The experience of headache — An assessment of the qualities of tension headache pain

The subjective component of headache pain has been neglected in headache research. In this study of 65 chronic headache sufferers, assessment of the subjective component was amplified using the McGill Pain Questionnaire (MPQ) as well as headache diaries. The overall level of pain experienced was as high as that previously reported for cancer and phantom-limb patients. Assessment of sensory pain qualities (MPQ) revealed differences between tension and migraine headache types; tension headaches were felt to be “tight”, while migraines were experienced as “sharp”, “blinding”, “nauseating” and “sickening”. The results thus support a dichotomous rather than a continuum model of headache.The relationship between the subjective experience of headache and mood (Wakefield Depression Scale) and personality (EPQ) was examined. Pain intensity and affective reactions to pain were associated with general mood state; however, no subjective measures correlated with personality indices.It was argued that the MPQ provided valuable additional information to be used with headache diaries, particularly in the assessment of sensory qualities and affective reactions to pain.     

Sex differences in adolescent chronic pain and pain-related coping

Sex differences exist in pain and the strategies used to cope with pain. Although it is has been proposed that such differences become apparent around puberty, somewhat surprisingly very little research has specifically investigated sex as a moderator of pain within adolescents. The primary aim of the current study was to investigate sex differences in pain and coping within a group of 46 male and 115 female adolescent chronic pain sufferers. All were aged between 11 and 19 years and had been referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases, United Kingdom. Patients completed a battery of measures including pain experiences and a pain coping questionnaire. No sex differences were found in pain chronicity, although males and females did differ in self-reported pain experiences (females reported higher pain). Sex differences were also found in coping behaviours. Females used more social support, positive statements and internalizing/catastrophizing, whereas males reported engaging in more behavioural distraction. Of these strategies internalizing/catastrophizing was found to mediate the relationship between sex and pain. This suggests that not only do sex differences exist in the pain experiences and pain-coping strategies of adolescents with chronic pain, but that internalizing/catastrophizing may be an important mechanism in understanding such differences. More research examining potential sex differences in children and adolescents is recommended.     

Activities as indices of illness behaviour in chronic pain

Activities reported by pain sufferers over a 7 day period were categorised on the basis of social context, and sleep, passive and recreational activities were found to differentiate between groups when dimensions of illness behaviour, mood and pain intensity were taken into account. The most interesting differences between groups were between organic and non-organic pain patients where the latter reported more sleep-related activities and these were related to strong beliefs in disease conviction, intense pain, and intense sadness. Both non-patient pain groups reported more passive activities indicating a greater awareness of the importance of rest. A comparison of qualitative and quantitative pain measures suggests that the MPQ may not be sufficient alone to measure the painful experience. The results have implications for the study and management of chronic pain patients, and provide evidence that reports of activity per se may be diagnostic indicators valuable in the study of illness behaviour.     

Pain assessment methods in mechanical dysfunction

This paper considers the reliability and validity of pain assessment methods in mechanical dysfunction. A distinction is drawn between measures of subjective report and those of pain behaviour. The latter is observable and therefore more amenable to direct study than subjective report. Measures of subjective report include rating scales, the McGill Pain Questionnaire, and diary cards. Consideration is also given to personality assessment in this context. It is concluded that measurement needs to proceed from a number of standpoints, with the importance of each of these dependent upon the context. For chronic pain, emphasis on pain behaviours is appropriate.     

An epidemiological follow-up survey of persistent pain sufferers in a group family practice and specialty pain clinic

