Mindfulness and Chronic Headache/Migraine: Mechanisms Explored Through the Fear-Avoidance Model of Chronic Pain

Athlete Fear Avoidance, Depression, and Anxiety Are Associated with Acute Concussion Symptoms in Athletes

Background: Assessing sport-related concussions in athletes presents challenges due to symptom variability. This study aimed to explore the relationship between acute concussion symptoms and athlete fear avoidance, pain catastrophizing, depression, and anxiety. Anxiety and depression have previously been associated with the number of symptoms after a concussion, but no prior research has examined the possible link between athlete fear avoidance and acute concussion symptoms. Methods: Thirty-four collegiate athletes (mean age = 20.9 ± 1.8 years) were assessed within 48 h of a concussion using the Sport Concussion Assessment Tool 5, Athlete Fear Avoidance Questionnaire (AFAQ), Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. Results: Results showed a significant association between the athlete fear avoidance and the number of concussion symptoms (r = 0.493, p = 0.003), as well as depression and anxiety measured by HADS (r = 0.686, p < 0.001). Athlete fear avoidance and HADS scores were predictors of symptom severity, explaining 41% of the variance (p = 0.001). Athletes with higher fear avoidance tended to report more symptoms post concussion. Conclusions: This study underscores the link between athlete fear avoidance, anxiety, depression, and the severity of concussion symptoms. Administering the AFAQ to assess athlete fear avoidance at the initial assessment of a concussion may be helpful in interpreting the symptoms of an acute concussion.

Mindful attention is inversely associated with pain via mediation by psychological distress in orthopedic patients

BACKGROUND

Orthopedic patients report pain as their main symptom complaint. Subjective pain experience is correlated with self-reported psychological state, such as distress.

PURPOSE

This study tests whether scores from a measure of mindful attention are associated with subjective pain levels and whether psychological distress scores function as a mediation path.

METHODS

During routine visits to a single orthopedic clinic in East Los Angeles, California, 525 patients were recruited to participate in the study. Participants reported on measures of pain (Universal Pain Assessment Tool [UPAT]), mindful attention (Five-Facet Mindfulness Questionnaire [FFMQ]), and psychological distress (Depression, Anxiety, Stress Scale [DASS]). We used Pearson correlations to examine relationships between FFMQ and UPAT scores and mediation analyses to test indirect effects of DASS scores as a mediation path.

RESULTS

The average age of the sample was 54 years (range 18-98 years), 61% were male, and 64% were non-Hispanic White individuals. The locations of injury were the shoulder (72%), elbow (21%), and clavicle or wrist (7%). Ninety-one percent reported mild or greater pain in the prior 2 weeks (mean = 4.2 ± 2.5, range 0-10), and 49% reported mild or more severe distress symptoms (DASS: 13.0 ± 11.5). FFMQ scores inversely predicted UPAT scores (β = -0.22, P < .01), mediated through DASS scores. DASS subscale scores for depression (β = -0.10, P = .02) and stress (β = -0.08, P = .04) but not anxiety (β = -0.03, P = .33) produced significant indirect effects. FFMQ acting-with-awareness and non-judging subscales had the largest effect on depression and stress DASS subscale scores.

CONCLUSIONS

We find statistical support to suggest that distress-particularly depressed mood and stress-mediates the association between mindful attention and pain intensity among orthopedic patients. A disposition of mindful attention might counter distress ailments that exacerbate subjective pain, and this has possible implications for mindfulness training interventions offered to orthopedic patients.

A meta-analytic review of acceptance-based interventions for migraine

OBJECTIVE

To determine the efficacy of acceptance and mindfulness-based interventions on migraine disability, medication use, and attack frequency.

BACKGROUND

Acceptance-based approaches to headache management are those in which individuals learn to mitigate the influence of pain-related experiences on their general functioning without controlling pain itself. Treatment approaches include acceptance and commitment therapy (ACT) and mindfulness-based practices. Both have shown promise in improving broad functioning and disability among individuals with headache. Despite a growing body of research examining acceptance-based interventions for headache broadly and migraine specifically, no meta-analytic review of ACT interventions for headache exists, and two meta-analytic reviews of mindfulness-based practices yielded conflicting results.

METHODS

The present study aimed to systematically and quantitatively review the literature related to the efficacy of acceptance-based interventions among adults with migraine. A multi-database search (PubMed/MEDLINE, Scopus, PsycINFO, and the Cochrane Central Register of Controlled Trials) identified clinical trials among individuals with migraine that compared structured ACT or mindfulness-based interventions to control treatment. Random-effects meta-analyses were performed using RevMan 5.4 meta-analytic software, and standardized mean differences (SMD) with 95% confidence intervals (CIs) quantified effect sizes on outcomes of disability, medication use, and headache frequency. Heterogeneity was quantified via I2 index and explored via subgroup analyses.

RESULTS

Acceptance-based interventions yielded significant improvements in disability (SMD = -0.38, 95% CI = -0.56 to -0.20; I2  = 25%, p = 0.20) but not in medication use (SMD = -0.25, 95% CI: -0.57 to 0.06; I2  = 0%, p = 0.82) or headache frequency (SMD = -0.16, 95% CI = -0.37 to 0.05; I2  = 0%, p = 0.73).

