shows that there were statistically significant differences between medium and high stress groups in AsI TA (p = 0.01) and between low and high stress groups in AsI MM (p = 0.02). Perceived stress measured by PSS-10 questionnaire seems to be associated with changes in muscular asymmetry in functional clenching activity.

Poor social support and loneliness in chronic headache: Prevalence and effect modifiers

OBJECTIVE

To explore the prevalence of poor social support and loneliness among people with chronic headache, and how these might be effect modifiers in the relationships between chronic headache and stress, medication overuse, and self-rated health.

BACKGROUND

Poor social support and loneliness are consistently linked to worse health outcomes. There are few epidemiologic studies on their effect on headache.

METHODS

The Danish Capital Region Health Survey, a cross-sectional survey, was conducted in 2017. Participants were asked about headache, pain medication use, social support, loneliness, perceived stress, and self-rated health. Data were accessed from sociodemographic registers. Logistic regression analyses were performed to test for effect modification.

RESULTS

The response rate was 52.6% (55,185 respondents) and was representative of the target population. People with chronic headache were more likely to report poor social support and loneliness compared to those without chronic headache (p < 0.0001 for both). Odds ratios for the combination of chronic headache and poor social support were very high for stress (odds ratio 8.1), medication overuse (odds ratio 21.9), and poor self-rated health (odds ratio 10.2) compared to those without chronic headache and with good social support. Those who reported both chronic headache and loneliness had a very high odds ratio for stress (odds ratio 14.4), medication overuse (odds ratio 20.1), and poor self-rated health (odds ratio 15.9) compared to those without chronic headache and low loneliness score. When adjusted for sociodemographic factors, poor social support and loneliness were not significant effect modifiers in almost all these associations. Loneliness was a significant effect modifier in the association between chronic headache and medication overuse, but exerted greater effect among those who did not report they were lonely.

CONCLUSION

Poor social support and loneliness were prevalent among people with chronic headache. The combination of chronic headache and poor social support or loneliness showed higher odds ratios for stress, medication overuse, and poor self-rated health compared to those with good social support and low loneliness scores. The effect of loneliness in the relationship between chronic headache and medication overuse warrants further study.

Perceived stress in the time of COVID-19: the association with brooding and COVID-related rumination in adults with and without migraine

Background

The main goal of this research was to explore whether migraineurs had a higher level of perceived stress than healthy controls during the times of the coronavirus and related restrictive measures, and to examine the relationship between different subtypes of rumination and perceived stress in these groups. We measured two facets of depressive rumination, brooding and reflection, along with rumination about the current COVID-19 situation to see whether these different subtypes of rumination explained perceived stress among migraineurs and healthy controls.

Methods

Healthy adults (n = 64) and migraine patients (n = 73) filled out self-report questionnaires online. A multiple linear regression model was used to test whether depressive rumination (i.e. brooding and reflection) and COVID-related rumination explained perceived stress among adults with and without migraine during the times of COVID-19, after controlling for gender, age, migraine/control group status and migraine disability.

Results

Although we did not find any difference in the level of perceived stress among migraineurs and the control group, perceived stress was more strongly associated with brooding as well as COVID-related rumination among migraineurs than healthy controls. COVID-related rumination and brooding (but not reflection) explained the level of perceived stress after controlling for gender, age, migraine/control group status and migraine disability.

Conclusions

The similar degree of perceived stress among migraineurs and the control group may imply that there is great variation in the personal experience of people regarding the pandemic, that may be determined by numerous other factors. Our results demonstrate that ruminating about the pandemic and related difficulties, as well as brooding (but not reflection) appear to be associated with higher level of perceived stress during the times of the coronavirus. This association was slightly stronger among migraineurs, hinting at the increased vulnerability of this patient group in stressful situations like the COVID-19 pandemic. Our results also suggest that ruminating about the pandemic and its consequences is weakly associated with trait-level depressive rumination, thus may be more contingent on specific factors.

