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Mínguez-Olaondo A, Días PA, de Munáin EL, Grozeva V, Laspra-Solís C, Villalba IM, García-Martín V, Vila-Pueyo M, Barandiarán M, Zabalza RJ, Bengoetxea A. Behavioral therapy in migraine: Expanding the therapeutic arsenal. Eur J Neurol 2024:e16414. [PMID: 39034641 DOI: 10.1111/ene.16414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND AND PURPOSE The US Headache Consortium developed evidence-based guidelines for the treatment of migraine and found grade A evidence in support of behavior therapy (BT). Understanding the mechanisms of BT may improve the management of migraine and reduce its burden. METHODS We performed a narrative review to define the current evidence of BT and determine its usefulness in migraine management. RESULTS The information was obtained from 116 publications, with 56 of them retrieved through direct searches in PubMed (2011-2020) and the remainder selected by the authors to complete the content. BT might reduce migraine impact by decreasing the sympathetic nervous system's response to stress and increasing pain tolerance. Acting in headache-related surroundings can be improved, together with headache duration and self-efficacy. Applications such as mobile health and electronic health applications can help to carry out healthier lifestyle patterns. Regarding medication overuse, BT seems to be a good choice, with similar results to pharmacological prophylaxis. Advantages of using BT are the lack of adverse effects and the unrestricted use in children, where BT is postulated to be even more effective than the standardized pharmacopeia. CONCLUSIONS BT is an interesting tool that can be used as an add-on therapy in migraine. Through BT, the autonomy and empowerment of migraine patients is enhanced. BT may not cure migraine, but it could help to reduce pain severity perception, disability, and migraine impact, adding an emotive and cognitive approach to the perceptive role of pharmacopeia. Thus, a better approach in migraine, implementing specific therapeutic management, can improve migraine control.
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Affiliation(s)
- Ane Mínguez-Olaondo
- Neurology Department, Hospital Universitario Donostia-Osakidetza , Neuroscience Area, Biogipuzkoa Health Institute, Donostia, Spain
- Athenea Neuroclinics, Donostia, Spain
- Department of Medicine and Department of Physical Therapy, Faculty of Health Sciences, University of Deusto, Bilbao and San Sebastian, Spain
| | - Patricia Alves Días
- Neurology Department, Hospital Universitario Donostia-Osakidetza , Neuroscience Area, Biogipuzkoa Health Institute, Donostia, Spain
- Athenea Neuroclinics, Donostia, Spain
- Department of Medicine and Department of Physical Therapy, Faculty of Health Sciences, University of Deusto, Bilbao and San Sebastian, Spain
| | | | | | - Carmen Laspra-Solís
- Department of Psychiatry and Clinical Psychology, University Clinic of Navarra, Madrid, Spain
| | | | - Valvanuz García-Martín
- Neurology Department, Hospital Universitario Donostia-Osakidetza , Neuroscience Area, Biogipuzkoa Health Institute, Donostia, Spain
| | - Marta Vila-Pueyo
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Myriam Barandiarán
- Neurology Department, Hospital Universitario Donostia-Osakidetza , Neuroscience Area, Biogipuzkoa Health Institute, Donostia, Spain
- Athenea Neuroclinics, Donostia, Spain
- Department of Medicine and Department of Physical Therapy, Faculty of Health Sciences, University of Deusto, Bilbao and San Sebastian, Spain
| | - Ramon J Zabalza
- Neurology Department, Hospital Universitario Donostia-Osakidetza , Neuroscience Area, Biogipuzkoa Health Institute, Donostia, Spain
| | - Ana Bengoetxea
- Athenea Neuroclinics, Donostia, Spain
- Unité de Recherche en Sciences de l'Ostéopathie, Faculté des Sciences de la Motricité, Université Libre de Bruxelles, Brussels, Belgium
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Ramírez-Maestre C, Barrado-Moreno V, Esteve R, Serrano-Íbañez ER, de la Vega R, Ruiz-Párraga GT, Fernández-Baena M, Jensen MP, López-Martínez AE. Vulnerability Factors, Adjustment, and Opioid Misuse in Chronic Noncancer Pain Individuals. THE JOURNAL OF PAIN 2024:104606. [PMID: 38871145 DOI: 10.1016/j.jpain.2024.104606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 06/03/2024] [Accepted: 06/08/2024] [Indexed: 06/15/2024]
Abstract
