Biobehavioral treatments of migraine.

Pharmacotherapies are the mainstays of migraine management, though it is not uncommon for them to be poorly tolerated, contraindicated, or only modestly effective. There is a clear need for nonpharmacologic migraine therapies, either employed alone or in combination with pharmacotherapies. Behavioral and psychosocial factors known to contribute to the onset, exacerbation, and persistence of primary headache disorders (e.g., stress, sleep, diet) serve as targets within a self-management model for migraine-a model that features headache pharmacotherapies, behavioral skills training, medication adherence facilitation, relevant lifestyle changes, and techniques to limit headache-related impairment. Behavioral self-management interventions for migraine with the strongest empirical validation (e.g., relaxation training, biofeedback training, cognitive-behavior therapies) presently are available in specialty headache treatment centers and routinely show promise for reducing headache pain frequency/severity and related impairment, reducing reliance on pharmacotherapies, enhancing personal control over headache activity, and reducing headache-related distress and symptoms. These approaches may be particularly well-suited among patients for whom pharmacotherapies are unwanted, poorly tolerated, or contraindicated. Though underutilized, clinical trials indicate that new and well-established behavioral therapies are similarly effective to migraine medications for migraine prevention among adults and can be successfully employed in various settings.

Headache management in a Veteran population: First considerations.

It is estimated that almost half the general population has a headache disorder. The majority of these are considered tension-type headaches. Migraines and chronic daily headache (CDH) are not as common but are much more debilitating. Although CDH/chronic migraine (CM) occurs in about 3% of the population, it has been found to be 20% or higher in the post 9/11 combat Veteran population. Data from the Veterans Health Administration show that more than 380,000 Veterans, younger than 50 years, received care for a headache in 2017. Approximately 75% of the headache care was from a primary care provider. The purpose of the article is to review physical examination for the veteran with a history of a headache disorder, discuss contributing factors and comorbid conditions, as well as give an overview of current treatment options, with a focus on the post-9/11 combat Veteran who has CDH/CM.

Prevalence and burden of headache in children and adolescents in Austria - a nationwide study in a representative sample of pupils aged 10-18 years.

BACKGROUND: Headache disorders are highly prevalent worldwide, but not so well investigated in children and adolescents as in adults: few studies have included representative nationwide samples. No data exist for Austria until now. In a representative sample of children and adolescents in Austria, we estimated the prevalence and attributable burden of headache disorders, including the new diagnostic category of "undifferentiated headache" (UdH) defined as mild headache lasting less than 1 hour. METHODS: Within the context of a broader national mental health survey, children and adolescents aged 10-18 years were recruited from purposively selected schools. Mediated self-completed questionnaires included sociodemographic enquiry (gender, age, socioeconomic status, family constellation, residence [urban or rural] and migration background). Prevalence and attributable burden of all headache, UdH, migraine (definite plus probable), tension-type headache (TTH: definite plus probable) and headache on ≥15 days/month (H15+) were assessed using the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents. Health-related quality of life (HrQoL) was assessed using the KIDSCREEN questionnaire. RESULTS: Of 7643 selected pupils, 3386 (44.3%) completed the questionnaires. The 1-year prevalence of headache was 75.7%, increasing with age and higher in girls (82.1%) than in boys (67.7%; p < 0.001). UdH, migraine, TTH and H15+ were reported by 26.1%, 24.2%, 21.6% and 3.0% of participants. Attributable burden was high, with 42% of those with headache experiencing restrictions in daily activities. Medication use (50% overall) was highest in H15+ (67%) and still considerable in UdH (29%). HrQoL was reduced for all headache types except UdH. Participants in single parent or patchwork families had a higher probability of migraine (respectively, OR 1.5, p < 0.001; OR 1.5, p < 0.01). Participants with a migration background had a lower probability of TTH (OR 0.7, p < 0.01). CONCLUSIONS: Headache disorders are both very common and highly burdensome in children and adolescents in Austria. This study contributes to the global atlas of headache disorders in these age groups, and corroborates and adds knowledge of the new yet common and important diagnostic category of UdH. The findings call for action in national and international health policies, and for further epidemiological research.

Evaluation of efficacy and feasibility of foot reflexology in children experiencing chronic or persistent pain.

