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Objective: Chronic pain negatively impacts spouse/partner relationships, with greater impact associated with higher pain severity and co-morbid mood disturbance. This study investigated the role of pain episode frequency in migraineurs on relationship effects. Methods: An online survey was conducted, collecting information about migraine, psychological distress, and relationship impact using standardized measures. Adults previously diagnosed with migraine were invited to participate through postings on migraine community websites and social media. Impact was evaluated based on four migraine frequency categories (migraines/month): less than weekly (0-3), one to two episodes weekly (4-9 and 10-15), and more than twice weekly (>15). Results: A total of 1,399 adult migraineurs were included. Spouse/partner relationships had been mildly-moderately damaged for 30% with 0-3 migraine monthly, increasing to 40% with >15 migraine monthly. Migraine had contributed to a break-up for 4% with 0-3 migraines monthly, increasing to 8% for those with >15 migraines monthly. About 57% of participants reported satisfaction with their current spouse/partner, with satisfaction unaffected by migraine frequency among those who were satisfied with their partners. Negative impact on relationships with children and close friends also increased with migraine frequency. Depression and anxiety were significantly correlated with migraine frequency (P

Objective To validate the 2011 modification of the 2010 American College of Rheumatology (ACR) preliminary criteria for the diagnosis of fibromyalgia (2011ModCr) and develop alternative criteria in a sample of patients with diverse pain disorders that are commonly seen in everyday practice by pain specialists, rheumatologists, and psychologists. Methods Eight clinicians from geographically varied locations in the US evaluated patients with chronic pain and psychiatric disorders using a standard set of questions that included the 2011ModCr questions, the Symptom Impact Questionnaire (SIQR), a 28-area pain location inventory (PLI), and the Short Form 36. Alternative diagnostic criteria were developed from the same data set using logistic regression and receiver operating curve analysis. Results Complete data on 321 patients were evaluated; there were 135 patients with fibromyalgia (according to the 1990 ACR criteria) and 186 patients with 16 other common chronic pain problems. Comparing the 2011ModCr with the 1990 ACR criteria provided a sensitivity of 83%, a specificity of 67%, and a correct classification of 74%. Alternative criteria were derived from the 10-item symptom score from the SIQR symptoms and the 28-area PLI. Maximal diagnostic accuracy was obtained with ≥17 pain sites (range 0–28) and an SIQR symptom score of ≥21 (range 0–50). These alternative criteria had a diagnostic sensitivity of 81%, a specificity of 80%, and a correct classification of 80%. Conclusion The 2011ModCr had robust operating characteristics. Alternative criteria based on symptom items from the SIQR and pain locations from the PLI had comparable operating characteristics, with somewhat better specificity and ease of use.

This case study explores the impact of improving communication for reducing complaints in an outpatient pain clinic. A retrospective review was conducted for two 6-month periods prior to and for 6 months after implementing a structured communication strategy that included changes in staff behavior and documentation. Most complaints were related to not receiving opioids as part of the treatment plan. In the first treatment period prior to implementation, 6 of 3,653 patients lodged complaints. In the second period prior to implementation, 8 of 3,992 patients lodged complaints. Following implementation, 3 of 3,879 patients lodged complaints. Using structured communication strategies appeared to reduce complaints and facilitate chart documentation when addressing difficult patient situations including opioid issues.

Background Fibromyalgia is associated with substantial functional disability. Current drug and non-drug treatments result in statistically significant but numerically small improvements in typical numeric measures of pain severity and fibromyalgia impact. Objective The aim of the present study was to evaluate additional measures of pain severity and functional outcome that might be affected by fibromyalgia treatment. Methods This retrospective review evaluated outcomes from 274 adults with fibromyalgia who participated in a six-week, multidisciplinary treatment programme. Pain and function were evaluated on the first and final treatment visit. Pain was evaluated using an 11-point numerical scale to determine clinically meaningful pain reduction (decrease ≥ 2 points) and from a pain drawing. Function was evaluated by measuring active range of motion (ROM), walking distance and speed, upper extremity exercise repetitions, and self-reports of daily activities. Results Numerical rating scores for pain decreased by 10–13% (p

CME Educational Objectives 1. Understand the pathophysiology of neurosensory sequelae of mild traumatic brain injury. 2. Understand treatment options for the neurosensory sequelae of mild traumatic brain injury. 3. Understand the interactions of neurosensory sequelae in patients with mild traumatic brain injury. Historically, research to explore traumatic brain injury (TBI) has focused on blunt head trauma, particularly as associated with severe consequences. In this injury pattern, treatment focuses on initial life-saving measurements, intensive care in the hospital, and rehabilitating activities of daily living. 1,2 Far less attention has been focused on mild traumatic brain injury (mTBI).