The course and prognosis of persistent pain are largely unknown. In addition, follow-up studies of chronic pain sufferers have come from specialized pain clinics and have ignored the question of how representative this special group is to the general population who suffer persistent pain. Because health care planners are assumed to require these data for projection of health care needs, it is important to determine the course of persistent pain in those persistent pain sufferers in the general population as well as those referred to a specialty clinic. An epidemiological study compared 2 groups of self-reported persistent pain sufferers from a Family Practice Clinic and a Specialty Pain Clinic over a 2 year period. All subjects reporting a persistent problem with pain at the time of the initial survey were contacted 2 years later to determine whether the initial differences between the 2 groups remained constant over time and whether there were any changes within each group over time. Despite the similarities between the study groups on multiple socioeconomic and demographic variables, the Specialty Pain Clinic group remained distinctly different from the Family Practice pain sufferers on many pain behavior and emotional variables. Thirteen percent of the persistent pain sufferers from the Pain Clinic group and 36% of the persistent pain sufferers from the Family Practice group no longer reported pain as a problem at follow-up. Of those pain sufferers from either group who continued to experience pain at 2 years follow-up, their pain became more intermittent, psychological distress factors improved, and the use of health services decreased. The implications are that persistent pain does not necessarily continue forever and that persistent pain sufferers in the general population have a better prognosis than those who are referred to a Specialty Pain Clinic. All follow-up studies need to be interpreted in light of these findings.     

An empirical assessment of pain beliefs

Pain beliefs represent patients' own conceptualizations of what pain is and what pain means for them. Such beliefs may be discordant with current scientific understanding and may serve to adversely affect compliance with modern methods of chronic pain treatment. This study attempts to assess several of the core dimensions around which pain beliefs develop and examines the relationship between pain beliefs and behavioral manifestations of the pain experience. An empirically and factorially derived product of this study, the Pain Beliefs and Perceptions Inventory (PBAPI) assess 3 dimensions of pain beliefs: (1) self-blame, (2) perception of pain as mysterious, and (3) beliefs about the duration of pain. These core pain beliefs were found to be predictive of subjective pain intensity, multidisciplinary chronic pain treatment compliance, poor self-esteem, somatization and psychological distress, and associated with attributions about health locus of control.     

Behavioural evaluation in patients affected by chronic pain: a preliminary study

The aim was to analyse the existing relation between a subjective evaluation of pain with the use of the Verbal Numerical Scale (VNS) and an objective behavioural measure associated with pain, by means of the Pain Behaviour Rating Scale (UAB). An observational correlation study was carried out in a hospital environment. The study included 61 patients affected with multiple forms of non-malignant chronic pain; the behaviour was observed by the nursing staff. In general, a positive but moderate correlation was obtained between VNS and UAB scales (r=0.29, p<0.0001). Observing behaviour and listening to the patient constituted two complementary and non-interchangeable methods for assessing the level of pain capable of providing a global and objective portrayal of the pain experience.     

II. Indices of Pain Intensity Derived From Ecological Momentary Assessments and Their Relationships With Patient Functioning: An Individual Patient Data Meta-analysis

Pain intensity is a complex and dynamic experience. A focus on assessing patients’ average pain levels may miss important aspects of pain that impact functioning in daily life. In this second of 3 articles investigating alternative indices of pain intensity derived from Ecological Momentary Assessments (EMA), we examine the indices’ associations with physical and psychosocial functioning. EMA data from 10 studies (2,660 patients) were reanalyzed to construct indices of Average Pain, Maximum Pain, Minimum Pain, Pain Variability, Time in High Pain, Time in Low Pain, Pain after Wake-up. Three sets of individual patient data meta-analyses examined 1) the test-retest reliability of the pain indices, 2) their convergent validity in relation to physical functioning, fatigue, depression, mental health, and social functioning, and 3) the incremental validity of alternative indices above Average Pain. Reliabilities approaching or exceeding a level of .7 were observed for all indices, and most correlated significantly with all functioning domains, with small to medium effect sizes. Controlling for Average Pain, Maximum Pain and Pain Variability uniquely predicted all functioning measures, and Time in High Pain predicted physical and social functioning. We suggest that alternative pain indices can provide new perspectives for understanding functioning in chronic pain.PerspectiveAlternative summary measures of pain intensity derived from EMA have the potential to help better understand patients’ pain experience. Utilizing EMA for the assessment of Maximum Pain, Pain Variability, and Time in High Pain may provide an enhanced window into the relationships between pain and patients’ physical and psychosocial functioning.     

