Limbically Augmented Pain Syndrome (LAPS): Kindling, Corticolimbic Sensitization, and the Convergence of Affective and Sensory Symptoms in Chronic Pain Disorders

Shared genetic risk and causal associations between Post-traumatic stress disorder and migraine with antithrombotic agents and other medications

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that frequently co-occurs with pain disorders including migraine. There are proposed biological, genetic and environmental factors associated with both PTSD and migraine suggesting shared etiology. Genome-Wide Association Studies (GWAS) have been used to identify genomic risk loci associated with various disorders and to investigate genetic overlap between traits. There is a significant genetic correlation between PTSD and migraine with no evidence of a causal relationship that could be attributed to pleiotropy. Cross-disorder genetic analyses were applied to investigate the genetic overlap and causal associations using GWAS summary statistics of PTSD (n = 214408), migraine (n = 873341) and 23 medication use traits (n = 78808-305913) including anti-depressants, anti-migraine preparations and beta-blocking agents. Across the entire genome, anti-thrombotic agents had a significant and negative genetic correlation with PTSD (rG = -0.2, P FDR = 0.032) and a positive genetic correlation with migraine (rG = 0.26, P FDR = 2.23 x 10-8). PTSD showed significant genetic correlation with 11 other medication use traits including beta blocking agents (rG = -0.11, P FDR = 0.034). Of the 2495 genomic regions tested, PTSD showed significant local genetic correlation with 12 medication use traits at 43 loci; while migraine showed significant genetic correlation with only anti-inflammatory agents and anti-rheumatic products at locus 12:57522282-57607142 (DAB1) (P < 2 x 10-5). The genetic liability to PTSD had a causal effect on increased risk of using pain medication such as opioids (β ivw = 0.59, P = 5.21 x 10-5) while the genetic liability to migraine had a causal effect on the increased risk of using anti-thrombotic agents (β ivw = 0.59, P = 1.69 x 10-7). The genes in the genomic regions shared between PTSD and medication use traits were enriched in neural-related pathways such as neuron development, neurogenesis and protein kinase activity. These results provide further insight into the genetically controlled biological and environmental factors underlying the shared etiology between PTSD and migraine. The identified biomarkers can be used as a basis for investigation as potential drug targets for both disorders. These findings are significant for drug re-purposing and treatment of PTSD and migraine using monotherapy.

Comorbid conditions in Egyptian patients with migraine

BACKGROUND

Identifying migraine comorbidities may guide prognosis and treatment options. This study aimed to assess the frequency of comorbid conditions among adults with migraine living in Greater Cairo.

METHODS

In this cross-sectional study, Egyptian migraine sufferers aged ≥ 18 years living in Greater Cairo were consecutively recruited (April 2019 - April 2021). Following The International Classification of Headache Disorders-third edition, diagnosis of migraine was confirmed, and the type of migraine was defined as whether episodic or chronic, with or without aura, with childhood/adolescence or adulthood onset. Specialist physicians from the research team assessed comorbid conditions among the respondents.

RESULTS

The mean age of respondents (n = 1064) was 35 ± 7. Irritable bowel syndrome represented the most common comorbidity in our patients (45.5%), followed by vitamin D deficiency (41.8%). The frequency of epilepsy, stroke, multiple sclerosis, and systemic lupus erythematosus was significantly higher in patients with chronic than episodic type (χ2 = 4.514, P = 0.034), (χ2 = 12.302, P = 0.001), (χ2 = 12.302, P = 0.001), (χ2 = 4.806, P 0.028), respectively. Females with menstrual migraines had a significantly higher frequency of generalized anxiety disorder, panic attacks, and restless leg syndrome than those with non-menstrual migraines (χ2 = 7.636, P 0.006), (χ2 = 9.245, P = 0.002), and (χ2 = 11.997, P = 0.001), respectively. The frequency of diabetes was significantly higher in patients with migraine with aura than in those without aura (χ2 = 4.248, P value 0.039).

CONCLUSION

This study provides a better understanding of the comorbidities in Egyptian patients with migraine and will provide new avenues for developing individualized therapy for migraine patients.

Chronic pain outcomes of patients receiving electroconvulsive therapy: A systematic review and case series

INTRODUCTION

The potential benefits of electroconvulsive therapy (ECT) in chronic pain and several theories for its mechanism have been reported in the past, but mixed findings have also been reported. In the current systematic review and case series, our primary aim was to assess whether pain and functional outcomes are improved after ECT in patients with chronic pain. Secondary objectives included examining whether psychiatric improvement, specific pain diagnoses, and demographic or medical characteristics were associated with differences in pain treatment response.

METHODS

We performed a retrospective chart review to identify patients with chronic pain diagnoses for more than 3 months prior to the initiation of ECT and a systematic literature search on electronic databases for studies on chronic pain outcomes after ECT.

RESULTS

Eleven patients with various chronic pain diagnoses and comorbid psychiatric conditions were identified in the case series. Six patients reported improvement in pain while 10 patients reported improvement in mood following ECT. Systematic review identified 22 articles reporting a total of 109 cases. Eighty-five (78%) of cases reported reduction in pain while 96.3% of the patients with a comorbid psychiatric diagnosis reported improvement in mood symptoms post-ECT. While there was an association between improvement in mood and pain in studies with numeric ratings in both outcomes (r = 0.61; p < 0.001), some patients reported pain improvement without improvement in mood in both the case series and the pooled analysis of cases in the review. Certain pain diagnoses such as CRPS, phantom limb pain, neuropathic pain, and low back pain have consistently reported benefits and should be further studied in future studies with matched case controls.

