Cheryl D. Bernstein

Fibromyalgia and headache: an epidemiological study supporting migraine as part of the fibromyalgia syndrome

Fibromyalgia is defined by widespread body pain, tenderness to palpation of tender point areas, and constitutional symptoms. The literature reports headache in about half of fibromyalgia patients. The current epidemiological study was designed to determine the prevalence and characteristics of headache in fibromyalgia patients. Treatment-seeking fibromyalgia patients were evaluated with measures for fibromyalgia, chronic headache, quality of life, and psychological distress. Multivariate analysis of variance (MANOVA) and t-tests were used to identify significant differences, as appropriate. A total of 100 fibromyalgia patients were screened (24 fibromyalgia without headache and 76 fibromyalgia with headache). International Headache Society diagnoses included: migraine alone (n=15 with aura, n=17 without aura), tension-type alone (n=18), combined migraine and tension-type (n=16), post-traumatic (n=4), and probable analgesic overuse headache (n=6). Fibromyalgia tender point scores and counts and most measures of pain severity, sleep disruption, or psychological distress were not significantly different between fibromyalgia patients with and without headache. As expected, the fibromyalgia patients with headache scored higher on the Headache Impact Test (HIT-6) (62.1±0.9 vs 48.3±1.6, p<0.001). HIT-6 scores were >60 in 80% of fibromyalgia plus headache patients, representing severe impact from headache, and 56–58 in 4%, representing substantial impact. In summary, chronic headache was endorsed by 76% of treatment-seeking fibromyalgia patients, with 84% reporting substantial or severe impact from their headaches. Migraine was diagnosed in 63% of fibromyalgia plus headache patients, with probable analgesic overuse headache in only 8%. General measures of pain, pain-related disability, sleep quality, and psychological distress were similar in fibromyalgia patients with and without headache. Therefore, fibromyalgia patients with headache do not appear to represent a significantly different subgroup compared to fibromyalgia patients without headache. The high prevalence and significant impact associated with chronic headache in fibromyalgia patients, however, warrants inclusion of a headache assessment as part of the routine evaluation of fibromyalgia patients.

Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College of Rheumatology criteria and the development of alternative criteria.

To validate the 2011 modification of the 2010 American College of Rheumatology (ACR) preliminary criteria for the diagnosis of fibromyalgia (2011ModCr) and develop alternative criteria in a sample of patients with diverse pain disorders that are commonly seen in everyday practice by pain specialists, rheumatologists, and psychologists.

Animal-Assisted Therapy at an Outpatient Pain Management Clinic

OBJECTIVE The objective of this study was to evaluate the effects of brief therapy dog visits to an outpatient pain management facility compared with time spent in a waiting room. DESIGN The design of this study is open-label. Setting.  This study was conducted in a university tertiary care adult chronic pain outpatient clinic. SUBJECTS The subjects of this study include outpatients, adults accompanying outpatients to their appointments, and clinic staff. Intervention.  Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS Two hundred ninety-five therapy dog visits (235 with patients, 34 family/friends, and 26 staff) and 96 waiting room surveys (83 from patients, 6 family/friends, and 7 staff) were completed over a 2-month study period. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit but not the waiting room control, with clinically meaningful pain relief (decrease ≥2 points) in 23% after the therapy dog visit and 4% in the waiting room control. Significant improvements were likewise seen after therapy dog visits for family/friends and staff. CONCLUSIONS Therapy dog visits in an outpatient setting can provide significant reduction in pain and emotional distress for chronic pain patients. Therapy dog visits can also significantly improve emotional distress and feelings of well-being in family and friends accompanying patients to appointments and clinic staff.

A prospective comparison between ICHD-II and probability menstrual migraine diagnostic criteria.

Objective.— To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems.

Perimenstrual Eletripan Prevents Menstrual Migraine: An Open‐Label Study

Objective.— To prospectively evaluate the efficacy of perimenstrual prophylaxis with eletriptan to reduce headaches in women identified with menstrual migraine (MM).

Impact of animal-assisted therapy for outpatients with fibromyalgia.

OBJECTIVES Animal-assisted therapy using dogs trained to be calm and provide comfort to strangers has been used as a complementary therapy for a range of medical conditions. This study was designed to evaluate the effects of brief therapy dog visits for fibromyalgia patients attending a tertiary outpatient pain management facility compared with time spent in a waiting room. DESIGN Open label with waiting room control. SETTING Tertiary care, university-based, outpatient pain management clinic. SUBJECTS A convenience sample of fibromyalgia patients was obtained through advertisements posted in the clinic. INTERVENTIONS Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES.: Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS Data were evaluated from 106 therapy dog visits and 49 waiting room controls, with no significant between-group demographic differences in participants. Average intervention duration was 12 minutes for the therapy dog visit and 17 minutes for the waiting room control. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit, but not the waiting room control. Clinically meaningful pain relief (≥2 points pain severity reduction) occurred in 34% after the therapy dog visit and 4% in the waiting room control. Outcome was not affected by the presence of comorbid anxiety or depression. CONCLUSIONS Brief therapy dog visits may provide a valuable complementary therapy for fibromyalgia outpatients.

