Meredith Barad

Interpreting pain improvements after interventions in clinical settings is challenging because placebo effects can influence patient-reported outcomes. In clinical practice, pain intensity reductions of 30% or greater are commonly considered indicative of meaningful analgesic benefit. However, the likelihood of achieving such reductions after placebo interventions is not known. We conducted a comprehensive meta-analysis to quantify pain intensity changes reported after placebo interventions in clinical trials of facial pain (FP). We systematically searched for randomized controlled trials (RCTs) and uncontrolled case series of FP treatments that included placebo or sham arms. The primary outcome was percentage change in pain intensity. The primary analysis focused on RCTs, with pooled effect sizes estimated using random-effects meta-analysis. Data from 115 studies (n = 3,208) were analyzed, including 71 RCTs (n = 2,128) and 44 uncontrolled case series (n = 1,080). Sham interventions yielded an average pain reduction of 29.73% (95% CI 24.09%-35.36%), with a prediction interval (−14.51% to 73.96%) among RCTs. Placebo responses varied by diagnosis ( P < 0.001), with larger effects in temporomandibular disorders and classical trigeminal neuralgia. Cumulative probability analyses showed that ≥50% pain relief occurred in ∼25% of placebo-treated patients, whereas ≥75% improvement was reported in ∼2.5%. In FP, placebo interventions often produce mild to moderate relief but rarely yield dramatic improvements of ≥75%. These results can guide the interpretation of reported pain relief in clinical settings and inform clinical trial design in chronic pain conditions, suggesting that ≥75% pain intensity reductions after analgesic interventions are unlikely to be primarily driven by placebo effects.

Background: Pain medicine fellowship training has evolved significantly since the Accreditation Council for Graduate Medical Education accreditation in 1993. Recent years have seen substantial changes in applicant demographics and match outcomes, particularly a dramatic decline in the number of anesthesiology applicants. Objective: To analyze trends in the Pain Medicine Fellowship Match from 2019 to 2025, examining applicant demographics, match outcomes, and implications for workforce development and training standardization. Methods: Retrospective analysis of National Resident Matching Program and Electronic Residency Application Service data from 2019 to 2025 pain medicine fellowship cycles, including applicant specialty backgrounds, positions offered, fill rates, and program-level outcomes. Results: Total applicants declined from 520 (2019) to 442 (2025), with anesthesiology applicants decreasing by 70%, from 351 to 106, over this period. During that time, physical medicine and rehabilitation applicants increased from 101 in 2019 to 170 in 2025, representing a 68% increase and making it the largest single specialty group in 2025. Emergency medicine applicants increased from 10 to 61 while neurology and psychiatry applicants remained stable. From 2024 to 2025, total positions stabilized (389 to 390) with a trend toward improvement in the fill rate (82.3% to 85.4%). The applicant pool shifted from anesthesiology-dominant to multidisciplinary, with significant regional disparities in program fill rates. Conclusions: The pain medicine fellowship match reflects a fundamental transformation in specialty composition, driven by anesthesiology workforce dynamics and reimbursement concerns. This evolution presents both challenges in training standardization and opportunities for enhanced multidisciplinary care. Strategic interventions, including early specialty exposure, enhanced mentorship, and curriculum adaptation, are essential to sustain workforce capacity and address access disparities.

Objective: Chronic migraine (CM) is a condition marked by highly frequent, intense, and disabling headaches. However, less commonly examined symptoms, such as persistent fatigue, widespread non-cephalic pain, and post-traumatic stress disorder, may also play a key role in migraine-relevant clinical outcomes. Methods: The current study utilized retrospective clinical registry data from 704 treatment-seeking patients with CM to examine longitudinal trajectories of pain intensity and pain-related life interference using linear growth modeling. Results: High levels of co-occurring non-cephalic pain (71.9% of patients) were noted in this sample. Patients endorsing more widespread pain reported higher average levels of pain intensity over time (β = 0.189 [0.103-0.275], P < .001) and less improvement in pain interference over time (β = 0.328 [0.131-0.525], P = .001). Additional findings included greater reductions in pain interference among patients with higher baseline levels of pain intensity (β = −0.185 [−0.351 to −0.020], P = .028) and fatigue (β = −0.280 [−0.493 to −0.067], P = .010) and non-significant associations between post-traumatic stress symptoms and pain intensity and pain interference in all models. Conclusions: The current findings suggest that clinical factors sometimes overlooked in headache research, such as co-occurring non-cephalic pain and fatigue, may contribute to trajectories of treatment response and psychosocial function in CM. Future research may benefit from examining these factors in headache-specific treatment settings and in the context of examining the effects of multidisciplinary care on patients with complex symptom presentations.