CONCLUSION

ECT may be offered to patients with certain pain conditions who have not responded sufficiently to conventional therapies, particularly when comorbid mood symptoms are present. Improved documentation practices on the outcomes in chronic pain patients receiving ECT will help generate more studies that are needed on this topic.

Early analgesic administration and headache presence 7 days post-concussion in children

OBJECTIVE

This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth.

METHODS

A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models.

RESULTS

2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)].

CONCLUSIONS

Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

Cross-Sectional Study of Headache in Flemish Children and Adolescents

Background: Although headache is common in pediatrics, data for the Flemish population are missing. We explored headache-prevalence, and its association with communication-technology (CT) and physical activity (PA) in Flemish children and adolescents. Methods: A cross-sectional exploratory school-based questionnaire study was designed. Flemish boys and girls (5–18 years) completed a symptom-questionnaire. Primary outcomes: sociodemographic background, headache-prevalence, headache-characteristics, CT-use and PA characteristics (self-report). Secondary outcomes: associations between headache-characteristics, age, gender, and CT-use and PA-characteristics. Results: Four hundred twenty-four questionnaires were analysed: 5–7-years: n = 58; 8–11-years: n = 84; 12–15-years: n = 137; 16–18-years: n = 145. Fifty-five percent suffered from headache. Prevalence increased with age. More 16–18-year girls versus boys had headache. CT-use was the main headache-provocateur. Headache prevalence was significantly higher in a frequently physical active population. Conclusion: Our results suggest presence of headache in Flemish children and adolescents. PA-level associates with headache prevalence. However, children and adolescents with headache did not report more CT-use compared to controls.

Implications on hypnotherapy: Neuroplasticity, epigenetics and pain

We provide a brief review about the significance of hypnosis with respect to applications and physiological processes in hypnotherapy. Our review concludes that hypnosis is a promising method to manage acute and chronic pain. In addition, we discuss indications pointing toward the view that hypnosis can induce changes in neuroplasticity possibly involving epigenetic mechanisms.

Management of Pediatric Post-Concussion Headaches: National Survey of Abortive Therapies Used in the Emergency Department

Children frequently present to an Emergency Department (ED) after concussion, and headache is the most commonly associated symptom. Recent guidelines emphasize the importance of analgesia for post-concussion headache (PCH), yet evidence to inform treatment is lacking. We sought to characterize abortive therapies used to manage refractory PCH in the pediatric ED and factors associated with treatment. A scenario-based survey was distributed to ED physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding ED treatment of acute (48 h) and persistent (1 month) PCH refractory to appropriate doses of acetaminophen/ibuprofen. Logistic regression was used to assess factors associated with treatment. Response rate was 63% (137/219). Nearly all physicians (128/137, 93%) endorsed treatment in the ED for acute PCH of severe intensity, with most selecting intravenous treatments (116/137, 84.7%). Treatments were similar for acute and persistent PCH. The most common treatments were metoclopramide (72%), physiologic saline (47%), and nonsteroidal anti-inflammatory agents (NSAIDS; 35%). Second-line ED treatments were more variable. For acute PCH of moderate intensity, overall treatment was lower (102/137, 74%; p < 0.0001), and NSAIDS (48%) were most frequently selected. In multi-variable regression analyses, no physician- or ED-level factor was associated with receiving treatment, or treatment using metoclopramide specifically. Treatment for refractory PCH in the pediatric ED is highly variable. Importantly, patients with severe PCH are most likely to receive intravenous therapies, often with metoclopramide, despite a paucity of evidence supporting these choices. Further research is urgently needed to establish the comparative effectiveness of pharmacotherapeutic treatments for children with refractory PCH.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

[EMDR as a psychotherapeutic approach in the treatment of chronic pain : Is Eye Movement Desensitization and Reprocessing an effective therapy for patients with chronic pain who do not suffer from posttraumatic stress disorder?]

The efficacy of Eye Movement Desensitization and Reprocessing (EMDR) has been demonstrated for posttraumatic stress disorder. Despite promising research, it is still not clear if EMDR is a similarly effective treatment for chronic pain. Controlled trials are lacking and whether specific mechanisms underlie the effects remains unknown. The treatment of chronic pain aims at a reduction of subjective pain sensations. To achieve this goal without the usage of pain medications, i. e. through psychotherapy, is desirable for many reasons (e. g. reduction of treatment costs and side effects). Whether or not EMDR is an effective intervention for all chronic pain patients (or just a specific subgroup) constitutes an important question for psychological pain research.

Adaption of the Biopsychosocial Model of Chronic Noncancer Pain in Veterans

Population

Veterans with chronic noncancer pain (CNCP) are a vulnerable population whose care remains a challenge for clinicians, policy-makers, and researchers. As a result of military experience, veterans are exposed to high rates of musculoskeletal injuries, trauma, psychological stressors (e.g., post-traumatic stress disorder, depression, anxiety, substance abuse), and social factors (e.g., homelessness, social isolation, disability, decreased access to medical care) that contribute to the magnitude and impact of CNCP. In the veteran population, sound theoretical models are needed to understand the specific physiological, psychological, and social factors that influence this unique experience.

Objective

This paper describes an adaption of Gatchel and colleagues' biopsychosocial model of CNCP to veterans and summarizes research findings that support each component of the revised model. The paper concludes with a discussion of important implications for the use of this revised model in clinical practice and future directions for research.

