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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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Supplemental Digital Content is available in the text.

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 (www.PRSJournal.com).

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

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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PATIENTS AND METHODS

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), http://links.lww.com/PRS/C518.]

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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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RESULTS

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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DISCUSSION

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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CONCLUSIONS

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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REFERENCES

1. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1–226.
2. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg. 2005;115:1–9.
3. Guyuron B, Kriegler JS, Davis J, Amini SB. Five-year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg. 2011;127:603–608.
4. Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009;124:461–468.
5. Janis JE, Barker JC, Javadi C, Ducic I, Hagan R, Guyuron B. A review of current evidence in the surgical treatment of migraine headaches. Plast Reconstr Surg. 2014;134(Suppl 2):131S–141S.
6. Jhingran P, Davis SM, LaVange LM, Miller DW, Helms RW. MSQ: Migraine-Specific Quality-of-Life Questionnaire: Further investigation of the factor structure. Pharmacoeconomics 1998;13:707–717.
7. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology 2001;56(Suppl 1):S20–S28.
8. Yang M, Rendas-Baum R, Varon SF, Kosinski M. Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine. Cephalalgia 2011;31:357–367.
9. Nicholas MK. The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain 2007;11:153–163.
10. Di Pietro F, Catley MJ, McAuley JH, et al. Rasch analysis supports the use of the Pain Self-Efficacy Questionnaire. Phys Ther. 2014;94:91–100.
11. Adachi T, Nakae A, Maruo T, et al. Validation of the Japanese version of the pain self-efficacy questionnaire in Japanese patients with chronic pain. Pain Med. 2014;15:1405–1417.
12. Asghari A, Nicholas MK. An investigation of pain self-efficacy beliefs in Iranian chronic pain patients: A preliminary validation of a translated English-language scale. Pain Med. 2009;10:619–632.
13. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Psychometric properties of the Portuguese version of the Pain Self-Efficacy Questionnaire. Acta Reumatol Port. 2011;36:260–267.
14. Rasmussen MU, Rydahl-Hansen S, Amris K, Samsøe BD, Mortensen EL. The adaptation of a Danish version of the Pain Self-Efficacy Questionnaire: Reliability and construct validity in a population of patients with fibromyalgia in Denmark. Scand J Caring Sci. 2016;30:202–210.
15. Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour: A prospective study. Pain 2001;94:85–100.
16. Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J. 2010;19:1484–1494.
17. Lincoln N, Moreton B, Turner K, Walsh D. The measurement of psychological constructs in people with osteoarthritis of the knee: A psychometric evaluation. Disabil Rehabil. 2017;39:372–384.
18. Menendez ME, Baker DK, Oladeji LO, Fryberger CT, McGwin G, Ponce BA. Psychological distress is associated with greater perceived disability and pain in patients presenting to a shoulder clinic. J Bone Joint Surg Am. 2015;97:1999–2003.
19. Kortlever JT, Janssen SJ, van Berckel MM, Ring D, Vranceanu AM. What is the most useful questionnaire for measurement of coping strategies in response to nociception? Clin Orthop Relat Res. 2015;473:3511–3518.
20. Bendinger T, Plunkett N, Poole D, Turnbull D. Psychological factors as outcome predictors for spinal cord stimulation. Neuromodulation 2015;18:465–471; discussion 471.
21. Hageman MG, Briet JP, Oosterhoff TC, Bot AG, Ring D, Vranceanu AM. The correlation of cognitive flexibility with pain intensity and magnitude of disability in upper extremity illness. J Hand Microsurg. 2014;6:59–64.
22. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014;472:2542–2549.
23. Kennedy SA, Vranceanu AM, Nunez F, Ring D. Association between psychosocial factors and pain in patients with trigger finger. J Hand Microsurg. 2010;2:18–23.
24. Andrew Walsh D, Jane Kelly S, Sebastian Johnson P, Rajkumar S, Bennetts K. Performance problems of patients with chronic low-back pain and the measurement of patient-centered outcome. Spine (Phila, Pa 1976) 2004;29:87–93.
25. Arnstein P, Caudill M, Mandle CL, Norris A, Beasley R. Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain 1999;80:483–491.
26. Guyuron B, Nahabet E, Khansa I, Reed D, Janis JE. The current means for detection of migraine headache trigger sites. Plast Reconstr Surg. 2015;136:860–867.
27. Gfrerer L, Maman DY, Tessler O, Austen WG Jr. Nonendoscopic deactivation of nerve triggers in migraine headache patients: Surgical technique and outcomes. Plast Reconstr Surg. 2014;134:771–778.
28. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
29. Torrance N, Ferguson JA, Afolabi E, et al. Neuropathic pain in the community: More under-treated than refractory? Pain 2013;154:690–699.
30. Bot AG, Bossen JK, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after fingertip injuries. Psychosomatics 2014;55:372–380.
31. Hageman MG, Bossen JK, Neuhaus V, Mudgal CS, Ring D; Science of Variation Group. Assessment of decisional conflict about the treatment of carpal tunnel syndrome, comparing patients and physicians. Arch Bone Jt Surg. 2016;4:150–155.
32. Hageman MG, Bossen JK, King JD, Ring D. Surgeon confidence in an outpatient setting. Hand (N Y) 2013;8:430–433.
33. Chiarotto A, Vanti C, Cedraschi C, et al. Responsiveness and minimal important change of the Pain Self-Efficacy Questionnaire and short forms in patients with chronic low back pain. J Pain 2016;17:707–718.
34. Chiarotto A, Vanti C, Ostelo RW, et al. The Pain Self-Efficacy Questionnaire: Cross-cultural adaptation into Italian and assessment of its measurement properties. Pain Pract. 2015;15:738–747.
35. Costa Lda C, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: Inception cohort study. BMJ 2009;339:b3829.
36. Macedo LG, Latimer J, Maher CG, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: A randomized controlled trial. Phys Ther. 2012;92:363–377.
37. Pengel LH, Refshauge KM, Maher CG, Nicholas MK, Herbert RD, McNair P. Physiotherapist-directed exercise, advice, or both for subacute low back pain: A randomized trial. Ann Intern Med. 2007;146:787–796.
38. Bot AG, Bekkers S, Herndon JH, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics 2014;55:595–601.
39. McWilliams LA, Kowal J, Wilson KG. Development and evaluation of short forms of the Pain Catastrophizing Scale and the Pain Self-efficacy Questionnaire. Eur J Pain 2015;19:1342–1349.
40. Nicholas MK, McGuire BE, Asghari A. A 2-item short form of the Pain Self-Efficacy Questionnaire: Development and psychometric evaluation of PSEQ-2. J Pain 2015;16:153–163.
41. Briet JP, Bot AG, Hageman MG, Menendez ME, Mudgal CS, Ring DC. The pain self-efficacy questionnaire: Validation of an abbreviated two-item questionnaire. Psychosomatics 2014;55:578–585.

Supplemental Digital Content

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