BACKGROUND: Complementary and Alternative Medicines (CAM) are increasingly used in the therapeutic arsenal, particularly for pain management. Foot reflexology (FR) is still poorly evaluated, specifically in the pediatric population. The aim of this study was to evaluate the effectiveness of FR sessions in children experiencing chronic or persistent pain. METHODS: We conducted a prospective study in two pediatric centers from January 2011 to January 2014. Sessions of FR were offered to children regardless of their age, experiencing persistent pain (>72h) or chronic pain (>3 months). A form was completed by the patient before and after each FR sessions. The effectiveness of the session was evaluated using a Visual Analogue Scale (VAS) for both pain and anxiety. RESULTS: One hundred and twenty-two patients suffering from persistent pain were included. We observed a significant decrease of mean VAS pain scores after each session (respectively P<0.001, P<0.001 and P=0.015) and of mean VAS anxiety scores (P<0.001) for all sessions). Seventy patients suffering from chronic pain were included. Decrease in VAS pain scores was statistically significant after each reflexology session for children suffering from headache and musculoskeletal pain (P<0.001). Anxiety was significantly lower after each session (P<0.001). CONCLUSION: In 192 pediatric patients, FR significantly reduce pain and anxiety in children suffering from persistent or chronic pain. This CAM could have a place in pain management in children but needs to be evaluated in larger cohorts.

Integrative Management of Pediatric Primary Headaches.

Pediatric primary headache disorders are best treated using a comprehensive and integrative approach, due to the complex interactions between psychosocial and biological processes. Although more quality research is needed for treatment approaches to pediatric headaches, current practice management includes both pharmaceutical and nonpharmaceutical management. This article describes the integrative treatments used in a large regional pediatric headache program. Lifestyle approaches, nutraceuticals and dietary supplements, acupuncture, transcutaneous neurostimulation, relaxation, clinical hypnosis, biofeedback, and psychological services are discussed in detail for clinicians who may consider applying to their practice. [Pediatr Ann. 2019;48(6):e231-e235.].

Cross-Sectional Evaluation of the Psychometric Properties of the Headache-Specific Locus of Control Scale in People With Migraine.

OBJECTIVE: This study aims to investigate the psychometric properties (component structure, reliability, and construct validity) of the Headache-Specific Locus of Control scale in several clinical migraine populations. BACKGROUND: Headache-specific locus of control beliefs may impact a person's behavioral decisions that affect the likelihood of migraine attack onset, emotional responses to migraine attacks, coping strategies used, and treatment adherence. The 33-item Headache-Specific Locus of Control scale is the most widely used measure of locus of control specific to headache yet psychometric evaluations remain limited. METHODS: Six hundred and ninety-five adults with a diagnosis of migraine from 5 different research studies completed cross-sectional self-report measures including the Headache-Specific Locus of Control scale and measures of quality of life and disability (Migraine-Specific Quality of Life Questionnaire and Migraine Disability Assessment). RESULTS: Five Headache-Specific Locus of Control components emerged from Horn's Parallel Analysis, Minimum Average Partial test, and Principal Component Analysis (eigenvalues: Presence of Internal = 5.7, Lack of Internal = 4.0, Luck = 2.9, Doctor = 2.0, and Treatment = 1.5). The 33 Headache-Specific Locus of Control items demonstrated adequate internal consistency for total (α = 0.79) and subscale scores (α's = 0.69 to 0.88). This study found preliminary evidence of convergent validity. For example, Lack of Internal (r = -0.12, P = 0.004), Doctor (r = -0.20, P < .001), and Treatment (r = -0.12, P = .004) beliefs were associated with higher overall migraine-specific quality of life impairments. CONCLUSIONS: The Headache-Specific Locus of Control scale is a reliable and valid measure of headache-specific locus of control. Findings suggest that headache-specific locus of control is more multidimensional than previous conceptualizations and contribute to our understanding of control beliefs as a potential mechanism for migraine treatment.

Behavioral Therapies and Mind-Body Interventions for Posttraumatic Headache and Post-Concussive Symptoms: A Systematic Review.

