Psychosocial factors of relevance to sex and gender studies in headache

Sex and gender differences in humans are being increasingly recognized not only in experimental pain paradigms but also clinically. Women experience various chronic pain conditions such as headache more than men and evidence differences in pain threshold and pain tolerance experimentally. In addition to biological underpinnings, psychosocial factors such as gender and social role expectations, coping strategies, and affective variables likely contribute to observed sex- and gender-related differences in headache. The present narrative reviews and summarizes extant literature pertaining to these psychosocial factors. Gender and social role expectations and coping styles differ between men and women who experience headache and pain, in turn affecting differences in responding to pain. Epidemiologic findings that women have higher rates of headache-related disability and psychiatric comorbidity have not been replicated regularly among treatment-seeking headache samples. Awareness of these differences may stimulate further research and enhance therapeutic opportunities for headache patients.     

Headache Disorders in Children and Adolescents: Their Association With Psychological,Behavioral, and Socio‐Environmental Factors

Objective.— This cross‐sectional study on a randomly drawn population sample of children and adolescents (n = 3399; aged 9 to 15) aimed at the assessment of patterns of associations between psychosocial variables and primary headache disorders like migraine (MIG) or tension‐type headache. A headache‐free group served as a control. Methods.— Data on headache and psychological trait variables (eg, internalizing symptoms), behavioral factors (eg, physical activities), and socio‐environmental factors (eg, life events) were gathered by questionnaire. Logistic regression analyses were conducted with headache types (MIG, tension‐type, and non‐classifiable headache) as dependent variables. Results.— The pattern of correlations was largely congruent between the headache disorders. Associations were closest regarding maladaptive psychological traits (in particular internalizing symptoms with an odds ratio > 4 regarding MIG) compared with socio‐environmental factors and particularly the behavioral factors. Unfavorable psychological traits and socio‐environmental strains demonstrated distinctly stronger associations with MIG than tension‐type headache and explained more variance in the occurrence of pediatric headache disorders than parental headache. Sex‐specific analyses showed similarities as well as differences regarding the correlations, and in general, the associations were stronger in girls than boys. Conclusions.— A common path model as posited by several researchers in the field may explain the parallelism in biopsychosocial vulnerability regarding the different headache disorders.     

Biopsychosocial profiles of different pain diagnostic groups.

Different pain diagnoses have been examined separately in various research studies. The major aim of the present investigation was to add to the current understanding of the various groups of patients who make up the chronic pain population. This study expanded the research literature by including 7 different predominantly chronic pain syndromes (fibromyalgia, upper extremity pain, cervical pain, thoracic pain, lumbar pain, lower extremity pain, and headache). These 7 groups were examined by using a broad array of variables focusing on demographic, self-reported psychosocial, and physical/functional factors. There were 661 patients included from an interdisciplinary treatment program who had been given 1 physical pain diagnosis. Results revealed differences among the 7 groups with regard to self-reported physical/functional limitations. The headache group had less physical/functional impairment than most of the other groups. On the other hand, the lumbar, fibromyalgia, and lower extremity groups had the most physical/functional problems. On self-reported psychosocial measures, the fibromyalgia group had the most difficulties, and the lower extremity and lumbar groups had fewer problems in this area. Overall, though, besides the fibromyalgia group, there was a lack of differences among the other groups on the psychosocial measures. PERSPECTIVE: Biopsychosocial profiles were examined for different pain diagnostic groups. Seven different pain groups were compared. It was discovered that, in general, the lumbar, fibromyalgia, and lower extremity groups reported more physical/functional limitations, and the fibromyalgia and headache groups reported more psychosocial difficulties.     

Biopsychosocial Correlates of Headache: What Predicts Pediatric Headache Occurrence?

