Modification of the SF-36 for a headache population changes patient-reported health status.

BACKGROUND: Using standard quality of life and disability measures may not accurately capture these constructs in specific health populations such as headache patients. Modifying the wording of standard measures such as the Short-Form 36 (SF-36) should be considered in order to make them more applicable to specific patient populations. OBJECTIVE: To investigate the possibility that headache patients may not consider their headaches when responding to SF-36 questions pertaining to health, physical health, pain, and bodily pain. METHODS: The wording of several SF-36 questions were adapted for a headache population by making specific reference to "headaches" when asking people to rate the impact of health issues on their life. The results of the modified "Headache" SF-36 were compared with a similar population of transformed migraine patients who had completed the "Standard" SF-36. RESULTS: Significant differences were found between scores for the "Standard" SF-36 group and the "Headache" SF-36 group across all SF-36 variables except for "General Health." CONCLUSIONS: Misinterpretation of the concepts of "health,""physical health,""pain," and "bodily pain," although commonly used by the SF-36 in many populations, could influence responses on this measure, as respondents may not relate their head/headaches to these constructs. To ensure that accurate data are obtained in relation to the quality of life of headache patients, consideration should be given to using a form of the SF-36 that has been modified to allow appropriate interpretation of the questions completed by headache patients.

Understanding the role of culture in pain: Maori practitioner perspectives of pain descriptors.

AIMS: There is growing interest in the role of cultural diversity within healthcare settings yet minority ethnic groups are underrepresented in the healthcare literature, including the literature on pain. To better assess and treat pain in different cultures the perspectives and experiences of that culture must be taken into consideration and therefore the present study was undertaken to better understand Maori perspectives of pain. METHODS: Maori healthcare providers and kaumatua (tribal leaders/elders) completed questionnaires relating to the experience of pain and were asked to provide feedback regarding the suitability of words and phrases typically used to describe symptoms of pain and pain-related disability. Participants were also asked to provide words, or phrases (in te reo Maori or English) representing characteristics of pain which had not been provided but would be useful in the assessment of pain in a Maori population. RESULTS: All of the pain descriptors, and 92% of the phrases regarding the experience of pain, provided were endorsed by the majority of participants demonstrating that, as in many cultures, Maori perceive pain as a multidimensional experience impacting them on physiological, psychological, and social dimensions and that the terms and phrases of measures commonly used to assess pain appropriately capture their pain experiences. CONCLUSIONS: The implications of these findings are that established measures can be used when assessing pain in Maori. However, it is beneficial to confirm that the descriptors used in those measures accurately capture the experiences being measured.

Understanding the role of culture in pain: Maori practitioner perspectives relating to the experience of pain.

AIMS: As there is growing interest in the role of cultural diversity within healthcare settings it is important to determine how culture can influence such things as pain. A person's culture can impact not only how they perceive and experience pain but also how they interact with healthcare professionals and adhere to advice provided. To better assess and treat pain in different cultures the perspectives and experiences of that culture must be taken into consideration and therefore the present study was undertaken to better understand Maori perspectives of pain. METHODS: Maori healthcare providers and kaumatua (tribal leaders/elders) were interviewed in order to gain insight into how pain was perceived and expressed by Maori with whom they had health-related interactions. RESULTS: The interviews reflected themes consistent within the greater body of literature in that as with many cultures, Maori perceive pain as a multidimensional experience impacting them physically, psychologically, socially and spiritually. CONCLUSIONS: While our findings indicate that there is a commonality between cultures with regard to the experience of pain, it is valuable to understand a culture's perceptions and experiences regarding pain before assessing and treating it as indicated in the findings from this study wherein cultural factors such as the role of the whanau (family) and the importance of the development of relationships with healthcare providers were points of emphasis in terms of ways to enhance Maori health.

Factors associated with depression in patients referred to headache specialists.