BACKGROUND: There are no clear guidelines on how to treat posttraumatic headache (PTH) or post-concussive symptoms (PCS). However, behavioral interventions such as cognitive behavioral therapy, biofeedback, and relaxation are Level-A evidence-based treatments for headache prevention. To understand how to develop and study further mind-body interventions (MBIs) and behavioral therapies for PTH and PCS, we developed the following question using the PICO framework: Are behavioral therapies and MBIs effective for treating PTH and PCS? METHODS: We conducted a systematic search of 3 databases (Medline, PsycINFO, and EMBASE) for behavioral interventions and MBIs with the subject headings and keywords for PTH, concussion, and traumatic brain injury (TBI). Inclusion criteria were (1) randomized controlled trials, (2) the majority of the intervention had to be behavioral or mind-body therapy focused, (3) the majority of the participants (>50%) had to have had a mild TBI (not a moderate or severe TBI), (4) published in a peer-reviewed publication, and (5) meeting pre-specified primary and/or secondary outcomes. Primary outcome(s): whether there was a significant change in concussion symptom severity (yes/no) based on the symptom severity checklist/scale used, whether there was a 50% reduction in headache days and/or disability; secondary outcome(s): sleep variables, cognitive complaints, depression, and anxiety. The search identified 917 individual studies. Two independent reviewers screened citations and full-text articles independently. Nineteen articles were pulled for full article review. Seven articles met the final inclusion criteria. The systematic review was registered in Prospero (CRD42017070072). RESULTS: Overall, there was vast heterogeneity across the studies, making it difficult to fully assess efficacy. The heterogeneity ranged from differences in patient populations, the timing of when the interventions were initiated, the types of intervention implemented, and the measures used to assess outcomes. Seven studies were identified as meeting final inclusion criteria, resulting in a total of 1108 adult participants ranging from 18 to 80. Sixty-nine percent were male. Of the 7 studies, 3 were focused on military staff (retired and active). Time post-injury for inclusion into the studies varied from 48 hours post-injury to more than 2 years post-injury. One of the 7 studies did not include time post-TBI in the inclusion criteria. Two studies recruited patients who had visited their emergency departments, 4 of the studies recruited subjects through outpatient referrals, and 1 study recruited patients who had been in a prior traffic accident with resulting chronic PTH directly from a headache center. Group cognitive behavioral therapy (CBT) sessions and telephonic counseling or communication were common intervention methods used in the studies, with group CBT being used in 2 of the studies and telephonic counseling being used in 3. Other intervention methods used included individual CBT, cognitive training, psychoeducation, and computer-based and/or therapist-directed cognitive rehabilitation. CONCLUSIONS: Many of the interventions offered vastly different methods of delivery of intervention and doses of intervention. Many of the negative studies were done after an extended duration post-injury (>1-year posttraumatic brain injury [TBI]). In addition, the participants were lumped together regardless of their pre-concussion comorbidities, their mechanism of injury, their symptoms, and the duration from injury to the start of the intervention. The mass heterogeneity found between the studies led to inconclusive findings. Thus, there are various considerations for the design of the intervention for future behavioral/MBI studies for PTH and concussion that must be addressed before the leading question of this review may be effectively answered.

The Relaxation Response Resiliency Program (3RP) in Patients with Headache and Musculoskeletal Pain: A Retrospective Analysis of Clinical Data.

BACKGROUND: Headache and musculoskeletal pain are associated with both physical and mental health symptoms, which together are mutually reinforcing. Addressing mental and physical health symptoms (including pain) concomitantly may provide an effective and efficient way to improve outcomes in this population. We tested an evidence-based, eight-session multimodal group program, the Relaxation Response Resiliency Program (3RP), in patients with headache and musculoskeletal pain. A total of 109 adults (30 with headaches, 79 with musculoskeletal pain). METHODS: Participant were 109 adults (30 with headaches, 79 with musculoskeletal pain) referred by their medical doctor, who completed a battery of questionnaires before and after completion of the 3RP. RESULTS: On average, patients with headache and musculoskeletal pain had higher pretreatment scores for anxiety, depression, and somatization symptoms than the nonpatient normative sample for the Symptom Checklist 90-Revised. Significant improvements were identified from pre- to post-treatment in all mental health symptoms (moderate to large effects) and frequency of pain and co-occurring physical health symptoms (small to moderate effects). Patients also reported significant decreases in degree of discomfort and life interference, which were relatively more modest in the musculoskeletal pain group compared with the headache group. CONCLUSIONS: Overall, results of this study suggest that the 3RP may be an effective treatment for reducing pain and psychological symptoms in patients with headaches and musculoskeletal pain. Future work is needed to evaluate the 3RP via a randomized clinical trial in these patient populations.

