Pain acceptance as a change mechanism for mindfulness-based cognitive therapy for migraine.

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.

Psychiatric comorbidities of migraine.

Migraine is commonly comorbid with psychiatric conditions, particularly major depressive disorder, anxiety disorders, and sleep disorders. The presence of psychiatric disorders can make diagnosis and treatment more challenging. Existing studies suggest that the relationship between migraine and psychiatric disorders is bidirectional, such that each disorder confers increased risk for onset of the other. Mechanisms underlying this comorbidity are largely speculative but include serotonergic dysfunction, medication overuse, allostatic load, and behavioral factors such as pain-related appraisals and unwarranted avoidance behaviors. Psychiatric comorbidities present unique clinical considerations for assessment and treatment, foremost among which is a need to routinely screen migraine patients for depression, anxiety, and insomnia. Common screening considerations and measures validated on headache patients are reviewed. Comprehensive treatment of migraine requires interventional attention also to any psychiatric comorbidities, though few randomized trials have rigorously evaluated the efficacy of pharmacologic or behavioral migraine interventions for comorbid psychiatric symptoms. Most modern antidepressants lack strong efficacy for migraine, and providers often utilize separate agents to treat migraine and any psychiatric comorbidities. Recent research on adjunctive behavioral interventions such as cognitive-behavioral therapy and acceptance-based approaches suggests they hold value in reducing psychiatric symptoms, though larger trials are needed.

Neuropsychological Function in Migraine Headaches: An Expanded Comprehensive Multidomain Meta-Analysis

BACKGROUND AND OBJECTIVES: A sizable literature has studied neuropsychologic function in persons with migraine (PwM), but despite this, few quantitative syntheses exist. These focused on circumscribed areas of the literature. In this study, we conducted an expanded comprehensive meta-analysis comparing performance on clinical measures of neuropsychological function both within and across domains, between samples of PwM and healthy controls (HCs). METHODS: For this Meta-analyses Of Observational Studies in Epidemiology-compliant meta-analysis, a unified search strategy was applied to OneSearch (a comprehensive collection of electronic databases) to identify peer-reviewed original research published across all years up until August 1, 2023. Using random-effects modeling, we examined aggregated effect sizes (Hedges' g), between-study heterogeneity (Cochran Q and I2), moderating variables (meta-regression and subgroup analyses), and publication bias (Egger regression intercept and Duval and Tweedie Trim-and-Fill procedure). Study bias was also coded using the NIH Study Quality Assessment Tools. RESULTS: Omnibus meta-analysis from the 58 studies included (PwM n = 5,452, HC n = 16,647; 612 effect sizes extracted) indicated lower overall cognitive performance in PwM vs HCs (g = -0.37; 95% CI -0.47 to -0.28; p < 0.001), and high between-study heterogeneity (Q = 311.25, I2 = 81.69). Significant domain-specific negative effects were observed in global cognition (g = -0.46, p < 0.001), executive function (g = -0.45, p < 0.001), processing speed (g = -0.42, p < 0.001), visuospatial/construction (g = -0.39, p = 0.006), simple/complex attention (g = -0.38, p < 0.001), learning/memory (g = -0.25, p < 0.001), and language (g = -0.24, p < 0.001). Orientation (p = 0.146), motor (p = 0.102), and intelligence (p = 0.899) were not significant. Moderator analyses indicated that age (particularly younger HCs), samples drawn from health care facility settings (e.g., tertiary headache centers) vs community-based populations, and higher attack duration were associated with larger (negative) effects and accounted for a significant proportion of between-study heterogeneity in effects. Notably, PwM without aura yielded stronger (negative) effects (omnibus g = -0.37) vs those with aura (omnibus g = -0.10), though aura status did not account for heterogeneity observed between studies. DISCUSSION: Relative to HCs, PwM demonstrate worse neurocognition, as detected by neuropsychological tests, especially on cognitive screeners and tests within executive functioning and processing speed domains. Effects were generally small to moderate in magnitude and evident only in clinic (vs community) samples. Aura was not meaningfully associated with neurocognitive impairment.

Headache and psychological variables as predictors of disability in individuals with primary headache disorders.

