Stress as a trigger for headaches: Relationship between exposure and sensitivity

Abstract

This study investigated the relationship between length of exposure to a stressor and capacity of the stressor to elicit head pain. Some 127 participants, 93 of whom suffered from regular headaches, were randomly assigned to five experimental conditions, defined by length of exposure to a stressor. Participants attended a single laboratory session divided into three phases: pre-intervention test, intervention and post-intervention test. The main finding was a significant cubic trend between length of exposure to the stressor and ratings of head pain. This trend indicated that very short exposure to the stressor increased sensitivity, whilst longer exposure decreased sensitivity, but even longer exposure increased sensitivity. These results build on earlier studies that suggest the traditional clinical advice to headache sufferers, that the best way to prevent headaches is to avoid the triggers, runs the risk of establishing an insidious sensitization process, thereby increasing headache frequency.     

How do trigger factors acquire the capacity to precipitate headaches?

This study tested two contrasting theories of how trigger factors acquire the capacity to precipitate headaches. The sample consisted of 110 participants, of whom 48 suffered from regular headaches. Participants were exposed to a validated headache trigger factor for one of five exposure durations. The trigger used was "visual disturbance" (flicker, glare and eyestrain) induced by a very bright, stroboscopic light. Response to the stimulus was measured by participant ratings of the degree of visual disturbance and head pain caused by the stimulus. As expected, the headache sufferers experienced more visual disturbance and head pain in response to the stimulus than the non-headache individuals. Longer exposure to the stimulus was associated with a subsequent reduction in pain ratings in response to the stimulus. This desensitization effect supported an avoidance model of how trigger factors acquire the capacity to precipitate headaches. The findings of this study have implications for the etiology of headache disorders. Also, the findings imply that the traditional clinical advice that the best way to prevent migraine and headache is to avoid the factors that trigger them, may be counterproductive, as any short-term gains may be more than wiped out by decreased tolerance for the trigger factors.     

Pain-elicited responses and their role in predicting future pain duration and severity.

The first objective of this study was to carry out a prospective investigation of the behavioral and affective responses to headache pain over a 72 hr period. A sample of 74 headache sufferers provided self-reported ratings of affective and behavioral responses as measured by a composite of standardized questionnaires. Highly significant and clinically meaningful levels of both types of responses were found on the headache day. Interestingly, significant levels of behavioral and affective disturbances were also reported 24 hr after pain termination, indicating that responses to pain actually outlasted pain perception by at least 1 day. The second goal of this study was to investigate whether affective or behavioral responses were predictors of future pain intensity, duration or severity. A smaller sample of 25 subjects provided ratings on two sequential headaches. A series of time-lag analyses indicated that, unlike behavioral responses, strong affective responses during a given episode were associated with subsequently longer and more severe headaches. These results suggest that affective pain-elicited responses may be a risk factor for suffering a worse headache during the episode that follows.     

Headache triggers: To avoid or not to avoid,that is the question

Abstract

Traditional clinical advice in the management of headaches is to avoid trigger factors. There is a danger, however, that avoidance of triggers results in a sensitisation process whereby tolerance for the triggers decreases, in a manner analogous to increments in anxiety arising from avoidance of anxiety-eliciting stimuli. Reported here are six single-case experiments in which the aim was to desensitise headache sufferers to an experimentally validated trigger, namely “visual disturbance”. The results demonstrated that repeated, prolonged exposure to a headache trigger led to desensitisation with participants experiencing less visual disturbance, less negative affect and less head pain in response to the trigger. These findings have theoretical significance as they speak to the issue of the aetiology of chronic headache, and practical significance as they suggest that a key aspect of current management may contribute to the disorder becoming worse rather than better.     

