Pain and Headache Center

Our overarching objective was to determine whether autonomic reflex dysfunction and heightened sensory sensitivity contribute to orthostatic intolerance (OI) in patients with migraine. Adults with migraine (N = 30) underwent autonomic function tests summarized as the Composite Autonomic Severity Score (CASS) and vagal/adrenergic baroreflex sensitivity (BRS-V/A). Postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension/hypertension were diagnosed during tilt table testing. A cold pressor test (CPT) evaluated sympathetic vasomotor function. Participants completed the Migraine Disability Assessment (MIDAS), the 2011 Fibromyalgia (FM) Survey Criteria, and chronic overlapping pain condition (COPC) screening. The number of headache days per month correlated with CASS (p = 0.001), BRS-V (p < 0.001), and the CPT (p = 0.003) in the expected direction, with increasing autonomic nervous system (ANS) reflex dysfunction correlating with increasing number of headache days. During tilt testing, OI was prevalent (25/30; 83%) and was reported by all patients with chronic migraine. An abnormal cardiovascular response to tilt was present in 63%; POTS was the most common etiology (56.2%). Patients reporting OI during tilt table testing despite a normal cardiovascular response (33%) had higher FM scores (15.8 ± 3.6 vs. 7.5 ± 4.6; p < 0.01) and a greater prevalence of non-headache COPCs (88.8% vs. 20.0%, p = 0.02) than asymptomatic patients. Increased headache frequency correlates with increasing ANS reflex dysfunction. The high prevalence of OI in patients with migraine may be due to both autonomic reflex dysfunction and an abnormal cardiovascular response to tilt (i.e., concordant OI) and heightened sensory sensitivity (i.e., discordant OI).

The aim of this study was to determine interventions recommended by nurses working in rural America to promote wellness in the workplace. Over the last decade, persistent nursing shortage and an unprecedented post-pandemic period challenged health care systems. There is limited literature addressing these challenges from the perspective of nurses in rural America. The longitudinal, qualitative study used focus groups to understand the nurses' recommended interventions. Clinical nurses (n=14), nurse leaders (n=17), and advanced practice nurses (n=12) from tertiary and rural settings participated in the first focus group session. Clinical nurses (n=11), nurse leaders (n=13), and advanced practice nurses (n=9) participated in the second focus group session. The participants prioritized wellness interventions that could impact nurses in their role and work setting across the United States. Recommended unique interventions aligning with role and work setting are provided by the authors. Study findings provide organizational leaders with interventions to explore that may have a positive impact on nurse wellness in their health care systems. Future research is recommended to investigate the effects of these interventions on nurses' wellness.

Background: Digital approaches to preconception care (PCC) may help increase reproductive health awareness among women of reproductive age. This pilot study evaluated the usability, acceptability, and perceived impact of a digital PCC tool delivered during workplace health checkups in Japan.Methods: A quick response (QR) code linking to a digital PCC tool was distributed during routine workplace health checkups for women aged 18-40 years. Participants completed a questionnaire assessing perceived usefulness, ease of understanding, relevance to personal health, intention to seek medical consultation, and understanding of PCC. Because not all participants answered every item, denominators varied across outcomes. Age-group differences were examined using chi-square tests.Results: A total of 277 participants completed at least one questionnaire item and were included in the analysis. Perceived usefulness was high overall (92.8%) with a significant age-group difference (p = 0.001). Ease of understanding also showed a significant difference, with lower ratings in the 35-40 years group (p < 0.001). No significant age-group differences were observed for relevance to personal health (p = 0.795), intention to seek consultation (p = 0.748), or understanding of PCC (p = 0.444). PCC understanding remained high across all age groups (93.8%).Conclusions: The digital PCC tool was well accepted by women of reproductive age in a workplace setting. Although usefulness and ease of understanding varied by age, other outcomes were consistent across age groups. Further research with larger samples and longitudinal designs is needed to determine whether digital PCC tools influence real-world healthcare engagement.