OBJECTIVE: To examine the relative contribution of headache symptoms and psychological factors to headache-related disability. BACKGROUND: Both headache symptoms and comorbid psychological factors (psychiatric symptoms and transdiagnostic constructs) negatively impact functioning among individuals with migraine and tension-type headache, but few studies have explored their relative contribution to headache-related disability. We hypothesized that psychiatric symptoms and transdiagnostic variables would afford incremental contribution to disability beyond headache symptoms, and we investigated the moderating role of headache diagnosis on these relationships. METHODS: This cross-sectional study examined data from a southern U.S. university online sample of 1818 young adults (mean [SD] age 19.0 [5.1] years; 74.6% female) who met the International Classification of Headache Disorders, third edition criteria for primary headache disorders (46.6% episodic migraine, 11.6% chronic migraine, 38.3% episodic tension-type headache, 3.5% chronic tension-type headache) and completed measures assessing psychological factors and headache-related disability. Headache, psychiatric symptoms, and transdiagnostic factors were examined in relation to headache-related disability, after controlling for sex. Moderation analyses examined the conditional effect of diagnosis on disability. RESULTS: As predicted, both psychiatric and transdiagnostic symptoms accounted for unique variance in headache-related disability beyond headache symptoms (R2 changes of 2.7% and 2.3%, respectively). Significant three-way interactions revealed the relationship between psychiatric symptoms and disability (b = -3.16, p = 0.002), and between transdiagnostic variables and disability (b = -2.37, p = 0.034). Tests of simple slopes showed greater psychiatric symptoms and transdiagnostic variables were associated with higher levels of disability. However, the associations of these variables with disability were strongest among individuals with chronic tension-type headache (B = 3.93 for psychiatric symptoms and B = 4.62 for transdiagnostic symptoms, both p < 0.001). CONCLUSION: Psychiatric and transdiagnostic factors contribute uniquely to headache-related functional impairment, which may be important for expanding targeted assessment and behavioral interventions.

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 Micro-Longitudinal Study of Naps, Sleep Disturbance, and Headache Severity in Women with Chronic Migraine.

OBJECTIVE: To examine the relationship between headaches, naps, and nocturnal sleep in women with chronic migraine (CM) using micro-longitudinal data from diaries and actigraphy. METHODS: 20 women with CM and 20 age and sex-matched healthy controls (HC) completed self-report questionnaires, electronic diaries, and wrist actigraphy over a 4-week period. Between-group comparisons were conducted with naps (frequency and duration) as the primary variable of interest. Within-group analyses were conducted on the CM group using hierarchical linear mixed models to examine the temporal relationships between headache severity, sleep behaviors, and sleep parameters. The primary variables of interest were naps (number and duration) and nocturnal sleep efficiency (diary and actigraphy). RESULTS: The CM group reported significantly more days with naps (25.85%) compared to the HC group (9.03%) during the study period (p = .0025). Within-group analyses in CM revealed that greater headache severity was associated with longer nap duration (p = .0037) and longer nap duration was associated with lower sleep efficiency measured using diaries (p = .0014) and actigraphy (p < .0001). CONCLUSIONS: Napping is more frequent in CM than HC and nap duration in CM is associated with headache severity and nocturnal sleep disturbance. These findings provide initial support for the hypothesis that daytime napping is a behavioral coping strategy used in CM that could contribute to insomnia.

The effect of the COVID-19 pandemic on headache-related disability among young adults with migraine.

OBJECTIVE: The present study aimed to explore the relationship between the COVID-19 pandemic and headache-related disability among a sample of young adults with migraine. BACKGROUND: Comorbid psychological symptoms compound migraine-related disability. Due to COVID-19 pandemic procedures, many students experienced institutional closures and corresponding increases in depression, stress, and anxiety. The present study sought to examine changes in headache-related disability before (Spring and Fall of 2019) and during (Fall of 2020 and Spring 2021) the COVID-19 pandemic and whether psychological symptoms mediated such changes. METHODS: A cross-sectional study at a southern U.S. university assessed 365 individuals with migraine on headache and psychological variables, comparing those surveyed before COVID-19 with another group surveyed during the pandemic. The direct and indirect effects of COVID-19 status (pre- versus during COVID-19) on headache-related disability through depression, anxiety, and stress symptoms were assessed. RESULTS: Statistically higher levels of depression, (M = 13.9 [SD = 12.2] vs. M = 8.7 [SD = 8.7], p < 0.001), anxiety (12.3 [10.0] vs. 9.7 [8.2], p = 0.01), and stress symptoms (17.6 [10.2] vs. 13.2 [7.9], p < 0.001) were endorsed during the COVID-19 pandemic. The direct path from COVID-19 status to headache-related disability was significant and negative, c' = -1.6 (95% CI: -3.1, -0.1). Anxiety (b = 0.3 [95% CI: 0.01, 0.9]) and depression (b = 0.7 [95% CI: 0.07, 1.4]) symptoms acted as mediators of this relationship, rendering the total effect nonsignificant and negating the lowered disability observed during the pandemic. Only depression symptoms remained a significant mediator after controlling for headache frequency (b = 0.7 [95% CI: 0.09, 1.4]). CONCLUSIONS: Increased depression and anxiety symptoms attenuated the improvements in disability associated with the pandemic. As such, interventions that address comorbid psychological symptoms may hold value in reducing headache-related disability and improving outcomes for young adults whose headache developed or worsened during the COVID-19 pandemic.