Estrategias de afrontamiento, estrés percibido y bienestar psicológico en individuos con cefalea primaria

El propósito de este estudio fue evaluar la asociación entre las estrategias de afrontamiento, el bienestar subjetivo y el estrés en personas con cefalea primaria - es decir, con dolor de cabeza sin origen orgánico. En total, participaron 150 personas adultas -135 mujeres y 15 hombres-diagnosticadas con cefalea primaria y episodios de cefalea en los últimos seis meses. Los instrumentos de medida utilizados fueron la Escala de satisfacción con la vida de Diener, la escala de estrategias de afrontamiento Brief Cope, la Escala de estrés percibido de Cohen, dos preguntas sobre la intensidad y frecuencia del dolor, y un cuestionario sociodemográfico. En general, se encontró que el bienestar subjetivo se relaciona positivamente con la planificación y negativamente con el uso de sustancias y la frecuencia del dolor; a la vez que el estrés percibido se asocia positivamente con negar la realidad del acontecimiento estresante, culpabilizarse por la situación ocurrida y la frecuencia del dolor, y negativamente con la aceptación de la situación estresante. Además, se observó un mayor estrés percibido en usuarios de atención pública de salud que en aquellos que son atendidos en el sistema privado. Este estudio permite identificar las estrategias que deben ser potenciadas o modificadas con ayuda del personal de salud para mejorar la calidad de vida de las personas con cefalea primaria.

A Behavioral-Analytic Model for Assessing Stress in Firefighters

Research has documented a number of acute and chronic stressors unique to the fire service. Due to the rise in mental health concerns in firefighters, there has been increased awareness of the negative effects of unmanaged stress. The present study employed a behavioral-analytic model to construct a brief screening measure of stress for this population: the Firefighter Assessment of Stress Test (FAST). Psychometric properties of the FAST were evaluated using data from active-duty firefighters throughout the United States. Results indicated the FAST has good internal reliability (α = 0.89), as well as good convergent and discriminant validity. Also, the factor structure of the FAST revealed three significant subscales reflective of stress associated with responding to calls, administrative difficulties, and being overworked. Scoring and interpretation guidelines were established to suggest when further assessment is warranted. The FAST offers a brief and valid method of self-assessment of current stress levels in firefighters. Information obtained from the FAST (i.e., overall stress level and domains) has the potential to facilitate more immediate identification and recognition of stress in firefighters than what has been possible to date. Moreover, heightened awareness of stress and its effects will hopefully culminate in expanded efforts directed toward stress reduction and intervention for firefighters and their families.

Association of Personal Protective Equipment with De Novo Headaches in Frontline Healthcare Workers during COVID-19 Pandemic: A Cross-Sectional Study

OBJECTIVES

 This study aimed to determine the association of personal protective equipment (PPE) usage with new-onset headaches and exacerbation of pre-existing headache disorders among healthcare workers at the frontlines during coronavirus disease 2019 (COVID-19) pandemic.

MATERIALS AND METHODS

 A descriptive cross-sectional survey was conducted across Pakistan in June-July 2020. The study was approved by Ethical Committee, Armed Forces Institute of Dentistry, Rawalpindi (IRB form no.905/Trg-ABP 1K2). A qualitative questionnaire was developed and was shared via different social networks. The questionnaire was closed when 241 responses were received.

STATISTICAL ANALYSIS

 Descriptive analysis was performed on demographic data. Chi-squared analysis was performed between demographic data and PPE-usage patterns among participants with or without de novo headaches. Univariable and multivariable logistic regression models were used to compare variables with the development of new-onset headaches. Chi-squared test was also performed between demographic data and other factors that may be causing new-onset headaches. A p-value < 0.05 was considered significant.

