Race/ethnicity-based discrimination, depressive symptoms, and smoking-related variables among people with HIV participating in a randomized clinical trial for cigarette smoking cessation.

People with HIV smoke cigarettes at a high prevalence, and it is important to identify modifiable variables related to smoking in this population. Race/ethnicity-based discrimination is common among people with HIV from minoritized racial and ethnic groups and results in significant adverse effects. The goal of this study was to examine the relationship between race/ethnicity-based discrimination, depression, and smoking-related variables among people with HIV who smoke. This was a secondary analysis of data from a prospective, randomized controlled smoking cessation trial for people with HIV. Participants were recruited from three HIV clinical care sites and randomly assigned to an HIV-tailored group therapy intervention or a control condition. Participants completed measures of demographics, smoking-related variables, race/ethnicity-based discrimination, and depressive symptoms at baseline and were followed up 3- and 6-months after study completion. Depressive symptoms had an indirect effect on the relationship between race/ethnicity-based discrimination and self-efficacy to quit smoking at 3-month follow-up. Depressive symptoms mediated the relationship between race/ethnicity-based discrimination and both nicotine dependence and self-efficacy to quit smoking at 6-month follow-up. Findings highlight the importance of considering race/ethnicity-based discrimination and depressive symptoms in the development and implementation of smoking cessation treatment interventions for people with HIV.

German language adaptation of the Cogniphobia Scale for Headache Disorders (CS-HD) and development of a new short form (CS-HD-6).

OBJECTIVE: This study is part of the ODIN-migraine (Optimization of Diagnostic Instruments in migraine) project. It is a secondary, a priori analysis of previously collected data, and aimed to assess the psychometric properties and factor structure of the Cogniphobia Scale for Headache Disorders (CS-HD). We aimed to construct a German-language version and a short version. BACKGROUND: Cogniphobia is the fear and avoidance of cognitive exertion, which the patient believes triggers or exacerbates headache. High cogniphobia may worsen the course of a headache disorder. METHODS: The 15-item CS-HD was translated into German and back translated in a masked form by a professional translator. Modifications were discussed and carried out in an expert panel. A cross-sectional online survey including the CS-HD and further self-report questionnaires was conducted in a sample of N = 387 persons with migraine (364/387 [94.1%] female, M = 41.0 [SD = 13.0] years, migraine without aura: 152/387 [39.3%], migraine with aura: 85/387 [22.0%], and chronic migraine: 150/387 [38.8%]). RESULTS: Exploratory factor analysis resulted in two clearly interpretable factors (interictal and ictal cogniphobia). Confirmatory factor analysis yielded an acceptable to good model fit (χ2(89) = 117.87, p = 0.022, χ2/df = 1.32, RMSEA = 0.029, SRMR = 0.055, CFI = 0.996, TLI = 0.995). Item response theory-based analysis resulted in the selection of six items for the short form (CS-HD-6). Reliability was acceptable to excellent (interictal cogniphobia subscale: ω = 0.92 [CS-HD] or ω = 0.77 [CS-HD-6]; ictal cogniphobia subscale: ω = 0.77 [CS-HD] or ω = 0.73 [CS-HD-6]). The pattern of correlations with established questionnaires confirmed convergent validity of both the CS-HD and the CS-HD-6. CONCLUSION: Both the CS-HD and the CS-HD-6 have good psychometric properties and are suitable for the assessment of cogniphobia in migraine.

Pain acceptance as a change mechanism for mindfulness-based cognitive therapy for migraine.