OBJECTIVE: The study aims at identifying biopsychosocial risk factors for headache in children and adolescents aged 9 to 14. METHODS: An epidemiological survey was conducted in a randomly drawn population sample of families with children in the above age group. Questionnaires were mailed to parents and children (n=6400), on whose data this report is based. The objective of the study was to establish a profile of risk factors regarding the occurrence of headache. Headache, as the criterion variable, was ranked according to its frequency in the last 6 months (no, rare, monthly, weekly). Independent variables came from 6 domains: health, socioeconomic, family, school, leisure/peers, and psychological factors. Data analysis was conducted via multinomial regression analyses in a 4-step strategy: (1) analysis of age and sex as control variables; (2) analysis of single variables from each of the 6 domains (controlled for age and sex); (3) domain analyses; and (4) comprehensive analysis including all significant variables from the domain analyses. RESULTS: Age and sex explained a small but significant proportion of the variance in headache frequency (3.5%). All health variables, several socioeconomic, and most family- and school-related as well as the psychological variables demonstrated a significant association with the criterion in the single variable models. However, only a few of the variables related to leisure/peer activities reached significance. The domain model comprising health variables explained 27% of the variance, achieving the best model fit, followed by the psychological model with 13%. CONCLUSIONS: The comprehensive model was able to explain one third of the total variance in headache occurrence. Contrary to our hypothesis, the addition of psychosocial variables to health-related predictors did not markedly improve model fit.     

Psychosocial impact of headache and comorbidity with other pains among Swedish school adolescents

BACKGROUND: The psychosocial impact of headache combined with other pains has previously been insufficiently investigated. OBJECTIVE: The present study examined the prevalence of headache, its comorbidity with other pains and psychosocial impact among adolescents. METHODS: 793 adolescents in a sample recruited from 8 schools in the middle of Sweden were assessed. RESULTS: Forty-five percent of the adolescents reported ongoing pain during assessment and more than half of the adolescents reported at least one frequent pain during the previous 6 months. The most common pain among girls was headache (42%), but for boys muscle pain (32%) was most prevalent. Number of pains and perceived pain disability were also higher among girls than boys. One-third of the headache sufferers had headache only, while one-third reported one other frequent pain and the others had at least two other frequent pains. Overall, adolescents with frequent headaches had higher levels of anxiety or depressive symptoms, in addition to functional disability and usage of analgesic medication. Frequent headache sufferers reported more problems in everyday life areas than those with infrequent headaches. CONCLUSIONS: It is recommended that adolescents suffering from recurrent headaches routinely should be asked about the presence of other pains, anxiety and depressive symptoms, medication usage, in addition to psychosocial consequences in their everyday life activities. Longitudinal research is also needed to delineate causal relationships between psychosocial factors and recurrent pains, in particular regarding possible sex differences.     

Psychiatric and behavioral aspects of headache

This article reviews the recent literature on psychiatric and behavioral aspects of headache. Treatment and psychologic management of migraine and headache pain are also discussed. The authors emphasize that a variety of psychosocial factors may contribute to or exacerbate headache problems.     

Relative Contributions of Life Events Versus Daily Hassles to the Frequency and Intensity of Headaches

This study investigated headache parameters (frequency and intensity) in relation to (the number and severity of) two types of psychosocial stress: major life events (as assessed by a revised Social Readjustment Rating Scale) and minor daily hassles (as assessed by a revised Hassles Scale). Subjects were 261 volunteers reporting headache. Results revealed that both headache frequency and intensity were significantly predicted by daily hassles, in particular, the average severity of these hassles, but there was a negligible relationship between headache parameters and any of the life event measures. Furthermore, a significant relationship emerged between life events and daily hassles themselves. This fits with recent findings that life events (while exerting little direct effect on headache) may trigger a succession of hassles which culminate in headaches. Also, it is not the number of hassles, but the perceived severity of these hassles that best predicts headache frequency and intensity. Finally, though significant as predictors, daily hassles explained a small portion of the variance in headache, thus pointing to the host of other possible biological and psychosocial contributions to headache.     

Headache in schoolchildren: association with other pain, family history and psychosocial factors

Limited information exist about associations between different headache types and other pains, family history of pain, and psychosocial factors among children from the general population suffering from less severe headache. We interviewed 130 schoolchildren together with a parent to find out whether such factors differ between children with mainly infrequent and moderate migraine or tension-type headache as compared to those without primary headache. Children with headache, especially those with migraine reported other pains and physical symptoms more frequently than children without primary headache. Coherently, parents of children suffering from migraine reported their children to have significantly more somatic symptoms than parents of children without primary headache. In addition, first-degree relatives of children with headache suffered from more migraine, other pains, and physical symptoms compared with first-degree relatives of children without primary headache. Children with migraine visited the school nurse, used medication and were absent from school because of headache more often than those with tension-type headache. Few other differences in psychosocial factors were found between the three groups. Migraine among first-degree relatives and the total sum of physical symptoms in children were the strongest predictors of headache in logistic regression analysis. It is concluded that in schoolchildren with mainly infrequent and moderate headache, pain and physical symptoms cluster within individuals as well as their families, however, psychological and social problems are uncommon.     