RESULTS

 A total of 241 healthcare workers participated, of which 68 participants (28.2%) reported de novo headaches since the start of the pandemic. Incidence of pre-existing headaches (odds ratio [OR] = 1.91; 95% confidence interval [CI]: 0.99-0.37; p = 0.049) was associated with new-onset headaches. Post hoc multivariable logistic regression analysis stated that incidence of pre-existing headaches (OR = 1.88; 95% CI: 0.94-3.78; p = 0.75) and age (OR = 2.21; 95% CI: 0.47-10.33; p = 0.36) was independently associated with new-onset PPE-induced headaches but was not statistically significant. Chi-squared analysis showed a statistically significant relationship between other factors (sleep deprivation, emotional stress, etc.) and department of activity, gender, and occupation (p < 0.05).

CONCLUSION

 Healthcare workers with previous history of pre-existing headaches were found to be more susceptible to PPE-induced headaches during COVID-19 pandemic. However, age and the department where the healthcare workers performed may also be risk factors.

Explaining Disparities in Severe Headache and Migraine Among Sexual Minority Adults in the United States, 2013-2018

Previous work has not examined how the association of sexual orientation and severe headache/migraine may be explained by differences between sexual minorities and heterosexuals in sociodemographic and health-related characteristics. Using data from the 2013-2018 National Health Interview Survey, regression decomposition was used to identify determinants of disparities in headache/migraine between sexual minorities collectively and heterosexuals, as well as between bisexual men and gay men, and bisexual women and lesbians. The prevalence of headache/migraine was the highest among bisexual women (36.8%), followed by lesbians (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%). Across all models, the largest percentage of the disparity between sexual orientation/gender groups was attributable to age (range, 18.3%-42.2%), serious psychological distress (range, 6.6%-14.0%), and hours of regular sleep (range, 1.7%-8.2%). Although age accounted for the largest part of the disparity in headache/migraine by sexual orientation, several modifiable risk factors also played a role.

Development and Internal Validation of a Multivariable Prediction Model for Individual Episodic Migraine Attacks Based on Daily Trigger Exposures

OBJECTIVE

To develop and internally validate a multivariable predictive model for days with new-onset migraine headaches based on patient self-prediction and exposure to common trigger factors.

BACKGROUND

Accurate real-time forecasting of one's daily risk of migraine attack could help episodic migraine patients to target preventive medications for susceptible time periods and help decrease the burden of disease. Little is known about the predictive utility of common migraine trigger factors.

METHODS

We recruited adults with episodic migraine through online forums to participate in a 90-day prospective daily-diary cohort study conducted through a custom research application for iPhone. Every evening, participants answered questions about migraine occurrence and potential predictors including stress, sleep, caffeine and alcohol consumption, menstruation, and self-prediction. We developed and estimated multivariable multilevel logistic regression models for the risk of a new-onset migraine day vs a healthy day and internally validated the models using repeated cross-validation.

RESULTS

We had 178 participants complete the study and qualify for the primary analysis which included 1870 migraine events. We found that a decrease in caffeine consumption, higher self-predicted probability of headache, a higher level of stress, and times within 2 days of the onset of menstruation were positively associated with next-day migraine risk. The multivariable model predicted migraine risk only slightly better than chance (within-person C-statistic: 0.56, 95% CI: 0.54, 0.58).

CONCLUSIONS

In this study, episodic migraine attacks were not predictable based on self-prediction or on self-reported exposure to common trigger factors. Improvements in accuracy and breadth of data collection are needed to build clinically useful migraine prediction models.

Patterns of Perceived Stress Throughout the Migraine Cycle: A Longitudinal Cohort Study Using Daily Prospective Diary Data

OBJECTIVES

To describe patterns of perceived stress across stages of the migraine cycle, within and between individuals and migraine episodes as defined for this study.

METHODS

Individuals with migraine aged ≥18 years, who were registered to use the digital health platform N1-Headache^TM , and completed 90 days of daily data entry regarding migraine, headache symptoms, and lifestyle factors were eligible for inclusion. Perceived stress was rated once a day at the participant's chosen time with a single question, "How stressed have you felt today?" with response options graded on a 0-10 scale. Days were categorized into phases of the migraine cycle: P_pre  = pre-migraine headache (the 2 days prior to the first day with migraine headache), P₀  = migraine headache days, P_post  = post-migraine headache (the 2 days following the last migraine day with migraine headache), and P_i  = interictal days (all other days). Episodes, defined as discrete occurrences of migraine with days in all 4 phases, were eligible if there was at least 1 reported daily perceived stress value in each phase. Individuals with ≥5 valid episodes, and ≥75% compliance (tracking 90 days in 120 calendar days or less) were eligible for inclusion in the analysis.