Migraine is one of the leading causes of disability worldwide. Third wave therapies, such as Mindfulness Based Cognitive Therapy for Migraine (MBCT-M), have proven efficacious in reducing headache-related disability. However, research is needed to better understand the change mechanisms involved in these third-wave therapies. Acceptance is a fundamental component of third wave therapies, and more research is warranted on the role of pain acceptance in MBCT-M. It is also valuable to understand the independent roles of the two components of pain acceptance-pain willingness (PW) and activity engagement (AE). The current study is a secondary analysis of a randomized control trial of MBCT-M. Sixty participants were included in the study (MBCT = 31; WL/TAU = 29). Baseline correlations between overall pain acceptance, PW, AE, and headache-related disability were run. Mixed models assessed change from baseline to one-month post-treatment and treatment-by-time interaction for overall pain acceptance, PW, and AE. Mixed models also assessed maintenance of changes at 6-month follow-up in the MBCT-M group. Longitudinal mediation models assessed whether change in pain acceptance, PW, and AE mediated the relationship between treatment and change in headache-related disability. Pain acceptance, PW, and AE were all negatively correlated with headache-related disability at baseline. Pain acceptance, PW, and AE all significantly increased over time in both the waitlist/ treatment-as-usual group (WL/TAU) and the MBCT-M group. Only AE increased more in the MBCT group than the WL/TAU group. Change in pain acceptance, PW, and AE all significantly mediated the relationship between MBCT and change in headache-related disability. The study supports the importance of pain acceptance, specifically the activity engagement component, in MBCT-M.

A neuropsychologically based employment intervention for women with multiple sclerosis: A quasi-randomized controlled trial.

OBJECTIVE: Job loss is common in multiple sclerosis (MS) and frequently associated with depression, fatigue, and cognitive dysfunction. Identifying these modifiable risk factors and providing "at-risk" women with a neuropsychologically-based intervention may improve employment outcomes. Our study seeks to investigate the utility of a neuropsychologically-based intervention with varying levels of treatment and follow-up, and evaluate treatment and employment outcomes among groups. METHOD: In this longitudinal, quasi-randomized controlled trial, employed women with MS meeting criteria on screening measures were considered "at-risk" for job instability and randomized to one of two neuropsychological testing interventions (standard-care group received testing and phone feedback of results and recommendations; experimental group received testing and in-person feedback with subsequent care-coordinator calls from a nurse to help coordinate recommendation completion). Participants who did not meet criteria were considered "low-risk" and only followed over time. RESULTS: 56 women in the treatment groups (standard-care = 23; experimental = 33) and 63 women in the follow-only group were analyzed at 1 year. Rates of decreased employment were similar between standard-care (17.4%) and experimental (21.2%) groups (OR = .782, 95% CI .200-3.057). However, the experimental group completed significantly more treatment recommendations, t(53) = -3.237, p = .002. Rates of decreased employment were also similar between the "low-risk" (17.5%) and "at-risk" groups (19.6%), (OR = .721, 95% CI .285-1.826). CONCLUSION: Employment outcomes were similar at 1 year between treatment groups receiving differing levels of a neuropsychologically-based intervention, however treatment adherence significantly improved in the experimental group. Treatment groups also had similar employment outcomes as compared to a "low-risk," no intervention group, suggesting that engaging in either neuropsychological intervention may have impacted job stability.

Changes in cognitive appraisal in a randomized controlled trial of mindfulness-based cognitive therapy for patients with migraine.