Patients with chronic pain, frequently report cognitive problems ('brain fog'), particulary those with nociplastic pain, which involves dysregulated pain processing. However, the association with objective executive dysfunction and decline over time is unclear. We examined whether nociplastic pain severity is associated with executive dysfunction and decline, and explored which factors, such as sex or associated non-pain symptoms, mediate this relationship. We conducted a prospective cohort study using UK Biobank. Baseline cognitive assessments (2017-20), a pain questionnaire (2019), and follow-up cognitive assessments (2021-2) were analysed. Nociplastic pain severity was measured using the fibromyalgia index (0-31), a continuous measure of widespread pain and symptom severity. A latent executive function measure was derived using confirmatory factor analysis. Cross-sectional associations were examined using linear regression, and longitudinal structural equation modelling assessed cognitive decline. Mediation analysis evaluated indirect effects of abnormal sleep duration, anxiety, depression, brain fog, fatigue, and pain qualities. We included 35 423 participants (median age 65 yr; 52% female). Greater nociplastic pain severity was associated with worse executive function cross-sectionally (β=-0.49 centiles per 1 point increase in fibromyalgia index; 95% confidence interval -0.59 to -0.39), with a stronger effect in males. However, nociplastic pain severity was not associated with a faster rate of executive function decline. Abnormal sleep duration, anxiety, pain intensity, and neuropathic pain features partially mediated the cross-sectional association. Nociplastic pain severity is associated with worse executive function but reassuringly does not suggest worse cognitive decline. Abnormal sleep duration, anxiety, and pain intensity are highlighted as potential intervention targets.

BackgroundMigraine is a complex disabling neurological disease characterized by recurrent headache attacks lasting 4-72 h with moderate to severe intensity and other accompanying symptoms. While chronic migraine (CM) and episodic migraine (EM) are primarily differentiated by the frequency of headache and migraine days, underlying clinical and functional differences have been described. OnabotulinumtoxinA (onabotA) has been approved as a preventive treatment for CM with controlled clinical and real-world evidence suggesting potential benefits for treatment of EM. Given the lack of randomized controlled trial data, PRECLUDE, a prospective phase 3 trial was designed to evaluate the efficacy and safety of onabotA for the preventive treatment of EM.MethodsThe PRECLUDE trial was a phase 3 multicenter, randomized, double-blind, placebo-controlled, parallel-group trial with an open-label onabotA 195 U extension phase. In total, 775 patients aged 18-65 years with a history of migraine attacks were randomized (1:1:1) to receive placebo, onabotA 155 U, or onabotA 195 U. Patients recorded daily headache data and medication use via an electronic diary (eDiary) during a four-week screening phase, 24-week double-blind phase, followed by a 24-week open-label extension phase. The primary endpoint was the change in the frequency of monthly migraine days from baseline across months 5 and 6.ResultsAll treatment groups showed a reduction in the frequency of monthly migraine days from baseline; however, neither the onabotA 155 U group nor the 195 U group demonstrated a statistically significant improvement compared to the placebo group (p >0 .05). Similarly, secondary endpoints, including changes in monthly headache days, 50% responder rates and monthly acute medication use days, did not reach statistical significance. Adverse events in this trial were consistent with previous findings for onabotA in CM and were generally mild to moderate in severity.ConclusionsThe PRECLUDE trial demonstrated that onabotA was well tolerated but did not show significant efficacy compared to placebo for the endpoint reducing migraine days from baseline in patients with EM as defined by the trial protocol. While onabotA is effective for CM, these findings highlight the need for further research to better understand the pathophysiological differences between EM and CM and to understand whether there is a potential subset of EM patients which respond to onabotA.