Allodynia and Disability in Migraine: The Mediating Role of Stress.

OBJECTIVE: This study sought to investigate the relationship between allodynia, psychological variables, and disability among individuals with migraine. BACKGROUND: A growing body of research views migraine as a condition of stress-related physiological dysregulation. Cutaneous allodynia is one manifestation of this dysregulation and affects a majority of individuals with migraine, though it is typically discussed in the context of headache pathophysiology. Stress, like allodynia, is implicated in the development of central sensitization and migraine progression. However, the contributions of stress and related psychological factors in allodynia and resulting disability remain largely unknown. METHODS: A cross-sectional study at a Southern U.S. university queried young adults with migraine regarding headache symptoms, disability, allodynia symptom frequency, and psychological variables using validated measures. Relations among allodynia and psychological variables of relevance were examined, including the association between allodynia and disability after controlling for pain severity. Subsequently, we assessed whether stress mediated the relationship between allodynia and disability. RESULTS: The final sample consisted of 147 young adults (87.8% [129/147] female, mean age = 19.0 ± 2.4) with an average headache frequency of 9.9 days per month (SD = 5.9). Increases in allodynia showed small associations with increases in stress, (r = 0.26, P = .001), fear of pain (r = 0.22, P = .008), and headache-related disability (r = 0.18, P = .003); and a small association with reduced self-efficacy (r = -0.16, P = .049). Allodynia significantly predicted disability even after controlling for pain severity (∆R2  = 0.02, P = .040), and the allodynia-disability relationship was mediated by stress (point estimate = 0.10, 95% CI [0.02-0.21]), such that as allodynia severity increased, stress increased and subsequent disability worsened. CONCLUSIONS: This study establishes meaningful relationships between allodynia and psychological variables of importance to headache self-management and adaptive coping. Allodynia exerts some effect on disability independent of pain itself, and this relationship is partially driven by stress. This study highlights the potential role of the stress response among those with allodynia, and further research is needed to determine if migraine interventions that target maladaptive stress responses may reduce disability by impeding the feedforward loop of allostatic load.

Efficacy of Galcanezumab for Migraine Prevention in Patients With a Medical History of Anxiety and/or Depression: A Post Hoc Analysis of the Phase 3, Randomized, Double-Blind, Placebo-Controlled REGAIN, and Pooled EVOLVE-1 and EVOLVE-2 Studies.