Conclusions

The adaption of the biopsychosocial model of CNCP for veterans provides a useful and relevant conceptual framework that can be used to guide future research and improve clinical care in this vulnerable population.

Sport-related injury and pain classification

Pain is common in athletes, and pain management in sport has traditionally been equated with injury management. Although both pain and injury interfere with sport performance, they are not synonymous. Acute musculoskeletal injury commonly manifests as nociceptive pain, inflammatory pain, or both. Pain that persists beyond expected injury recovery must account for all potential contributors to pain, including ongoing biomechanical abnormalities, underlying pathophysiology, and psychosocial issues. Pain chronification involves multiple pathophysiologic and neurobehavioral processes that lead from acute injury-related pain to subacute and chronic pain, and must be distinguished from an ongoing biomechanical overuse pattern. The foundation of pain management in athletes is proper pain classification, which involves assessing for any combination of nociceptive/inflammatory pain, neuropathic pain, central sensitization, and autonomic/motor/affective manifestations of pain. Understanding this foundation is critical because there are scant evidence-based guidelines for the management of pain in sport. This chapter will explore the relationship of sport-related injury and pain, and will provide a management framework that is consistent with International Olympic Committee consensus.

Investigating the effect of Eye Movement Desensitization and Reprocessing (EMDR) on postoperative pain intensity in adolescents undergoing surgery: a randomized controlled trial

AIM

To investigate the efficacy of Eye Movement Desensitization and Reprocessing for postoperative pain management in adolescents.

BACKGROUND

Eye Movement Desensitization and Reprocessing is an inexpensive, non-pharmacological intervention that has successfully been used to treat chronic pain. It holds promise in the treatment of acute, postsurgical pain based on its purported effects on the brain and nervous system.

DESIGN

A randomized controlled trial was used.

METHODS

Fifty-six adolescent surgical patients aged between 12-18 years were allocated to gender-balanced Eye Movement Desensitization and Reprocessing (treatment) or non-Eye Movement Desensitization and Reprocessing (control) groups. Pain was measured using the Wong-Baker FACES(®) Pain Rating Scale (WBFS) before and after the intervention (or non-intervention for the control group).

FINDINGS

A Wilcoxon signed-rank test demonstrated that the Eye Movement Desensitization and Reprocessing group experienced a significant reduction in pain intensity after treatment intervention, whereas the control group did not. Additionally, a Mann-Whitney U-test showed that, while there was no significant difference between the two groups at time 1, there was a significant difference in pain intensity between the two groups at time 2, with the Eye Movement Desensitization and Reprocessing group experiencing lower levels of pain.

CONCLUSION

These results suggest that Eye Movement Desensitization and Reprocessing may be an effective treatment modality for postoperative pain.

Topographic Analysis of Electroencephalographic Changes during Photic Driving Responses in Patients with Migraine

OBJECTIVE

Migraineurs demonstrate abnormal information processing such as photic hypersensitivity. The photic driving response to photic stimulation (PS) is a reaction to the visual stimulation of electroencephalography (EEG). Both the photic driving response and photic hypersensitivity appear during light stimulation. We considered that evaluation of a migraineur's photic driving response may help to elucidate the mechanism of the migraineur's sensitive condition. Our study aimed to investigate EEG photic driving responses with a source-localizing method.

METHODS

We recorded spontaneous resting EEG with eyes closed from 20 electrodes on the scalp during the interictal phase. After recording, each PS was separately selected. We also analyzed EEG by fast Fourier transform and observed the spectrum frequency peaks and topographies in response to PS.

RESULTS

The photic driving response could be observed at a flashing rate of >15 Hz. Patients with photic hypersensitivity tended to show more photic driving regardless of the migraine subtype. Moreover, in topographies, their activated areas were shifted anteriorly from fundamental driving to harmonic driving for each photic frequency. This anterior shift was more evident with a longer duration of illness, although no significant differences were seen between migraine subtypes. The global field power value had a positive correlation with the duration of illness.

CONCLUSION

Photic hypersensitivity and photic driving responses were increased in migraineurs. Photic hypersensitivity might result in sensitization of the limbic system. © 2015 S. Karger AG, Basel.

The relationship of anxiety, depression and behavioral problems with recurrent headache in late adolescence – a Young-HUNT follow-up study

Background

The comorbidity of headache and psychiatric symptoms is a well-recognized clinical phenomenon, but there are only limited data regarding the temporal relationship between headache and symptoms of anxiety and depression as well as behavioral problems in adolescents. This study investigates the relationship of anxiety and depressive symptoms and behavioral problems at baseline with recurrent headache at follow-up four years later.

Methods

Within the Nord-Trøndelag Health Study (HUNT), including repeated population-based studies conducted in Norway, 2399 adolescents in junior high schools aged 12–16 years (77% of the invited) participated in Young-HUNT1 (1995–1997) and again at follow-up four years later, in Young-HUNT2 (2000–2001). The same comprehensive questionnaire that included assessment of symptoms of anxiety and depression and behavioral problems, i.e. conduct and attention difficulties was completed in both studies. In addition 1665 of the participants were interviewed about their headache complaints in Young-HUNT2.

