Determination of psychosocial factors in cluster headache - construction and psychometric properties of the Cluster Headache Scales (CHS)

Disability in cluster headache is more than attack frequency - results from and validation of the English version of the Cluster Headache Impact Questionnaire (CHIQ)

BACKGROUND

Cluster headache (CH) is associated with high disability. The Cluster Headache Impact Questionnaire (CHIQ) is a short, disease-specific disability questionnaire first developed and validated in German. Here, we validated the English version of this questionnaire.

METHODS

The CHIQ was assessed together with nonspecific headache-related disability questionnaires in CH patients from a tertiary headache center and an American self-help group.

RESULTS

155 active episodic and chronic CH patients were included. The CHIQ showed good internal consistency (Cronbach's α = 0.91) and test-retest reliability (ICC = 0.93, n = 44). Factor analysis identified a single factor. Convergent validity was shown by significant correlations with the Headache Impact Test™ (HIT-6™, ρ = 0.72, p < 0.001), the Hospital Anxiety and Depression Scale (HADS depression: ρ = 0.53, HADS anxiety: ρ = 0.61, both p < 0.001), the Perceived Stress Scale (PSS-10, ρ = 0.61, p < 0.001) and with CH attack frequency (ρ = 0.29, p < 0.001). Chronic CH patients showed the highest CHIQ scores (25.4 ± 7.9, n = 76), followed by active episodic CH and episodic CH patients in remission (active eCH: 22.2 ± 8.7, n = 79; eCH in remission: 14.1 ± 13.1, n = 127; p < 0.001). Furthermore, the CHIQ was graded into 5 levels from "no to low impact" to "extreme impact" based on the patients' perception. Higher CHIQ grading was associated with higher attack and acute medication frequency, HIT-6™, HADS and PSS scores.

CONCLUSION

The English version of the CHIQ is a reliable, valid, and disease-specific patient-reported outcome measure to assess the impact of headaches on CH patients.

Epidemiology, burden and clinical spectrum of cluster headache: a global update

BACKGROUND

This narrative review aims to broaden our understanding of the epidemiology, burden and clinical spectrum of cluster headache based on updated findings with a global perspective.

METHODS

We conducted a literature search on the following topics: (a) epidemiology; (b) burden: quality of life, disability, economic burden, job-related burden and suicidality; and (c) clinical spectrum: male predominance and its changes, age, pre-cluster and pre-attack symptoms, aura, post-drome, attack characteristics (location, severity, duration and associated symptoms), bout characteristics (attack frequency, bout duration and bout frequency), circadian and seasonal rhythmicity and disease course.

RESULTS

New large-scale population-based reports have suggested a lower prevalence than previous estimations. The impact of cluster headache creates a significant burden in terms of the quality of life, disability, economic and job-related burdens and suicidality. Several studies have reported decreasing male-to-female ratios and a wide age range at disease onset. The non-headache phases of cluster headache, including pre-cluster, pre-attack and postictal symptoms, have recently been revisited. The latest data regarding attack characteristics, bout characteristics, and circadian and seasonal rhythmicity from different countries have shown variability among bouts, attacks, individuals and ethnicities. Studies on the disease course of cluster headache have shown typical characteristics of attacks or bouts that decrease with time.

CONCLUSIONS

Cluster headache may be more than a "trigeminal autonomic headache" because it involves complex central nervous system phenomena. The spectrum of attacks and bouts is wider than previously recognised. Cluster headache is a dynamic disorder that evolves or regresses over time.

Validation of the Italian version of the Cluster Headache Impact Questionnaire (CHIQ)

BACKGROUND

The Cluster Headache Impact Questionnaire (CHIQ) is a specific and easy-to-use questionnaire to assess the current impact of cluster headache (CH). The aim of this study was to validate the Italian version of the CHIQ.

METHODS

We included patients diagnosed with episodic CH (eCH) or chronic CH (cCH) according to the ICHD-3 criteria and included in the "Italian Headache Registry" (RICe). The questionnaire was administered to patients through an electronic form in two sessions: at first visit for validation, and after 7 days for test-retest reliability. For internal consistency, Cronbach's alpha was calculated. Convergent validity of the CHIQ with CH features and the results of questionnaires assessing anxiety, depression, stress, and quality of life was evaluated using Spearman's correlation coefficient.

RESULTS

We included 181 patients subdivided in 96 patients with active eCH, 14 with cCH, and 71 with eCH in remission. The 110 patients with either active eCH or cCH were included in the validation cohort; only 24 patients with CH were characterized by a stable attack frequency after 7 days, and were included in the test-retest cohort. Internal consistency of the CHIQ was good with a Cronbach alpha value of 0.891. The CHIQ score showed a significant positive correlation with anxiety, depression, and stress scores, while showing a significant negative correlation with quality-of-life scale scores.

CONCLUSION

Our data show the validity of the Italian version of the CHIQ, which represents a suitable tool for evaluating the social and psychological impact of CH in clinical practice and research.

Guidelines of the International Headache Society for Controlled Clinical Trials in Cluster Headache

In 1995, a committee of the International Headache Society developed and published the first edition of the Guidelines for Controlled Trials of Drugs in Cluster Headache. These have not been revised. With the emergence of new medications, neuromodulation devices and trial designs, an updated version of the International Headache Society Guidelines for Controlled Clinical Trials in Cluster Headache is warranted. Given the scarcity of evidence-based data for cluster headache therapies, the update is largely consensus-based, but takes into account lessons learned from recent trials and demands by patients. It is intended to apply to both drug and neuromodulation treatments, with specific proposals for the latter when needed. The primary objective is to propose a template for designing high quality, state-of-the-art, controlled clinical trials of acute and preventive treatments in episodic and chronic cluster headache. The recommendations should not be regarded as dogma and alternative solutions to particular methodological problems should be explored in the future and scientifically validated.