OBJECTIVE: This study is a secondary analysis evaluating changes in cognitive fusion and pain catastrophizing over 8 weeks of mindfulness-based cognitive therapy for migraine (MBCT-M) intervention versus waitlist/treatment as usual. BACKGROUND: Migraine is a common disabling neurological condition. MBCT-M combines elements of cognitive behavioral therapy with mindfulness-based approaches and has demonstrated efficacy in reducing migraine-related disability. METHODS: A total of 60 adults with migraine completed a 30-day run-in before randomization into a parallel design of either eight weekly individual MBCT-M sessions (n = 31) or waitlist/treatment as usual (n = 29): participants were followed for 1 month after. Participants completed the Pain Catastrophizing Scale (PCS) and the Cognitive Fusion Questionnaire (CFQ) at Months 0, 1, 2, and 4. RESULTS: The PCS scores decreased more in the MBCT-M group (mean [SD] at baseline = 22.5 [9.6]; at Month 4 = 15.1 [8.8]) than in the waitlist/treatment as usual group (mean [SD] at baseline = 24.9 [9.0]; at Month 4 = 22.5 [10.4]) from Month 0 to 4 (ß = -7.24, p = 0.001, 95% confidence interval [CI] -11.39 to -3.09). The CFQ (mean [SD] baseline = 27.6 [8.0]; at Month 4 = 25.0 [8.0]) did not change significantly from Month 0 to 4 (ß = -1.2, p = 0.482, 95% CI -4.5 to 2.1). Parallel mediation analyses indicated that decreases in the PCS and CFQ together (ß = -6.1, SE = 2.5, 95% CI -11.6 to -1.8), and the PCS alone (ß = -4.8, SE = 2.04, 95% CI -9.1 to -1.1), mediated changes in headache disability in the MBCT-M treatment completer group (n = 19). CONCLUSION: In this study, pain catastrophizing showed strong promise as a potential mechanism of MBCT-M. Future research should continue to explore cognitive appraisal changes in mindfulness-based interventions.

Lifetime history of an anxiety or depression disorder and adherence to medications used for the acute treatment of migraine.

OBJECTIVE: In this secondary analysis of mobile health headache diary data, we evaluated the relationship between adherence to medication used for the acute treatment of migraine and lifetime history of an anxiety or depression disorder. BACKGROUND: Medication non-adherence can produce poor clinical efficacy and may be associated with medication overuse. Medication overuse was defined by taking a migraine-specific medication (MSM) for ≥10 days/month, an opioid or barbiturate for ≥10 days/month, or a nonsteroidal anti-inflammatory drug for ≥15 days/month and having ≥15 headache days/month. Extant literature predominantly evaluates fixed-schedule medication adherence. Little is known about predictors of adherence to as-needed medication such as those used for the acute treatment of migraine. METHODS: Adults with prior migraine diagnosis and at least 4 headache days/month completed baseline questionnaires assessing lifetime history of depression or anxiety disorder diagnoses and were asked to record 90 days of once-daily electronic headache diaries soliciting: Headache occurrence; symptoms; medication taken, if any, for the acute treatment of migraine; and their pain level (mild, moderate, severe) when the medication was taken. The 193 participants who completed ≥30 days of headache diary were included in this secondary analysis. RESULTS: A MSM was used as the first medication taken on 45.7% (2825/6176) of headache days. Nearly a quarter of the sample (45/193, 23.3%) overused medications for acute treatment of migraine. Medication overuse was more common in patients with a history of an anxiety disorder, odds ratio (OR) 2.01 (95% confidence interval [CI] 1.01-3.69), but this relationship was not significant when headache days were accounted for, OR 2.02 (95% CI 0.83-4.91). Neither a history of a depression disorder, OR 1.40 (95% CI 0.90-2.16), nor an anxiety disorder, OR 1.11 (95% CI 0.71-1.72), was associated with taking medications early; however, duration of self-monitoring was associated with taking MSM early, OR 1.006 (95% CI 1.004-1.009). CONCLUSION: Lifetime history of depression and anxiety were not associated with taking a MSM early. Medication overuse may be more common in patients who have both migraine and anxiety. Taking a MSM early improved over time for all participants, even when adjusting for a history of an anxiety and or a depression disorder.

Mechanisms of mindfulness in patients with migraine: Results of a qualitative study.