Results

In adjusted multivariate analyses we found that higher scores of anxiety and depressive symptoms at baseline were associated with recurrent headache at follow-up four years later (OR: 1.6, 95% CI: 1.2-2.1, p = 0.001), evident for migraine (OR: 1.8, 95% CI: 1.2-2.7, p = 0.008) and non-classifiable headache (OR: 1.7, 95% CI: 1.0-2.8, p = 0.034), but not statistically significant for tension-type headache (OR: 1.4, 95% CI: 1.0-1.9, p = 0.053). Higher scores of anxiety and depressive symptoms at baseline were significantly associated with more frequent headache at follow-up (monthly vs. no recurrent headache OR: 1.8, 95% CI: 1.3-2.5, p = 0.001, weekly or daily vs. no recurrent headache OR: 1.9, 95% CI: 1.2-2.9, p = 0.005). Among adolescents without recurrent headache at baseline, higher scores for symptoms of anxiety and depression were associated with new onset migraine four years later (OR: 2.6, 95% CI: 1.1-4.8, p = 0.036). Higher scores of attention problems at baseline were associated with non-classifiable headache at follow-up (OR: 2.0, 95% CI: 1.3-3.4, p = 0.017).

Conclusions

Results from the present study showed that symptoms of anxiety and depression in early adolescence were associated with recurrent headache four years later. Recognizing anxiety and depressive symptoms should be considered part of the clinical assessment in young headache patients, as early identification of these associated factors may lead to improved headache management.

Influence of the number and severity of somatic symptoms on the severity of depression and suicidality in community-dwelling elders

INTRODUCTION

Older adults commonly experience somatic symptoms, and those who do are more likely to have depressive disorders as well. Our goal in this study is to examine the influence of the number and severity of somatic symptoms on the severity of depressive symptoms, including suicidality, in elderly adults.

METHODS

This study was conducted as part of the Ansan Geriatric (AGE) Study, a community-based cohort study in Ansan City, South Korea. A total of 3,210 elderly adults aged 60 years or over (1,388 males and 1,770 females) participated in this study. The Korean version of the Beck Depression Inventory (BDI) was used to measure depressive symptoms and suicidality. Somatic symptoms were assessed by the Patient Health Questionnaire-15 (PHQ-15).

RESULTS

Both mild and severe somatic symptoms significantly increased the risk for severe depression and high suicidality. Severe somatic symptoms doubled the risk for severe depression and suicidal intent.

DISCUSSION

Somatic symptoms not fully explained as medical illnesses are closely associated with late-life depression, even after adjustments for comorbid physical illnesses and other confounding factors. The presence of somatic symptoms concurrent with, but not fully explained by comorbid physical illness or disability, seems to be an independent marker for predicting the severity of late-life depression and suicidality.

Activation of extracellular signal-regulated kinase1/2 in the medial prefrontal cortex contributes to stress-induced hyperalgesia

Stressful stimuli can exacerbate persistent pain disorder. However, the underlying mechanism is still unknown. Here, to reveal the underlying mechanism for stressful stimuli-induced hyperalgesia in chronic pain, we investigated the effect of extracellular signal-regulated kinase1/2 (ERK1/2) activation on pain hypersensitivity using single-prolonged stress (SPS) model, complete Freund's adjuvant (CFA) model and SPS + CFA model. The experimental results revealed significantly reduced paw withdrawal threshold in the SPS, CFA, and SPS + CFA group compared with the control group. However, the increased phosphorylation of ERK1/2 in the medial prefrontal cortex (mPFC) was observed in the SPS- or SPS + CFA-exposed group but not the CFA group compared with control group. There was also a significant increase in mPFC ERK1/2 phosphorylation and mechanical allodynia after SPS + CFA treatment compared to SPS or CFA treatment alone. Furthermore, inhibiting ERK1/2 phosphorylation by microinjection of U0126, a MAPK kinase (MEK) inhibitor, into the mPFC attenuated SPS + CFA- and SPS- but not CFA-induced mechanical allodynia, anxiety-like behavior, and cognitive impairments. These results suggest that the activation of ERK1/2 in the mPFC may contribute to the process of stress-induced cognitive and emotional disorders, leading to an increase in pain sensitivity.

Psychological processing in chronic pain: a neural systems approach

Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.

Effects of eye movement desensitization and reprocessing (EMDR) treatment in chronic pain patients: a systematic review

OBJECTIVE

This study systematically reviewed the evidence regarding the effects of eye movement desensitization and reprocessing (EMDR) therapy for treating chronic pain.

DESIGN

Systematic review.

METHODS

We screened MEDLINE, EMBASE, the Cochrane Library, CINHAL Plus, Web of Science, PsycINFO, PSYNDEX, the Francine Shapiro Library, and citations of original studies and reviews. All studies using EMDR for treating chronic pain were eligible for inclusion in the present study. The main outcomes were pain intensity, disability, and negative mood (depression and anxiety). The effects were described as standardized mean differences.

RESULTS

Two controlled trials with a total of 80 subjects and 10 observational studies with 116 subjects met the inclusion criteria. All of these studies assessed pain intensity. In addition, five studies measured disability, eight studies depression, and five studies anxiety. Controlled trials demonstrated significant improvements in pain intensity with high effect sizes (Hedges' g: -6.87 [95% confidence interval (CI95 ): -8.51, -5.23] and -1.12 [CI95 : -1.82, -0.42]). The pretreatment/posttreatment effect size calculations of the observational studies revealed that the effect sizes varied considerably, ranging from Hedges' g values of -0.24 (CI95 : -0.88, 0.40) to -5.86 (CI95 : -10.12, -1.60) for reductions in pain intensity, -0.34 (CI95 : -1.27, 0.59) to -3.69 (CI95 : -24.66, 17.28) for improvements in disability, -0.57 (CI95 : -1.47, 0.32) to -1.47 (CI95 : -3.18, 0.25) for improvements in depressive symptoms, and -0.59 (CI95 : -1.05, 0.13) to -1.10 (CI95 : -2.68, 0.48) for anxiety. Follow-up assessments showed maintained improvements. No adverse events were reported.