OBJECTIVE: This post hoc analysis evaluated the efficacy of galcanezumab for the prevention of migraine in patients with and without comorbid anxiety and/or depression. BACKGROUND: Patients with migraine have a higher risk of anxiety and/or depression. Given the high prevalence of psychiatric symptoms and their potential negative prognostic impact, determining the efficacy of migraine treatments in patients with these comorbidities is important. METHODS: The results of 2 phase 3 episodic migraine studies of patients with 4-14 migraine headache days (MHD) per month were pooled. A third chronic migraine study, which was evaluated separately, enrolled patients with ≥15 headache days per month, of which ≥8 had migraine-like features. Patients in all 3 studies were randomized 2:1:1 to placebo, galcanezumab 120 mg, or galcanezumab 240 mg. The efficacy of galcanezumab on migraine was measured in subgroups of patients with anxiety and/or depression (current or past) and patients without. A repeated measures model was used to compare treatment groups within each subgroup and to test for consistency of treatment effect across the anxiety/depression subgroups (subgroup-by-treatment interaction) during the double-blind treatment phases. RESULTS: Among 1773 intent-to-treat patients with episodic migraine, both doses of galcanezumab demonstrated statistically significant improvements relative to placebo in overall number of MHD for the subgroups of patients with anxiety and/or depression (mean change difference from placebo [95% CI]: -2.07 [-2.81, -1.33] for galcanezumab 120 mg [P < .001], -1.91 [-2.78, -1.04] for 240 mg [P < .001]) and without anxiety and/or depression (mean change difference from placebo [95% CI]: -1.92 [-2.36, -1.47] for 120 mg [P < .001], -1.77 [-2.20, -1.33] for 240 mg [P < .001]), as was observed for the secondary outcomes of MHD with acute medication use and functional impairment. Among 1113 intent-to-treat patients with chronic migraine, those with anxiety and/or depression had significant reductions in overall MHD frequency with the 240-mg dose (mean change difference from placebo [95% CI]: -1.92 [-3.52, -0.33]; P = .018), whereas significant reductions were observed at both the 120-mg (mean change difference from placebo [95% CI]: -2.29 [-3.26, -1.31]; P < .001) and 240-mg (-1.85 [-2.83, -0.87]; P < .001) doses in patients without anxiety and/or depressions. Significant reductions (P < .01) in MHD with acute medication use were observed at both doses within both anxiety/depression subgroups and for overall functional impairment for patients without anxiety and/or depression, though neither dose significantly reduced overall functional impairment beyond placebo in the subgroup with anxiety and/or depression. In the episodic and chronic migraine studies, the subgroup-by-treatment interaction was not statistically significant for MHD, MHD with acute medication use, or functional impairment (chronic study only), suggesting a lack of evidence of differential effect between subgroups. Furthermore, differences between subgroups in the mean change differences from placebo, as well as overlapping 95% confidence intervals for the subgroups, indicated lack of a clinical or statistical difference between subgroups for these outcome variables. There was a significantly higher percentage of patients with episodic migraine attaining ≥50%, ≥75%, and 100% reductions, and a higher percentage of patients with chronic migraine attaining ≥50% and ≥75% reductions from baseline with galcanezumab compared with placebo, regardless of medical history of anxiety and/or depression. CONCLUSIONS: A medical history of anxiety and/or depression does not seem to interfere with response to galcanezumab among patients with episodic migraine, and both doses of galcanezumab appear efficacious for these individuals regardless of this psychiatric history. Among patients with chronic migraine and comorbid anxiety and/or depression, the 240-mg dose, but not the 120-mg dose, significantly decreased overall MHD, but neither dose resulted in significantly greater functional improvement. Patients with migraine and comorbid anxiety and/or depression often require additional interventions, and this may be more important in chronic migraine.

Objectively Measured Physical Activity in Migraine as a Function of Headache Activity.

OBJECTIVE: This study sought to compare ambulatory physical activity (PA) between young adults with migraine, tension-type headache (TTH), and non-headache controls and determine if differences in PA were attributable to headache activity or other relevant covariates. BACKGROUND: PA has been implicated in the development, manifestation, and treatment of various headache disorders. However, objective quantification of PA across headache types is lacking, and no study has quantified both prospective PA and the influence of headache occurrence on PA. METHODS: A prospective cohort study followed university participants with migraine, with TTH, or without headache for 7 days using an Omron HJ-112 pedometer and daily headache diaries. Daily free-living PA was compared between groups, and differences in PA as a function of headache day vs non-headache day were compared among those with migraine and TTH. RESULTS: The final sample consisted of 516 observations from 100 young adults (81/100 female, mean age = 19.0 ± 1.7) comprised of 28 individuals with migraine, 37 individuals with TTH, and 35 non-headache controls. On average, individuals with migraine engaged in less total PA than non-headache controls (6847 vs 8573 steps/day; mean difference = -1726 [95% CI: -3135 to -318], P = .017) across the 7-day monitoring period. After adjusting for relevant covariates (psychological symptoms, body mass index, weekend vs weekday), this difference was evident on both non-headache days (adjusted mean = 5987 vs 8610, P = .002) and headache days (adjusted mean = 6986 vs 9958, P = .017). In contrast, PA of individuals with TTH (mean = 7691 steps/day) did not significantly differ from those with migraine. PA within groups as a function of headache day (vs non-headache day) did not significantly differ for individuals with migraine (mean = 7357 vs 6191, P = .061) or individuals with TTH (mean = 7814 vs 7641, P = .736). CONCLUSIONS: Consistent with other studies, individuals with migraine reported lower levels of PA compared to non-headache controls. Notably, relative reductions in PA occurred even on days in which headache was not experienced and were not attributable to the examined covariates, instead supporting a more global pattern of reduced PA. Further research is needed to isolate the mechanisms underlying interictal reductions in PA among those with migraine.