OBJECTIVE: To understand the mechanisms of mindfulness' impact on migraine. BACKGROUND: Promising mindfulness research demonstrates potential benefit in migraine, but no data-driven model exists from the lived experiences of patients that explains the mechanisms of mindfulness in migraine. METHODS: Semi-structured qualitative interviews were conducted with adults with migraine who participated in two mindfulness-based stress reduction (MBSR) clinical trials (n = 43). Interviews were audio-recorded, transcribed, and summarized into a framework matrix with development of a master codebook. Constructivist grounded theory approach was used to identify themes/subthemes. RESULTS: Participants who learned mindfulness techniques through MBSR experienced altered pain perception, altered response to migraine attacks and disease, increased awareness of external and internal experiences, improved overall well-being, and group benefits. Mindfulness resulted in earlier stress-body awareness and increased interoceptive awareness resulting in earlier attack recognition, leading to earlier and more effective management. Interictal factors of self-blame, guilt, and stigma decreased while migraine acceptance, hope, empowerment, self-efficacy, and self-compassion increased. Improved emotion regulation resulted in decreased fear of migraine, pain catastrophizing, anticipatory anxiety, and pain reactivity. Although taught as prevention, mindfulness was used both acutely and prophylactically. We created a conceptual model hypothesizing that MBSR skills led to an infusion of mindfulness in daily life, resulting in altered pain perception and experience, ultimately leading to improvement in overall well-being, which may positively feed back to the infusion of mindfulness in daily life. The therapeutic benefit of learning mindfulness in a group setting may moderate these effects. CONCLUSIONS: This study identified several new potential mechanisms of mindfulness' effect on migraine. After learning MBSR skills, participants reported altered pain and migraine perception and experiences. Increased stress-body and interoceptive awareness resulted in earlier migraine awareness and treatment. Mindfulness may target important interictal factors that affect disease burden such as fear of migraine, pain catastrophizing, and anticipatory anxiety. This is the first data-driven study to help elucidate the mechanisms of mindfulness on migraine from patient voices and can help direct future research endeavors.

Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis.

OBJECTIVE: To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020). BACKGROUND: Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown. METHODS: This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD). RESULTS: A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre-pandemic period, 323.6 opioid prescriptions (interquartile range 292.1-325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0-24.4) days supplied and 31.8 (31.2-32.5) MMEs. Transition to stay-at-home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866-0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078-1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long-term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay-at-home (IRR 1.017, 95% CI 1.009-1.025) and reopening phase (IRR 1.014, 95% CI 1.007-1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant. CONCLUSION: Prescription opioid access was maintained for veterans within VHA during the pandemic. The de-escalation of opioid prescribing observed prior to the pandemic was not seen in our study.

The Relationship of Tobacco Use and Migraine: A Narrative Review.

PURPOSE OF REVIEW: Tobacco use is associated with significant health consequences especially for people with medical conditions. Although lifestyle strategies (e.g., sleep, diet) are commonly recommended as part of migraine treatment, tobacco-related strategies (e.g., smoking cessation) are rarely included. This review is aimed at elucidating what is known about tobacco use and migraine and at identifying gaps in the research. RECENT FINDINGS: The prevalence of smoking is higher among people with migraine, and people with migraine believe that smoking makes migraine attacks worse. There is also evidence that smoking may exacerbate migraine-related consequences (e.g., stroke). Very few studies have examined other aspects of smoking and migraine or tobacco products other than cigarettes. There are significant gaps in our knowledge of smoking and migraine. More research is needed to understand the relationship of tobacco use to migraine and potential benefits of adding smoking cessation efforts into migraine care.

The Headache Psychologists' Role in Pediatric and Adult Headache Care: A Qualitative Study of Expert Practitioners.