Brief, self-report fibromyalgia screener evaluated in a sample of chronic pain patients.

OBJECTIVE To validate a self-report fibromyalgia screener in a chronic pain population. DESIGN Adults with chronic pain were evaluated with a six-item, self-report fibromyalgia screening tool based on revised American College of Rheumatology (ACR) fibromyalgia diagnostic criteria, with fibromyalgia diagnosed when patients experienced chronic pain and scored ≥13 on the ACR fibromyalgia symptom severity scale. Patients were independently assigned clinical diagnoses by treating clinicians. SETTING University-based, tertiary care pain clinic. SUBJECTS Three hundred thirty-seven mixed chronic pain patients. RESULTS Agreement between the clinical diagnosis and screener diagnosis was good (P < 0.001), with 76% sensitivity and 82% specificity. CONCLUSION A self-administered, brief fibromyalgia screening questionnaire can effectively identify chronic pain patients who will likely have clinical fibromyalgia.

Including a Range of Outcome Targets Offers a Broader View of Fibromyalgia Treatment Outcome: Results from a Retrospective Review of Multidisciplinary Treatment

BACKGROUND Fibromyalgia is associated with substantial functional disability. Current drug and non-drug treatments result in statistically significant but numerically small improvements in typical numeric measures of pain severity and fibromyalgia impact. OBJECTIVE The aim of the present study was to evaluate additional measures of pain severity and functional outcome that might be affected by fibromyalgia treatment. METHODS This retrospective review evaluated outcomes from 274 adults with fibromyalgia who participated in a six-week, multidisciplinary treatment programme. Pain and function were evaluated on the first and final treatment visit. Pain was evaluated using an 11-point numerical scale to determine clinically meaningful pain reduction (decrease ≥ 2 points) and from a pain drawing. Function was evaluated by measuring active range of motion (ROM), walking distance and speed, upper extremity exercise repetitions, and self-reports of daily activities. RESULTS Numerical rating scores for pain decreased by 10-13% (p < 0.01) and Fibromyalgia Impact Questionnaire (FIQ) scores decreased by 20% (p < 0.001). More substantial improvements were noted when using alternative measures. Clinically meaningful pain relief was achieved by 37% of patients, and the body area affected by pain decreased by 31%. ROM showed significant improvements in straight leg raise and cervical motion, without improvements in lumbar ROM. Daily walking distance increased fourfold and arm exercise repetitions doubled. CONCLUSION Despite modest albeit statistically significant improvements in standard measures of pain severity and the FIQ, more substantial pain improvement was noted when utilizing alternative measures of pain and functional improvement. Alternative symptom assessment measures might be important outcome measures to include in drug and non-drug studies to better understand fibromyalgia treatment effectiveness.

Milnacipran for fibromyalgia: a useful addition to the treatment armamentarium

Introduction: Antidepressants are used to treat a variety of chronic pain conditions including peripheral neuropathy, headache, and more recently, fibromyalgia. The antidepressant milnacipran blocks the reuptake of norepinephrine and serotonin and is used for the management of fibromyalgia. Areas covered: The article contains data primarily obtained from the MEDLINE database using a PubMed search of the keywords including milnacipran, fibromyalgia and depression. Of the available serotonin norepinephrine reuptake inhibitors, milnacipran has greater potency in inhibiting reuptake of norepinephrine relative to serotonin and is proposed to work by attenuating pain signals. Milnacipran is well tolerated and effective for fibromyalgia pain when given in divided doses of 100 – 200 mg daily. Studies show that milnacipran may be effective for fibromyalgia-associated symptoms including depression and fatigue. Expert opinion: Milnacipran provides modest fibromyalgia pain relief and is best used as part of a multidisciplinary treatment approach. While milnacipran was not studied in fibromyalgia patients with major depression, it may be a wise choice for fibromyalgia patients with depressive symptoms and patients for whom sedation, dizziness, edema or weight gain with gabapentin and pregabalin is a problem. Milnacipran has been found to be beneficial for treating some troublesome fibromyalgia-associated symptoms, including fatigue and cognitive dysfunction.

Pain Medicine in Older Adults: How Should It Differ?

Older adults (commonly defined as those ≥ age 65) are not simply a chronologically older version of younger patients. Homeostenosis, that is, progressive restriction of an aging organism’s capacity to respond to stress because of diminution of its biological, psychological, and social reserves, underlies the distinction of old from young. As pain is a stressor that commonly accompanies aging, the provision of safe, clinically effective, and cost-effective pain care to older adults requires awareness of these specific aging-related changes. The main goals of this chapter are to (1) educate the pain practitioner in basic principles of aging needed to guide the evaluation and treatment of older adults, (2) provide clinical case examples to illustrate the advantages of treatment that is guided by these principles as compared with traditional pain care and why traditional pain care may actually harm these patients, and (3) offer specific therapeutic guidelines for the treatment of nociceptive, neuropathic, and widespread pain in older patients.