Several person variables predate injury or pain onset that increase the probability of maladjustment to pain and opioid misuse. The aim of this study was to evaluate the role of 2 diathesis variables (impulsiveness and anxiety sensitivity [AS]) in the adjustment of individuals with chronic noncancer pain and opioid misuse. The sample comprised 187 individuals with chronic noncancer pain. The hypothetical model was tested using correlation and structural equation modeling analyses. The results show a significant association between impulsiveness and AS and all the maladjustment variables, and between impulsiveness and AS and opioid misuse and craving. However, although the correlation analysis showed a significant association between adjustment to pain and opioid misuse, the structural equation modeling analysis showed a nonsignificant association between them (as latent variables). The findings support the hypothesis that both impulsiveness and AS are vulnerability factors for maladaptive adjustment to chronic pain and opioid misuse. PERSPECTIVE: This article adds to the empirical literature by including AS and impulsiveness as antecedent variables in a model of dual vulnerability to chronic pain maladjustment and opioid misuse. The findings suggest the potential utility of assessing both factors in individuals in the first stages of chronic pain.
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Affiliation(s)
- Carmen Ramírez-Maestre
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.
| | - Victoria Barrado-Moreno
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain
| | - Rosa Esteve
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Elena R Serrano-Íbañez
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Rocío de la Vega
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Gema T Ruiz-Párraga
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | | | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Alicia E López-Martínez
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology and Speech Therapy, University of Málaga, Andalucía Tech, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
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3
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Best RD, Ozmeral A, Grinberg AS, Smitherman TA, Seng EK. Pain acceptance as a change mechanism for mindfulness-based cognitive therapy for migraine. J Behav Med 2024; 47:471-482. [PMID: 38407727 DOI: 10.1007/s10865-024-00475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/27/2024] [Indexed: 02/27/2024]
Abstract
Migraine is one of the leading causes of disability worldwide. Third wave therapies, such as Mindfulness Based Cognitive Therapy for Migraine (MBCT-M), have proven efficacious in reducing headache-related disability. However, research is needed to better understand the change mechanisms involved in these third-wave therapies. Acceptance is a fundamental component of third wave therapies, and more research is warranted on the role of pain acceptance in MBCT-M. It is also valuable to understand the independent roles of the two components of pain acceptance-pain willingness (PW) and activity engagement (AE). The current study is a secondary analysis of a randomized control trial of MBCT-M. Sixty participants were included in the study (MBCT = 31; WL/TAU = 29). Baseline correlations between overall pain acceptance, PW, AE, and headache-related disability were run. Mixed models assessed change from baseline to one-month post-treatment and treatment-by-time interaction for overall pain acceptance, PW, and AE. Mixed models also assessed maintenance of changes at 6-month follow-up in the MBCT-M group. Longitudinal mediation models assessed whether change in pain acceptance, PW, and AE mediated the relationship between treatment and change in headache-related disability. Pain acceptance, PW, and AE were all negatively correlated with headache-related disability at baseline. Pain acceptance, PW, and AE all significantly increased over time in both the waitlist/ treatment-as-usual group (WL/TAU) and the MBCT-M group. Only AE increased more in the MBCT group than the WL/TAU group. Change in pain acceptance, PW, and AE all significantly mediated the relationship between MBCT and change in headache-related disability. The study supports the importance of pain acceptance, specifically the activity engagement component, in MBCT-M.