Fear, Avoidance, and Disability in Headache Disorders.

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.

Development of a measure to assess acceptance of headache: The Headache Acceptance Questionnaire (HAQ).

BACKGROUND: Disability resulting from headache disorders is attributable in part to avoidant coping. Acceptance of pain connotes a willingness to experience pain in the service of life values, such that meaningful activities and goals are pursued despite pain. Acceptance facilitates positive health outcomes but has rarely been investigated in headache. Because headache disorders manifest differently than other forms of chronic pain, the present study sought to develop and validate a measure of acceptance of headache. METHODS: Forty-five candidate items were developed and, with input from an expert panel, reduced to 24 items. Five items were eliminated following administration to a development sample and exploratory factory analysis. Nineteen items were administered to a validation sample for confirmatory factory analysis and assessment of psychometric properties. RESULTS: Factor analysis produced a unidimensional six-item measure, the Headache Acceptance Questionnaire (HAQ). The HAQ evidenced good internal consistency, convergent validity with headache disability and related psychological constructs, and divergent validity with social desirability. The measure also distinguished between headache diagnostic groups. CONCLUSIONS: Pending further validation in clinical settings, the HAQ may have utility in assessing psychological responses to headache symptoms, identifying targets of treatment for interventions that focus on reducing avoidance, and studying mechanisms of change.

Acceptance, Psychiatric Symptoms, and Migraine Disability: An Observational Study in a Headache Center.

OBJECTIVE: To evaluate relationships between psychiatric symptoms, acceptance, and migraine-related disability in a sample of people with migraine presenting at a tertiary care headache center. BACKGROUND: Migraine is a chronic disease that can be severely disabling. Despite a strong theoretical basis and evidence in other pain conditions, little is known about relationships between acceptance, psychiatric symptoms, and migraine-related disability. METHODS: Ninety patients with physician-diagnosed migraine completed surveys assessing demographics, headache symptoms, severe migraine-related disability (Migraine Disability Assessment Scale total score dichotomized at ≥ 21), depression (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder-7), and acceptance (Chronic Pain Acceptance Questionnaire; subscales: Pain Willingness and Activity Engagement). RESULTS: Participants (77.8% white, non-Hispanic; 85.6% women; and 50.0% with a graduate level education) reported an average headache pain intensity of 6.7/10 (SD = 2.0). One-third (36.0%) reported chronic migraine, and half (51.5%) reported severe migraine-related disability. Lower acceptance was associated with severe migraine-related disability, t(54) = 4.13, P < .001. Higher activity engagement was associated with lower average headache pain intensity (r = -.30, P = .011). Higher acceptance was associated with lower levels of depression (r = -.48, P < .001) and anxiety symptoms (r = -.37, P = .003). Pain willingness and activity engagement serially mediated relationships between depression symptoms and severe migraine-related disability (indirect effect = 0.05, 95% CI = 0.01, 0.15), and between anxiety symptoms and severe migraine-related disability (indirect effect = 0.12, 95% CI = 0.02, 0.31). CONCLUSION: Results provided preliminary support for a theoretical pathway by which psychiatric symptoms may influence migraine-related disability, in part, through their relationships with pain willingness and activity engagement.

Cognitive-Behavioral Therapy for Insomnia to Reduce Chronic Migraine: A Sequential Bayesian Analysis.