Mindfulness and Chronic Headache/Migraine: Mechanisms Explored Through the Fear-Avoidance Model of Chronic Pain.

OBJECTIVES: To replicate a study by Schutze and colleagues on a headache sample, rather than a heterogenous chronic pain sample, investigating whether level of mindfulness predicts key components in the Fear-Avoidance Model of chronic pain (pain intensity, negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional disability); to investigate the relationships between level of mindfulness and headache/migraine pain intensity, frequency, and duration. MATERIALS AND METHODS: Participants were 217 individuals who self-reported chronic headache/migraine (51 male, 166 female), aged between 18 and 65 years. Participants completed an online survey measuring demographics, mindfulness, the key components of the Fear-Avoidance Model, and headache pain intensity, duration, and frequency. RESULTS: Mindfulness had significant negative correlations (P<0.05) with all variables except headache pain intensity and headache frequency. Mindfulness significantly predicted negative affect, pain catastrophizing, fear of pain, pain hypervigilance, and headache duration (P<0.05). Mindfulness remained a significant predictor of negative affect and pain hypervigilance after controlling for other key components and background characteristics (P<0.05). Mindfulness did not moderate the relationship between pain intensity and pain catastrophizing (P=0.204). DISCUSSION: Findings suggest that mindfulness may be integrated into the Fear-Avoidance Model of chronic pain for individuals with chronic headache/migraine. Directions for future research are discussed.

Mindfulness-based cognitive therapy for headache pain: An evaluation of the long-term maintenance of effects.

OBJECTIVES: This study aimed to examine the durability of gain patterns following an 8-week Mindfulness-Based Cognitive Therapy (MBCT) for headache pain program. DESIGN: A secondary analysis of a randomized controlled trial was conducted. Participants (N=19) were individuals with headache pain who completed both the MBCT program as well as a 6-month follow-up assessment at a headache clinic or a university psychology clinic. Standardized measures of the primary outcomes (pain intensity and pain interference) and secondary outcomes (pain catastrophizing, mindfulness, activity engagement, pain willingness, and self-efficacy) were administered. Paired-samples t tests and effect sizes were examined. RESULTS: Significant (uncorrected ps<.05) pre- to post-treatment gains were found for pain intensity, pain interference, pain catastrophizing, activity engagement and self-efficacy, and these gains were maintained at 6-months post-treatment. Effect sizes for the significant changes from pre- to post-treatment, and from pre-treatment to follow-up were mostly consistent across epochs (.62≤ds≤-1.40), indicating steady maintenance of effects. Improvement in mindfulness and pain willingness was non-significant immediately post-treatment and at follow-up, with small effects observed. CONCLUSIONS: This study adds to a growing body of literature supporting the durability of MBCT for painful conditions. Results indicated a consistent pattern of maintenance of treatment-related gains across a number of key pain-related outcomes. Future research with a larger sample is needed to investigate the mechanisms underlying these continued gains in order to optimize targeted relapse-prevention.

[The optimization of management of chronic daily headache patients]. / Optimizatsiya vedeniya patsientov s khronicheskoi ezhednevnoi golovnoi bol'yu.

AIM: To optimize the management of chronic daily headache (CDH) using cognitive-behavioral therapy (CBT). MATERIAL AND METHODS: The study included 90 patients (76 women and 14 men), aged from 23 to 78 years (mean age 46.71±11.99) with primary forms of CDH. The patients were followed-up by the neurologist during 12 months, psychological characteristics were studied together with the psychiatrist. Patients received combined treatment, including optimized pharmacotherapy, educational program, relaxation training, CBT and exercise therapy. RESULTS: The diagnosis of CDH has not been previously established in 86.7% of the patients. All patients received unnecessary additional diagnostic examinations, ineffective treatment (86.7%) that resulted in the formation of wrong conceptions about their state (90%). Three months after combined treatment, a significant positive effect has been achieved in 62.2% of the patients and after 12 months in 72.2%. CONCLUSION: The combined treatment program that included CBT can relatively rapidly help patients with CDH and exerts a stable positive effect during 12 months of the follow-up.

[PSYCHO-MEDICAL ASPECTS OF PRIMARY HEADACHES].