OBJECTIVE: We examined the perspectives of expert headache psychologists to inform best practices for integrating headache psychologists into the care of children and adults with headache disorders within medical settings. BACKGROUND: Headache disorders are prevalent, chronic, and disabling neurological conditions. As clinical providers trained in evidence-based behavior change interventions with expertise in headache disorders, headache psychologists are uniquely positioned to provide behavioral headache treatment. METHODS: In 2020, we conducted semi-structured interviews with a purposive sample of expert headache psychologists working across the United States. Open-ended questions focused on their roles, clinical flow, and treatment content. Interviews were audio-recorded, transcribed, de-identified, and analyzed using a rapid qualitative analysis method. RESULTS: We interviewed seven expert headache psychologists who have worked for an average of 18 years in outpatient settings with pediatric (n = 4) and adult (n = 3) patients with headache. The themes that emerged across the clinical workflow related to key components of behavioral headache treatment, effective behavioral treatment referral practices, and barriers to patient engagement. The expert headache psychologists offered evidence-based behavioral headache interventions such as biofeedback, relaxation training, and cognitive behavioral therapy emphasizing lifestyle modification as standalone options or concurrently with pharmacological treatment and were of brief duration. Participants reported many of their patients appeared reluctant to seek behavioral treatment for headache. Participants believed referrals were most effective when the referring provider explained to the patient the rationale for behavioral treatment, treatment content, and positive impact on headache activity, functioning, and quality of life. Barriers cited by participants to integrating headache psychology into headache care included the paucity of psychologists with specialized headache training, lack of insurance reimbursement, limited patient time to seek behavioral treatment, and inadequate patient knowledge of what behavioral treatment entails. CONCLUSION: Headache psychologists are often core members of multidisciplinary headache teams offering short-term, evidence-based behavioral interventions, both as a standalone treatment or in conjunction with pharmacotherapy. However, barriers to care persist. Enhancing referring providers' familiarity with psychologists' role in headache care may aid successful referrals for behavioral interventions for headache.

The unique role of stigma in migraine-related disability and quality of life.

BACKGROUND: Stigma is increasingly recognized as an important social feature of living with migraine. METHODS: Adults with migraine recruited from neurology offices completed the validated Stigma Scale for Chronic Illnesses 8-item version (SSCI-8); two outcome measures (the Migraine Disability Assessment [MIDAS] and the Migraine-Specific Quality of Life Questionnaire v 2.1 [MSQ]); and measures of allodynia (Allodynia Symptom Checklist [ASC-12]), pain cognition (Pain Catastrophizing Scale [PCS]), and psychiatric symptoms (Patient Reported Measurement Information System Anxiety [PROMIS-A] and Depression [PROMIS-D]). Pearson and Spearman correlations evaluated bivariate relationships, and linear (MSQ) and logistic (MIDAS Severe Disability, scores ≥21) regressions evaluated the unique variance associated with SSCI-8 beyond other study variables. Conditional process analysis evaluated mediation hypotheses between study variables. RESULTS: Participants (n = 121) reported levels of stigma on par with other chronic illnesses (SSCI-8 M = 53.0, standard deviation [SD] = 7.8), with 25/127 (19.6%) reporting clinically significant levels of stigma (SSCI-8 T-score ≥ 60). Higher SSCI-8 scores were associated with higher monthly headache day frequency (r = 0.35), MIDAS (ρ = 0.41), ASC-12 (r = 0.24, p < 0.01), PCS (r = 0.46), both PROMIS-A (r = 0.43) and D (r = 0.42), and lower MSQ subscale scores (Role Restriction r = -0.50; Role Prevention r = -0.48; Emotion Function r = -0.50), all ps <0.001 unless otherwise noted. The SSCI-8 contributed significantly beyond migraine symptoms and other psychological factors for MSQ Emotion Function (5% unique variance) and MIDAS Severe Disability (6% of unique variance). The SSCI-8 mediated relationships between headache frequency and the MSQ subscales and MIDAS Severe Disability. The PCS mediated relationships between the SSCI-8 and MSQ subscales. The PROMIS-D mediated relationships between the SSCI-8 and MSQ Role Restriction and MSQ Role Prevention. CONCLUSIONS: Migraine stigma has medium to large associations with migraine outcomes and psychiatric symptoms and is independently associated with migraine disability and emotion-related quality of life. Migraine stigma is an important contributor to the relationship between headache frequency and migraine outcomes.

Digital headache self-management interventions for patients with a primary headache disorder: A systematic review of randomized controlled trials.