Socio-economic factors, lifestyle, and headache disorders - a population-based study in Sweden

Objective.— To study the association between socio‐economic factors, lifestyle habits, and self‐reported recurrent headache/migraine (RH/M) in a general population. Methods.— The study population comprised a random sample of men and women aged 18‐79 years. The data were obtained using a postal survey questionnaire during March‐May 2000. The overall response rate was 65%. The area investigated covers 58 municipalities with about one million inhabitants in central part of Sweden. The study is based on 43,770 respondents. Odds ratios for RH/M were calculated for a set of variables using multiple logistic regression models. Results.— The overall prevalence of self‐reported RH/M during the last 3 months was 10% among men and 23% among women and decreased with increasing age. Physically inactive subjects were more likely to suffer from headache disorders than physically active subjects. Smoking was only moderately associated with RH/M. There was an inverse relationship between heavy alcohol use and RH/M. Underweight and obesity were not associated with headache disorders when adjusted for socio‐economic factors. Subjects with frequent economic problems had almost twice the risk of RH/M compared with subjects with no economic problems. Poor social support was associated with headache disorders and subjects who had been belittled during the last 3 months were more than twice as likely to suffer from RH/M as subjects who had not been belittled. The effect of educational level was modest. Marital status and country of origin were not associated with headache disorders after adjustment for other socio‐economic factors. Dissatisfaction with work, worry about losing one's job, and absenteeism due to illness were strongly associated with headache disorders. Physical working conditions and working hours were not associated with RH/M. Conclusion.— Headache disorders mainly affect young and middle‐aged adults. There are, however, socio‐economic disparities in self‐reported recurrent headache and migraine. The relationship was particularly evident for economic hardship and psychosocial factors. Of lifestyle factors, physical inactivity was strongly associated with headache disorders independent of economic and psychosocial factors.     

Epidemiological and clinical characteristics with psychosocial aspects of tension-type headache in Turkish college students

We investigated the prevalence and clinical characteristics of tension-type headache (TTH), psychosocial factors contributing to the onset and aggravation of headache and coping mechanisms of individuals in a young population in Turkey. The sample consisted of 2226 university students, aged 7 to 21 years old. A self-administered questionnaire inquiring about epidemiological and clinical features of headache was filled out by participants. TTH diagnosis was determined in accordance with the International Headache Society Criteria of 1988. The prevalence of TTH was 20.35% (25.54% for women and 14.25% for men). 43.7% of headache sufferers had one or more stressful life events before the onset of headache and stress was the most frequent aggravating factor of headache (52%). Resting (58.1%) was the most common coping style. In conclusion, TTH is not a rare condition in Turkish young people and psychosocial factors are always taken into consideration for diagnosis and treatment of TTH.     

Prevalence of frequent headache in young Finnish adults starting a family

A questionnaire study on pre-pregnancy headache and its predictors was carried out in a representative sample of young adults expecting their first baby. The study was part of a major project on the competence of Finnish families. It included 1322 women and 1257 men, either married or cohabiting (in total, 1262 families), followed from their first contact with a maternity health care unit. A questionnaire was given separately to the women and men inquiring about their health and health behaviour, as well as about sociodemographic and psychosocial factors. The prevalence of frequent headache (at least one episode per month) was 34.3% in women, 19.3% in men and 47.1% in families. On multivariate analysis, after age-adjustment, the independent predictors of headache occurrence in women were depression, menstrual pain, responsibilities at work and psychosocial stress. The predictors in men were nervousness, psychosocial stress, lack of or irregular physical exercise and long-term disease, depression, responsibilities at work and insomnia.     

