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Ability to Cope with Pain Puts Migraine Surgery Patients in Perspective

Gfrerer, Lisa M.D., Ph.D.; Lans, Jonathan M.D.; Faulkner, Heather R. M.D., M.P.H.; Nota, Sjoerd M.D., Ph.D.; Bot, Arjan G. J. M.D., Ph.D.; Austen, William Gerald Jr. M.D.

Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 169–174
doi: 10.1097/PRS.0000000000003955
Reconstructive: Head and Neck: Original Article
Press Release

Background: Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients’ pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome.

Methods: Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison.

Results: All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome.

Conclusions: The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery.


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Boston, Mass.; and Amsterdam, The Netherlands

From the Division of Plastic and Reconstructive Surgery, the Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School; and the Orthopaedic Research Center Amsterdam, Academic Medical Center.

Received for publication April 28, 2017; accepted July 13, 2017.

Presented at the 96th Annual Meeting of the American Association of Plastic Surgeons, in Austin, Texas, March 25 through 28, 2017; and the 62nd Annual Meeting of the Plastic Surgery Research Council, in Durham, North Carolina, May 4 through 7, 2017.

Disclosure: The authors have no conflicts of interest to disclose. None of the authors has a financial interest in any of the products or devices mentioned in this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (

William Gerald Austen, Jr., M.D., Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 435, Boston, Mass. 02114,

Migraine surgery candidates at our institution are chronic pain patients refractory to conservative treatment options, and can be classified as such.1 This very specific patient population is currently not well understood, and it is unclear how to categorize these patients in the wide spectrum of pain conditions. Studies have used several migraine-specific questionnaires to describe migraine surgery patients and to evaluate outcomes after surgery.2–5 However, pain questionnaires used in the evaluation of better understood and more common pain syndromes have not been applied to surgical migraine headache patients. This study proposes use of the Pain Self-Efficacy Questionnaire (PSEQ) to supplement currently used migraine-specific outcome tools.

The most common outcome measure in migraine surgery is the Migraine Headache Index (MHI). It is calculated by multiplying migraine headache frequency, duration, and severity. Although this measure is very important, it describes migraine characteristics, not the impact of migraine on everyday life. Therefore, other migraine-specific questionnaires that focus on migraine-related disability have been used to supplement the MHI. Examples are the Migraine Disability Assessment Survey, the Migraine-Specific Quality-of-Life Questionnaire, and the Headache Impact Test.6–8 Although these questionnaires are well established, well validated, and widely used in migraine, scores are not easy to interpret in surgical migraine patients. A representative example is the Migraine Disability Assessment Survey score. Five questions determine how many days at work/school, days with family/friends, and days of productivity were lost over the past 3 months. The days are added up to a total score. A score of greater than or equal to 21 indicates severe disability. Migraine surgery candidates at our institution have a mean preoperative Migraine Disability Assessment Survey score of 101.7 ± 93.1, which is five times the cutoff for severe disability. It is therefore difficult to fully understand this score.

Because of the limitations of the MHI and migraine-specific questionnaires, the PSEQ is an interesting supplement to currently used measures. The PSEQ is a well-established outcome tool used in pain patients.9–15 It determines patients’ functional disability and ability to cope with pain when performing normal activities. Items cover a range of activities, including household chores, work, socializing, and pain without medications. Pain self-efficacy has been shown to be a significant predictor of success after therapy in heterogeneous pain populations, as patients with low pain self-efficacy have been found to have worse treatment outcomes.16–24 Scores under 30 predict a high prevalence of long-term disability and depression.25

The PSEQ has been applied to a variety of pain conditions and therefore allows comparison of migraine surgery patients to better characterized pain populations.16–24 Furthermore, it evaluates functional status of patients and their ability to cope with pain, which are important factors to take into account when evaluating chronic pain patients.

The aims of this study were to quantify pain self-efficacy in migraine surgery patients and determine the relationship of preoperative self-efficacy and postoperative migraine symptoms/disability. Furthermore, pain self-efficacy scores in these patients were compared to scores in other pain populations.

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Data Collection

Institutional review board approval was obtained at Massachusetts General Hospital in Boston, Massachusetts. Ninety patients who underwent migraine surgery performed by the senior author (W.G.A.) were enrolled in this study prospectively between 2013 and 2015. All patients were diagnosed with chronic migraine headache that had failed conservative management by a neurologist before presentation. At the preoperative visits, trigger sites were determined using a combination of history, physical examination, and nerve block, as described in previous publications.26 , 27 If patients were candidates for surgery, they were enrolled in the study. The senior author (W.G.A.) performed all procedures as described previously.27 Patients were asked to complete a detailed migraine history, the MHI, and the PSEQ at baseline (preoperatively) and 12 months postoperatively online using RedCap.28 Sixteen patients were lost to follow-up and were excluded from the study. A total of 74 patients were analyzed. Mean follow-up for patients included in the study was 12.7 months (range, 11 to 14 months). All 16 subjects lost to follow-up did not follow up at 12 months. All of the subjects followed up in the office at 3 months. The average PSEQ score for these subjects at 3 months was 41, indicating good average scores and outcome. Average MHI score at 3 months in this group was 25, with an average improvement of MHI of 76 percent. Two subjects had improvement of less than 50 percent at 3 months. A literature review of publications that used the PSEQ was performed. Pretreatment and posttreatment scores were summarized and compared to migraine surgery subject scores.