CONCLUSIONS

Although the results of our study suggest that EMDR may be a safe and promising treatment option in chronic pain conditions, the small number of high-quality studies leads to insufficient evidence for definite treatment recommendations.

Pain and suicidality: insights from reward and addiction neuroscience

Suicidality is exceedingly prevalent in pain patients. Although the pathophysiology of this link remains unclear, it may be potentially related to the partial congruence of physical and emotional pain systems. The latter system's role in suicide is also conspicuous during setbacks and losses sustained in the context of social attachments. Here we propose a model based on the neural pathways mediating reward and anti-reward (i.e., allostatic adjustment to recurrent activation of the reward circuitry); both are relevant etiologic factors in pain, suicide and social attachments. A comprehensive literature search on neurobiology of pain and suicidality was performed. The collected articles were critically reviewed and relevant data were extracted and summarized within four key areas: (1) physical and emotional pain, (2) emotional pain and social attachments, (3) pain- and suicide-related alterations of the reward and anti-reward circuits as compared to addiction, which is the premier probe for dysfunction of these circuits and (4) mechanistically informed treatments of co-occurring pain and suicidality. Pain-, stress- and analgesic drugs-induced opponent and proponent states of the mesolimbic dopaminergic pathways may render reward and anti-reward systems vulnerable to sensitization, cross-sensitization and aberrant learning of contents and contexts associated with suicidal acts and behaviors. These findings suggest that pain patients exhibit alterations in the brain circuits mediating reward (depressed function) and anti-reward (sensitized function) that may affect their proclivity for suicide and support pain and suicidality classification among other "reward deficiency syndromes" and a new proposal for "enhanced anti-reward syndromes". We suggest that interventions aimed at restoring the balance between the reward and anti-reward networks in patients with chronic pain may help decreasing their suicide risk.

Prevalence of chronic headache in Croatia

BACKGROUND

Chronic headache describes the presence of headache for >15 days per month on average for >3 months and fulfills the rest of the IHS criteria. The prevalence of chronic headache is within the range of 0.5-7.3% worldwide. The aim of this study was to determine the 1-year prevalence of chronic headache in adult Croatian population.

METHODS

The data were collected from a cross-sectional survey of an adult population (>18 years of age) sample. Randomly selected patients from the general population in four Croatian cities were asked to fulfill a self-completed questionnaire. The prevalence of chronic headache was calculated in the sample representing 3,383,769 Croatian adults.

RESULTS

The total sample included 1542 responders among which 616 were with headache. The 1-year prevalence of chronic headache was 2.4%, and 0.9% of responders declared having headache 30 days per month. According to these results, 81,192 adult inhabitants in Croatia suffer from chronic headache.

CONCLUSIONS

The prevalence of chronic headache in Croatia is comparable to other countries worldwide. These patients require special attention and should be offered multidisciplinary medical support.

Depressive-like history alters persistent pain behavior in rats: Opposite contribution of frontal cortex and amygdala implied

Numerous studies have shown that pain perception is strongly influenced by depression. However, very few studies have examined whether pain perception is altered in the remission period of depression, and what role the fronto-limbic circuits may play in the behavioral changes associated with remission. Using an unpredictable chronic mild stress (UCMS) animal model of depression, the present study investigated pain-related behaviors in rats with prior exposure to a UCMS stimulus. The γ-aminobutyric acid (GABA)A receptor agonist muscimol was microinjected bilaterally into the basolateral amygdala (BLA) and the medial prefrontal cortex (mPFC) to examine the modulation of pain by these brain regions in the recovery state. Rats with a depression-like history displayed increased ongoing pain behavior in the formalin test, although their thermal pain thresholds were unchanged. Intra-BLA muscimol during the recovery phase dramatically decreased formalin-induced pain behavior and also significantly increased rats' sucrose preference. By contrast, in the mPFC, muscimol produced the opposite effect, suggesting different, perhaps opposing, roles of the BLA and mPFC in mediating the influence of prior UCMS exposure on pain perception. Taken together, these results demonstrated that a depressive experience may cause long-term alterations in limbic circuit excitability and thus lead to long-lasting changes in pain perception.

Alexithymia and depression in a chronic pain patient sample

OBJECTIVE

The aim of the present study was to assess the prevalence of alexithymia in a sample of general chronic pain patients, to explore possible differences in depression and pain variables between alexithymic and nonalexithymic chronic pain patients and to analyze if depression is a mediator between alexithymia and pain disability.

METHODS

Two hundred and seventy-one patients making their first visit to a pain clinic completed the study questionnaire including various pain measures, the Beck Depression Inventory-II (BDI-II) and the 20-item Toronto Alexithymia Scale (TAS-20). The sample was dichotomized to alexithymic and nonalexithymic groups. The means of the study variables were compared between the groups. The correlation analysis of the variables was carried out separately in both groups. Path analysis was done to ascertain the mediation effect of BDI-II between the TAS-20 and pain disability.

RESULTS

Every fifth chronic pain patient was alexithymic. The BDI-II and pain variable scores were significantly higher in the alexithymic group than in the nonalexithymic group. Pain variables were not associated with alexithymia when BDI-II was controlled for. BDI-II worked as a full mediator between TAS-20 and pain disability.