Expressive dimensions of pain catastrophizing: a comparative analysis of school children and children with clinical pain

We investigated the role of the child's pain catastrophizing in explaining (1) children's self-reported tendency to verbally share their pain experience with others and (2) different dimensions of pain expression, as described by the mother and the father, including non-verbal and verbal communicative pain behaviour and protective pain behaviour. Participants were school children, children with chronic or recurrent pain, and their parents. The results showed that: (1) Pain catastrophizing was associated with children's greater self-acknowledged tendency to verbally share their pain experience with others. (2) Mothers and fathers perceived highly catastrophizing children to be more communicative about their pain. (3) The role of pain catastrophizing in the child's verbal sharing of pain experiences and in explaining expressive behaviour as rated by parents did not differ between the school children and children with recurrent and chronic pain. (4) Nevertheless, findings indicated marked differences between school children and the clinical sample. Children of the clinical sample experienced more severe pain, more pain catastrophizing, more protective pain behaviour, but less verbal communications about their pain. These results further corroborate the position that catastrophic thoughts about pain have interpersonal consequences. Findings are discussed in terms of the possible functions and effects upon others of pain catastrophizing and associated categories of pain behaviour.     

Fear of Pain in Recurrent Headache Sufferers

We investigated the role of fear of pain in headache sufferers using the Fear of Pain Questionnaire (FPQ). Seventy-six headache sufferers and 58 controls completed the FPQ and measures of depression, anxiety, and anger. Headache sufferers also completed measures of stress-related physical symptoms and coping with pain. We found that the FPQ has excellent internal consistency as well as good concurrent and construct validity indicated by the high correlations between the FPQ subscales and both anxiety and depression but low correlations with anger. There were marked differences between headache sufferers and controls on the FPQ; headache sufferers showed much greater fear of severe and medical pain and lower fear of minor pain. Fear of pain was generally not related to headache characteristics such as frequency, severity, or duration. On the other hand, it was related to headache impact such as disruption of pleasurable activities. These results are consistent with models of chronic pain disorders which emphasize the role of fear of pain over the nociceptive intensity of the pain stimulus.     

Psychometric Characteristics of the Bakal Headache Assessment Questionnaire

SYNOPSIS
To assist the therapist in understanding the psychological components of headache pain, Bakal¹ developed the Headache Assessment Questionnaire (HAQ). The HAQ consists of statements describing nonproductive or distressing thoughts or negative affect experienced at headache onset. In the present study, the discriminant and construct validity of the HAQ was assessed by exploring its relationship with various other indices and examining the HAQ's ability to differentiate chronic headache sufferers from people who occasionally experience headaches.
The HAQ successfully differentiated the high frequency and moderate frequency headache groups and a discriminant function accurately classified 82% of the subjects. For frequent headache sufferers, the HAQ was significantly correlated with headache activity indices suggesting that people who experience more frequent and severe headaches also tend to experience more dysfunctional thoughts and feelings. In addition, principal components analyses suggest that the HAQ has several dimensions (e.g., nonproductive rumination, self-denigration, and tension and worry}. The development of HAQ sub-scales on these dimensions might provide both useful research tools for classifying samples of headache sufferers and useful clinical tools for identifying the types of dysfunctional thoughts and affect a patient experiences.     

The relationship between activity and chronic back pain

Thirty chronic back pain patients participated in a study of the relationship between activity level and pain intensity. Activity is presumed to cause increases in pain. If this is true, then chronic sufferers should regulate their activities so that when they have pain, they should avoid participating in activities. This assumption was examined by comparing pain intensity with several measures of activity. The activity measures ranged from global reports to observed behaviour. The results showed that patients do report a connection between activity and pain on a global interview question, and patients with much pain tend to make lower ratings of ability to participate in daily activities. However, no significant correlation was found between pain intensity and actual activity levels as measured by self-monitoring or observed behaviour in a test situation. These findings provide little support for the idea that activity level is directly related to chronic pain intensity and they underscore the importance of comprehensive behavioural assessment.     