Vestibular migraine is becoming recognised as a distinct clinical entity that accounts for a high proportion of patients with vestibular symptoms. A temporal overlap between vestibular symptoms, such as vertigo and head-movement intolerance, and migraine symptoms, such as headache, photophobia, and phonophobia, is a requisite diagnostic criterion. Physical examination and laboratory testing are usually normal in vestibular migraine but can be used to rule out other vestibular disorders with overlapping symptoms. The pathophysiology of vestibular migraine is incompletely understood but plausibly could include neuroanatomical pathways to and from central vestibular structures and neurochemical modulation via the locus coeruleus and raphe nuclei. In the absence of controlled trials, treatment options for patients with vestibular migraine largely mirror those for migraine headache.

Triptans are the first-line treatment for moderate-to-severe migraine headaches. Sumatriptan , the first triptan, is available in different formulations, including subcutaneous (SQ), intranasal, transdermal, oral, and suppository options.Sumatriptan formulations have different pharmacokinetic, efficacy, and adverse event profiles. The fastest and most complete migraine relief occurs with SQ dosing; a needle-free option is available for patients fearful of injections. Oral administration is generally preferred by patients, although variability with absorption limits efficacy, especially for more severe attacks. Intranasal, transdermal, and suppository formulations are options for patients with nausea who do not require or prefer to avoid SQ administration. Transdermal treatment may be limited in some cases by skin irritation.Patients should use an attack-based treatment approach for their migraine attacks to balance the speed of relief, efficacy, and tolerability. Different sumatriptan formulations allow its use as both first-line and rescue therapies, with additional treatment if needed. This article develops a treatment algorithm that offers suggested roles for different formulations of sumatriptan based on attack severity and response to initial sumatriptan therapy.

Anecdotal reports suggest that changes in dog behavior might be used to predict impending migraine episodes. This survey was designed to investigate how companion dogs react to migraines that occur in their owners.Online survey was available from January 4-31, 2012.Survey was conducted through SurveyMonkey, with links to the survey posted at Migraine.com and promoted through social media.Adults ≥18 years old who experience migraine episodes and live with a dog were eligible to participate.Participants completed an 18-question online survey that asked about participant demographics, migraines, and their dog's behavior before or during migraine episodes.The survey was completed by 1029 adult migraineurs (94.9% women), with migraines typically occurring ≤8 days per month in 63.4% of participants. A recognized change in the dog's behavior prior to or during the initial phase of migraine was endorsed by 552 participants (53.7%), most commonly unusual attentiveness to the owner (39.9%). Among the 466 participants providing details about their dog's behavior with their migraines, 57.3% were able to identify dog alerting behavior before symptoms of a migraine attack would typically begin, with changes usually noticed within 2 hours before the onset of initial migraine symptoms. The dog's behavior was considered to be often or usually linked with the development of a migraine for 59.2% of migraineurs, and 35.8% of migraineurs endorsed beginning migraine treatments after the dog's behavior was recognized and before migraine symptoms had started. Participant demographics, migraine frequency, and breed of dog in the home were similar between the 470 participants with no alerting behavior endorsed and the 466 participants providing detailed alerting information.About one in four migraineurs living with a companion dog endorsed recognizing a change in their dog's behavior before recognizing initial symptoms of a migraine attack.

Continuous or frequent exposure to nociceptive input produces neuroplastic changes that allow pain perception with lower levels of stimulation. As the nervous system becomes more sensitized, receptive fields increase recruiting addition input that is perceived as pain. The allodynia (perception of pain with normal input) of an acute migraine attack is the result of a completely sensitized nervous system. Understanding central sensitization allows individuals to change their response to the input and take better control of their migraine pain.

Migraine is always more than a headache. Migraine is comorbid with many common conditions including, depression, anxiety, bipolar disorder, insomnia, fibromyalgia, and epilepsy. Migraineurs have increased risk for cardiovascular disease. Migraine also creates difficulties with familial and social functioning when family, friends, and the workplace do not understand migraine.