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Affiliation(s)
- Rachel D Best
- Ferkauf Graduate School of Psychology, Yeshiva University, 1165 Morris Park Ave, The Bronx, New York, NY, 10461, USA.
| | - Ali Ozmeral
- Ferkauf Graduate School of Psychology, Yeshiva University, 1165 Morris Park Ave, The Bronx, New York, NY, 10461, USA
| | - Amy S Grinberg
- Headache Centers of Excellence Research and Evaluation Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology Service, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Todd A Smitherman
- Department of Psychology, University of Mississippi, Oxford, MS, USA
| | - Elizabeth K Seng
- Ferkauf Graduate School of Psychology, Yeshiva University, 1165 Morris Park Ave, The Bronx, New York, NY, 10461, USA
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
- Montefiore Headache Center, Montefiore Medical Center, New York, NY, USA
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4
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Moitra E, Stein MD, Busch AM, Pinkston MM, Abrantes AM, Baker JV, Weisberg RB, Anderson BJ, Uebelacker LA. Acceptance of chronic pain in depressed patients with HIV: correlations with activity, functioning, and emotional distress. AIDS Care 2022; 34:1338-1346. [PMID: 34554879 PMCID: PMC8940733 DOI: 10.1080/09540121.2021.1981819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 09/09/2021] [Indexed: 01/26/2023]
Abstract
Chronic pain is highly prevalent among persons with HIV (PWH), as is depression. Both comorbidities might contribute to, as well as be maintained by, avoidance-based coping. A promising alternative to avoidance-based coping is acceptance. Acceptance of pain is associated with improved functioning and quality of life in chronic pain patients, but this relationship has not been substantially explored among PWH. Cross-sectional data from 187 adult outpatients enrolled in a randomized trial for depressed PWH with chronic pain were analyzed. Controlling for pain severity and demographics, the relationships among pain acceptance and indicators of activity, functioning, and emotional distress (i.e., anxiety and anger) were assessed in seven regression models. No significant relationships were found between self-reported physical activity or objective measurement of mean steps/day with pain acceptance. Results revealed an inverse relationship between chronic pain acceptance and pain-related functional interference (by.x = -.52, p < .01) and a positive relationship with self-reported functioning (by.x = 7.80, p < .01). A significant inverse relationship with anxiety symptoms (by.x = -1.79, p < .01) and pain acceptance was also found. Acceptance of chronic pain can facilitate decreased emotional distress, improved well-being, and better functioning and quality of life. Further investigation of chronic pain acceptance among PWH could inform the development of acceptance-based interventions.
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Affiliation(s)
- Ethan Moitra
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
| | - Michael D. Stein
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston MA, USA
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis MN, USA
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis MN, USA
| | - Megan M. Pinkston
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Lifespan Physicians Group, The Miriam Hospital, Providence RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Ana M. Abrantes
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
| | - Jason V. Baker
- Department of Medicine, Hennepin Healthcare, Minneapolis MN, USA
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis MN, USA
| | - Risa B. Weisberg
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Bradley J. Anderson
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
| | - Lisa A. Uebelacker
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Psychosocial Research, Butler Hospital, Providence RI, USA
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The Role of Pain Inflexibility and Acceptance among Headache and Temporomandibular Disorders Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137974. [PMID: 35805650 PMCID: PMC9265370 DOI: 10.3390/ijerph19137974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 01/27/2023]
Abstract
Temporomandibular disorders (TMD) and headache are complex. This study aims to assess the association between TMD, headache, and psychological dimensions such as psychological inflexibility and pain acceptance. The sample consisted of 120 participants following a non-probabilistic convenience sampling strategy through a direct invitation to the patients attending our facilities and their relatives (n = 61 diagnosed with headache, n = 34 diagnosed with TMD-headache, n = 25 control group). Diagnostic Criteria for Temporomandibular Disorders (DC-TMD), International Classification of Headache Disorders (ICHD-3 beta version), Chronic Pain Acceptance Questionnaire (CPAQ-8), and Psychological Inflexibility in Pain Scale (PIPS) were used as assessment tools. One-way ANOVA, multiple regression analysis (MRA), and the Johnson-Neyman approach were run by IBM SPSS, version 27 (IBM® Company, Chicago, IL, USA). The significance level was 0.05. One third of our sample presented with headache with TMD. Females were predominant. Males with headache, no systemic disease, less pain severity but higher frequency, living longer with the disease and having sensitive changes, showed higher pain acceptance. When headache occurs with TMD, women with higher education, no headache family history, less pain, and no motor changes showed higher pain acceptance. Patients with both conditions are more liable to have chronic pain and pain inflexibility. Pain intensity and willingness explain 50% of the psychological inflexibility in the headache group. In our sample, individuals suffering from both conditions show greater pain inflexibility, implicating more vivid suffering experiences, leading to altered daily decisions and actions. However, further studies are needed to highlight this possible association.