CONCLUSION

Results suggest that acceptance-based interventions are effective in improving disability among adults with migraine and are a viable non-pharmacological treatment option, in addition to well-established behavioral migraine management approaches, for patients seeking functional improvement.

A Single-Group Study on the Effect of OnabotulinumtoxinA in Patients with Chronic Migraine Associated with Medication Overuse Headache: Pain Catastrophizing Plays a Role

Pain catastrophizing and cutaneous allodynia are commonly altered in patients with chronic migraine associated with medication overuse headache (CM-MOH) and tend to improve in parallel with clinical improvement. The relation between pain catastrophizing and cutaneous allodynia is poorly understood in patients with CM-MOH receiving OnabotulinumtoxinA therapy. In this single-arm open-label longitudinal observational study, patients with CM-MOH were assigned to structured withdrawal and then administered OnabotulinumtoxinA (5 sessions on a three-month basis, 195 UI per 31 sites). Headache frequency, medication intake, disability, impact, cutaneous allodynia and pain catastrophizing were evaluated with specific questionnaires. In total, 96 patients were enrolled and 79 completed the 12-month follow-up. With the exclusion of cutaneous allodynia and the magnification subscale of the pain catastrophizing questionnaire, all variables showed significant improvement by the sixth month, which was maintained at 12 months. Reduction of pain catastrophizing, and particularly of its helplessness subscale, was a significant predictor of reduction in headache frequency and medication intake. Pain catastrophizing is often implicated in the clinical improvement in patients with CM-MOH receiving behavioral treatments, but, in this study, also showed a role in patients receiving OnabotulinumtoxinA; combining OnabotulinumtoxinA and behavioral treatments specifically addressing pain catastrophizing might further enhance patients' clinical outcome.

Effects of a trauma‐informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof‐of‐concept study

BACKGROUND

A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum.

METHODS

Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks.

RESULTS

Positive urine toxicology decreased over time for cocaine (β = -.266, p = .008) and benzodiazepines (β = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.

Mindfulness in migraine: A narrative review

Introduction: Migraine is the second leading cause of disability worldwide, yet many patients are unable to tolerate, benefit from, or afford pharmacological treatment options. Non-pharmacological migraine therapies exist, especially to reduce opioid use, which represents a significant unmet need. Mindfulness-based interventions (MBI) have potential as a non-pharmacological treatment for migraine, primarily through the development of flexible attentional capacity across sensory, cognitive, and emotional experiences.Areas covered: The authors review efficacy and potential mechanisms of MBIs for migraine, including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).Expert opinion: While most mindfulness research studies for migraine to date have been pilot trials, which are small and/or lacked rigor, initial evidence suggests there may be improvements in overall headache-related disability and psychological well-being. Many research questions remain to help target the treatment to patients most likely to benefit, including the ideal dosage, duration, delivery method, responder characteristics, and potential mechanisms and biomarkers. A realistic understanding of these factors is important for patients, providers, and the media. Mindfulness will not 'cure' migraine; however, mindfulness may be an important tool as part of a comprehensive treatment approach to help patients 'mindfully' engage in valued life activities.

Complementary and Integrative Medicine for Episodic Migraine: an Update of Evidence from the Last 3 Years

PURPOSE OF REVIEW

The purpose of this review is to evaluate evidence from the last 3 years on complementary and integrative medicine treatment options for episodic migraine. Using Pubmed, Embase, and Cochrane databases, research published from 2015-2018 evaluating the modalities of mind/body therapies, supplements, and manual therapies for treatment of migraine were assessed.

RECENT FINDINGS

Although many studies had major methodological challenges that limit interpretation, several studies reported decreased headache frequency, improved quality of life, or less affective responses to pain. The evidence is currently most promising for the mind/body treatment options of mindfulness, yoga, and tai chi. Mindfulness meditation may be as effective as pharmacological treatment for medication-overuse headache after the offending medication is withdrawn. While older research has shown magnesium, riboflavin, feverfew, and butterbur to be helpful in migraine treatment, new research is promising to suggest potential benefit with melatonin, vitamin D, higher dosages of vitamin B6 (80 mg)/folic acid 5 mg combinations, and the combination of magnesium 112.5 mg/CoQ10 100 mg/feverfew 100 mg. Omega 3s have limited evidence of efficacy in migraine. Butterbur needs to be free of pyrrolizidine alkaloids (PA) to ensure safety given their hepatotoxicity. Physical therapy (PT) continues to have strong evidence of support, and acupuncture is superior to sham acupuncture and placebo. Side effects and risks reported were minimal and well tolerated overall, with the exception of the life-threatening risk of cervical artery dissection with high-velocity chiropractic manipulation and hepatotoxicity with the PAs in butterbur. Several studies are ongoing to further evaluate mindfulness, melatonin, PT, exercise, chiropractic manipulation, and acupuncture. The American Academy of Neurology (AAN) and American Headache Society (AHS) are currently updating the guidelines for integrative treatment options for migraine, so additional recommendations may be available soon. In conclusion, many complementary and integrative treatment options may be helpful for patients with migraines, and understanding potential efficacy, benefits, and risks can help providers discuss these modalities with their patients. Such a conversation can empower patients, build the therapeutic relationship, and increase self-efficacy, thus improving outcomes and patient-centered care.