OBJECTIVE: This article systematically reviews the empirical literature examining the efficacy of digital headache management interventions for patients with a primary headache disorder. BACKGROUND: Digital headache management interventions provide opportunities to improve access to behavioral headache interventions to underserved groups. METHODS: A systematic search of PubMed, Scopus, and EBSCO (PsycInfo, Education Research Complete, ERIC, Health Source: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection) and reference review was conducted. Included studies had to recruit a sample with a primary headache diagnosis, be a randomized controlled trial including a digital component, assess a headache outcome (i.e., frequency, duration, severity, intensity, disability) or quality of life, and be published in English. Two authors independently extracted data for included studies. The methodological quality of studies was assessed using the revised Cochrane risk-of-bias tool. RESULTS: Thirteen studies with unique interventions met inclusion criteria. More than half of the studies were pilots; however, nearly 70% (9/13) demonstrated significant between-group or within-group improvements on one or more headache-related outcomes. All interventions included some form of relaxation training and the majority were delivered via interactive website. While fewer than half the studies report participant race and/or ethnicity, of those that do, 83% (5/6) reported a predominately White/Caucasian sample. CONCLUSIONS: Efficacy testing of digital headache interventions is in its infancy with the majority of these studies relying on pilot studies with small samples comprised of homogenous patient populations. Interactive websites were the most common digital medium to deliver digital headache management interventions and have demonstrated promising results. Further testing using large-scale randomized controlled trials and exploration of other digital tools is warranted. Future studies with more diverse samples are needed to inform health equity of digital headache interventions.

Telehealth perceptions and utilization for the delivery of headache care before and during the COVID-19 pandemic: A mixed-methods study.

OBJECTIVE: The objective of this study was to evaluate the utilization of telehealth for headache services within the Veterans Health Administration's facilities housing a Headache Centers of Excellence and multiple stakeholder's perspectives to inform future telehealth delivery. BACKGROUND: Telehealth delivery of headache treatment may enhance patient access to headache care, yet little is known about the utilization or patient and provider perceptions of telehealth for veterans with headache. METHODS: This mixed-methods study analyzed multiple data sources: (1) administrative data, which included 58,798 patients with medically diagnosed headache disorders, documented in at least one outpatient visit, from August 2019 through September 2020 from the 12 Veterans Health Administration's facilities with a Headache Center of Excellence and (2) qualitative semistructured interviews with 20 patients and 43 providers 6 months before the coronavirus disease 2019 (COVID-19) pandemic, and 10 patients and 20 providers 6 months during the beginning of the pandemic. RESULTS: During the pandemic, in-person visits declined from 12,794 to 6099 (52.0%), whereas video (incidence rate ratio [IRR] = 2.05, 95% confidence interval [CI] = 1.66, 2.52), and telephone visits (IRR = 15.2, 95% CI = 10.7, 21.6) significantly increased. Utilization differed based on patient age, race/ethnicity, and rurality. Patients and providers perceived value in using telehealth, yet had limited experience with this modality pre-pandemic. Providers preferred in-person appointments for initial encounters and telehealth for follow-up visits. Providers and patients identified benefits and challenges of telehealth delivery, often relying on multiple delivery methods for telehealth to enhance patient engagement. CONCLUSIONS: The uptake of telehealth delivery of headache-related care rapidly expanded in response to the pandemic. Patients and providers were amenable to utilizing telehealth, yet also experienced technological barriers. To encourage equitable access to telehealth and direct resources to those in need, it is crucial to understand patient preferences regarding in-person versus telehealth visits and identify patient groups who face barriers to access.

Essential components of care in a multidisciplinary headache center: Perspectives from headache neurology specialists.