RESULTS

Data from 351 participants and 2115 episodes were included in this analysis. Eighty-six percent of the sample (302/351) were female. The mean number of migraine days per month was 6.1 (range 2-13, standard deviation = 2.3) and the mean number of episodes was 6.0 (range 5-10, standard deviation = 1.0) over the 90-day period. Only 8 (8/351, 2.3%) participants had chronic migraine (defined as 15 or more headache days per month with at least 8 days meeting criteria for migraine). Cluster analysis revealed 3 common patterns of perceived stress variation across the migraine cycle. For cluster 1, the "let down" pattern, perceived stress in the interictal phase (P_i ) falls in the pre-headache phase (P_pre ) and then decreases more in the migraine phase (P₀ ) relative to P_i . For cluster 2, the "flat" pattern, perceived stress is relatively unchanging throughout the migraine cycle. For cluster 3, the "stress as a trigger/symptom" pattern, perceived stress in P_pre increases relative to P_i , and increases further in P₀ relative to P_i . Episodes were distributed across clusters as follows: cluster 1: 354/2115, 16.7%; cluster 2: 1253/2115, 59.2%, and cluster 3: 508/2115, 24.0%. Twelve participants (12/351, 3.4%) had more than 50% of their episodes fall into cluster 1, 216 participants (216/351, 61.5%) had more than 50% of their episodes fall into cluster 2, and 25 participants (25/351, 7.1%) had more than 50% of their episodes fall into cluster 3. There were 40 participants with ≥90% of their episodes in cluster 2, with no participants having ≥90% of their episodes in cluster 1 or 3.

CONCLUSIONS

On an aggregate level, perceived stress peaks during the pain phase of the migraine cycle. However, on an individual and episode basis, there are 3 dominant patterns of perceived stress variation across the migraine cycle. Elucidating how patterns of perceived stress vary across the migraine cycle may contribute insights into disease biology, triggers and protective factors, and provide a framework for targeting individualized treatment plans.

Triggers of Primary Headaches: Issues and Pathways Forward

The triggers of primary headaches have considerable significance for our understanding and management of headache and migraine. Triggers explain the variance in headaches - why they occur when they do. Trigger management is generally viewed as an important component of a comprehensive treatment approach for headaches. Historically, however, triggers have not had a prominent place in the headache literature. This situation began to change 20 to 30 years ago, and the pace of change has increased exponentially in recent times. Nevertheless, the field is beset with issues that have held it back from achieving more. This review will focus on elaborating those issues with the goal of suggesting ways forward. The first issue considered will be the definition of a trigger, and how specific triggers are labeled. Consideration will then be given to a classification system for triggers. The review will discuss next the evidence relating to whether self-reported triggers can, indeed, precipitate headaches, and how the capacity to elicit headaches may be acquired or extinguished. Attention will be given to the very important clinical issue of trigger management. Finally, the pathways forward will be proposed. Perhaps the most useful thing to accomplish at this point in time would be agreement on a definition of headache triggers, a list of triggers, and a classification system for triggers. This would greatly assist in comparing research on triggers from different research groups as well as eliminating some of the issues identified in this review. An authoritative body such as the American Headache Society or the International Headache Society, could establish a multidisciplinary committee that would complete these tasks. Consideration should also be given to incorporating triggers into the International Classification of Headache Disorders as an axis or via the use of codes, as this would raise the profile of triggers in assessment and management.

Efficacy of adding midazolam to paracetamol in pain control of patients with a primary headache: A randomized, clinical trial study

OBJECTIVES:

This study aimed to determine the effect of adding intravenous midazolam to paracetamol in the treatment of patients with primary headache referring to the emergency department.