As migraine transforms from episodic to chronic, there is a commensurate need for the incorporation of behavioral interventions. Behavioral intervention reduces reliance on passive interventions. Better outcomes are achieved when behavioral therapies are included with medications. Behavioral therapies include relaxation (biofeedback, guided imagery, meditation), exercise (yoga, aerobic), and schedule management (sleep, diet). Migraine patients should set aside time in their schedule for their daily behavioral treatment.

Diaries are more than just haphazard markings in a record. They should be approached with specificity and intent. Daily recording should cover occurrences of interest, including but not limited to pain, sleep, diet, stress, activity, and potential triggers. Diaries can help fill in patient histories and allow for cultivation of a more effective treatment plan. Diaries can also have a role in assessing any change in a primary headache pattern that is suggestive of a condition that requires further investigation.

The most productive approach to migraine management involves collaborative care. At its most fundamental form this collaboration recognizes the presence of two headache experts: the patient and the provider. The headache expert provider’s role is to insure that the headache expert patient is provided with sufficient guidance and feedback in order to facilitate successful management. Often other team members are involved (nurse, psychologist, dietician, and physical therapist). Family members can become important team members with proper education.

When headache is made a medical complaint, the headache is almost always migraine. However, the clinician should not be lulled into a sense of complacency. The first question rightly remains “Is this a primary (headache as disease) or secondary (headache as symptom)?” Red flags are helpful in identifying which headaches require further investigations and validated brief questionnaires have been developed for diagnosing migraine. Once a diagnosis is made, the patient should be told what is causing their headache and in the case of migraine that their headache is not the result of a serious threat to their life. It is important for the patient to accept that migraine alone is a sufficient explanation for their headache.

When migraines fail to respond to the usual therapies, we can believe that we are either cursed or that we have missed something. Only one of these thoughts allows us to move forward. When we believe that we have missed something, we go back to the beginning. We repeat a history and physical looking for missed clues. We consider intervention previously tried and those untried. We adopt new approaches and mindsets that allow patients to become comfortable with being uncomfortable. When people say that they have done everything, it should be pointed out that it is unlikely that they have “done everything” because they have not found out what the next thing to do is. There are multiple interventions that have demonstrated benefit in refractory cases, and if these interventions fail to improve the condition, then it is always appropriate to adopt new perceptions and behaviors regarding pain. It is always too early to quit.

There is a strong genetic component in developing migraine. Genetic markers have been identified for several rare autosomal dominant migraine types. Migraine with and without aura has been linked to various genetic variations.

Medications have an important role in migraine management. It is important to understand the distinct role and limitations in migraine prevention, acute treatment, and rescue. Prevention should be started when migraine has an intolerable effect on functioning. Acute medication use should be focused on restoring function, but their use also needs to be limited because of the propensity to induce migraine progression. The frequent use of both acute and rescue medications indicate that prevention should have an increasingly prominent role. Successful migraine management will always include an acute treatment plan and a rescue plan, and frequently a preventive plan.

Patient’s thoughts regarding their migraines will greatly influence their capacity for action. When left alone to their own intuitive thoughts, patients will frequently catastrophize which ultimately facilitates migraine progression. Catastrophic thinking also exaggerates pain severity, impact, and patient helplessness. Adopting productive thoughts and attitudes will allow patients to reduce helplessness, symptom magnification, and negative ruminating. Cognitive restructuring allows for the more productive endeavor of changing the body’s response to stress rather than the often impossible goal of avoiding stress.

Background Fibromyalgia is frequently associated with impairments in activities of daily living and work disability. Limited data have investigated the impact of fibromyalgia on relationships with family and friends. Objectives This exploratory study was designed to survey a large community sample of adults with fibromyalgia about the impact on the spouse/partner, children and close friends. Methods A 40-question, multiple-choice survey was made available online for a two-month period, with potential participants recruited through fibromyalgia and migraine community websites. Items included questions about demographics, fibromyalgia symptoms, comorbid mood disturbance and relationship impact, including the Relationship Assessment Scale. Results The survey was completed by 6,126 adults who had been diagnosed with fibromyalgia. Using updated diagnostic criteria from the American College of Rheumatology, 91% satisfied the criteria for fibromyalgia (Fibromyalgia Severity score ≥13 and pain ≥3 months). Half of participants endorsed that fibromyalgia had mildly to moderately damaged relationship(s) with their spouse(s)/partner(s) or contributed to a break-up with a spouse or partner. Half of participants scored as not being satisfied with their current spouse/partner relationship, with satisfaction negatively affected by the presence of mood disturbance symptoms and higher fibromyalgia severity. Relationships with children and close friends were also negatively impacted for a substantial minority of participants. Conclusions In addition to physical impairments that are well documented among individuals with fibromyalgia, fibromyalgia can result in a substantial negative impact on important relationships with family and close friends. Copyright © 2012 John Wiley & Sons, Ltd.