CONCLUSION

The alexithymic patient group was more morbid than the nonalexithymic group. The results suggest that depression is the main factor in pain conditions of alexithymic chronic pain patients. The authors recommend screening and treatment of depression in alexithymic chronic pain patients.

Psychiatric morbidities, sleep disturbances, suicidality, and quality-of-life in a community population with medically unexplained pain in Korea

We examined the psychiatric morbidities, sleep disturbances, suicidality, quality-of-life, and psychological distress of community-dwelling subjects in Korea who had medically unexplained pain. A total of 6510 subjects (age 18-65 years) participated in this study. A medically unexplained pain symptom (MUS-pain) was defined as pain lasting for 6 months or longer that was sufficiently severe to cause significant distress or to materially interfere with normal activities in the previous year, and that could not be explained by a medical condition or substance use/abuse. Diagnostic assessments were based on responses to the Composite International Diagnostic Interview, which was administered by lay colleagues. The presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders, sleep disturbances, suicidal tendency, quality-of-life issues, and psychological distress was determined in subjects with and without MUS-pain. There were significant positive associations between MUS-pain and nicotine dependence and withdrawal, alcohol dependence, major depressive disorder, dysthymic disorder, bipolar disorder, post-traumatic stress disorder, social phobia, generalized anxiety disorder, and psychotic disorder. In addition, subjects with MUS-pain reported more sleep disturbances, suicidality, psychological distress, and a poorer quality-of-life than did subjects without MUS-pain. The results of this study suggest that clinicians should carefully evaluate and treat comorbid psychiatric problems in individuals with MUS-pain.

Beyond neurovascular: migraine as a dysfunctional neurolimbic pain network

No single model of migraine explains all of the known features of the disorder. Migraine has recently been characterized as an abnormality in pain-modulating circuits in the brainstem. The periaqueductal gray appears to have a critical role in migraine genesis and has been labeled the "migraine generator." The concept of a "pain matrix," rather than a specific locus of pain, is widely accepted in the pain literature and offers a new dimension to understanding migraine. Recent neuroimaging studies of migraineurs suggest altered functional connectivity between brainstem pain-modulating circuits and cortical (limbic) centers. Numerous clinical observations suggest that limbic influences play an important role in migraine expression. We propose a model of migraine as a dysfunction of a "neurolimbic" pain network. The influence between brainstem and cortical centers is bidirectional, reflecting the bidirectional interaction of pain and mood. Neurolimbic dysfunction may increase as migraine becomes more chronic or refractory. The neurolimbic model expands the model of migraine as a dysfunction of brainstem nuclei. A neurolimbic model may help bridge a gap in understanding the migraine attack, the interictal dysfunctions of episodic migraine, the progression to chronic migraine, and the common comorbidities with other disorders (such as fibromyalgia, irritable bowel syndrome, and mood and anxiety disorders), which may also be considered neurolimbic. A neurolimbic model of migraine may be a useful heuristic that would impact both clinical treatment and research agendas, as well as education of physicians and patients.

Relationship between painful physical symptoms and severity of depressive symptomatology and suicidality

We examined the prevalence of painful physical symptoms in patients with major depressive disorder (MDD), clinical correlations therewith, and associations between painful symptoms and depression severity, quality of life, and suicidality, in a clinical sample in Korea. A total of 414 psychiatric outpatients at least 18years of age, with a primary diagnosis of MDD based on the DSM-IV-TR, were enrolled at the discretion of their treating psychiatrist. Patients were assessed for the presence or absence of painful physical symptoms (PPS+ and PPS-, respectively), defined by a total score ≥5 on the pain subscale (PS) of the Depression and Somatic Symptoms Scale (DSSS). DSSS and the Clinical Global Impressions-Severity of Illness scale (CGI-S) determined depression severity, and the EuroQoL Questionnaire-5 dimensions (EQ-5D) determined perceived quality of life. Questions about suicidality during current depressive episode were also asked to the participants. Overall, 30.4% of patients were classified as PPS+. PPS+ patients were older, less educated, less frequently unmarried, and more frequently widowed/divorced/separated compared to PPS- patients. PPS+ patients showed a significantly greater depression severity (CGI-S mean difference 0.92; 95% CI=0.68 to 1.16; DSSS mean difference 18.39; 95% CI=16.28 to 20.50), a significantly lower quality of life (EQ-5D VAS mean difference -18.15; 95% CI=-22.68 to -13.62), and significantly higher suicidal ideation (OR 1.73; 95% CI 1.04-2.86) during the current depressive episode. This study suggests that assessment of depressive patients should include detailed questions about painful physical symptoms, and treatment of MDD should involve management targeting painful physical symptoms as well as emotional and non-painful physical symptoms.

Pain and emotion: a biopsychosocial review of recent research

OBJECTIVE AND METHOD

Research on emotion and pain has burgeoned. We review the last decade's literature, focusing on links between emotional processes and persistent pain.

RESULTS

Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection.

CONCLUSIONS

Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

The use of slow-frequency prefrontal repetitive transcranial magnetic stimulation in refractory neuropathic pain

OBJECTIVE

A number of antidepressant medications, as well as electroconvulsive therapy, have been shown to reduce chronic pain. Slow-frequency repetitive transcranial magnetic stimulation (rTMS) applied to the right dorsolateral prefrontal cortex has also been shown to have an antidepressant effect. Given the high degree of suffering experienced by subjects with chronic neuropathic pain and the treatment resistance noted in this population, the use of slow-frequency rTMS as adjuvant therapy may be of significant clinical benefit.