BACKGROUND: Primary headaches such as migraine and tension type headaches are extremely common and present a significant clinical challenge. These conditions involve a complex interaction between biological and psychological processes. As part of a "vicious cycle" effect, primary headaches can be deleterious to patients, causing stress, anxiety and catastrophization, while at the same time becoming exacerbated by those very same cognitive and emotional states. OBJECTIVES: Medications often have a limited effect in treating chronic primary headache. Additionally, there are a number of sub-populations for whom many common medications are contraindicated, such as: pregnant women, patients with sensitivities to medication and patients in danger of medication overuse. Mind-body therapies for reducing stress, such as relaxation training and biofeedback, as well as cognitive and behavioral therapies have been used to treat primary headache for the better part of the last four decades. These treatments have been shown to be efficacious in reducing symptoms as well as in improving patient functioning and quality of life. Treatment effects have been shown to continue even after termination of therapy, as patients are given tools to regulate their sympathetic arousal and taught to adopt more constructive coping behaviors and thought processes regarding their condition. Despite the plethora of studies demonstrating the effectiveness of mind-body and cognitive-behavioral therapies and despite recommendations made by various consensus groups, these therapies remain under-used in routine medical practice. DISCUSSION: In order to address this problem we propose a graded, integrative model currently being implemented in the "Functional Neurology Clinic" at 'Soroka' University Medical Center. This model contains a three-step treatment algorithm for quickly and effectively teaching patients self-relaxation techniques. The model is meant to be used in conjunction with pharmacological treatments for primary headaches and can be used in inpatient hospitalization, outpatient clinics or multi-disciplinary treatment centers.

Mindfulness and headache: A "new" old treatment, with new findings.

Background Mindfulness refers to a host of procedures that have been practiced for centuries, but only recently have begun to be applied to varied pain conditions, with the most recent being headache. Methods We reviewed research that incorporated components of mindfulness for treating pain, with a more in depth focus on headache disorders. We also examined literature that has closely studied potential physiological processes in the brain that might mediate the effects of mindfulness. We report as well preliminary findings of our ongoing trial comparing mindfulness alone to pharmacological treatment alone for treating chronic migraine accompanied by medication overuse. Results Although research remains in its infancy, the initial findings support the utility of varied mindfulness approaches for enhancing usual care for headache management. Our preliminary findings suggest mindfulness by itself may produce effects comparable to that of medication alone for patients with chronic migraine and medication overuse. Conclusions Much work remains to more fully document the role and long term value of mindfulness for specific headache types. Areas in need of further investigation are discussed.

An Empirical Examination of the Role of Common Factors of Therapy During a Mindfulness-based Cognitive Therapy Intervention for Headache Pain.

OBJECTIVE: It is often assumed that psychosocial pain treatments work because of specific active components of the intervention. The degree to which common factors may contribute to improved pain outcomes is not well researched. The purpose of this study was to examine patient-related and therapist-related common factors during a Mindfulness-Based Cognitive Therapy (MBCT) for headache pain trial. MATERIALS AND METHODS: This study was a secondary analysis of a parallel group, unblinded, randomized controlled trial in which MBCT was compared with a control. A series of linear regression models and 1 bootstrap mediation model were conducted with the sample of participants that completed MBCT (N=21). RESULTS: In-session participant engagement was positively associated with treatment dose indicators of session attendance (P=0.038) and at-home meditation practice (P=0.027). Therapist adherence and quality were both significant predictors of posttreatment client satisfaction (P=0.038 and 0.034, respectively). Therapist appropriateness was not significantly associated with any of the variables of interest (P>0.05). Baseline pain intensity was positively associated with pretreatment expectations and motivations (P=0.049) and working alliance (P=0.048), and working alliance significantly predicted posttreatment patient satisfaction (P<0.001). Higher pretreatment expectations and motivation significantly predicted greater improvement in pretreatment to posttreatment change in pain interference (P=0.016); however, this relation was fully mediated by baseline pain intensity (P<0.05). DISCUSSION: Common factors play an important role in improving pain outcomes and patient satisfaction during a MBCT for headache pain intervention. Stimulating positive pretreatment expectations and patient motivation, as well as building strong rapport is an important component of treatment success.

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents.