IntroductionDespite expert recommendations against using opioids for migraine treatment, their use remains common in the USA. We aimed to evaluate the use of opioids among people with active migraine using data from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) (US) study.MethodsThis observational, longitudinal, web-based survey study included a demographically representative sample of adults with migraine in the USA (2018–2020). Participants with migraine (International Classification of Headache Disorders, third edition [ICHD-3]) and ≥ 1 headache in the previous 12 months were identified via a questionnaire and/or self-reported diagnosis. Information on opioid use for acute migraine treatment was collected. Demographics, clinical, and migraine-related characteristics among those with current opioid use and those with non-use were evaluated in the cross-sectional analysis using standardized mean difference (SMD). Multivariable analysis was conducted using machine learning (least absolute shrinkage and selection operator regression, random forest) and logistic regression models to assess factors associated with current opioid use.ResultsOf 61,932 respondents with active migraine, 13,331 (21.5%) reported currently using opioids to treat migraine. Among those using opioids, 68.0% were female, 64.3% identified as White, and 13.7% identified as Hispanic. Those currently using opioids differed from those not using opioids in various characteristics, including higher tobacco/marijuana use, more comorbidities, higher migraine-related disability, and higher interictal burden (all SMD > 0.2). The factors most associated with current opioid use were “currently taking recommended acute medications for migraine” (odds ratio [OR], 10.1; confidence interval [CI], 9.47, 10.78), “currently taking barbiturates for migraine” (OR, 2.2; CI, 2.03, 2.34), and “sought care at an Emergency Department/Urgent Care for migraine in the previous 12 months” (OR, 1.7; CI, 1.67, 1.85).ConclusionsThis study shows that opioid use for migraine is associated with using recommended acute medications, barbiturates, and emergency department care for migraine. Understanding how to limit these factors is key to developing interventions to reduce opioid use in migraine.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-025-00774-y.

Methadone is frequently used for chronic pain management due to its long half-life and NMDA receptor activity, making it an effective option for opioid-tolerant patients. Buprenorphine-naloxone is increasingly explored as an alternative for chronic pain and opioid use disorder, offering partial opioid agonism with a ceiling effect on respiratory depression. The transition from methadone to buprenorphine-naloxone remains clinically challenging, requiring careful management to prevent withdrawal and ensure adequate pain control. Two patients with chronic pain were transitioned from methadone to buprenorphine-naloxone. The first patient, a mid-40s female, was abruptly switched from methadone 10 mg twice daily dosing to buprenorphine-naloxone 4 mg-1 mg twice daily dosing without a taper, resulting in severe withdrawal requiring hospitalization. The second patient, a late-50s male, underwent a two-month methadone taper before initiating buprenorphine-naloxone 4 mg-1 mg twice daily dosing, but reported persistent uncontrolled pain despite dose escalation to 4 mg-1 mg three times a day. Both patients reported significant dissatisfaction with buprenorphine-naloxone therapy, citing inadequate pain relief. Both patients eventually left the practice and were lost to follow up. These cases underscore the challenges of transitioning chronic pain patients from methadone to buprenorphine-naloxone formulations. Transitioning patients between these medications may lead to issues regarding withdrawal symptoms, inadequate pain control, and patient attrition.

BackgroundCognitive behavioral therapy for headache (CBT-HA) improves headache-related outcomes, but accessibility barriers limit its use. This pilot study evaluated the feasibility, acceptability and clinical signal of an interactive voice response (IVR)-delivered CBT-HA intervention for veterans with post-traumatic headache (PTH).MethodsA single-arm pilot trial was conducted with 18 veterans diagnosed with PTH. Participants completed a 10-week IVR-CBT-HA program. Outcomes were assessed at baseline, immediately post-treatment and one-month follow-up. Primary outcomes included changes in headache days, interference, disability, feasibility and acceptability.ResultsFifteen participants completed the study. Headache frequency, headache-related disability, depressive symptoms, anxious symptoms, sleep quality and headache catastrophizing were not statistically significant. Self-efficacy significantly improved from baseline to post-treatment (F2,12 = 8.71, p = 0.001), and remained stable at follow-up. Participants reported high satisfaction with the intervention (27.73/32, SD = 5.66) but low system usability (mean = 20.83/100, SD = 15.72). Study therapists rated the intervention as highly acceptable (acceptability of intervention: mean = 4.83/5, SD = 0.37) and feasible (feasibility of intervention measure: mean = 4.92/5, SD = 0.28). Interactive CBT for headache and relaxation training (i.e. iCHART) resulted in an approximately 33% cost savings compared to traditional CBT-HA.ConclusionsAsynchronous, IVR-delivered CBT-HA was feasible, acceptable and cost-effective for veterans with PTH. Although headache reductions were not statistically significant, self-efficacy improvements suggest long-term benefits. Future research should explore technology refinements and larger randomized trials.Trial RegistrationClinicalTrials.gov: NCT05093556 (registered 26 October 2021).