Characteristics of Children Presenting to a Behavioral Treatment Program for Pediatric Headache

This study examined headache characteristics and psychological variables associated with pediatric headache in a specialty treatment clinic. Children were referred by pediatric neurologists to a hospital-based pediatric behavioral medicine clinic for behavioral treatment in conjunction with medical management of the pain. Headache typology of the children indicated that 1/3 of the sample reported at least daily headaches, and a large percentage of patients described experiencing headaches that lasted for more than a day (26%). Child and parent report of pain revealed a fairly high level of correspondence for headache activity. Regarding other psychological characteristics, children in this study endorsed higher than expected levels of somatization even after adjusting for headache symptoms. Compared with children's report, parents' report showed only slightly higher levels of secondary gain experienced by children because of pain. Gender differences were not found. The implications of these findings for improving our understanding of pediatric headache are discussed.     

Diagnosis and clinical management of headaches

In this article, we will first present an overview of the epidemiology and classification of headaches, distinguishing between primary headaches (in which the headache itself is the primary disorder) and secondary headaches (ie, headaches due to an underlying condition, such as a neoplastic and/or space-occupying lesion, a cerebrovascular accident, or other type of structural brain lesion). We will use the current classification system of the International Headache Society, focusing on primary headache disorders (migraine, tension-type headache, cluster headache), which we will discuss from the practical clinical perspectives of diagnosis and clinical management. Throughout this article, we will emphasize the chronicity and periodicity of headaches as a type of chronic pain syndrome.     

Memory of pain and affect associated with migraine and non-migraine headaches

The main aims of this study were to assess memory of pain and pain-related affect in headache sufferers and to compare the pain memories of individuals who suffer from migraines and those who experience non-migraine headaches. A total of 313 women participated in the study, 86 of whom had a diagnosis of migraine headache. The women rated their state anxiety about having a headache, the intensity and unpleasantness of headache pain, and their emotions while actually experiencing a headache. Either three or six months later, the participants were asked to recall their state anxiety, the intensity and unpleasantness of pain, and the emotions they had felt. Regardless of the length of recall delay or migraine diagnosis, participants accurately remembered both pain intensity and unpleasantness. Together, recalled anxiety, experienced pain and recalled positive affect were the most important predictors of memories for headache, accounting for 41% and 37% of the total variance in recalled pain intensity and unpleasantness, respectively. However, participants overestimated recalled positive and negative affect. The effect of recalled affect on memory of headache, together with the overestimation of recalled affect, suggests that although memory of headache is accurate, it is influenced by distorted memories of affect.     

Empowering chronic headache sufferers

Chronic headache pain affects sufferers and their families. Many headache sufferers lack self-discipline in controlling their headache pains. Although preventive medication is a must, medical treatment which excludes psychotherapeutic intervention reduces its effectiveness. Sufferers report increased tensions and stress with members of their families. This article reports on a program which includes headache sufferers' involvement in both family and individual therapy activities in a clinical setting. The role of the family therapist is primarily to encourage and empower sufferers to become involved in activities which can promote and increase communication, trust and self-confidence, leading toward a development of skills which can enable sufferers to utilize positive coping strategies in their effort to control headaches.     

Physiological changes after biofeedback and relaxation training for multiple-pain tension-headache patients

This paper is concerned with the psychophysiology of "muscle-contraction" headaches in a group of Compensation patients suffering from multiple pain problems in addition to headaches. A total of 55 of these patients were divided into 4 groups which received frontalis EMG biofeedback, relaxation training, combined biofeedback-relaxation training, or no treatment. Differences were observed among the 3 experimental treatments and the control group with respect to headache changes, but there were no differences among groups with respect to the changes observed in four underlying physiological responses as a function of time or practice. While the subjects who showed the largest changes in headache characteristics were those who exhibited the largest decreases in frontalis EMG, these were also the subjects whose initial frontalis EMG levels were the highest. It is concluded that, in keeping with a growing literature, the link between frontalis EMG and "muscle-contraction" headaches is a tenuous one and that the changes brought about in headache symptomatology through biofeedback or relaxation training are most likely attributable to a generalization of feelings of mastery over the environment or of self-efficacy brought about in the subjects through apparent success at the task.     