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Measurement Tools

The MHI is a commonly used tool to describe severity of migraine pain. It is calculated by multiplying migraine headache frequency (days per month), migraine headache duration (fraction of 24 hours), and migraine headache pain (on a scale of 0 to 10). We defined successful treatment when the MHI improved greater than or equal to 50 percent.

The PSEQ is a 10-item questionnaire that rates how confident subjects are doing things at present, despite pain. The scale ranges from 0 (not confident at all) to 6 (completely confident). A total score is calculated by adding the items. [See Appendix 1, Supplemental Digital Content 1, which shows the Pain Self-Efficacy Questionnaire (PSEQ). Printed with permission from Michael Nicholas (Nicholas MK. The Pain Self-Efficacy Questionnaire: Taking pain into account. Eur J Pain 2007;11:153–163),]

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Data Analysis

Data were analyzed with STATA Version 12.1 (StataCorp, College Station, Texas). For all variables, descriptive statistics were computed. Paired sample t tests were used to compare preoperative and postoperative migraine headache frequency, duration, pain, MHI, and PSEQ score. A value of p < 0.05 was considered significant. Pearson correlation was carried out to determine correlation of PSEQ with postsurgical disability as assessed using the MHI.

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Migraine headache frequency, duration, pain severity, and MHI total score decreased significantly from baseline to 12 months postoperatively (Table 1).

Table 1

Table 1

There was a significant increase in PSEQ scores comparing preoperative and postoperative scores (Table 2). There was no correlation between preoperative pain coping scores (PSEQ) and posttreatment migraine headache severity scores (MHI) (p > 0.05). There was no significant difference in preoperative PSEQ scores between patients who did very well (≥99 percent MHI improvement, n = 13) and those who did very poorly (<5 percent MHI improvement, n = 3) after surgery (p > 0.05). However, there was a significant difference in postoperative PSEQ scores between the two groups (Table 3).

Table 2

Table 2

Table 3

Table 3

In comparison to other pain populations, PSEQ scores in migraine surgery patients were extremely poor before treatment (18.2 ± 11.7) (Table 4).16 , 18 , 29–38 Furthermore, posttreatment improvement of PSEQ score (112 percent at 12 months) in migraine surgery patients was considerably higher when compared to other pain conditions (Fig. 1).

Table 4

Table 4

Fig. 1

Fig. 1

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Commonly, migraine surgery outcomes are evaluated using migraine-specific questionnaires such as MHI, the Migraine Disability Assessment Survey, the Migraine-Specific Quality-of-Life Questionnaire, and the Headache Impact Test. This is the first study to include an instrument widely used in better understood and more common pain patient populations (PSEQ).

Migraine surgery outcomes continue to show promising results when patients are chosen carefully. In this prospective cohort, all outcome measures including migraine headache frequency, duration, pain, MHI total score, and PSEQ improved significantly from baseline (Tables 1 and 2).

The increase in mean PSEQ score after migraine surgery was remarkable, with an improvement of 112 percent after surgery (Table 2 and Fig. 1). This is important, as PSEQ scores describe pain coping during daily activities and therefore extent of disability during everyday life. Rather than evaluating changes in migraine severity, it indicates the functional change that patients experience after migraine surgery. Improved functional outcome is ultimately more important than change in migraine characteristics (i.e., frequency, duration, and pain).

PSEQ scores further put migraine pain in perspective with pain experienced with other pain conditions. Mean preoperative pain coping scores for migraine surgery candidates were 18.2 ± 11.7. This is a lower score than reported for severe chronic pain (average pain ≥7 for >6 months) with neuropathic character (26.4 ± 16.0), carpal tunnel syndrome (45 ± 12), fingertip fractures, amputations and lacerations (median PSEQ score, 54), chronic pain of the upper extremity such as arthritis (44 ± 15), and chronic back pain (36 to 44).16 , 29–37 By this comparison, the magnitude of debility in migraine surgery candidates becomes apparent.

Low PSEQ scores (<30) have been correlated with a high prevalence of long-term disability and depression in non–migraine-related disorders.25 Interestingly, although preoperative PSEQ scores were very low in migraine surgery patients, postoperative results were not worse with lower scores. On the contrary, improvement of PSEQ score after migraine surgery was higher than that seen in other pain conditions. Mean scores after migraine surgery improved by 112 percent. In comparison, chronic back pain patients after conservative therapy experienced an improvement in their score of 19 percent,33 and patients with finger injuries (e.g., amputations, lacerations, proximal interphalangeal joint dislocations) experienced an improvement between 2.6 and 7.4 percent.30 , 38 Partly, very low baseline scores in migraine surgery candidates and higher baseline scores in other pain conditions can explain a higher percentage improvement. However, it seems that migraine surgery patients can recover function and ability to cope with pain very well after surgery, in stark contrast to what has been shown in other pain conditions.

Overall, the PSEQ allows for evaluation of functional impairment in migraine surgery patients. It further significantly improves our understanding of pain in migraine surgery patients by comparison to other pain conditions. Because of these advantages, it should be considered as an outcome measure in migraine surgery patients. Recently, the short-form PSEQ-2 (two questions) was developed and validated, which would make it easy to include this measure in patient evaluation.39–41

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In conclusion, we report continued positive outcomes after migraine surgery. Chronic pain questionnaires such as the PSEQ (or PSEQ-2) add to our understanding of functional outcome after surgery and put pain in migraine surgery patients in perspective with better known pain conditions.

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Supplemental Digital Content

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