METHODS

Fifteen sessions of 1-Hz rTMS (1600 stimulations/session) were applied to the right dorsolateral prefrontal cortex as adjuvant treatment in 9 subjects with refractory neuropathic pain over 3 weeks. Pain and depression ratings were performed at baseline, weekly during rTMS treatment, and monthly for up to 3 months after treatment.

RESULTS

Five males and 4 females participated, and all had longstanding refractory neuropathic pain (range, 1-19 years), with an average baseline pain rating of 7.3 and no depression (Hamilton Rating Scale for Depression average, 3.6; range, 0-8). Three subjects had a greater than 50% decline in pain ratings by the completion of rTMS treatments, and 1 subject responded more slowly with greater than 50% improvement in pain by the end of the 3-month follow-up. An improvement in pain ratings was noted in responders within the first week.

CONCLUSIONS

Although these are preliminary findings in an open treatment trial, the subjects in this trial are among the least likely to have a placebo response. Given that rTMS is a well-tolerated and noninvasive intervention, any sustained improvement in neuropathic pain with rTMS is encouraging.

The Role of the Mental Health Practitioner in the Assessment and Treatment of Child and Adolescent Chronic Pain

Chronic and recurrent benign pain complaints are common among children and adolescents. Although many young persons with chronic pain adapt well, a small, but significant, proportion experience marked functional deficits. Pain can produce life disruptions, e.g. impeding activities and maturation, and interferes with family functioning. Conventional medically-based approaches have been inadequate in addressing chronic pain and its sequelae. Instead, effective management requires an interdisciplinary approach involving paediatricians and mental health practitioners working collaboratively to treat psychiatric comorbidities, enhance the patient's functional adaptation, restore the child or adolescent's maturational and social capabilities and reduce family disruptions.

Influence of barometric pressure in patients with migraine headache

OBJECTIVE

Barometric pressure has been reported as a triggering and exacerbating factor in migraine headaches, although there are few reports concerning the association of weather change and migraine headache. The relationship between barometric pressure changes and migraine headaches was prospectively examined.

METHODS

A total of 28 migraine patients who lived within 10 km of the Utsunomiya Local Meteorological Observatory kept a headache diary throughout the year. Daily and monthly mean barometric pressure data of the Utsunomiya Local Meteorological Observatory were obtained via the homepage of the Meteorological Office.

RESULTS

The correlation between headache frequency obtained by the headache diaries for 1 year and changes in the barometric pressure during the period of 2 days before and 2 days after the headache onset were evaluated. The frequency of migraine increased when the difference in barometric pressure from the day the headache occurred to the day after was lower by more than 5 hPa, and decreased when the difference in barometric pressure from the day the headache occurred to 2 days later was higher by more than 5 hPa. Of 28 patients, weather change was associated with migraine headache development in 18 (64%) patients, 14 of which reported low barometric pressure to be a cause of headache. There was no association between the monthly mean barometric pressure and headache frequency throughout the year.

CONCLUSION

Barometric pressure change can be one of the exacerbating factors of migraine headaches.

Activation of mitogen-activated protein kinase in descending pain modulatory system

The descending pain modulatory system is thought to undergo plastic changes following peripheral tissue injury and exerts bidirectional (facilitatory and inhibitory) influence on spinal nociceptive transmission. The mitogen-activated protein kinases (MAPKs) superfamily consists of four main members: the extracellular signal-regulated protein kinase1/2 (ERK1/2), the c-Jun N-terminal kinases (JNKs), the p38 MAPKs, and the ERK5. MAPKs not only regulate cell proliferation and survival but also play important roles in synaptic plasticity and memory formation. Recently, many studies have demonstrated that noxious stimuli activate MAPKs in several brain regions that are components of descending pain modulatory system. They are involved in pain perception and pain-related emotional responses. In addition, psychophysical stress also activates MAPKs in these brain structures. Greater appreciation of the convergence of mechanisms between noxious stimuli- and psychological stress-induced neuroplasticity is likely to lead to the identification of novel targets for a variety of pain syndromes.

Early maladaptive schemas in Finnish adult chronic pain patients and a control sample

Engel (1959) suggested that negative physical or emotional experiences in childhood predispose to the development of chronic pain. Studies have shown that physical and sexual abuse in early life is connected with chronic pain. Emotional adversities are much less studied causes contributing to the development of chronic pain and disability. Early emotional abuse, neglect, maltreatment and other adversities are deleterious childhood experiences which, according to Young's schema theory (1990), produce early maladaptive schemas (EMSs). The primary goal of this study was to examine whether early adversities were more common in chronic pain patients than in a control group. A total of 271 (53% women) first-visit chronic pain patients and 331 (86% women) control participants took part in the study. Their socio-demographic data, pain variables and pain disability were measured. To estimate EMSs the Young Schema Questionnaire was used. Chronic pain patients scored higher EMSs reflecting incapacity to perform independently, catastrophic beliefs and pessimism. The most severely disabled chronic pain patients showed an increase in all the EMSs in the Disconnection and Rejection schema domain, namely Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame and Social Isolation/Alienation EMSs. The results of the study suggested that chronic pain patients had suffered early emotional maltreatment.