METHODS:

In a randomized clinical trial, 120 patients (18–65 years old) with primary headache referring to the emergency department were enrolled. Patients were divided into two groups (case: paracetamol + midazolam and control: paracetamol + placebo), and the treatment was administered based on the treatment group. The severity of pain (according to the initial Visual Analog Scale) and at different times after the treatment onset (15, 30, and 60 min) and the degree of satisfaction with the treatment were compared in two groups of patients.

RESULTS:

There were no statistically difference between the two groups about the median of pain severity at the time of 0 min (case: 8 vs. control: 8), 15 min (case: 6 vs. control: 6), and 30 min (case: 4 vs. control: 4) with P > 0.05. Headache severity at 60 min after the treatment onset in the case group (median: 1) was less than that of the control group (median: 3). There was also a statistically significant difference in the median of patient satisfaction in the case group (case: 9 and control: 7 with P < 0.001) and satisfaction in the case group was higher.

CONCLUSIONS:

Based on our primary and secondary outcomes and the results of the study, we conclude that adding intravenous midazolam to paracetamol do not improve the therapeutic response ratio over time, but the effect of this intervention appeared after 1 h.

Headaches Associated With Personal Protective Equipment - A Cross-Sectional Study Among Frontline Healthcare Workers During COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease of pandemic proportions. Healthcare workers in Singapore working in high-risk areas were mandated to wear personal protective equipment (PPE) such as N95 face mask and protective eyewear while attending to patients.

OBJECTIVES

We sought to determine the risk factors associated with the development of de novo PPE-associated headaches as well as the perceived impact of these headaches on their personal health and work performance. The impact of COVID-19 on pre-existing headache disorders was also investigated.

METHODS

This is a cross-sectional study among healthcare workers at our tertiary institution who were working in high-risk hospital areas during COVID-19. All respondents completed a self-administered questionnaire.

RESULTS

A total of 158 healthcare workers participated in the study. Majority [126/158 (77.8%)] were aged 21-35 years. Participants included nurses [102/158 (64.6%)], doctors [51/158 (32.3%)], and paramedical staff [5/158 (3.2%)]. Pre-existing primary headache diagnosis was present in about a third [46/158 (29.1%)] of respondents. Those based at the emergency department had higher average daily duration of combined PPE exposure compared to those working in isolation wards [7.0 (SD 2.2) vs 5.2 (SD 2.4) hours, P < .0001] or medical ICU [7.0 (SD 2.2) vs 2.2 (SD 0.41) hours, P < .0001]. Out of 158 respondents, 128 (81.0%) respondents developed de novo PPE-associated headaches. A pre-existing primary headache diagnosis (OR = 4.20, 95% CI 1.48-15.40; P = .030) and combined PPE usage for >4 hours per day (OR 3.91, 95% CI 1.35-11.31; P = .012) were independently associated with de novo PPE-associated headaches. Since COVID-19 outbreak, 42/46 (91.3%) of respondents with pre-existing headache diagnosis either "agreed" or "strongly agreed" that the increased PPE usage had affected the control of their background headaches, which affected their level of work performance.

CONCLUSION

Most healthcare workers develop de novo PPE-associated headaches or exacerbation of their pre-existing headache disorders.

Gender-specific correlates of perceived life stress: a population-based study, Montreal, Canada, 2012

OBJECTIVES

To identify the gender-specific correlates of perceived life stress in a representative sample of the Montreal population.

METHOD

Data were extracted from the Local Health Survey Program (called "TOPO") collected in 2012. TOPO-2012 provided information on chronic diseases, their determinants and risk factors, as well as lifestyle and health services utilization. Poisson regression was used to identify significant correlates of perceived life stress.