Assessing the significant others of chronic pain patients: the psychometric properties of significant other questionnaires

Contemporary reviews of psychological models of chronic pain have favoured behavioural and cognitive-behavioural formulations. These have often assumed that pain behaviours are maintained by environmental reinforcers. One of the most commonly hypothesized sources of reinforcement has been patients' significant others. Further, it has often been recognized that significant others may also be affected by pain behaviours and that they may experience changes in their lifesyles and in their mood as a consequence of living with someone who has pain. Somewhat surprisingly, relatively little clinical research has been published investigating significant others and their relationships with pain patients. Among other things, one of the limiting factors has been the lack of measurement tools available for assessing the relevant variables thought to be important with regards to significant others (such as their responses to, and perceptions of, chronic pain). This study attempted to remedy this situation by developing and testing the psychometric properties of a number of questionnaires specifically designed for significant others of chronic pain patients. The questionnaires have been selected to assess both significant others' (behavioural and cognitive) responses to pain as well as the extent to which pain impacts on their lives. Although not all of the questionnaires were found to possess equally strong psychometric properties, the availability of several solid measures opens the way for more empirical analyses of significant others and their interactions with chronic pain patients.     

The effects of persistent pain: the chronic headache sufferer

A survey of the psychological characteristics of a large sample of chronic headache cases (n = 360), including classical and common migraine and tension headache sufferers, was carried out. Comparing groups defined in terms of the chronicity of their headache problems, it was found that those with a longer history of headache had a higher level of behavioural disruption and a stronger bond between pain experience, and both complaint levels and behavioural avoidance patterns. Despite the common somatic components (sleep disturbance, fatigue, irritability, etc.), depression was not found to be elevated in this chronic pain group. In addition, there was no evidence of depression levels being higher in the populations who had had a longer history of headache problems. Higher levels of complaint were found in those with higher depression and higher extroversion and neuroticism scores. Behavioural avoidance was significantly related to the emotional reaction component of pain. The implications of these findings with respect to the development of chronic headache are discussed.     

The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey

Pain is one of the most common medical complaints, but despite its prevalence, many individuals still suffer with unrelieved or undertreated pain. This marketing research survey was designed to determine the physical, psychological, and economic impact pain has on the lives of individuals suffering with pain and to identify the unmet needs of patients who have taken opioid medications to treat their pain. In addition, the survey sought to address the challenges physicians face when treating patients with pain. Pain sufferers were recruited through e-mail invitation to an Internet survey; 173,854 invitations were sent out, 22,018 people responded (12.7%), and 606 met the criteria for inclusion in the survey as pain sufferers. Of these, 359 people had moderate to moderately severe chronic pain and 247 people had moderate to moderately severe acute pain. Additionally, physicians currently treating pain were recruited through e-mail and postal mail invitations and 492 met eligibility criteria: 241 specialists (orthopedic or general surgeons, pain specialists or anesthesiologists), 125 primary care, and 126 emergency medicine physicians. Results of this survey supported what many physicians observe in their practice and hear from their patients, that pain has a negative impact on daily activities in the majority of pain sufferers. Many chronic pain sufferers reported that pain had deleterious effects on their mental health, employment status, sleep, and personal relationships. The impact of pain on patient quality of life and the unmet needs in pain management were recognized by the majority of physicians surveyed, with inadequate pain control, end-of-dose pain, and side effects associated with increased dosing reported as negative factors influencing their choice of pain medication. In conclusion, effective communication between physicians and patients is encouraged to not only improve overall pain management but also to establish shared treatment goals with functional outcomes.     

Quality of life in adolescents with chronic pain in the head or at other locations

The differences in quality of life and school absence were studied in one hundred adolescents from the open population who had reported chronic headache or chronic, physically unexplained, pain at other locations. The adolescents kept a 3-week diary about their pain and completed a quality of life questionnaire. Of all chronic pain sufferers in this study, it was the adolescents with headache who showed the least frequent pain, but they reported the poorest quality of life and the largest school absence due to their pain. Adolescents with headache or adolescents with back pain showed the highest negative correlations between pain parameters and quality of life. Headache sufferers showed highly negative relationships between pain parameters and most quality of life domains (median r = -0.46), and only in headache sufferers did this involve both intensity and frequency of pain. Qualitative studies are needed to reveal the background to these differences.     

Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults

Title. Item selection and content validity of the Critical‐Care Pain Observation Tool for non‐verbal adults. Aim. This paper is a report of the item selection process and evaluation of the content validity of the Critical‐Care Pain Observation Tool for non‐verbal critically ill adults. Background. Critically ill patients experience moderate to severe pain in the intensive care unit. While critical care clinicians strive to obtain the patient’s self‐report of pain, many factors compromise the patient’s ability to communicate verbally. Pain assessment methods often need to match the communication capabilities of the patient. In non‐verbal patients, observable behavioural and physiological indicators become important indices for pain assessment. Method. A mixed method study design was used for the development of the Critical‐Care Pain Observation Tool in 2002–2003. More specifically, a four‐step process was undertaken: (1) literature review, (2) review of 52 patients’ medical files, (3) focus groups with 48 critical care nurses, and interviews with 12 physicians, and (4) evaluation of content validity with 17 clinicians using a self‐administered questionnaire. Results. Item selection was derived from different sources of information which were convergent and complementary in their content. An initial version of the Critical‐Care Pain Observation Tool was developed including both behavioural and physiological indicators. Because physiological indicators received more criticism than support, only the four behaviours with content validity indices >0·80 were included in the Critical‐Care Pain Observation Tool: facial expression, body movements, muscle tension and compliance with the ventilator. Conclusion. Item selection and expert opinions are relevant aspects of tool development. While further evaluation is planned, the Critical‐Care Pain Observation Tool appears as a useful instrument to assess pain in critically ill patients.     

Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar--a blinded, prospective randomized study

Purpose: To describe and explore the relationships between pain, emotional state and coping strategies in patients with chronic radicular neck pain before and after surgery or conservative treatments. Methods: We randomize 81 conseutive patients with cervical radicular pain and nerve root compression, verified by MRI, to either surgical decompression with fusion or physiotherapy or neck collar. Emotional state was both measured with Mood Adjective Check List, Hospital Anxiety and Depression Scale and with a Coping Strategies Questionnaire. Pain was measured with VAS and function with Disability Index Rating. Measurements were made before treatment, and follow ups after 3 and 12 months post treatment. Results: We found generally a low emotional state with anxiety, depression and sleep-disturbances not only connected to pain. Pain improved faster in the surgery group but after one year no differences were seen. Surgery and physiotherapy improved function with heavy work compared to collar after 3 months. Many patients used active coping before treatment, but after treatment more passive coping strategies were found. Conclusion: We recommend a multidisciplinary rehabilitation with cognitive behavioural therapy and psychological interventions.     

The Role of Personality in the Etiology of Chronic Headache

SYNOPSIS
Whether a neurotic personality is a precursor to or a consequence of the experience of living with chronic pain has been a topic of much heated debate in the psychosomatic research literature. To investigate this question, 151 chronic headache sufferers from three headache types (migraine, tension, combined), matched on age and gender, were divided into three equal groups on the basis of their percentage of life with headache. Each headache sufferer was administered a comprehensive battery of psychological tests. ANCOVAs, using age as the covariate and diagnosis and %-life groupings as the between subjects factors, were then performed on the clinical scale data. Results indicated no significant differences greater than that expected by chance among the %-life groups, indicating that the percentage of life one spends with head pain has no differential effect on a number of psychological test measures. One interpretation of the above results is that the characterological personality traits so often found in headache sufferers are not a result of the pain experience but in fact were present before the pain problem started.     

Pain,coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery,physiotherapy or neck collar - a blinded,prospective randomized study

Purpose: To describe and explore the relationships between pain, emotional state and coping strategies in patients with chronic radicular neck pain before and after surgery or conservative treatments. Methods: We randomize 81 conseutive patients with cervical radicular pain and nerve root compression, verified by MRI, to either surgical decompression with fusion or physiotherapy or neck collar. Emotional state was both measured with Mood Adjective Check List, Hospital Anxiety and Depression Scale and with a Coping Strategies Questionnaire. Pain was measured with VAS and function with Disability Index Rating. Measurements were made before treatment, and follow ups after 3 and 12 months post treatment. Results: We found generally a low emotional state with anxiety, depression and sleep-disturbances not only connected to pain. Pain improved faster in the surgery group but after one year no differences were seen. Surgery and physiotherapy improved function with heavy work compared to collar after 3 months. Many patients used active coping before treatment, but after treatment more passive coping strategies were found. Conclusion: We recommend a multidisciplinary rehabilitation with cognitive behavioural therapy and psychological interventions.