The Role of Fear of Pain in Headache
The Role of Fear of Pain in Headache
Background. Recurrent headache sufferers are often fearful of pain, which disrupts thought processes, interferes with daily activities, and may maintain headache-related disability through avoidance and associated negative reinforcement.
Objective. The aim of this cross-sectional study was to (1) examine differences in fear of pain (FOP) between headache sufferers and non-headache controls; (2) examine differences in FOP across primary headache diagnostic groups; (3) assess the extent to which FOP predicts headache variables (eg., severity, frequency, disability); and (4) determine whether FOP mediates the relationship between pain severity and headache-related disability.
Methods. The sample consisted of 908 young adults (M age = 19.5 years; 64.9% female). Of those, 237 (26.1%) met the diagnostic criteria for episodic tension-type headache (TTH), 232 (25.6%) for episodic migraine (167 [18.4%] without aura and 65 [7.2%] with aura), 38 (4.2%) for chronic migraine, and 19 (2.1%) for chronic TTH; 382 (42.1%) served as non-headache controls.
Results. FOP differed among groups, with headache sufferers reporting greater FOP than those without headache; migraineurs typically endorsed greater FOP than those with TTH. Among those with headache, FOP significantly predicted headache severity (R = 6.1%) and frequency (R = 4.5%), and accounted for more variance in disability (R = 17.5%) than gender, anxiety, and depression combined (13.8%). Pain severity and disability were strongly associated (r = 0.61, P < .001), and FOP partially mediated this association (indirect effect point estimate = 0.38; 95% confidence interval: 0.23–0.57).
Conclusions. FOP differentiates migraineurs from those without headache and plays a significant role in primary headache, particularly in headache-related disability. Findings build upon and extend those from previous chronic pain studies and highlight the need for longitudinal and experimental studies to further explore this construct in headache.
Tension-type headache (TTH) and migraine are the second and third most common medical conditions in the world, with lifetime prevalence rates of 42% and 14%, respectively. Both disorders result in substantial personal disability such as lost wages and decreased productivity, as well as high healthcare costs at both an individual and societal level. These neurological disorders commonly co-occur with psychiatric disorders such as anxiety and depression, the presence of which compounds the negative impact of headache.
In addition to psychiatric disorders, other psychological constructs are implicated in the relationship between headache and disability. A related literature has used the fear avoidance (FA) model to explain the transition from acute to chronic pain. In this well-established model of chronic musculoskeletal pain, fear of pain (FOP), the fear of physical movement or activity due to a presumed susceptibility to pain, develops when pain is perceived as being threatening or harmful. FOP not only restricts physical performance, leads to overpredictions of pain, and correlates strongly with self-reported disability, but in the broader chronic pain literature appears to be more disabling than pain itself. The cognitive, affective, and physiological components of FOP contribute to pain-related escape and avoidance behaviors. Specifically, individuals with high FOP manifest hypervigilance both to the physiological symptoms of pain (eg, sympathetic arousal) and environmental stimuli putatively associated with pain. When prolonged beyond the point of recovery, hypervigilance prompts avoidance of activities and contexts unrelated to pain and contributes to physical deconditioning, social withdrawal, and increased functional impairment. As avoidance behavior minimizes the likelihood of pain onset and thus continues because it is negatively reinforced, these behaviors maintain and strengthen FOP and related disability over time.
The FA model may be of particular relevance among recurrent headache disorders given the cyclical and unpredictable nature of headache attacks and the variety of physiological and environmental factors that may trigger these attacks. The cyclical attack pattern and myriad potential triggers contribute to significant interictal anxiety, hypervigilance, and avoidance of triggers, which may actually increase pain sensitivity over time. Some perceived triggers may not actually perpetuate headache often (or at all) but are still avoided, and unwarranted avoidance of environmental contexts in anticipation of experiencing a headache attack (eg, turning down a social event because of fear of having a migraine at the event) may also foster social isolation and depression. Although FOP has been studied infrequently among headache patients, existing evidence suggests that recurrent headache sufferers often report high FOP. In 2 studies of headache outpatients, FOP accounted for unique variance in a 1-item proxy of disability, even after controlling for pain severity. In another, FOP was associated with prescription and over-the-counter analgesic use independent of pain severity, suggesting that high FOP may serve as a risk factor for overuse of acute headache medications. Thus, understanding the role of FOP in headache is essential and may help spawn more effective treatment programs to prevent or reduce subsequent disability.
Studies are needed that compare FOP across primary headache diagnostic groups, quantify its relation with other headache variables and a validated measure of disability, and assess the role of FOP as a mediator variable between pain severity and headache-related disability. The aims of the present study thus were to (1) compare FOP among primary headache diagnostic groups and non-headache controls; (2) assess the extent to which FOP predicts headache variables (eg, severity, frequency, disability); and (3) determine if FOP mediates the relationship between pain severity and headache-related disability. We hypothesized that migraineurs would report greater FOP than individuals with TTH and non-headache controls, that FOP would be positively associated with headache variables, and that FOP would partially mediate relations between headache severity and disability.