RESULTS

Single-parent females were 21% more likely (RR = 1.21; 95% CI = 1.04-1.42) to report stressful life compared to females living alone. Females born in Canada or established female immigrants were significantly more likely to report stressful life (respectively RR = 1.34; 95% CI = 1.12-1.60 and RR = 1.31; 95% CI = 1.08-1.58) than recent female immigrants. Furthermore, females living in a privileged material neighbourhood reported significantly higher perceived life stress (14% higher) than females living in a deprived neighbourhood. On the other hand, males with higher annual household income were 9% more likely (OR = 1.09; 95% CI = 1.05-1.14) to perceive life stress than males reporting a lower income. Also, overweight males reported higher stress (RR = 1.13; 95% CI = 1.01-1.26) than their normal weighted counterparts. Additionally, males who were diagnosed with a physical health problem were more likely to report stressful life (RR = 1.44; 95% CI = 1.28-1.61) than males who did not report any physical health problem.

CONCLUSION

Identifying correlates of stress at the population level may help researchers characterize people vulnerable to daily stress, provide health agencies the advantage to forecast and prevent its occurrence and diseases associated with it, as well as offer policy advocates a pivotal edge to reduce disparities in population health.

Resilience acts as a moderator in the relationship between infertility-related stress and fertility quality of life among women with infertility: a cross-sectional study

BACKGROUND

Infertility-related stress can seriously impact the fertility quality of life (QoL) of infertile women. Resilience, as a coping resource, can effectively combat psychological stress. This study aimed to evaluate the fertility QoL of infertile women and to examine whether resilience moderates the association of infertility-related stress with fertility QoL.

METHODS

This cross-sectional study was conducted in northeast of China from December 2017 to February 2018. Out of 559 women outpatients with infertility, 498 (89.1%) completed self-reported questionnaires including the FertiQoL Scale, Fertility Problem Inventory (FPI) and Connor-Davidson Resilience Scale (CD-RISC). Hierarchical multiple regression analysis and simple slope analysis were applied to explore the influencing factors related to fertility QoL as well as to examine the moderating effect of resilience on the association of infertility-related stress with fertility QoL.

RESULTS

The mean FertiQoL score was 64.54 ± 16.90 among the participants. Household monthly income and causes of infertility were significantly related to fertility QoL. In addition, infertility-related stress was negatively related to fertility QoL, and resilience was positively associated with fertility QoL, explaining 36.3% of the variance. Resilience moderated the association of infertility-related stress with fertility QoL. Specifically, the effect of infertility-related stress on fertility QoL varied by low(1 SD below the mean, B = - 0.496, β = - 0.714, P < 0.001), mean (B = - 0.293, β = - 0.422, P < 0.001) and high (1 SD above the mean, B = - 0.090, β = - 0.130, P < 0.001) levels of resilience. The higher resilience was, the weaker the effect of infertility-related stress on fertility QoL was.

CONCLUSIONS

Overall, women with infertility in China had relatively low FertiQoL scores. Resilience influenced the association of infertility-related stress with fertility QoL. Infertile patients' psychological status must be addressed and adequate resilience-based interventions such as mindfulness-based skills should be provided to improve fertility QoL of women with infertility.

Non-Pharmacological Treatment for Primary Headaches Prevention and Lifestyle Changes in a Low-Income Community of Brazil: A Randomized Clinical Trial

BACKGROUND

Primary headaches can be reduced by lifestyle changes, such as stress management and physical activity. However, access to programs focused on behavioral interventions is limited in underserved, poor communities.

OBJECTIVES

We performed a randomized open-label clinical trial to test the therapeutic and behavioral effects of aerobic exercise, relaxation, or the combination of both, in individuals with primary headaches of a small, low-income community of the Brazilian Amazon.

METHODS

Participants were screened from the riverine/rural population, and individuals with primary headache were included. We assessed clinical characteristics and physical activity levels. Interventions were delivery 3 times/week for 6 months. The primary outcome variable was changes in days with headache, while changes in duration of attacks, pain intensity, and physical activity levels were secondary outcomes variables.