BACKGROUND: Chronic pain is common during childhood and adolescence and is associated with negative outcomes such as increased severity of pain, reduced function (e.g. missing school), and low mood (e.g. high levels of depression and anxiety). Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. However, new and innovative technology is being used to deliver these psychological therapies remotely, meaning barriers to access to treatment such as distance and cost can be removed or reduced. Therapies delivered with technological devices, such as the Internet, computer-based programmes, smartphone applications, or via the telephone, can be used to deliver treatment to children and adolescents with chronic pain. OBJECTIVES: To determine the efficacy of psychological therapies delivered remotely compared to waiting-list, treatment-as-usual, or active control treatments, for the management of chronic pain in children and adolescents. SEARCH METHODS: We searched four databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) from inception to June 2014 for randomised controlled trials of remotely delivered psychological interventions for children and adolescents (0 to 18 years of age) with chronic pain. We searched for chronic pain conditions including, but not exclusive to, headache, recurrent abdominal pain, musculoskeletal pain, and neuropathic pain. We also searched online trial registries for potential trials. A citation and reference search for all included studies was conducted. SELECTION CRITERIA: All included studies were randomised controlled trials that investigated the efficacy of a psychological therapy delivered remotely via the Internet, smartphone device, computer-based programme, audiotapes, or over the phone in comparison to an active, treatment-as-usual, or waiting-list control. We considered blended treatments, which used a combination of technology and face-to-face interaction. We excluded interventions solely delivered face-to-face between therapist and patient from this review. Children and adolescents (0 to 18 years of age) with a primary chronic pain condition were the target of the interventions. Each comparator arm, at each extraction point had to include 10 or more participants. DATA COLLECTION AND ANALYSIS: For the analyses, we combined all psychological therapies. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. Pain, disability, depression, anxiety, and adverse events were extracted as primary outcomes. We also extracted satisfaction with treatment as a secondary outcome. We considered outcomes at two time points: first immediately following the end of treatment (known as 'post-treatment'), and second, any follow-up time point post-treatment between 3 and 12 months (known as 'follow-up'). We assessed all included studies for risk of bias. MAIN RESULTS: Eight studies (N = 371) that delivered treatment remotely were identified from our search; five studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, and two studies included mixed samples of children with headache and mixed (i.e. recurrent abdominal pain, musculoskeletal pain) chronic pain conditions. The average age of children receiving treatment was 12.57 years.For headache pain conditions, we found one beneficial effect of remotely delivered psychological therapy. Headache severity was reduced post-treatment (risk ratio (RR) = 2.65, 95% confidence interval (CI) 1.56 to 4.50, z = 3.62,p < 0.01, number needed to treat to benefit (NNTB) = 2.88). For mixed pain conditions, we found only one beneficial effect: psychological therapies reduced pain intensity post-treatment (standardised mean difference (SMD) = -0.61, 95% CI -0.96 to -0.25, z = 3.38, p < 0.01). No effects were found for reducing pain at follow-up in either analysis. For headache and mixed conditions, there were no beneficial effects of psychological therapies delivered remotely for disability post-treatment and a lack of data at follow-up meant no analyses could be run. Only one analysis could be conducted for depression outcomes. We found no beneficial effect of psychological therapies in reducing depression post-treatment for headache conditions. Only one study presented data in children with mixed pain conditions for depressive outcomes and no data were available for either condition at follow-up. Only one study presented anxiety data post-treatment and no studies reported follow-up data, therefore no analyses could be run. Further, there were no data available for adverse events, meaning that we are unsure whether psychological therapies are harmful to children who receive them. Satisfaction with treatment is described qualitatively.'Risk of bias' assessments were low or unclear. We judged selection, detection, and reporting biases to be mostly low risk for included studies. However, judgements made on performance and attrition biases were mostly unclear. AUTHORS' CONCLUSIONS: Psychological therapies delivered remotely, primarily via the Internet, confer benefit in reducing the intensity or severity of pain after treatment across conditions. There is considerable uncertainty around these estimates of effect and only eight studies with 371 children contribute to the conclusions. Future studies are likely to change the conclusions reported here. All included trials used either behavioural or cognitive behavioural therapies for children with chronic pain, therefore we cannot generalise our findings to other therapies. However, satisfaction with these treatments was generally positive. Larger trials are needed to increase our confidence in all conclusions regarding the efficacy of remotely delivered psychological therapies. Implications for practice and research are discussed.

Development of the headache activities of daily living index: initial validity study.