Introduction: Antidepressants offer substantial analgesic benefits for a wide range of chronic pain conditions. Areas covered: The serotonin-norepinephrine reuptake inhibitor, duloxetine, is well established for reducing pain in patients with diabetic neuropathy and fibromyalgia. Indications were recently expanded also to include the treatment of chronic musculoskeletal pain related to osteoarthritis and chronic low back pain. In addition, animal studies and postoperative pain data indicate possible additional uses of duloxetine for the management of acute pain. Expert opinion: Antidepressants, such as duloxetine, offer a valuable therapy for patients with chronic pain, regardless of whether comorbid mood disorders are present or not. Clinicians must set reasonable expectations for anticipated improvements with duloxetine. In general, a 30% improvement in average nonmalignant pain severity represents a clinically meaningful improvement target. About 50 – 60% of patients with chronic osteoarthritis or chro...

Evaluation of: Scher AI, Gudmundsson LS, Sigurdsson S et al.: Migraine headache in middle age and late-life brain infarcts. JAMA 301, 2563–2570 (2009). Migraineurs are at increased risk for clinical cardiovascular events, although these events do not commonly occur. The long-term burden of migraine on brain health was considered to be more substantial than previously thought when data from the Dutch Cerebral Abnormalities in Migraine, an Epidemiological Risk Analysis study reported markedly increased risk of subclinical infarcts, primarily in the cerebellum, in migraineurs. The larger, Age Gene/Environment Susceptibility-Reykjavik study recently provided data that confirmed an increased risk of subclinical, cerebellar infarcts in women with migraine with aura, especially those experiencing visual aura. While these data were not linked with clinical examinations of subtle neurological loss over time, they raise important questions regarding the need to screen for and correct modifiable risk factors for cardiovascular disease in migraineurs.

Background: Limited evidence suggests that rizatriptan given before vestibular stimulation reduces motion sickness in persons with migraine-related dizziness. The present study was designed to test whether rizatriptan is also effective in protecting against visually-induced motion sickness and to test whether rizatriptan blocks the augmentation of motion sickness by head pain. Material and Methods: Using randomized double-blind, placebo-controlled methodology, 10 females, 6 with migrainous vertigo (V+) and four without vertigo (V-) received 10 mg rizatriptan or placebo two hours prior to being stimulated by optokinetic stripes. Visual stimulation was coupled with three pain conditions: no pain (N), thermally-induced hand pain (H) and temple pain (T). Motion sickness and subjective discomfort were measured. Results: Motion sickness was less after pre-treatment with rizatriptan for 4 of 10 subjects and more for 5 of 10 subjects. Augmentation of motion sickness by head pain was seen in 6 of 10 subjects; this effect was blunted by rizatriptan in 4 of these 6 subjects. Subjective discomfort was significantly more noticeable in V+ subjects as compared with V- subjects. Conclusions: These pilot data suggest that rizatriptan does not consistently reduce visually-induced motion sickness in migraineurs. Rizatriptan may diminish motion sickness potentiation by cranial pain.

Headache patterns for both primary and secondary headaches are often modified in women during pregnancy. Although approximately two thirds of women with migraines experience headache improvement during pregnancy; women who continue to suffer from migraine or other headaches during pregnancy need effective clinical care to include appropriate diagnostic studies, counseling about expectations during pregnancy and lactation, and modifications in therapeutic regimens to minimize risk to the fetus and nursing baby. This review describes the epidemiology of headache during pregnancy and lactation, to include both effects of these conditions on headache activity and possible concerns about how a maternal headache diagnosis may influence the course and outcome of pregnancy. Although restrictions in diagnostic testing and medication interventions are often necessary during pregnancy and breastfeeding, this review describes evaluation and management strategies that provide effective clinical care while minimizing risk to the developing baby.