BACKGROUND AND OBJECTIVE: Comprehensive headache care involves numerous specialties and components that have not been well documented or standardized. This study aimed to elicit best practices and characterize important elements of care to be provided in multidisciplinary headache centers. METHODS: Qualitative, semi-structured telephone interviews with a purposive sample of headache neurology specialists from across the US, using open-ended questions. Interviews were recorded, transcribed, and coded. Coded data were further analyzed using immersion/crystallization techniques for final interpretation. RESULTS: Mean years providing headache care was 17.7 (SD = 10.6). Twelve of the 13 participants held United Council for Neurologic Subspecialties headache certification. Six described their practice site as providing multidisciplinary headache care. Participants explained most of their patients had seen multiple doctors over many years, and had tried numerous unsuccessful treatments. They noted patients with chronic headache frequently present with comorbidities and become stigmatized. All participants asserted successful care depends on taking time to talk with and listen to patients, gain understanding, and earn trust. All participants believed multidisciplinary care is essential within a comprehensive headache center, along with staffing enough headache specialists, implementing detailed headache intake and follow-up protocols, and providing the newest medications, neuromodulation devices, botulinum toxin injections, monoclonal antibodies, nerve blocks and infusions, and treatment from a health psychologist. Other essential services for a headache center are other behavioral health practitioners providing cognitive behavioral therapy, mindfulness, biofeedback and pain management; and autonomic neurology, neuropsychology, vestibular audiology, sleep medicine, physical therapy, occupational therapy, exercise physiology, speech therapy, nutrition, complementary integrative health modalities, and highly trained support staff. CONCLUSION: While headache neurology specialists form the backbone of headache care, experts interviewed for this study maintained their specialty is just one of many types of care needed to adequately treat patients with chronic headache, and this is best provided in a comprehensive, multidisciplinary center.

Behavioral Management of Episodic Migraine: Maintaining a Healthy Consistent Lifestyle.

PURPOSE OF REVIEW: To describe the most recent findings related to lifestyle behaviors and migraine. RECENT FINDINGS: An individualized conceptualization of how lifestyle factors impact migraine activity has increased our understanding of the role of behavioral interventions for episodic migraine. Healthy diets of several types have been associated with migraine attack reduction, whereas disruptions in diet like skipping meals are associated with migraine attack onset. Both aerobic activity and lower intensity yoga interventions show promise for migraine prevention. Sleep disruption has been associated with migraine day and may have a bi-directional relationship. Both increases and decreases in stress have been associated with migraine activity. Evidence is converging around the principle that highly unusual disruptions in daily routine are particularly associated with migraine attack onset and that a consistent healthy lifestyle is a key feature of effective behavioral migraine prevention strategies.

Behavioral Health, Telemedicine, and Opportunities for Improving Access.

PURPOSE OF REVIEW: The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments. RECENT FINDINGS: Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.

Pain and medication adherence in adult cigarette smokers living with HIV: a cross-sectional observational study.

The present study examines relationships between pain, mental health symptoms, and medication adherence in adult smokers living with HIV. Sixty-eight adult HIV-positive smokers taking antiretroviral medication completed a survey measuring medication adherence, mental health symptoms, and pain. The presence of pain, OR = 3.81, 95% CI (1.19, 12.14), higher pain severity, OR = 1.22, 95% CI (1.05, 1.41), and higher anxiety, OR = 1.09, 95% CI (1.03, 1.14) were associated with inferior medication adherence (MMAS-8 score <6). Anxiety mediated the relationships between presence of pain (ab = .56, BCa CI (0.05, 1.61)) and pain severity (ab = .09, BCa CI (0.01, 0.24)) and medication adherence. The results of this study suggest that pain and anxiety are factors that significantly contribute to medication nonadherence and thus are important areas of assessment by clinicians treating adult smokers living with HIV.

Learning the full impact of migraine through patient voices: A qualitative study.