Change mechanisms in EMG biofeedback training: cognitive changes underlying improvements in tension headache

Forty-three college students suffering from recurrent tension headache were randomly assigned to 1 of 4 electromyographic (EMG) biofeedback training conditions. Although all subjects were led to believe they were learning to decrease frontal EMG activity, actual feedback was contingent on decreased EMG activity for half of the subjects and increased EMG activity for the other half. Within these 2 groups, subjects also viewed bogus video displays designed to convince them they were achieving large (high success) or small (moderate success) reductions in EMG activity. Regardless of actual changes in EMG activity, subjects receiving high-success feedback showed substantially greater improvement in headache activity (53%) than subjects receiving moderate success feedback (26%). Performance feedback was also related to changes in locus of control and self-efficacy. Changes in these 2 cognitive variables during biofeedback training were also correlated with reductions in headache activity following treatment, whereas changes in EMG activity exhibited during training were uncorrelated with outcome. These results suggest that the effectiveness of EMG biofeedback training with tension headache may be mediated by cognitive changes induced by performance feedback and not primarily by reductions in EMG activity.     

Effects of Frontalis EMG Biofeedback and Diazepam in the Treatment of Tension Headache

SYNOPSIS
Frontalis EMG biofeedback and diazepam treatments were compared in tension headache patients; headache scores (intensity and frequency) and frontalis EMG were used as control parameters. The study, conducted in a double blind manner, was split in three equal observation periods (4 weeks): baseline, treatment and follow-up. Four patient groups were chosen, two of which received placebo treatment. In both true conditions, biofeedback and diazepam, treatment effects differentiated from placebo groups; with diazepam the strongest results upon headache and frontalis EMG were observed during treatment, which, however, were lost at the follow-up period; biofeedback although with weaker effects during treatment showed, at follow-up, a long lasting reduction of headache scores even when frontalis activity reached baseline levels; in the false biofeedback group some decrease of EMG activity during treatment and of headache intensity at follow-up were also observed. The data suggest that biofeedback is a complex learning situation, where several uncompletely known factors are possibly at work; it also raises the possibility of a complex relation between frontalis muscular activity and headache since a simple linear relation of both variables was not observed.     

Tension Headache Patients: A Comparison of a Recruited Subject Sample and a Clinic-based Subject Sample

SYNOPSIS
To assess comparability of research populations, tension headache sufferers recruited through advertisement or obtained from a medical psychology clinic were compared on relevant psychological and physiological variables. Differences in headache activity, personality profiles, and muscle tension were noted which may have implications for generalization of treatment results from recruited subjects to clinic patients.     

Psychosocial factors in children and adolescents with migraine and tension-type headache: a controlled study and review of the literature

We investigated 341 children and adolescents to evaluate the relevance of psychosocial factors in idiopathic headache. According to the criteria of the International Headache Society, 151 subjects had migraine and 94 had tension-type headache (TTH). Ninety-six subjects were headache-free controls. Psychosocial factors covered family and housing conditions, school problems, relations in the peer group, and several other items. We found that migraine patients did not differ from headache-free controls. Patients with TTH more often had divorced parents than the headache-free controls, and they had fewer peer relations than migraineurs and controls. In addition, migraine patients were significantly more often absent from school due to headache. All other psychosocial factors failed to discriminate between the three study groups. In conclusion, this controlled study in children and adolescents suggests that migraine is not related to family and housing conditions, school situation, or peer relations, whereas TTH is associated with a higher rate of divorced parents and fewer peer relations.     

Headache in children in Dutch general practice

AIM: To describe the occurrence of headache in general practice, the diagnoses made in general practice, and the management. METHOD: Data from the Dutch national survey of morbidity and interventions in general practice were used. The practice population (103 practices) comprised 63,753 children aged 0-14 years. RESULTS: In 634 episodes, headache was a reason for encounter. The incidence of headache presented to the general practitioner was 40.2 per 1000 person years. More than half of the episodes were related to an infectious disease, among which upper respiratory tract infections predominated. The incidence rate of the diagnosis idiopathic headache was 7.3 episodes per 1000 person years. The incidence increased with age and was higher in girls than in boys. In only 12% of cases of idiopathic headache were special investigations carried out, mostly blood examinations. Medication was prescribed in 27% of all episodes of idiopathic headache. In the absence of an infectious disease, many headache episodes were associated with psychosocial problems. Family problems and school problems were mentioned most often. CONCLUSION: Headache in children as reason for encounter is a common problem in general practice, often associated with an infectious disease. When confronted with a child with idiopathic headache, the general practitioner should be aware of a possible psychosocial component.     