Conventional wisdom teaches that chronic headaches typically improve and often abate during pregnancy, leading many clinicians to take a wait-and-see approach of delaying treatment in hopes of seeing spontaneous improvement. Although headaches do improve in later pregnancy for up to 50% of chronic headache sufferers, headaches persist and may even worsen for the remainder. Clinicians must recognize that treating headache during pregnancy is important in order to limit excessive use of over-the-counter pain remedies, dehydration, and pain- related disability. Safe and effective medication and nonmedication treatment options are available for the pregnant headache sufferer, including both acute care and preventive therapies. Care of the pregnant headache patient should begin before she is known to be pregnant, when the fertile female is initially established as a patient. Preconception planning should include modification of medication regimes to include medications safe for use during early pregnancy, when the woman may not yet realize she is pregnant, and effective nonmedication therapies, such as relaxation, biofeedback, and lifestyle modification.

Headache is recognized as one of the most prevalent neurological disorders, and is the most frequently reported symptom following injury to the head, brain, or neck. Although studies of central nervous system abnormalities in headache sufferers have emerged in recent years, less is known about the associated functional impairments. The research literature addressing neuropsychological consequences of headache has been far from conclusive. Migraine has been most extensively studied, with some consistent evidence of subtle but potentially significant changes in cognition occurring during and between migraine episodes. It also appears likely that migraine patients with aura experience more neuropsychological deficits than those without aura. While the literature devoted to understanding the neurocognitive profile of migraine sufferers is growing, much less research has addressed the neuropsychology of tension-type headache and posttraumatic headache (PTHA). There is some suggestion of poorer neuropsychological function in tension-type headache than controls, but the evidence is inconclusive. The PTHA population is highly varied in degree and location of trauma, preexisting headache condition, and other injury-related variables, allowing little generalization across studies. This paper summarizes research regarding the cognitive symptoms associated with migraine, tension-type headache, and PTHA, provides an overview of the cognitive side effects of headache medications, and addresses clinical implications and priorities for future research.

Migraine-related dizziness (MRD) refers to a disorder in which vestibular symptoms are an integral part of migraine symptomatology. The purpose of this study was to better define the pathophysiology of MRD, which is incompletely understood and to generate hypotheses regarding MRD by assessing the semicircular canal-ocular reflex, the otolith-ocular reflex, visual-vestibular interaction, vestibulo-spinal function, and visually induced postural sway. Subjects included five subjects with MRD, five subjects with migraine without dizziness, and five headache-free controls. Subjects with migraine were tested interictally. Results indicated that the mean gain of the semicircular canal-ocular reflex during both sinusoidal and constant velocity rotation was reduced in subjects with MRD. No changes were noted in the dynamics of the semicircular canal-ocular reflex. The otolith-ocular reflex, assessed with constant velocity OVAR, indicated that subjects with MRD showed a larger modulation component. No group differences were found in the bias component during constant velocity OVAR, nor in semicircular canal-otolith interaction or visual-vestibular interaction. Computerized dynamic posturography indicated that subjects with MRD demonstrated a surface-dependent pattern. Postural sway during optic flow indicated that subjects with MRD swayed more than the other subjects. We hypothesize that competing processes of serotonergic excitation and inhibition alter central vestibular pathways differently for semicircular canal vs. otolithic responses and for vestibulo-ocular vs. vestibulo-spinal pathways.

Fibromyalgia is defined by widespread body pain, tenderness to palpation of tender point areas, and constitutional symptoms. The literature reports headache in about half of fibromyalgia patients. The current epidemiological study was designed to determine the prevalence and characteristics of headache in fibromyalgia patients. Treatment-seeking fibromyalgia patients were evaluated with measures for fibromyalgia, chronic headache, quality of life, and psychological distress. Multivariate analysis of variance (MANOVA) and t-tests were used to identify significant differences, as appropriate. A total of 100 fibromyalgia patients were screened (24 fibromyalgia without headache and 76 fibromyalgia with headache). International Headache Society diagnoses included: migraine alone (n = 15 with aura, n = 17 without aura), tension-type alone (n = 18), combined migraine and tension-type (n = 16), post-traumatic (n = 4), and probable analgesic overuse headache (n = 6). Fibromyalgia tender point scores and counts and most measures of pain severity, sleep disruption, or psychological distress were not significantly different between fibromyalgia patients with and without headache. As expected, the fibromyalgia patients with headache scored higher on the Headache Impact Test (HIT-6) (62.1 +/- 0.9 vs 48.3 +/- 1.6, p0.001). HIT-6 scores were60 in 80% of fibromyalgia plus headache patients, representing severe impact from headache, and 56-58 in 4%, representing substantial impact. In summary, chronic headache was endorsed by 76% of treatment-seeking fibromyalgia patients, with 84% reporting substantial or severe impact from their headaches. Migraine was diagnosed in 63% of fibromyalgia plus headache patients, with probable analgesic overuse headache in only 8%. General measures of pain, pain-related disability, sleep quality, and psychological distress were similar in fibromyalgia patients with and without headache. Therefore, fibromyalgia patients with headache do not appear to represent a significantly different subgroup compared to fibromyalgia patients without headache. The high prevalence and significant impact associated with chronic headache in fibromyalgia patients, however, warrants inclusion of a headache assessment as part of the routine evaluation of fibromyalgia patients.