Patient-identified burden and unmet needs in patients with cluster headache: An evidence-based qualitative literature review

Objectives:

To qualitatively identify evidence-based literature related to the daily burden and unmet treatment and psychosocial needs of patients with cluster headache (CH).

Methods:

A literature search was conducted through October 20, 2020 across MEDLINE, EMBASE, CINAHL, and PsychInfo databases exploring quality of life (QoL) and disease burden in adults with CH. The search was restricted to full-text reports in peer-reviewed journals. Methodologic quality was assessed using the Critical Skills Appraisal Program.

Results:

From 11 identified publications, QoL was reduced in persons living with CH, with significant psychological, social, and socio-economic burdens, and work-related disability. The CH disease trajectory is complex, with patients experiencing the impact of their disease across multiple domains beyond the biological manifestation of the disease including stigma, employment limitations, and suicidal ideation, and with a lack of effective treatment from the patient perspective.

Discussion:

These findings strengthen comprehension of the CH patient experience, enabling a deeper understanding of the patients’ perspective and experience of their disease andunmet needs, providing a basis for future research into this debilitating condition. Minor limitations of this study include data extraction and study selection biases.

Cluster Headache Impact Questionnaire (CHIQ) - a short measure of cluster headache related disability

BACKGROUND

Cluster headache (CH) is a severe, highly disabling primary headache disorder. However, there is little research on CH-related disability, and most of it is based on non CH-specific questionnaires. The aim of this study was to develop a short, CH-specific disability questionnaire.

METHODS

The 8-item Cluster Headache Impact Questionnaire (CHIQ) was developed based on a literature review and patient and expert interviews. The questionnaire was tested in 254 CH patients (171 males; 47.5 ± 11.4 years; 111 chronic CH, 85 active episodic CH, 52 episodic CH in remission) from our tertiary headache center or from a German support group.

RESULTS

Reliability and validity of the CHIQ was evaluated in active episodic and chronic CH patients (n = 196). Internal consistency (Cronbach's α = 0.88) and test-retest reliability (ICC 0.91, n = 41) were good. Factor analysis identified a single factor. Convergent validity was shown by significant correlations with the Headache Impact Test (HIT-6, r = 0.58, p < 0.001), subscales of the depression, anxiety and stress scales (DASS, r = 0.46-0.62; p < 0.001) and with CH attack frequency (r = 0.41; p < 0.001). CHIQ scores significantly differentiated between chronic CH (25.8 ± 6.5), active episodic CH (23.3 ± 6.9) and episodic CH patients in remission (13.6 ± 11.9, p < 0.05 for all 3 comparisons).

CONCLUSIONS

The CHIQ is a short, reliable, valid, and easy to administer measure of CH-related disability, which makes it a useful tool for clinical use and research.

Cluster headache, beyond the pain: a comparative cross-sectional study

OBJECTIVE

To compare the presence of allodynia, pain catastrophizing, and the impact of headaches on patients with cluster headache (CH) and healthy individuals. Our second aim was to analyze the relationship between catastrophism, psychological comorbidities, and the impact in CH.

METHODS

We designed this cross-sectional study to compare various factors among 47 patients diagnosed with CH and 40 healthy controls, and then focus on catastrophism, anxiety, depression, and impact in the CH group.

RESULTS

There were statistically significant differences between CH and the asymptomatic group in Allodynia Symptom Checklist (ASC) (p < 0.001), Pain Catastrophizing Scale (p < 0.001), and HIT-6 (p < 0.001) scores. We found a correlation among ASC, PCS, anxiety-depression, EuroQoL, and HIT-6 for the CH group. In this group, we observed a strong positive correlation between PCS and anxiety (rho = 0.69; p < 0.001), PCS and depression (rho = 0.62; p < 0.001) and depression and EuroQoL (rho = - 0.68; p < 0.001). The regression model showed that the combination of anxiety and HIT-6 was a significant predictor of PCS (adjusted R² = 0.52).

DISCUSSION

Our findings reveal significant differences regarding allodynia, pain catastrophism, and impact in CH group compared with controls. We found a significant relationship between psychological comorbidity, pain catastrophism, and quality of life in CH patients. Anxiety and HIT-6 were a predictor (adjusted R² = 52%) of pain catastrophism. Screening for these comorbidities should be implemented through a multidisciplinary approach.

Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability

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.

[Cluster headaches-proven and novel approaches : A critical evaluation of treatment studies]

Trigeminal autonomic cephalalgias are characterized by unilateral headaches accompanied by cranial autonomic symptoms and a sense of restlessness. Clinical trials have been conducted on acute therapy and prophylaxis of cluster headache in recent years. Since the other trigeminal autonomic cephalalgias are rare, it is virtually impossible to conduct controlled clinical trials for their investigation. Recent trials provide data on the efficacy of prednisolone, galcanezumab, fremanzeumab and noninvasive vagal nerve stimulation. Methodological difficulties arise in terms of patient recruitment for clinical trials, clinical endpoints and potential differences in the pathophysiology of episodic and chronic cluster headache.