Recurrent headache in adolescents: nonreferred versus clinic population

OBJECTIVE: To compare headache activity, psychosocial measures, and cold pressor response between referred and nonreferred adolescents with frequent headache. DESIGN: Thirteen boys and 19 girls with a mean age of 13.4 +/- 0.9 years who had been referred to a hospital-based behavioral treatment program for recurrent headache were compared with an age- and sex-matched school-based population of nonreferred students consisting of 31 adolescents with frequent headaches and 32 adolescents with infrequent or no headaches. All subjects completed the Spielberger State-Trait Anxiety Inventory/Trait form, the Children's Depression Inventory, the Childhood Somatization Inventory, and measures of headache activity and related functional disability. Additionally, all subjects reported interval discomfort scores on a 40-second cold pressor test with arm immersion in a 10 degrees +/- 1 degree C cold water bath. RESULTS: Subjects from both headache groups reported significantly more anxiety than those with infrequent or no headaches. The school-based nonreferred adolescents reported more depressive symptoms than the clinic-based referred subjects. In addition, the latter group reported headaches of longer duration and more school days missed due to headaches than both other groups. Whereas school-based subjects and those with infrequent or no headaches reported relatively low initial cold pressor test scores and gradually reported increasing scores with time, clinic-based subjects rated their discomfort as high at the initial interval report and maintained high levels throughout the test. No differences in somatization were found among groups. CONCLUSION: Although adolescents who seek behavioral treatment for recurrent headache do not report more psychological symptoms than nonreferred adolescents with frequent headaches, they report headaches of longer duration, miss more school days due to headache, and report higher initial sustained discomfort scores to a standardized noxious stimulus.     

Pain sensitivity and pain reactivity of pericranial muscles in migraine and tension-type headache

We investigated whether experimentally determined, suprathreshold pain sensitivity of pericranial musculature in patients with tension-type headache differs from that of migraine patients or from that of healthy subjects. Furthermore, we looked to see whether differences could be found in the effects of experimental pain induction on EMG activity of pericranial musculature and whether subgroups could be discovered with higher and lower pericranial pain sensitivity within the three diagnostic groups in terms of neurophysiological, psychological and clinical variables. In 20 patients with tension-type headache, 23 patients with migraine without aura, and 29 healthy individuals experimental pain was induced in the temporal muscle by mechanical pressure; pain sensitivity in the entire metrically subdivided suprathreshold pain sensitivity range was measured. Surface EMG activity of pericranial muscles was determined before, during and after experimental pain induction. In addition, headache characteristics as well as personality and mood states were determined and recorded in a standardized fashion. There were no significant differences in pain sensitivity of pericranial musculature between the three groups. Patients with tension-type headache showed significantly higher EMG scores during suprathreshold pain stimulation than did migraine patients. EMG scores of healthy subjects fell between these two groups. With respect to pericranial tenderness significant differences in clinical, neurophysiological and psychological variables were found only between subgroups within the group of patients with tension-type headache. The results indicate that significant differences in the examined groups are found not in pain perception but in the processing or reaction to experimental headache stimuli. In patients with tension-type headache subgroups evolve based on pericranial pain sensitivity with quantitatively and/or qualitatively impaired reactions; for this reason diagnostic grouping according to the IHS classification seems to be pathophysiologically relevant. The intraindividual phasic comparison of pain reactions appears to be more important than the absolute interindividual tonic comparison.     

Psychosocial Functioning in Schoolchildren With Recurrent Headaches

The psychosocial functioning of 113 schoolchildren (8 to 15 years old) reporting headaches at least once a month was compared to a group of headache-free control subjects matched for sex and age. Thirteen percent of the headache sufferers had migraine headaches, 28% had episodic tension-type headaches, 30% had chronic tension-type headaches, and 29% had migraine coexisting with tension-type headaches.
Overall, the headache sufferers experienced more somatic complaints, stress, and psychological symptoms, in addition to being absent from school (due to illness), more often and reported fewer caring persons as compared to headache-free controls. Although few differences between the four headache groups emerged in the children's psychosocial functioning levels, children with migraine coexisting with tension-type headaches had significantly more frequent somatic complaints than those having episodic tension-type headaches. In addition, children with migraine or migraine coexisting with tension-type headaches were more often absent from school than those having tension-type headaches only. A significant but weak relationship between children's headache severity and their somatic complaints was noted.