Abstract and Introduction
Abstract
Background. Recurrent headache sufferers are often fearful of pain, which disrupts thought processes, interferes with daily activities, and may maintain headache-related disability through avoidance and associated negative reinforcement.
Objective. The aim of this cross-sectional study was to (1) examine differences in fear of pain (FOP) between headache sufferers and non-headache controls; (2) examine differences in FOP across primary headache diagnostic groups; (3) assess the extent to which FOP predicts headache variables (eg., severity, frequency, disability); and (4) determine whether FOP mediates the relationship between pain severity and headache-related disability.
Methods. The sample consisted of 908 young adults (M age = 19.5 years; 64.9% female). Of those, 237 (26.1%) met the diagnostic criteria for episodic tension-type headache (TTH), 232 (25.6%) for episodic migraine (167 [18.4%] without aura and 65 [7.2%] with aura), 38 (4.2%) for chronic migraine, and 19 (2.1%) for chronic TTH; 382 (42.1%) served as non-headache controls.
Results. FOP differed among groups, with headache sufferers reporting greater FOP than those without headache; migraineurs typically endorsed greater FOP than those with TTH. Among those with headache, FOP significantly predicted headache severity (R = 6.1%) and frequency (R = 4.5%), and accounted for more variance in disability (R = 17.5%) than gender, anxiety, and depression combined (13.8%). Pain severity and disability were strongly associated (r = 0.61, P < .001), and FOP partially mediated this association (indirect effect point estimate = 0.38; 95% confidence interval: 0.23–0.57).
Conclusions. FOP differentiates migraineurs from those without headache and plays a significant role in primary headache, particularly in headache-related disability. Findings build upon and extend those from previous chronic pain studies and highlight the need for longitudinal and experimental studies to further explore this construct in headache.
Introduction
Tension-type headache (TTH) and migraine are the second and third most common medical conditions in the world, with lifetime prevalence rates of 42% and 14%, respectively. Both disorders result in substantial personal disability such as lost wages and decreased productivity, as well as high healthcare costs at both an individual and societal level. These neurological disorders commonly co-occur with psychiatric disorders such as anxiety and depression, the presence of which compounds the negative impact of headache.
In addition to psychiatric disorders, other psychological constructs are implicated in the relationship between headache and disability. A related literature has used the fear avoidance (FA) model to explain the transition from acute to chronic pain. In this well-established model of chronic musculoskeletal pain, fear of pain (FOP), the fear of physical movement or activity due to a presumed susceptibility to pain, develops when pain is perceived as being threatening or harmful. FOP not only restricts physical performance, leads to overpredictions of pain, and correlates strongly with self-reported disability, but in the broader chronic pain literature appears to be more disabling than pain itself. The cognitive, affective, and physiological components of FOP contribute to pain-related escape and avoidance behaviors. Specifically, individuals with high FOP manifest hypervigilance both to the physiological symptoms of pain (eg, sympathetic arousal) and environmental stimuli putatively associated with pain. When prolonged beyond the point of recovery, hypervigilance prompts avoidance of activities and contexts unrelated to pain and contributes to physical deconditioning, social withdrawal, and increased functional impairment. As avoidance behavior minimizes the likelihood of pain onset and thus continues because it is negatively reinforced, these behaviors maintain and strengthen FOP and related disability over time.
The FA model may be of particular relevance among recurrent headache disorders given the cyclical and unpredictable nature of headache attacks and the variety of physiological and environmental factors that may trigger these attacks. The cyclical attack pattern and myriad potential triggers contribute to significant interictal anxiety, hypervigilance, and avoidance of triggers, which may actually increase pain sensitivity over time. Some perceived triggers may not actually perpetuate headache often (or at all) but are still avoided, and unwarranted avoidance of environmental contexts in anticipation of experiencing a headache attack (eg, turning down a social event because of fear of having a migraine at the event) may also foster social isolation and depression. Although FOP has been studied infrequently among headache patients, existing evidence suggests that recurrent headache sufferers often report high FOP. In 2 studies of headache outpatients, FOP accounted for unique variance in a 1-item proxy of disability, even after controlling for pain severity. In another, FOP was associated with prescription and over-the-counter analgesic use independent of pain severity, suggesting that high FOP may serve as a risk factor for overuse of acute headache medications. Thus, understanding the role of FOP in headache is essential and may help spawn more effective treatment programs to prevent or reduce subsequent disability.
Studies are needed that compare FOP across primary headache diagnostic groups, quantify its relation with other headache variables and a validated measure of disability, and assess the role of FOP as a mediator variable between pain severity and headache-related disability. The aims of the present study thus were to (1) compare FOP among primary headache diagnostic groups and non-headache controls; (2) assess the extent to which FOP predicts headache variables (eg, severity, frequency, disability); and (3) determine if FOP mediates the relationship between pain severity and headache-related disability. We hypothesized that migraineurs would report greater FOP than individuals with TTH and non-headache controls, that FOP would be positively associated with headache variables, and that FOP would partially mediate relations between headache severity and disability.
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