RESULTS

Seven hundred and ninety individuals were screened (15.3% of rural/riverine population). Seventy-four participants were randomly assigned to relaxation (n = 25), physical activity orientation program (n = 25), or both (n = 24) interventions. Intention to treat analyses showed all interventions as effective to reduce days with headaches and duration of attacks (both P < .01). Pain intensity was reduced only in relaxation and relaxation + physical activity groups (both P < .01). Physical activity levels increased only in the relaxation + physical activity group (P < .05).

CONCLUSIONS

Non-pharmacological interventions such as physical activity and relaxation are effective for reducing headaches, while combining such interventions promote health behavior toward higher physical activity levels in low-income populations with primary headaches.

CLINICAL TRIAL REGISTRATION NUMBER

SGPP 1544.

Stress Is Associated with Poor Outcome of Acute Treatment for Chronic Migraine: A Multicenter Study

Background

Chronic migraine (CM) is associated with severe psychological symptoms and disabilities. Information on the relationship between stress and the outcomes of acute CM treatment is limited.

Methods

We evaluated the clinical presentation and stress levels of patients with CM who visited the neurology departments of 14 hospitals between September and December 2015. The patients were divided into stress and reference groups on the basis of the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K). Quality of life was evaluated using EuroQol Five Dimension Questionnaire Three-Level. The Migraine Assessment of Current Therapy questionnaire was used to assess the outcomes of acute treatment.

Results

This study included 186 CM patients. On the basis of the BEPSI-K score, 79 and 107 patients were assigned to the stress and reference groups, respectively. The stress group had more patients with poor outcomes of acute treatment than the reference group (67.1% vs 40.2%, P < 0.001). In a multivariate analysis, female gender (odds ratio [OR] = 3.266, 95% confidence interval [CI] = 1.172-9.103, P = 0.024), the number of headache-free days per month (OR = 0.932, 95% CI = 0.883-0.985, P = 0.012), and BEPSI-K score (OR = 1.667, 95% CI = 1.051-2.643, P = 0.030) predicted poor outcomes of acute treatment.

Conclusions

High levels of stress were reported by 42.5% of patients with CM. The association between stress and the outcomes of acute treatment suggests that stress is an important clinical variable for improving the management of CM.

Validation of a Chinese version of the stress overload scale-short and its use as a screening tool for mental health status

PURPOSE

Although stress emerges when environmental demands exceed personal resources, existing measurement methods for stress focus only on one aspect. The newly-developed Short Stress Overload Scale (SOS-S) assesses the extent of stress by assessing both event load (i.e., environmental demands) and personal vulnerability (i.e., personal resources). The present study was designed to evaluate the psychometric properties of the Chinese version of Stress Overload Scale-Short (SOS-SC), and further examine its roles in screening mental health status.

METHODS

A total of 1364 participants were recruited from communities and colleges for scale validation.

RESULTS

Reliabilities were good throughout the subsamples (ω > 0.80). Confirmatory factor analysis indicated the acceptable goodness-of-fit for the two-factor correlated model (Sample 1: 560 community residents). Multi-group confirmatory factor analysis confirmed measurement invariance across community residents (Sample 1) and college students (Sample 2 and Sample 3). Criterion validity and convergent validity were established (Sample 2: 554 college students). Latent moderated structural equations demonstrated that the relationship between SOS-SC and depression is moderated by social support (Sample 2), further validating the SOS-SC. In addition, the SOS-SC effectively screened individuals in a population at different levels of mental health status (i.e., "at risk" vs. "at low risk" for depression symptoms and/or wellbeing).

CONCLUSION

The SOS-SC exhibits acceptable psychometric properties in the Chinese context. That said, the two aspects of stress can be differentiated by the Chinese context, therefore, the SOS-SC can be used to measure stress and screen mental health status among the Chinese population, and monitor and evaluate health-promoting interventions.