Mentorship plays a vital role in pain medicine, guiding professionals from medical training through independent practice. This article explores how mentorship fosters research, enhances clinical competence, and promotes multidisciplinary collaboration. Drawing on insights from leading institutions, we propose a structured mentorship framework tailored to different career stages. Effective mentorship cultivates research skills, expands academic networks, and provides early exposure to the field, shaping long-term career trajectories. It also strengthens clinical expertise, encourages cross-disciplinary collaboration, and advances diversity, equity, and inclusion in medicine. Structured academic mentorship models offer longitudinal guidance for sustained professional development. By aligning mentor-mentee goals and ensuring consistent support, mentorship programs maximize professional growth and ultimately improve patient outcomes. This article outlines key strategies and tools for building effective mentorship programs, emphasizing their transformative impact on the field of pain medicine.

In. New discoveries in temporomandibular disorders have demonstrated that they are far more complex than the traditional dental mechanistic point of view. A 2020 consensus report released by the National Academies of Sciences, Engineering, and Medicine entitled “Temporomandibular Disorders: Priorities for Research and Care” highlighted this paradigm shift and its importance for patient care, education, and research. ESSENTIAL POINTS Orofacial pain comprises many disorders with different etiologies and pathophysiologies. The subjectivity of the pain experience and the interrelated anatomy and physiology of the craniofacial area add to the complexity of diagnosis when the source and etiology of pain are not clear. As orofacial pain straddles the expertise of multiple disciplines, a multidisciplinary approach combining medication, physical therapy, and procedural and psychological strategies is essential in treating patients with orofacial pain....

Spinal CSF leaks lead to spontaneous intracranial hypotension (SIH). While International Classification of Headache Disorders, Third Edition (ICHD-3) criteria necessitate imaging confirmation or low opening pressure (OP) for SIH diagnosis, their sensitivity may be limited. We offered epidural blood patches (EBPs) to patients with symptoms suggestive of SIH, with and without a documented low OP or confirmed leak on imaging. This study evaluates the efficacy of this strategy. We conducted a prospective cohort study with a nested case-control design including all patients who presented to a tertiary headache clinic with clinical symptoms of SIH who completed study measures both before and after receiving an EBP between August 2016 and November 2018. The mean duration of symptoms was 8.7 ± 8.1 years. Of 85 patients assessed, 69 did not meet ICHD-3 criteria for SIH. At an average of 521 days after the initial EBP, this ICHD-3-negative subgroup experienced significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical Health score of +3.3 (95% CI 1.5-5.1), PROMIS Global Mental Health score of +1.8 (95% CI 0.0-3.5), Headache Impact Test (HIT)-6 head pain score of -3.8 (95% CI -5.7 to -1.8), Neck Disability Index of -4.8 (95% CI -9.0 to -0.6) and PROMIS Fatigue of -2.3 (95% CI -4.1 to -0.6). Fifty-four percent of ICHD-3-negative patients achieved clinically meaningful improvements in PROMIS Global Physical Health and 45% in HIT-6 scores. Pain relief following lying flat prior to treatment was strongly associated with sustained clinically meaningful improvement in global physical health at an average of 521 days (odds ratio 1.39, 95% CI 1.1-1.79; p < 0.003). ICHD-3-positive patients showed high rates of response and previously unreported, treatable levels of fatigue and cognitive deficits. Patients who did not conform to the ICHD-3 criteria for SIH showed moderate rates of sustained, clinically meaningful improvements in global physical health, global mental health, neck pain, fatigue, and head pain after EBP therapy. Pre-treatment improvement in head pain when flat was associated with later, sustained improvement after EBP therapy among patients who did not meet the ICHD-3 criteria. This study provides Class IV evidence that epidural blood patch is an effective treatment of suspected CSF leak not conforming to ICHD-3 criteria for SIH.

This review focuses on the challenges of diagnosing and treating spontaneous intracranial hypotension (SIH), a condition caused by spinal CSF leakage. It emphasizes the need for increased awareness and advocates for early and thoughtful use of empirical epidural blood patches (EBPs) in suspected cases. SIH diagnosis is hindered by variable symptoms and inconsistent imaging results, including normal brain MRI and unreliable spinal opening pressures. It is crucial to consider SIH in differential diagnoses, especially in patients with connective tissue disorders. Early EBP intervention is shown to improve outcomes. SIH remains underdiagnosed and undertreated, requiring heightened awareness and understanding. This review promotes proactive EBP use in managing suspected SIH and calls for continued research to advance diagnostic and treatment methods, emphasizing the need for innovative imaging techniques for accurate diagnosis and timely intervention.