Early maladaptive schemas in Finnish adult chronic male and female pain patients

Background and aims of the study

The connection between chronic pain and traumatic experiences in childhood has been established in several studies. The association of emotional maltreatment with chronic pain has been studied, but to a lesser degree. Schema therapy [24] is an extension of cognitive therapy and presents the early maladaptive schema (EMS) concept. EMSs reflect early, mainly emotional maltreatment. The aim of the present study was to examine the existence of EMSs, the association between EMSs and pain variables and EMS driven patterns.

Patients and measures

The study consisted of 271 first visit pain patients. Their socio-demographic data, pain variables and pain disability were assessed. The presence of EMSs was measured using the Young Schema Questionnaire Short Form Extended. One hundred and three successive participants were also interviewed according to the cognitive case conceptualization.

Results

More than half (58.3%) of the chronic pain patients scored EMSs as meaningful. The patients with meaningful EMSs had significantly higher pain intensity, duration of pain and pain disability. The two most frequently occurring EMSs in male pain patients were Unrelenting Standards/Hypercriticalness (US) (36.2%) and Self-Sacrifice (SS) (23.6%) and in female pain patients SS (40.3%) and US (27.1%). The speech contents of five of the highest scoring US and SS male and female patients (n = 20) were analyzed. The analyses showed schema driven behavior which exacerbated the pain situation. US and SS schemas had a stronger motivational effect on their behavior than the pain itself. Regression analyses showed that Self-Sacrifice schema in women and Emotional Deprivation schema in the total sample predicted pain disability as did pain intensity and the number of pain locations.

Conclusions

This study suggested that a remarkable amount of chronic pain patients may suffer from early maladaptive schemas which have an effect on their current pain situation and may reflect underlying early emotional maltreatment.

Psychiatric comorbidity and suicide risk in patients with chronic migraine

The aim of this study was to explore the impact of mental illness among patients with migraine. We performed MedLine and PsycINFO searches from 1980 to 2008. Research has systematically documented a strong bidirectional association between migraine and psychiatric disorders. The relationship between migraine and psychopathology has often been clinically discussed rather than systematically studied. Future research should include sound methodologically-based studies focusing on the interplay of factors behind the relationship between migraine, suicide risk, and mental illness.

The relationship between sexual abuse and interstitial cystitis/painful bladder syndrome

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic syndrome characterized by irritative voiding symptoms and pelvic pain or discomfort. IC/PBS represents localized bladder pathophysiologic changes and central nervous system upregulation. Patients exhibit bladder hyperalgesia and allodynia. Childhood sexual abuse occurs in up to 27% of females in the United States. Adults with a prior history of abuse or traumatization demonstrate hypothalamic-pituitary-adrenal (HPA) axis abnormalities, similar to IC/PBS patients. Childhood sexual abuse and physical traumatization are associated with subsequent lifelong risks of chronic pain syndromes. IC/PBS patients have increased rates of sexual abuse or physical traumatization histories compared with controls. IC/PBS patients with abuse histories tend to have greater pain intensity and lesser irritative voiding symptoms compared with nonabused IC/PBS patients. This article reviews the relationship between sexual abuse, HPA axis abnormalities, IC/PBS pathophysiology, and the role of sexual abuse on subsequent IC/PBS.

Allodynia in migraine: association with comorbid pain conditions

BACKGROUND

Cutaneous allodynia (CA) in migraine is a clinical manifestation of central nervous system sensitization. Several chronic pain syndromes and mood disorders are comorbid with migraine. In this study we examine the relationship of migraine-associated CA with these comorbid conditions. We also evaluate the association of CA with factors such as demographic profiles, migraine characteristics, and smoking status that may have an influence on the relationships of CA to pain and mood.

METHODS

Data are from a cross-sectional multicenter study of comorbid conditions in persons seeking treatment in headache clinics. Diagnosis of migraine was determined by a physician based on the International Classification of Headache Disorders-II criteria. Participants completed a self-administered questionnaire ascertaining sociodemographics, migraine-associated allodynia, physician-diagnosed comorbid medical and psychiatric disorders, headache-related disability, current depression, and anxiety.

RESULTS

A total of 1413 migraineurs (mean age = 42 years, 89% women) from 11 different headache treatment centers completed a survey on the prevalence of comorbid conditions. Aura was reported by 38% and chronic headache by 35% of the participants. Sixty percent of the study population reported at least one migraine-related allodynic symptom, 10% reported > or =4 symptoms. Symptoms of CA were associated with female gender, body mass index, current smoking, presence of aura, chronic headaches, transformed headaches, severe headache-related disability, and duration of migraine illness from onset. The prevalence of self-reported physician diagnosis of comorbid pain conditions (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia) and psychiatric conditions (current depression and anxiety) was also associated with symptoms of CA. Adjusted ordinal regression indicated a significant association between number of pain conditions and severity of CA (based on symptom count). Adjusting for sociodemographics, migraine characteristics, and current depression and anxiety, the likelihood of reporting symptoms of severe allodynia was much higher in those with 3 or more pain conditions (odds ratio = 3.03, 95% confidence interval: 1.78-5.17), and 2 pain conditions (odds ratio = 2.67, 95% confidence interval: 1.78-4.01) when compared with those with no comorbid pain condition.

CONCLUSION

Symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions. A graded relationship was observed between number of allodynic symptoms and the number of pain conditions, even after adjusting for confounding factors. This study also presents the novel association of CA symptoms with younger age of migraine onset, and with cigarette smoking, in addition to confirming several previously reported findings.