Pain,emotion, and the situational specificity of catastrophising

Two studies were designed to explore the cross-situational nature of catastrophising and the emotions associated with pain and catastrophising. The crosssituational consistency of catastrophising in response to a finger-pressure procedure and during an episode of headache pain was examined in the first study. The second study examined differences between catastrophisers and noncatastrophisers with respect to state and trait measures of positive and negative emotions. Results of study one indicated that almost half of the subjects remained consistent in their classification as catastrophiser or noncatastrophiser in both pain situations. The majority of subjects that switched classification changed from being classified as catastrophisers during the headache experience to noncatastrophisers during the finger-pressure procedure. Results of the second study indicated that catastrophisers experienced significantly greater fear, sadness, anger, hostility, guilt, disgust, and shame during the finger-pressure procedure as compared to noncatastrophisers. Unexpectedly, catastrophisers were not a homogeneous group in regard to the pattern of negative emotions reported. Catastrophisers with headaches experienced greater sadness in response to finger-pressure pain than catastrophisers without headaches. Theoretical and clinical implications of these findings are discussed.     

The role of anxiety sensitivity in subjective and physiological responses to social and physical stressors

This study examined the specificity of the relationship between anxiety sensitivity (AS), a measure of catastrophizing about arousal-related sensations, and pain responses, by examining the effect of AS on responses to stressors of a physical and social nature. Healthy men and women (n = 129) between the ages of 18 and 25 years were recruited from the community to participate in a study examining subjective, cognitive and behavioural responses to different types of stressors. Participants were randomly assigned to one of 3 groups: (i) a neutral condition in which they sat quietly and read a popular magazine; (ii) a social stress condition in which they anticipated having to give a self-disclosing speech; and (iii) a physical stress condition in which they were presented with 3 countdown to shock trials where a mild electrical shock was administered on the non-dominant arm. Subjective ratings and physiological responses were recorded in anticipation of the stressor and immediately after stress exposure. Results indicated that AS was indirectly related to pain ratings via its effect on anticipatory anxiety ratings. AS was associated with anticipatory anxiety ratings, regardless of whether the stressor was of a physical or social nature. Furthermore, AS was not shown to be directly associated with exaggerated subjective or physiological reactions to the physical stressor. These results indicate that the role of AS in pain responses may be mediated through a global effect on anxiety, and limited to the anticipatory stage of the pain experience. If future studies yield similar findings in pain patients, then they would suggest that interventions for helping individuals high in AS should focus on catastrophic thinking in anticipation of stressors in general, rather than on pain-specific stressors.     

The Headache Symptom Questionnaire: Discriminant classificatory ability and headache syndromes suggested by a factor analysis

A brief Headache Symptom Questionnaire was administered to 129 chronic headache Sufferers. The questionnaire accurately classified 68.42% of headache subjects in their proper diagnostic category, comparable to, but statistically less accurate than, the 86.4% agreement between expert headache diagnosticians using clinical interviews. Results of a factor analysis of the Headache Symptom Questionnaire lend support for their being two commonly accepted global headache categories—vascular/migraine and muscle contraction—and one headache dimension concerned with duration of headache pain. Combined migraine-muscle contraction headache was found to be related more to migraine than to muscle contraction headache, and cluster headaches emerged as a separate clinical entity, not loading positively on any factor and loading negatively on all three.This research was supported in part by Grant NS-15235 from the National Institute of Neurological and Communicative Disorders and Stroke.     

Parent–Teen Interactions as Predictors of Depressive Symptoms in Adolescents with Headache

This study investigated parent–adolescent conflict, family functioning, and adolescent autonomy as predictors of depressive symptoms in adolescents with primary headache. Frequent headaches during adolescence can have a negative impact on activity levels and psychological functioning. Depression is particularly prevalent in adolescents with headache but little research has examined the role of parent–teen interactions in predicting depressive symptoms. Thirty adolescents diagnosed with migraine or chronic daily headache completed self-report measures of pain intensity, parent–adolescent conflict, family functioning, and depression. Adolescents and their parents also participated in three videotaped interaction tasks, scored by independent raters to assess adolescent autonomy. Regression models revealed that pain intensity, parent–adolescent conflict, and autonomy predicted depressive symptoms. Higher levels of conflict, poorer family functioning and lower levels of autonomy were associated with more depressive symptoms. This study highlights the association between parent–teen interactions and psychological functioning in adolescents with primary headache. Implications for intervention are discussed.     