BACKGROUND: Insomnia is frequently comorbid with chronic migraine, and small trials suggest that cognitive-behavioral treatment of insomnia (CBTi) may reduce migraine frequency. This study endeavored to provide a quantitative synthesis of existing CBTi trials for adults with chronic migraine using Bayesian statistical methods, given their utility in combining prior knowledge with sequentially gathered data. METHODS: Completer analyses of 2 randomized trials comparing CBTi to a sham control intervention (Calhoun and Ford, 2007; Smitherman et al, 2016) were used to quantify the effects of a brief course of treatment on headache frequency. Change in headache frequency from baseline to the primary endpoint (6-8 weeks posttreatment) was regressed on group status using a Gaussian linear model with each study specified in the order of completion. To estimate the combined effect, posterior distributions from the Calhoun and Ford study were used as informative priors for conditioning on the Smitherman et al data. RESULTS: In a combined analysis of these prior studies, monthly headache frequency of the treatment group decreased by 6.2 days (95%CrI: -9.7 to -2.7) more than the control group, supporting an interpretation that there is a 97.5% chance that the treatment intervention is at least 2.7 days better than the control intervention. The analysis supports the hypothesis that at least for those who complete treatment, there is high probability that individuals who receive CBTi experience greater headache reduction than those who receive a control intervention equated for therapist time and out-of-session skills practice. CONCLUSION: Cognitive-behavioral interventions for comorbid insomnia hold promise for reducing headache frequency among those with chronic migraine. These findings add to a small but growing body of literature that migraineurs with comorbid conditions often respond well to behavioral interventions, and that targeting comorbidities may improve migraine itself.

Factors Associated With Medication-Overuse Headache in Patients Seeking Treatment for Primary Headache.

BACKGROUND: Although risk factors for medication-overuse headache have been identified within the general population, most studies have neglected clinical samples. The present study examined the relative and combined associations of these factors with medication-overuse headache in a sample of US adults seeking treatment for primary headache disorders. METHODS: Treatment-seeking headache patients provided data on demographics, headache variables, psychiatric variables, use of headache medications, and use of other prescription medications and substances. A classification tree selection strategy was utilized within this cross-sectional study to differentiate between those with and without medication-overuse headache, and a final multivariable model assessed their combined utility. RESULTS: Forty-three of 164 participants (26.2%) met diagnostic criteria for medication-overuse headache. Relative to non-medication-overuse headache participants, participants with medication-overuse headache reported greater headache-related disability (odds ratio = 1.09, 95% confidence interval = 1.01-1.18), escape and avoidance responses indicative of fear of pain (odds ratio = 1.07, 95% confidence interval = 1.00-1.15), and use of combination medications for headache (odds ratio = 3.10, 95% confidence interval = 1.51-6.36). The final multivariable model differentiated well between the 2 groups (area under the receiver operating characteristic curve = .78; 95% confidence interval = .71-.86). CONCLUSIONS: Items that assess headache-related disability, use of combination medications, and fear of pain help identify patients who are currently overusing acute headache medications and may serve as indicators of treatment progress. Future studies should apply similar analytic approaches longitudinally to identify headache sufferers at risk for medication-overuse headache prior to headache progression.

A Diary Study of Basic Psychological Needs and Daily Headache Experience.

OBJECTIVE: A diary study was conducted to investigate the relationships between headache activity and basic psychological needs satisfaction. METHODS: One hundred sixteen young adults (M age = 19.17 (SD = 2.90); 81.7% female; 75.9% Caucasian) completed an online daily diary of headache activity and needs satisfaction for 3 weeks. Data were analyzed using hierarchical linear modeling. RESULTS: On days when headache occurred, participants reported decreased needs satisfaction of competence (γ10 = -0.18, P = .014) and relatedness (γ10 = -0.24, P = .003), and a marginal but not significant reduction in autonomy (γ10 = -0.13, P = .067). Additionally, more severe headaches were associated with decreased needs satisfaction in autonomy (γ10 = -0.08, P = .009), competence (γ10 = -0.08, P = .011), and relatedness (γ10 = -0.09, P = .005). Presence of a headache diagnosis did not moderate the relationship between headache occurrence and basic needs satisfaction (all Ps ≥ .24). CONCLUSIONS: This preliminary study is the first to show that headache is related to reduced basic psychological needs satisfaction, providing a potential account for one mechanism by which headache may negatively affect quality of life. Further research is needed to extend these findings to larger samples of migraine sufferers to enable more thorough between-group comparisons of headache-related burden on basic needs satisfaction. These findings may be informative for treatment approaches that focus on outcomes beyond mere symptom reduction.

Perceived triggers of primary headache disorders: A meta-analysis.