PURPOSE: The purpose of this study was to develop a novel instrument for assessing headache-related disability focusing solely on important activities of daily living. METHODS: Part 1: A literature search was conducted in PubMed and Google Scholar, supplemented by hand searches in bibliographies to retrieve the original article for any instrument for the assessment of headache-related disability. Each instrument was evaluated for item categories, specific item content, measurement scale format for each item, and instructions to users. Together, these features constituted the construct validity of these instruments. Qualitative evaluations of these results were summarized with respect to the adequacy of each component. Psychometric features such as reliability and validity were not assessed. Part 2: An existing instrument for assessing self-rated disability, the Neck Disability Index, was modified for content and format and subjected to 2 rounds of clinician and patient review. Item contents and formats received final consensus, resulting in a 9-item instrument: the Headache Activities of Daily Living Index (HADLI). This instrument was tested in a sample of headache patients. Cronbach α and individual item correlations were obtained. Principal Components Analysis was performed. RESULTS: Part 1: The search identified 6 reports on 5 preexisting instruments for self-rating of headache-related disability. Problems in content were found in all instruments, especially relating to the lack of items for specific activities of daily living. Problems were noted in most of the instruments for scaling and instructions with respect to the effect of headache on activities of daily living. Part 2: The authors first identified suitable items from an existing instrument for self-rating of disability. These were supplemented by items drawn from the literature. A panel of 3 clinicians and 2 laypersons evaluated these items. Two more focus groups of 7 headache sufferers each reviewed the new instrument. After this, a 9-item instrument for assessing activities of daily living in headache sufferers, the HADLI, was finalized. After this, 53 participants were recruited to study the face validity of the instrument. The sample consisted of 41 women and 12 men with a mean age of 37.3 (12) years; mean duration of headaches was 7.4 (8.3) years; mean frequency of headaches per week was 3.4 (2.4); and the intensity was 6 (2.4). The mean HADLI score was 26.2 (13.4), or 52%. There were no floor or ceiling effects for total score. The total Index Cronbach α was 0.96. The Principal Components Analysis identified one component which accounted for 75% of the variance. CONCLUSIONS: The HADLI was created using theory and empirical-based methods. Face validity was assessed by focus group input and by first-level psychometrics. The HADLI has good face validity and is suitable for further reliability and validity testing.

Older adults' use of care strategies in response to general and upper respiratory symptoms.

This study examined the use of complementary and medical treatments, both individually and in combination, to address common general and upper respiratory symptoms. Data for the analysis were collected from a series of 18 daily diary questionnaires administered to community-living older African American and white adults living in rural counties in North Carolina. Participants reported symptoms experienced on each diary day and the treatment strategies they used each day in response to the particular symptom(s). Older adults used diverse categories of strategies to treat symptoms; treatment strategies were used inconsistently across symptoms. Use of only complementary strategies, only medical conventional strategies, or both complementary and medical strategies to treat any one symptom rarely corresponded to the use of the same strategy to address other symptoms. Future research would benefit from analyzing how older adults use health care strategies across symptom categories.

Complementary and conventional medicine use among youth with recurrent headaches.

OBJECTIVE: To identify prevalence and patterns of complementary and alternative medicine (CAM) use among youth with recurrent headaches (HA) and evaluate associations with co-occurring health problems and limitations as well as with the use and expenditures for conventional medical care. METHODS: Variables were constructed for youth aged 10 to 17 by using linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey. Bivariate, logistic, and 2-part regression analyses were used. RESULTS: Of the 10.6% of youth experiencing HA, 29.6% used CAM, rising to 41% for the many HA sufferers who also experienced difficulties with emotions, concentration, behavior, school attendance, or daily activities. Biologically based products (16.2%) and mind-body therapies (13.3%) were most commonly used, especially by the 86.4% of youth with HA experiencing at least 1 other chronic condition. Compared with non-CAM users, youth with HA who used CAM also had higher expenditures for and use of most types of conventional care. CONCLUSIONS: CAM use is most common among youth with HA experiencing multiple chronic conditions and difficulties in daily functioning. Associations among CAM use, multiple chronic conditions, and higher use of conventional care highlight the need for medical providers to routinely ask about CAM use to meet the complex health needs of their patients and facilitate the optimal integration of care. Research is needed to identify models for coordinating complementary and conventional care within a medical home and to understand the health benefits or risks associated with CAM use in conjunction with conventional treatments for patients with HA.