Behavioral Treatments for Post-Traumatic Headache

PURPOSE OF REVIEW

Post-traumatic headache (PTH) is a common headache type after traumatic brain injury (TBI). There are no FDA approved medications for PTH, and it is unknown how medications can affect the brain's ability to recover from TBI. Thus, we sought to examine the biopsychosocial factors that influence PTH and the non-pharmacologic treatments studied for headache treatment. We also sought to determine if there is literature examining whether the non-pharmacologic treatments influence the biopsychosocial factors. The non-pharmacologic treatments assessed included cognitive behavioral therapy (CBT), biofeedback, progressive muscle relaxation therapy (PMR), acupuncture, and physical therapy (PT).

RECENT FINDINGS

Factors associated with prognosis in PTH may include the following: severity of TBI, stress, post-traumatic stress disorder, other psychiatric comorbidities, sociocultural and psychosocial factors, litigation, base rate misattribution, expectation as etiology, and chronic pain. There are few high quality studies on the non-pharmacologic treatments for PTH. Thermal and EMG biofeedback appear to have been examined the most followed by CBT. Studies did not have secondary outcomes examining the psychosocial factors related to PTH. Most of the behavioral studies involved a multi-modality intervention limiting the ability to assess the individual non-pharmacologic interventions we sought to study. There were very few randomized clinical trials evaluating the efficacy of non-pharmacologic interventions. Therefore, future research, which considers the noted biopsychosocial factors, is needed in the field to determine if these interventions reduce PTH.

The Headache Triggers Sensitivity and Avoidance Questionnaire: Establishing the Psychometric Properties of the Questionnaire

OBJECTIVE

The purpose of this study was to evaluate the psychometric properties of the newly developed Headache Triggers Sensitivity and Avoidance Questionnaire (HTSAQ) designed to measure variables relating to the Trigger Avoidance Model of Headaches.

BACKGROUND

The Trigger Avoidance Model of Headaches proposes that one pathway to developing a primary headache disorder is through the avoidance of headache triggers, resulting in an increase in trigger potency through sensitization. Conversely, prolonged exposure to certain triggers may reduce a potential trigger's ability to precipitate a headache. This model has led to an alternative approach to trigger management being proposed called Learning to Cope with Triggers, which advocates the desensitization of certain headache triggers through controlled exposure, while supporting avoidance of those triggers that are detrimental to health and wellbeing. To be able to evaluate predictions based on the Trigger Avoidance Model of Headaches and to investigate the effectiveness of Learning to Cope with Triggers, psychometrically sound measures of trigger sensitivity and trigger avoidance are needed.

METHOD

A convenience sample of 376 participants (87.5% female; 64.1% European descent) was recruited for the online study which consisted of a battery of measures including the HTSAQ, Brief Headache Screen, Pain Anxiety Symptoms Scale, Pain Sensitivity Questionnaire, Chronic Pain Acceptance Questionnaire, and demographic items. With an interval of 2-6 weeks, a subsample of participants (n = 201) completed the HTSAQ for a second time. The mean age of the sample was 31.4 years (SD = 12.8). The most common headache diagnoses (based on the Brief Headache Screen) were migraine (chronic = 62; episodic = 160), followed by medication-overuse headache (n = 87). The remaining participants (n = 67) were diagnosed as having episodic less severe headache (most likely tension-type headache).

RESULTS

Reliability was assessed through internal consistency and test-retest reliability over a period of 2-6 weeks, and both were excellent (alpha > .80). Strong construct validity was demonstrated by the measure's scale scores being significantly correlated in theoretically consistent ways with the Pain Sensitivity Questionnaire, Pain Anxiety Symptoms Scale, and Chronic Pain Acceptance Questionnaire. As the Trigger Avoidance Model of Headaches would predict, correlations between the HTSAQ Sensitivity scales and the Avoidance scale were strong (P < .001), and participants with chronic migraine had significantly higher HTSAQ scores than those with episodic headaches.

CONCLUSION

The findings support the use of the HTSAQ as a valid and reliable tool for assessing sensitivity to headache triggers and avoidance of headache triggers. Further research examining the factor structure of the HTSAQ is warranted.