Migraine is recognized as a primarily neural condition. Changes in neural physiology have been consistently identified in migraineurs. Numerous studies are available that evaluate physical and functional differences between migraineurs and headache-free controls. The most prominent neuroimaging findings reported in migraine sufferers have been white matter changes. However, physical changes on neuroimaging have not been clearly correlated with functional impairment in migraineurs. The current literature addressing the neuropsychologic consequences of migraine has been far from conclusive, and reports of cognitive testing in adult migraineurs and controls has yielded inconsistent results. Neuropsychologic testing suggests that there may be some subtle but possibly significant changes in cognition that occur both during and between migraine episodes. A finding emerging with some consistency is that migraine patients with aura experience more neuropsychologic deficits than migraine patients without aura. The few studies that assess nonmigraine headache suggest that physical changes may not be unique to migraine, although neuropsychologic changes do appear to be limited to migraineurs. An examination of the unmet needs and priorities for future research addressing this important topic is provided.

Dizziness is a common complaint that can result from abnormalities of the vestibular apparatus of the inner ear and of those portions of the central nervous system (CNS) that process information from the peripheral vestibular system and other senses, particularly vision and somatosensation. Recently, two CNS disorders, migraine and anxiety, have been recognised as being commonly associated with dizziness.1,2 These associations may be an expression of an aetiological relationship, for example, dizziness caused by migraine, or dizziness caused by anxiety; alternatively, migraine or anxiety may influence the presentation of a balance disorder. For example, chronic dizziness may become more disabling during the added stress of a migraine headache or panic attack. In addition, dizziness occurs comorbidly with both migraine headache and anxiety disorders.3,4 Finally, there is increased comorbidity between anxiety and migraine.5 Thus, it is not surprising that some patients with dizziness may suffer from a combination of a balance disorder, migraine, and an anxiety disorder, a symptom complex that we propose to name migraine−anxiety related dizziness (MARD) (fig 1). The general recognition of MARD may be limited because of the fragmented nature of our healthcare system, where specialists in one field, such as psychiatry or neurology, fail to recognise phenomena known to specialists in other fields, such as otoneurology. Figure 1 Venn diagram of the interfaces among migraine, anxiety, and balance disorders. The central sector, which denotes the three way interface, represents an hypothesised new ailment, migraine−anxiety related dizziness (MARD). This editorial will focus on the pathophysiology and clinical issues relating to MARD, including the interfaces among balance disorders, migraine, and anxiety. We use current epidemiological data and studies of pathogenesis to develop comorbidity models. These models serve as hypotheses that may lead to possible treatment options for many patients with dizziness, including those with MARD. …

Objective: To evaluate obesity as a marker for increased pain severity, disability, and psychologic distress in treatment-seeking, mixed chronic pain patients. Methods: Three hundred seventy-two consecutive chronic pain patients seeking evaluation at a university pain clinic were divided into 3 weight categories, based on body mass index (BMI): normal (BMI < 25 kg/m 2 ), overweight (BMI between 25 kg/m 2 and 30 kg/m 2 ), and obese (BMI ≥ 30 kg/m 2 ). Patients completed questionnaires to identify pain severity, disability, depression, anxiety, and quality of life. Results: Pain severity and days per week with pain were similar among the weight groups. Disability was related to increasing weight status, with increased BMI associated with more days per week with both reduced activity and complete disability. Depressive symptoms were also related to weight category, with an average Beck Depression Inventory score of 11.81 ± 7.55 in normal, 12.88 ± 11.64 in overweight, and 15.78 ± 9.88 in obese patients. Anxiety scores were similar among the weight categories. Physical function domain of quality of life was also reduced in relation to weight. Conclusions: Weight is associated with co-morbid disability, depression, and reduced quality of life for physical function in chronic pain patients. Calculation of the BMI should become a routine part of the screening evaluation for chronic pain patients, with additional screening for disability and psychologic distress in patients with elevated BMIs.