OBJECTIVE: To evaluate the relationship between selected demographic characteristics and clinical features in patients with headache and depression. METHODS: We studied demographic and clinical data collected at the time of consultation for 712 new patients with headache referred to five headache specialty clinics in Canada. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The Beck Depression Inventory (BDI-II) was used to identify the presence of depression. Multivariable logistic regression analysis was employed to evaluate associations between age, gender, employment status, marital status, diagnosis, headache days per month, medication overuse, headache impact (HIT-6), and headache disability (MIDAS) and the presence of depression as measured by the BDI-II. RESULTS: Among the sample of patients with headache, 27% (n = 189) had moderate to severe depression. Factors independently associated with depression included age less than 50 years, being unemployed, being on disability pension or welfare, being widowed, separated, or divorced, a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder, and showing severe headache impact as measured by the HIT-6, or severe disability as measured by the MIDAS. CONCLUSIONS: In patients with headache referred for specialist consultation, depression is strongly associated with being on disability or welfare, unemployment, age under 50 years, showing severe headache impact on the Headache Impact Test-6, and receiving a diagnosis of transformed migraine. The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics.

Demographics and clinical features of patients referred to headache specialists.

OBJECTIVE: To examine demographic characteristics and clinical features of headache patients referred to neurologists specializing in headache in Canada. METHODS: Demographic and clinical data were collected at the time of consultation for 865 new headache patients referred to five headache-specialty clinics in Canada. The Headache Impact Test (HIT-6) and Migraine Disability Questionnaire (MIDAS) were used to measure headache impact and disability. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. RESULTS: The average age of the patients was 40 years and the majority were female (78%). Most were employed either full time (49%) or part time (13%). The majority of patients were diagnosed with either migraine or tension-type headache (78%). Over a third of patients experienced headache every day, and half had experienced a headache in the previous month which was of severe intensity. Most (80%) scored in the "very severe" category of the HIT-6 and over half (55%) were severely disabled as measured by the MIDAS. CONCLUSION: Patients referred to headache specialists in Canada are severely disabled by their headache disorders. These patients are in the most productive phase of their lives in terms of age and employment. It is important to provide the best available treatment to headache patients in order to minimize the disability and impact of their headache disorders.

Effectiveness of a multidisciplinary treatment program for chronic daily headache.

BACKGROUND: Chronic daily headache (CDH: headache on fifteen days a month or more) is one of the most common forms of chronic pain. The relative efficacy of different treatment methods for these patients needs to be determined. OBJECTIVE: To compare treatment outcomes for patients with CDH treated in a traditional office-based pharmacological treatment program with a second group treated in a multidisciplinary management program. METHODS: Patient outcomes were measured using changes in the Headache Disability Inventory (HDI) and the Short-Form-36 (SF-36) over the treatment period. Outcomes from seventy patients treated in an office setting were compared to thirty-seven patients treated in a multidisciplinary headache treatment program. Both groups received similar pharmacological treatment. All patients treated in the office setting and the majority of patients in the multidisciplinary program had transformed migraine. RESULTS: Even though a reduction in headache days per month occurred, mean headache related disability (measured by HDI) and mean Health Related Quality of Life (HRQoL measured by SF-36) did not improve for the patient group treated in the office setting but did improve significantly for the patient group treated in the multidisciplinary headache program. CONCLUSION: For patients with CDH, headache-related disability and HRQoL is more likely to improve with management in a multidisciplinary headache treatment program as compared to the traditional specialist consultation-family physician office-based setting.

Migraine frequency and intensity: relationship with disability and psychological factors.

BACKGROUND: Migraine can be disabling, but it varies greatly in frequency and intensity between individuals. It is not clear which clinical features have the greatest impact on a migraineur's quality of life. OBJECTIVE: To determine the influence of headache intensity and frequency on headache-related disability. METHODS: Patients who were referred to a headache clinic and given a diagnosis of migraine with or without aura or transformed migraine (n = 115) were divided into different groups based on headache frequency and mean headache intensity. Headache frequency was determined from patient diaries. Headache intensity also was assessed from patient diaries and from scores on the pain severity scale of the Multidimensional Pain Inventory (MPI). Headache-related disability was assessed with the Headache Disability Inventory and by scores on the activity interference scale of the MPI. The degree of depression present was assessed with the Beck Depression Inventory, and emotional distress was measured by scores on the affective distress scale of the MPI. RESULTS: In our patient population, higher mean headache intensity levels were associated with higher levels of headache-related disability. Our results also suggested that increased headache intensity is associated with higher levels of depression and emotional distress, although this correlation was statistically significant in only 1 of 4 comparisons. Headache frequency did not correlate with disability, depression, or emotional distress. CONCLUSIONS: For a headache referral population, headache intensity appears to be a major determinant of headache-related disability, and it also correlates, to some extent, with the degree of depression and emotional distress present. Headache frequency was not clearly related to disability or psychological factors.