Objective To quantitatively synthesize extant literature on perceived triggers of primary headache disorders. Methods A meta-analytic review of headache trigger survey studies was conducted. Endorsement rates, assessment method, and headache and sample characteristics were extracted from included articles. Separate random-effects models were used to assess trigger endorsement rates and post-hoc meta-regressions examined potential moderator variables. Results 85 articles from 1958 to 2015 were included, involving 27,122 participants and querying 420 unique triggers (collapsed into 15 categories). Four-fifths (0.81; 95% CI .75 to .86) of individuals with migraine or tension-type headache endorsed at least one trigger. Rates increased with the number of categories queried (OR: 1.18, 1.08-1.30) and year of publication (OR: 1.04, 1.00-1.08). The triggers most commonly endorsed were stress (.58, .53-.63) and sleep (.41, .36-.47). Conclusions Extreme heterogeneity characterizes the headache trigger literature. Most individuals with a primary headache disorder perceive their attacks to be triggered by one or more precipitants, the most common of which are stress and sleep. However, trigger endorsement is influenced by method of assessment. Enhancing methodological consistency and prioritizing experimental studies would improve our understanding of headache triggers.

Pain worsening with physical activity during migraine attacks in women with overweight/obesity: A prospective evaluation of frequency, consistency, and correlates.

Background Migraine is a neurological disease involving recurrent attacks of moderate-to-severe and disabling head pain. Worsening of pain with routine physical activity during attacks is a principal migraine symptom; however, the frequency, individual consistency, and correlates of this symptom are unknown. Given the potential of this symptom to undermine participation in daily physical activity, an effective migraine prevention strategy, further research is warranted. This study is the first to prospectively evaluate (a) frequency and individual consistency of physical activity-related pain worsening during migraine attacks, and (b) potential correlates, including other migraine symptoms, anthropometric characteristics, psychological symptoms, and daily physical activity. Methods Participants were women (n = 132) aged 18-50 years with neurologist-confirmed migraine and overweight/obesity seeking weight loss treatment in the Women's Health and Migraine trial. At baseline, participants used a smartphone diary to record migraine attack occurrence, severity, and symptoms for 28 days. Participants also completed questionnaires and 7 days of objective physical activity monitoring before and after diary completion, respectively. Patterning of the effect of physical activity on pain was summarized within-subject by calculating the proportion (%) of attacks in which physical activity worsened, improved, or had no effect on pain. Results Participants reported 5.5 ± 2.8 (mean ± standard deviation) migraine attacks over 28 days. The intraclass correlation (coefficient = 0.71) indicated high consistency in participants' reports of activity-related pain worsening or not. On average, activity worsened pain in 34.8 ± 35.6% of attacks, had no effect on pain in 61.8 ± 34.6% of attacks and improved pain in 3.4 ± 12.7% of attacks. Few participants (9.8%) reported activity-related pain worsening in all attacks. A higher percentage of attacks where physical activity worsened pain demonstrated small-sized correlations with more severe nausea, photophobia, phonophobia, and allodynia (r = 0.18 - 0.22, p < 0.05). Pain worsening due to physical activity was not related to psychological symptoms or total daily physical activity. Conclusions There is large variability in the effect of physical activity on pain during migraine attacks that can be accounted for by individual differences. For a minority of participants, physical activity consistently contributed to pain worsening. More frequent physical activity-related pain worsening was related to greater severity of other migraine symptoms and pain sensitivity, which supports the validity of this diagnostic feature. Study protocol ClinicalTrials.govIdentifier: NCT01197196.

Psychometric investigation of the specific phobia of vomiting inventory: A new factor model.

Well-validated, standardized measures are lacking for the assessment of emetophobia, the specific phobia of vomiting. The Specific Phobia of Vomiting Inventory (SPOVI) was recently developed and shows promise as a useful measure of emetophobia. The goal of the present study was to further examine and investigate the psychometric properties of the SPOVI in a large student sample (n = 1626), specifically focusing on its factor structure, measurement invariance across gender, and convergent/divergent validity. Confirmatory factor analysis results provide support for a one-factor model of the SPOVI, in contrast to the previously proposed two-factor model. Internal consistency of the SPOVI was good (α = 0.89) and measurement invariance across gender invariance was supported. The SPOVI also demonstrated good psychometric properties with respect to convergent and divergent validity. The present study's demonstration of the reliability and validity of the SPOVI suggests that the instrument may be a valuable tool for assessing emetophobia symptoms based on its one-factor structure.