Estrogen exerts a strong influence on episodic headaches, such as migraine and tension-type headache. A relationship between sex hormones and chronic daily headache (CDH) is less well established. However, similarities between episodic and CDH suggest that estrogen also may significantly influence CDH. Pathophysiologic studies of CDH identify neurochemical abnormalities similar to those influenced by estrogen in episodic headache, such as aberrant 5-hydroxytryptamine activity. In addition, gender differences in CDH prevalence in pediatric and adult populations support a hormonal influence. Few studies have evaluated the ability of gynecologic events, such as menses, to influence CDH.

Recently revised guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) call for an increased awareness of the impact of chronic pain and recommend that physicians assess and treat pain complaints seriously. Although significant and persistent chronic pain is a common reason for primary care visits, the incidence of psychologic distress and personality disorder in patients with chronic pain often makes this population a difficult one for physicians and staff to treat. This discussion offers practical tips for managing patients with chronic pain and reducing staff burnout. The author also dispels various myths about chronic pain and focuses on the effective management of its comorbidities.

Objective.—To test the hypothesis that chronic posttraumatic headache is associated with greater severity and psychological distress than headache of nontraumatic origin. Methods.—Two hundred eighty-nine consecutive patients with chronic headache attending a university headache clinic were evaluated. Questionnaires about headache symptoms, quality of life (Medical Outcome Survey SF-36 Health Survey), and psychological distress were completed. Results.—Frequent headache (>4 days per week) occurred more often with traumatic (84%) than nontraumatic headache (60%). Traumatic headache resulted in greater reduced activity (3.31 ± 1.06 days per week versus 2.62 ± 1.11 days per week with nontraumatic headache; P

Objective.-To compare pain severity, disability, psychological distress, and quality of life between patients with headache and nonheadache treatment-seeking chronic pain patients. Methods.-Six hundred forty-three patients seeking treatment at a university pain clinic were divided into 3 categories based on primary pain complaint and the presence of focal or diffuse pain complaints: headache, nonheadache focal (pain involving

Animal-assisted therapy, including visits from certified therapy dogs, offer a valuable and often underutilized resource for addressing unmet needs in cancer patients. Prospective research studies have documented symptomatic benefits for reducing pain, psychological distress, and fatigue in a variety of patient populations, including cancer patients. Utilizing consistent policies minimizes patient risk and infection control concerns associated with animal visits.

Objective: To evaluate the effectiveness of handwarming biofeedback (HWB) and stress management training in comparison to attention (handcooling, HCB) and wait-list control groups. Thermal biofeedback has been used in many pediatric migraine treatment studies and has demonstrated a consistent therapeutic effect. No published studies to date have compared this treatment modality with credible attention control using biofeedback technology. Methods: Thirty-six children and adolescents (mean age: 12.8 years), as well as the mothers and fathers of these children enrolled in the study, were randomly assigned to the three groups. Thirty-four children completed treatment. Both treatment groups received four sessions of biofeedback training and a portable biofeedback device for home practice. Ratings of treatment credibility showed that the children rated the two treatments as equally credible. Assessment included anxiety and depression questionnaires for the children and both of their parents. Results: Children who had been assigned to the HWB group were more likely to achieve clinical improvement in migraine after treatment than the children in the HCB group. Treatment gains were maintained up to 6 months after treatment. Home practice data reflected a general increase in temperature in the HWB group and a decrease in temperature for the HCB group. Conclusions: The results of this study confirm the findings of earlier pediatric migraine biofeedback treatment studies and also provide support for the specific effect of treatments including stress management and HWB. Future studies with larger sample sizes will aid in delineating the appropriateness of HCB as a control treatment.

Chronic non-malignant pain (CNMP) is widely prevalent and associated with significant costs. Costs related to chronic pain include medical services and medications, treatment of medication-related toxicity and work absenteeism. The use of non-narcotic analgesics is associated with inadequate pain-relief for many patients, as well as significant and costly organ toxicity. When used appropriately and judiciously, opioid medications can be a useful addition to the treatment plan for patients with CNMP. Opioids can provide long-term, safe and cost-effective pain relief.