Environmental conditions influence hippocampus-dependent behaviours and brain levels of amyloid precursor protein in rats.

Sprague-Dawley rats were reared in enriched (EC; group housing, exposure to stimulating objects, frequent handling) or restricted (RC; individual housing, no exposure to stimulating objects, minimal handling) environments starting on day 23 of life. At six months of age, they underwent behavioural tests to assess 'cognitive' and 'stimulus-response' memory, selective attention, and inflammatory pain processing. Alterations in synapses and cell survival may occur as a result of environment differences; therefore we assessed the brain levels of several proteins implicated in neurite outgrowth, synaptogenesis, and cell survival. Brains were dissected and analysed for amyloid precursor protein (APP) and other synaptic and cytoskeletal proteins using Western blotting. The performance of EC animals in a hidden platform water maze task, and in a test of selective attention (both of which are thought to involve the hippocampus) was superior to that of RC animals. In contrast, performance of RC animals on two stimulus-response tasks, the visible platform water maze test and simple visual discrimination (both of which are thought to be hippocampal independent) was indistinguishable from that of EC animals. Male EC rats displayed a different behavioural response to formalin during the inflammatory phase of nociception--the phase affected by hippocampal processing; a similar trend was observed in females. Female but not male RC rats exhibited elevated plasma corticosterone levels; adrenal weights were unaffected by environmental conditions. Region-specific increases in brain levels of APP, neurofilament-70 (NF-70), and platelet-activating factor receptor (PAF-R) were found in EC rats. These data suggest that enriched animals manifest enhanced functioning of certain hippocampus-mediated behaviours when compared with that of their restricted counterparts; and that brain levels of various synaptic and structural proteins involved in neurite outgrowth, cell survival, and synaptogenesis, are affected by environmental factors.

Platelet-activating factor antagonists decrease the inflammatory nociceptive response in rats.

RATIONALE: Platelet-activating factor (PAF) is a membrane-derived phospholipid mediator that has biological effects on a variety of cells and tissues. A variety of stimuli, including those producing inflammation, promote the synthesis and release of PAF from various cell types. Evidence suggests that PAF exerts cellular actions through a plasma membrane receptor as well as via intracellular (microsomal) PAF binding sites. OBJECTIVE: The present study was designed to: 1) investigate the role of PAF in a model of inflammatory nociception in rats (i.e. the formalin test), and 2) localize PAF's site(s) of action in nociception. To do this, we assessed the effect of administering two PAF antagonists (BN 52021 and BN 50730, which are selective for cell surface and intracellular PAF binding sites, respectively) on formalin-induced nociceptive responses. METHODS: Forty minutes prior to formalin injection into the rat hindpaw, male Sprague-Dawley rats received systemic injections of BN 52021 (10, 1, or 0.1 mg/kg), BN 50730 (10, 1, or 0.1 mg/kg), or vehicle (45% 2-hydroxypropyl-beta-cyclodextrin in distilled water, HBC) and the effects of the drugs on nociceptive behavioral responses were measured. RESULTS: Rats receiving systemic BN 52021 or BN 50730 displayed a significant reduction of nociceptive responses in the late, but not early, phase of formalin-induced nociception. CONCLUSIONS: These findings suggest a role for endogenous PAF in nociceptive transmission, especially for persistent pain such as that which occurs in the late phase of the formalin test. The findings also indicate that both intracellular and cell surface PAF binding sites are involved in nociceptive modulation in rats, and that PAF antagonists might be useful for treating some patients with acute or chronic pain.

Additional evidence for the involvement of the basal ganglia in formalin-induced nociception: the role of the nucleus accumbens.

Identification of the brain areas that contribute to pain is an essential undertaking towards understanding persistent pain. Areas of the basal ganglia have been proposed to play important roles in nociception as previous studies have determined the involvement of the substantia nigra pars compacta and the dorsolateral striatum in pain. The purpose of the present study was therefore to expand upon these findings by determining the involvement of other areas of the basal ganglia such as the nucleus accumbens shell and core in formalin-induced nociception. It was found that injection of a local anaesthetic (bupivacaine) into the nucleus accumbens shell had no effect on formalin-induced nociception. However, injection into the nucleus accumbens core enhanced formalin-induced nociception. These results implicate the nucleus accumbens in the processing of pain and provide additional evidence for the involvement of the basal ganglia and possibly dopamine in pain.