OBJECTIVE: To better characterize the ways that migraine affects multiple domains of life. BACKGROUND: Further understanding of migraine burden is needed. METHODS: Adults with migraine randomized to mindfulness-based stress reduction or headache education arms (n = 81) in two separate randomized clinical trials participated in semistructured in-person qualitative interviews conducted after the interventions. Interviews queried participants on migraine impact on life and were audio-recorded, transcribed, and summarized into a framework matrix. A master codebook was created until meaning saturation was reached and magnitude coding established code frequency. Themes and subthemes were identified using a constructivist grounded theory approach. RESULTS: Despite most participants being treated with acute and/or prophylactic medications, 90% (73/81) reported migraine had a negative impact on overall life, with 68% (55/81) endorsing specific domains of life impacted and 52% (42/81) describing impact on emotional health. Six main themes of migraine impact emerged: (1) global negative impact on overall life; (2) impact on emotional health; (3) impact on cognitive function; (4) impact on specific domains of life (work/career, family, social); (5) fear and avoidance (pain catastrophizing and anticipatory anxiety); and (6) internalized and externalized stigma. Participants reported how migraine (a) controls life, (b) makes life difficult, and (c) causes disability during attacks, with participants (d) experiencing a lack of control and/or (e) attempting to push through despite migraine. Emotional health was affected through (a) isolation, (b) anxiety, (c) frustration/anger, (d) guilt, (e) mood changes/irritability, and (f) depression/hopelessness. Cognitive function was affected through concentration and communication difficulties. CONCLUSIONS: Migraine has a global negative impact on overall life, cognitive and emotional health, work, family, and social life. Migraine contributes to isolation, frustration, guilt, fear, avoidance behavior, and stigma. A greater understanding of the deep burden of this chronic neurological disease is needed to effectively target and treat what is most important to those living with migraine.

The Effects of Perceived Pain in the Past Month on Prefrontal Cortex Activation Patterns Assessed During Cognitive and Motor Performances in Older Adults.

OBJECTIVE: Pain is prevalent and functionally impactful in older adults. The prefrontal cortex is involved in pain perception, attentional control, and cortical control of locomotion. Although pain is a known moderator of attentional capacity, its moderating effect on cortical control of locomotion has not been assessed. This study aimed to examine the effects of subjective pain on changes in functional near-infrared spectroscopy-derived measurements of oxygenated hemoglobin (HbO2), gait velocity, and cognitive accuracy from single- to dual-task walking conditions among older adults. SUBJECTS: The sample consisted of 383 healthy older adults (55% female). METHODS: Participants completed two single tasks (Single-Task-Walk [STW] and Cognitive Interference [Alpha]) and the Dual-Task-Walk (DTW), during which participants performed the two single tasks simultaneously. The Medical Outcomes Study Pain Severity Scale and Pain Effects Scale were used to assess pain severity and interference. ProtoKinetics Movement Analysis Software was used to assess gait velocity and rate of correct letter generation to assess cognitive accuracy. Functional Near-Infrared Spectroscopy (fNIRS) was used to assess HbO2 during active walking. RESULTS: Linear mixed-effects models revealed that HbO2 increased from single- to dual-task conditions. Perceived pain presence was associated with an attenuated increase in HbO2 from Alpha to DTW. Among those with pain, worse pain severity was associated with an attenuated increase in HbO2 from STW to DTW. Pain interference did not moderate the increase in HbO2 from single to dual tasks. Pain did not have a moderating effect on behavioral outcomes. CONCLUSIONS: Task-related changes in the hemodynamic response in the prefrontal cortex during walking may be a sensitive marker of the effects of subjective pain on brain function in healthy older adults.

The Impact of Parental Migraine on Children.

PURPOSE OF REVIEW: This review surveys our current understanding of the impact of parental migraine on children. Understanding the impact of migraine on others in a family unit is critical to describing the full burden of migraine and to developing psychosocial supportive interventions for patients and their families. RECENT FINDINGS: Having a parent with migraine is associated with several early developmental features including infant colic. Adolescent children of parents with migraine self-report their parent's migraine interferes with school and activities and events. Further, migraine is perceived to impact the relationship between the parent and child. Having a parent with migraine increases a child's risk of having migraine, and having more severe migraine disease. However, children with migraine whose parent also has migraine appear to receive more early and aggressive treatment. The impact of migraine extends beyond the parent with migraine and influences children across biological, psychological, and social domains.