The vast majority of people experience tension-type headache during their lifetimes. Boys experience tension-type headache slightly more than girls during preadolescent years. During adolescence and adult years, tension-type headache occurs more commonly in females. Tension-type headache changes in women occur in relation to gynecologic changes, including menses, pregnancy, and menopause. These changes are related to estrogen fluctuations. Estrogen fluctuations cause changes in neurochemicals important for pain signal transmission, including serotonin, gamma-aminobutyric acid, and enkephalins.

Objective.—To identify gender differences within a group of patients seeking treatment for chronic headache. Previous studies of the general population have reported differences in headache symptoms, frequency, disability, and psychological distress, with women affected with more severe and disabling symptoms than men. This study evaluated these features in a population seeking treatment. Methods.—Two hundred fifty-eight consecutive patients with headache attending a university headache clinic were evaluated with questionnaires about headache symptoms and psychological distress. Comparisons between men and women were made for headache symptoms, severity, frequency, trigger factors, comorbid depression and anxiety, and response to treatment. Results.—There were no gender differences in headache symptoms, frequency, severity, and duration. Headache triggers were gender-specific, with men more likely to endorse exercise and women more likely to endorse stress and exposure to odors. Psychological comorbidity was similar among men and women seeking treatment, with a mean Beck Depression Inventory score of 10 and a mean Spielberger trait anxiety score of 39 for both men and women. Disability was greater in men, with 46% reporting restrictions in activities more than 3 days per week because of headache compared with 29% of women. In addition, men were more likely to contribute headache control to external figures than women. Conclusions.—Patients seeking treatment for chronic headache do not have the same gender-specific differences that have been reported in general population surveys. Men who seek treatment for headache are more likely to have significant disability, and are equally likely to have symptoms of depression and anxiety as women who seek treatment. Clinical and research investigations of headache triggers need to be gender-specific.

Objective.–To test the hypothesis that anxiety and depression are associated with headache frequency, severity, and disability. Background.–There is significant comorbidity between chronic headache and psychological distress. Headache associated with anxiety or depression tends to be more severe and often requires supplementary psychological treatment in addition to headache therapy. Therefore, the identification of patients with headache who are at risk of psychological distress is important. Methods.–One hundred twenty-seven consecutive patients with headache attending a university headache clinic were evaluated. Questionnaires about headache symptoms and psychological distress were completed. Comparisons were made between psychological distress and headache frequency, severity, and disability. Results.–Depression and anxiety were significantly greater in the subjects of this study who had frequent headache (>4 days per week) and frequent headache-associated disability (activities reduced or prohibited because of headache >3 days per week). Subjects who reported their headache severity as typically severe were no more likely to report depression or anxiety than those with mild or moderate headache severity. Quality-of-life measures of physical and social functioning, emotional distress, and general health and vitality were reduced in subjects with frequent episodes of headache-associated disability. All areas, with the exception of general health perception, were reduced in subjects with frequent headache. Severe headache was associated with reductions in role and social functioning. Conclusions.–Frequent headache and frequent disability are associated with depression, anxiety, and impaired quality of life. Reports of typical headache severity are less likely to correlate with psychological distress. Therefore, patients with headache who report frequent headache or frequent periods of headache-related disability should be further evaluated for the presence of psychological disturbance.

OBJECTIVES Research suggests that dysregulated pain modulation may play an important role in recurrent headaches and fibromyalgia syndrome (FMS). The primary objective of this study was to investigate algesic responses in localized cervical and pericranial regions (ie, headache-specific areas) and distal locations (ie, trochanter and gluteal) in patients with primary headaches (tension-type and migraine). The headache patients' algesic responses were compared with those of a sample of patients with musculoskeletal pain who report generalized hyperalgesia, or FMS. METHODS Seventy patients with mixed headache diagnoses and 66 patients with FMS underwent a standardized examination of generalized hyperalgesia based on American College of Rheumatology criteria. RESULTS Twenty-eight of the 70 headache patients reported the presence of widespread TP pain, suggesting generalized hyperalgesia. Headache diagnosis was unrelated to the presence or absence of generalized hyperalgesia. The subset of headache patients with generalized hyperalgesia did not differ from the FMS patients in pain sensitivity in the cervical and pericranial areas. Regression analyses revealed that pressure pain sensitivity was significantly related to self-reported pain only in the headache patients with generalized hyperalgesia. CONCLUSIONS These results suggest that extensive dysregulation in pain modulation is important for a substantial minority of recurrent headache patients, who seem to be quite similar to FMS patients. Differential treatment planning targeting generalized hyperalgesia may be useful in treating headache patients exhibiting generalized hyperalgesia more effectively.