Social problem‐solving,perceived stress,depression and life‐satisfaction in patients suffering from tension type and migraine headaches

This study aimed at investigating social problem solving, perceived stress, depression, and life‐satisfaction in patients with tension type and migraine headaches. Forty‐nine migraine and 42 tension type headache patients (n = 91) consenting to participate were compared to a total of 49 matched healthy control group. Participants filled in a questionnaire consisting self‐report measures of problem solving, perceived stress, depression and life satisfaction. They were also asked about headache duration, frequency, pain severity, psychiatric treatment and sense of control in one's life. T‐tests, chi‐square, analysis of variance, logistic regression analysis and Pearson product moment correlation coefficient procedures were used to analyze the data. Tension type headache patients reported having had more frequent headaches than the migraine patients but migraine patients reported having had more intense pain than the tension type headache patients. Instances of psychiatric treatment were more common among tension type headache patients than the migraine and the control group. Compared to the healthy controls, headache patients displayed a deficiency in problem solving, higher levels of perceived stress and depression. Levels of problem solving skills in headache patients were related inversely to depression, perceived stress and the number of negative life events but problem solving skills of headache patients was related positively to life‐satisfaction. The findings from this study suggested that cognitive behavioral problem solving therapy or training might be a viable option for reducing levels of stress and depression, and to increase life‐satisfaction in patients suffering from primary headache.     

The refractory headache patient--II. High medication consumption (analgesic rebound) headache

'Analgesic rebound headache' is identified by habituation of an individual to pain reducing medication, the exacerbation of headache pain a few hours after medication consumption and a marked increase in headache frequency and intensity for several weeks after medication is discontinued. We describe three studies undertaken to clarify the existence and characteristics of this proposed headache syndrome. In Study 1 we compared a group of headache sufferers who consume large amounts of analgesic medications to headache sufferers who did not consume excessive analgesics. It was found that the two groups did not differ on age, duration of headache problem or gender. However, the groups did differ on subjective headache pain (with the high medicators experiencing more headache pain than low medicators) and diagnosis (with high medicators being more likely to have a muscle contraction component to their headaches). In an analysis of drug use within the high medication group, it was found that 91% were taking some kind of analgesic and that a majority (84%) were taking more than one type of medication. In Study 2 we found that the group of high medicators were not as successful in reducing headache activity as a result of a self-regulatory behavioral treatment as the matched controls. Furthermore, there was a direct relationship between reduction and treatment success in the high medication consuming population. Lastly, in Study 3 we examined the current psychological functioning of the two groups; no differences were found between the two groups indicating the lack of 'addictive' personality characteristics as an explanation for the high medicating population. These findings all support the existence of a sub-population of headache sufferers who consume excessive amounts of analgesic medication and who are relatively refractory to behavioral treatment.     

Unexpected reduction in migraine and psychogenic headaches following rTMS treatment for major depression: a report of two cases

Our objective is to report a coincident reduction in headache pain in patients treated with repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD). Two patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of MDD, non-responsive to prior antidepressant treatment who were enrolled in a sham-controlled, double-blind study of rTMS for MDD. After the study, it was revealed that both were in the active-treatment arm. Both patients suffered from near daily headaches and kept logs of headache frequency and severity before, during, and after the study. Headache pain was significantly reduced under double-blind conditions with rTMS treatment, but returned to baseline following cessation of rTMS treatment. Ultimately, when receiving rTMS post-study as a maintenance intervention for MDD (approximately 2 rTMS sessions/week), the positive effects on headache amelioration were sustained. Headache pain is frequently comorbid with mood disorders and has been reported as the most common side effect with rTMS. In these subjects, rTMS was, in fact, associated with relief of depressive symptoms and preexisting headache pain. This indicates that rTMS may be beneficial for both disorders in some patients.     