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6
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Ribeiro dos Santos ERR, Oliveira DAD, Leite AFB, Rocha Filho PAS, Valença MM. Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality. HEADACHE MEDICINE 2021. [DOI: 10.48208/headachemed.2021.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
IntroductionCross-sectional studies on headache have not yet explored the influence of pain catastrophizing and associations with other psychosomatic comorbidities. The migraine-affected group of individuals was frequently associated with other clinical conditions such as depression, anxiety, stress, and poor sleep quality. These conditions exert a significant influence on carrier’s coping with daily pain and helplessness, since disability hampers work and daily living activities and overly burden individual, their family, society and the health system. Identifying the elements that contribute to disability is crucial in assisting interventions that minimize these conditions.ObjectiveThe aim of this cross-sectional study was to evaluate how the combination of migraine and catastrophizing, associated with functional disability, depression, anxiety, stress, and sleep quality in college students, can influence the perception of pain.MethodsThe 340 participants were selected by drawing lots, in which individuals with primary headaches were assigned. Therefore, the final analysis sample consisted of 288 individuals. The sample was divided into Group with migraine and Group with other primary headaches, with the application of scales: HIT-6 and the scale of pain catastrophizing.ResultsOf the 360 participants, 20 losses were recorded due to inadequate completion of scales, leaving out 340 participants. Of these, 52/340 (15.25%) did not suffer from headaches. 288/340 (84.7%) participants that reported headaches were included in this study, of which 133/288 (46.2%) had migraine, and 155/288 (53.8%) had non-migraine headache. Women who had migraine attacks were those with the most intense anxious symptoms, worse sleep quality, and catastrophization. The odds ratio of catastrophizing was higher for the Migraine Group. Linear and multivariate logistic regression revealed that the greater the presence of catastrophizing, the greater the occurrence of migraine. Catastrophizing had a greater power of contribution related to the disability generated by the crises in the group of migrainous (β = 0.564). The migraine group has a greater perception of pain.ConclusionHigher catastrophization was also associated with a greater intensity of depressive and anxiety symptoms, higher perceived stress, and worse quality of sleep in headache-affected individuals in our study.
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Ramírez-Maestre C, Esteve R, López-Martínez AE, Jensen MP, Miró J, de la Vega R. The Impairment and Functioning Inventory Revised-English version: A validation study in individuals with disabilities and bothersome pain. PM R 2021; 14:818-827. [PMID: 34181318 DOI: 10.1002/pmrj.12659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/14/2021] [Accepted: 06/11/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite the relevance of daily function in individuals with chronic pain, few questionnaires have been designed to assess this domain in individuals with musculoskeletal pain. In addition, the Impairment and Functioning Inventory-Revised (IFI-R) is the only instrument that assesses perceived decreases in levels of daily activity after the onset of pain. OBJECTIVE To evaluate the psychometric properties of the English version of the IFI-R. DESIGN Cross-sectional study. SETTING A database of individuals with medical conditions commonly associated with chronic pain maintained by the University of Washington. PATIENTS A total of 470 individuals with chronic pain. METHODS Factorial validity was analyzed by conducting a confirmatory factor analysis via structural equation modeling. Internal consistency was evaluated by calculating Cronbach's α coefficients. Convergent validity was assessed by calculating Pearson correlation coefficients between the two scales of the IFI-R and the Patient Reported Outcome Measurement Information System (PROMIS) Pain Interference Scale. Criterion validity was analyzed by regression analysis via structural equation modeling. MAIN OUTCOME MEASURES The English version of the IFI-R (IFI-R-EV) for individuals with chronic pain. RESULTS The IFI-R-EV consists of 30 items with two related subscales: The Daily Function subscale (α = .86). and the Impairment subscale (α = .89). A significant correlation was found between these subscales and a measure of pain interference (r's = - .33, and .35 respectively; p's < .01). We also found statistically significant associations (p < .05) between daily function and depression (β = -.14) and pain intensity (β = -.13), between impairment and depression (β = .14) and pain intensity (β = .16), and between daily function and pain acceptance (β = .14). CONCLUSIONS The findings indicate that the IFI-R-EV provides valid and reliable measures of daily function and impairment in English-speaking individuals with a disability and chronic pain. These results are consistent with those obtained with the Spanish version.
