Daniel G. Rogers

Objective: To examine differences in interictal avoidance of light and sound stimuli and to explore the moderating effect of psychological variables on behavioral avoidance. Background: The behavioral effects of migraine between attacks have become of recent interest, and a growing body of literature attests to the role of psychological factors such as fear of pain in influencing interictal behavior. Though light and sound sensitivity are common features of migraine attacks, it is unknown whether avoidance of these stimuli manifests outside of acute attacks. Such findings would inform our understanding of interictal disability and the potential role of psychological factors in migraine‐related avoidance. Methods: This was a within–between subjects, comparative cross‐sectional study among 32 participants with migraine (28 photophobia and phonophobia, three photophobia only, one phonophobia only), each with photophobia and/or phonophobia, and 23 controls denying headache. While headache‐free, participants were administered a series of self‐report measures and completed behavioral avoidance tasks (BATs) quantifying approach and tolerance of three light stimuli and three sound stimuli representing increasing stimulus intensities. Data were collected from a Southern US university from November 2019 to December 2022. Analyses focused on differences between and within groups across the BATs and whether psychological variables moderated observed effects for those with migraine. Results: Individuals with migraine engaged in greater avoidance of the highest intensity light stimuli on both the approach task ( mean = 101.5 in. vs. 117.8, p = 0.003, 95% confidence interval [CI] of difference: 5.8 to 26.8) and tolerance task ( mean = 59.4 s vs. 92.5, p = 0.006, 95% CI of difference: 9.8 to 56.3). Task‐by‐group interactions were observed such that those with migraine engaged in greater behavioral avoidance than controls moving from low to high intensity on approach tasks ( estimate = −16.9 in., p = 0.012, 95% CI: −30.0 to −3.7) and tolerance tasks ( estimate = −31.0 s, p = 0.004, 95% CI: −51.9 to −10.0). No between‐group differences or interactions were observed for the sound BATs. Among psychological variables, fear of pain and headache acceptance showed some associations with behavioral avoidance across various conditions and task intensities. Conclusion: This study provides empirical evidence of interictal avoidance of light stimuli among those with migraine and suggests psychological variables play a role in avoidance that manifests outside of migraine attacks. These findings among young, non‐treatment–seeking adults primarily with episodic migraine suggest that interictal behavioral avoidance manifests early in migraine progression. Further research exploring mechanisms and predictors of interictal avoidance, potential intervention targets, and manifestations in older adults and clinical samples is warranted.

Military sexual trauma (MST) is increasingly recognized in US veterans. MST is associated with psychiatric disease, substance abuse, and pain conditions, including headache. Little is known about the relationship between MST and specific headache disorders. This retrospective cross-sectional study analyzed administrative data from the Women Veterans Cohort Study, a sample of post-9/11 US veterans enrolled for Veterans Health Administration care. A positive MST screen in the electronic medical record defined exposure. We extracted demographic and clinical data from administrative coding for migraine and relevant confounders, comparing between subgroups with χ² tests. Health care utilization variables included designated sites of care and prescribed acute and preventive treatments and were evaluated with multivariable logit, negative binomial (nb), and zero-inflated nb models. Of 846,435 veterans screened for MST, 4.4% of veterans had a positive screen, whereas 9.5% had migraines. Veterans with migraine and a positive MST screen (21.7%) were more often non-White (45.3% vs 38.6%, p < 0.001), and 33 or less years old (55% vs 53%, p < 0.001) than veterans with migraine and a negative MST screen (9.0%). Adjusting for sex, the odds of migraine were greater for veterans with a positive MST screen (OR 1.62, 95% CI 1.57-1.67). Veterans with migraine and a positive MST screen were no more likely to receive triptan medications than veterans with migraine (46.2% vs 45.7%, p = 0.47) although were more likely to be prescribed opioids (36.1% vs 33.4%, p ≤ 0.001), compared with those with migraine and a negative MST screen. After controlling for sex, comorbidities (including chronic pain conditions), treatments, and other health care use, health care utilization was increased among migraine veterans with a positive MST screen, compared with migraine veterans without a positive MST screen for primary care (IRR 1.06, 95% CI 1.04-1.08, p < 0.001) and emergency department care (IRR 1.14, (95% CI 1.07-1.22), whereas neurology visits were not increased (IRR 0.97, 95% CI 0.92-1.02). Veterans with a positive MST screen constitute a vulnerable population more likely to have migraine, take opioid medications, and use emergency departments for migraine care.

Background: Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. Methods: The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. Results: Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (Δ_MEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. Conclusion: Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.

Purpose of Review The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments. Recent Findings Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Summary Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.