Electrode placement,EMG feedback,and relaxation for tension headaches

Fifteen tension headache subjects were allocated to one of three groups: direct EMG feedback (from a site corresponding to the source of pain), indirect EMG feedback (from a site not corresponding to the source of the pain) and relaxation instructions. There were two base-line, six treatment and one post-treatment sessions. No significant differences were found between base-line and post-treatment EMG levels, for any of the groups; however, some significant reductions in levels were obtained within sessions. EMG levels recorded during headache attacks did not differ significantly from levels recorded during base-line. Frequency and intensity of headaches were significantly reduced, particularly in the relaxation group. At follow-up this improvement was maintained for subjects with forehead pain, but differences between the groups had disappeared.     

Relationship between self-reported intensity of headache and magnitude of surface EMG

The study was designed to examine the relationship between self-reported intensity of headache and surface EMG. 98 patients, diagnosed by their neurologists with "muscle-contraction headaches" (tension-type headaches) were referred to evaluate their suitability for biofeedback therapy. At the time of examination, they were asked to rate their average headache intensity on a 10-point scale. Surface EMG data were collected to assess actual muscle contraction. Analysis indicated that among patients diagnosed with muscle contraction headache, there is a positive significant correlation between self-reported intensity of headache and actual muscle-contraction. The current data lend support to the hypothesis that the tension in the headaches currently described as "tension-type" may in fact refer to actual muscular tension or contraction.     

Psychosomatik der Kopfschmerzen

Headaches are subdivided into primary and secondary headaches according to the classification of the International Headache Society. While primary headaches represent the disease itself, secondary headaches are a manifestation as symptoms of another primary disease. This results in different therapeutic approaches so that secondary headaches are initially treated according to the actual cause of the headache. In contrast primary headaches have no further causes and necessitate fundamentally different treatment in comparison to secondary headaches. The psychosomatics integrate somatic procedures with psychiatric and social processes. This integration forms the basis of the biopsychosocial model which has the great advantage of being able to offer several approaches to psychiatric processes and accomanying alterations. For primary headaches psychotherapeutic strategies and modifications in the social environment of the patient can be applied in addition to medicinal (i.e. biological somatic) treatment procedures, in order to be able to positively influence the underlying disease. This article presents the most important primary headache diseases, migraine and tension-type headache and demonstrates treatment options which can be used in accordance with the biopsychosocial model presented.     

Anxiety sensitivity and fear of pain in patients with recurring headaches.

Anxiety sensitivity (AS) plays an important role in the cognitive, affective and behavioral profiles of patients with chronic pain related to musculoskeletal injury. However, investigators have not considered whether these findings extend to patients with other classes of chronic pain. The primary purpose of this investigation was to address this issue in 72 patients with recurring headaches who completed a self-report questionnaire inventory during a treatment visit to an outpatient neurology clinic. The mean ASI score for the group (mean = 24; SD = 11) was relatively high. When patients were classified on the basis of ASI scores, 20 (28%) met criteria for high, 41 (57%) for medium and 11 (15%) for low AS. Multivariate analysis of variance confirmed that these groups differed on specific aspects of their cognitive, affective, and behavioral profiles. High AS patients reported greater depression, trait anxiety, pain-related escape/avoidance behavior and fearful appraisals of pain than did patients with medium or low AS. High AS patients also indicated greater cognitive disruption in response to pain than did patients with low AS. Groups did not differ in headache severity, physiological reactivity, change in lifestyle, anger, nor did they differ in use of over-the-counter or prescribed analgesics. Multiple regression analysis identified AS, pain-related cognitive disruption, and sensory pain experience as significant predictors of fear of pain. Lifestyle changes attributed to headache were, on the other hand, predicted by headache severity, physiological and cognitive anxiety and escape/avoidance behavior. These results provide further evidence of the important association between AS and fear responses of patients with chronic pain syndromes. Implications and future directions are discussed.