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Affiliation(s)
- Carmen Ramírez-Maestre
- Faculty of Psychology, Andalucía Tech. Campus de Teatinos, Universidad de Málaga, Málaga, Spain.,Biomedical Research Institute of Málaga (IBIMA), Málaga, Spain
| | - Rosa Esteve
- Faculty of Psychology, Andalucía Tech. Campus de Teatinos, Universidad de Málaga, Málaga, Spain.,Biomedical Research Institute of Málaga (IBIMA), Málaga, Spain
| | - Alicia E López-Martínez
- Faculty of Psychology, Andalucía Tech. Campus de Teatinos, Universidad de Málaga, Málaga, Spain.,Biomedical Research Institute of Málaga (IBIMA), Málaga, Spain
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jordi Miró
- Department of Psychology, Unit for the Study and Treatment of Pain - ALGOS, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Catalonia, Spain
| | - Rocío de la Vega
- Faculty of Psychology, Andalucía Tech. Campus de Teatinos, Universidad de Málaga, Málaga, Spain
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Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010246. [PMID: 33396262 PMCID: PMC7795912 DOI: 10.3390/ijerph18010246] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022]
Abstract
Headache disorders have a strong impact on sufferers’ lives. However, the “content” of assessment instruments addressing concepts, such as disability and quality of life (QoL), has not comprehensively been addressed. We searched SCOPUS for research papers in which outcome measures were used in adult populations of patients with migraine, tension-type headache (TTH), and cluster headache (CH). The content of single instruments was then mapped against the International Classification of Functioning, Disability, and Health. A total of 150 papers and 26 instruments were included: 15 addressed disability or impact, two addressed work-related difficulties, and nine addressed QoL. Few instruments were commonly used across the conditions and covered domains of functioning were impact on daily life activities, homework, school, and work-related tasks, leisure time, informal and family relations, pain, emotional difficulties, energy level, and impulse control. Most of the research is based on instruments that were developed for migraine, which is critical for CH, and the impact of headache disorders on work-related activities is poorly acknowledged. Further research is needed to expand the scope of headaches impact on daily life activities, and on environmental factors relevant to headache disorders to raise knowledge on the less represented areas, e.g., TTH impact.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the role of avoidance behavior in headache-related disability and overview relevant clinical implications. RECENT FINDINGS Avoidance occupies a central role in contemporary psychological perspectives on headache disorders and other chronic pain conditions. Several cognitive constructs of relevance to headache are influenced and maintained by avoidance behavior. A growing body of literature attests to the notion that avoidance of headache triggers, of stimuli that exacerbate headache, and of broader life domains can negatively affect headache progression, disability/quality of life, and comorbid psychiatric symptoms. Interventions targeting avoidance behavior, such as therapeutic exposure to headache triggers, mindfulness, and acceptance and commitment therapy (ACT), hold promise for headache disorders but need to be tested in larger trials. Researchers and clinicians are encouraged to attend to functional impairment as a critically important treatment outcome. Comprehensive understanding of headache disorders necessitates attention not merely to diagnostic symptoms and their reduction, but to patterns of avoidance behavior that inadvertently exacerbate headache and contribute to functional impairment.
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