Predicting disability and quality of life in a community-based sample of women with migraine headache

Predicting Disability and Quality of Life in a Community-Based Sample of Women With Migraine Headache yyy Camille J. Kolotylo, RN, PhD, and Marion E. Broome, RN, PhD, FAAN

y

From Gurnee, IL, and the Department of Research, University of Alabama at Birmingham, Birmingham, AL. Supported in part by NRSA No. NR07252-01, which was awarded to the first author. Address correspondence and reprint requests to Camille J. Kolotylo, RN, PhD, 2248 Bellview Court, Gurnee, IL 60031-1089. E-mail: [email protected]. © 2000 by the American Society of Pain Management Nurses 1524-9042/00/0104-0002$3.00/0 doi: 10.1053/jpmn.2000.19344

ABSTRACT:

Migraine is a significant pain problem for almost one third of women in the United States. Little previous research has been conducted regarding the effects of migraine headache on the lives of women migraineurs. The purpose of this report is to determine the contribution of coping, depressive symptomatology, and the chronic pain experience on disability and quality of life in women with migraine. Two hundred and forty-seven women responded to a mailed survey about migraine headache, the chronic pain experience, coping, depressive symptomatology, and quality of life. Data were collected with the following: the Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias, and Facial Pain; the McGill Pain Questionnaire; the Chronic Pain Experience Instrument-Headache; the Coping Strategies Questionnaire; the Center for Epidemiologic Studies-Depression Scale; the Henry Ford Hospital Disability Inventory; and the Migraine-Related Quality of Life Questionnaire. Multiple regression analyses were conducted to determine the amount of variance that could be explained by selected predictor variables. Women ranged in age from 18 to 66 years and migraineurs reported suffering from migraine from 1 to 54 years. Nearly half of the migraineurs (41.5%) reported migraine headaches occurring monthly, and almost a quarter of the sample reported weekly migraines. Migraines were reported to last for several hours (53.4%). Results indicate that migraine headache pain was typically severe and throbbing, lasting for hours to days. The coping, depressive symptomatology, disability, and quality-of-life variables were all significantly correlated. Two separate regression analyses that examined predictor variables and the criterion variables, disability and quality of life, showed that a significant amount of both constructs could be explained by the predictor variables in the model tested. In the first regression analysis, depressive symptomatology, the chronic pain experience, and migraine headache pain accounted for 62.9% of the variance in disability. In the second Pain Management Nursing, Vol 1, No 4 (December), 2000: pp 139-151

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regression analysis, 64.8% of the variance in quality of life was accounted for by depressive symptomatology, migraine headache pain, and the chronic pain experience. The variance in both outcome variables, disability and quality of life, was accounted for by similar predictor variables: depressive symptomatology, the chronic pain experience, and migraine headache pain. Further study is needed to determine specific personal and illness-related factors, pain characteristics, and coping strategies used that may predict outcomes of migraine headache such as disability, quality of life, helplessness, and other as yet unidentified effects of migraine headache. © 2000 by the American Society of Pain Management Nurses

Migraine headache is a major health problem that affects between 6% to 19% of men and 15% to 29% of women in the United States (Lipton & Stewart, 1993; Lipton, Stewart, & Von Korff, 1997). Migraine has been described as a “public health problem of enormous scope that has impact on both the individual and society” (Lipton, Silberstein, & Stewart, 1994, p. 326). It is a major social and economic burden (Linet & Stewart, 1984; Stang & Osterhaus, 1993) that results in substantial human costs (Faucett & Levine, 1991), including individual suffering and lost workdays (Benassi et al., 1986; de Lissovoy & Lazarus, 1994; Merikangas, Angst, & Isler, 1990), loss of productivity (Merikangas, Merikangas, & Angst, 1993), decreased overall wellbeing (Stewart, Shechter, & Lipton, 1994), and high health care costs. Migraine headache has been consistently described as a disabling condition (Stewart & Lipton, 1994), precipitating high levels of headache-related disability in sufferers with severe migraine (Stewart, Lipton, Celentano, & Reed, 1992). In the United States, 18 million women and 5.6 million men report disability secondary to migraine (Lipton & Stewart, 1993) that affects their employment (Linet, Stewart, Celentano, Zeigler, & Sprecher, 1989; Lipton, 1995b), normal daily activities (Celentano, Linet, & Stewart, 1990; Lipton, 1995b), and social activities (Kryst & Scherl, 1994). In addition, migraineurs often live in fear with the knowledge that a migraine headache could occur at any time and disrupt their lives (Lipton et al., 1994). Even between migraine headaches, migraineurs report migraine symptoms, emotional distress, and impaired general well-being (Dalho ¨ f & Dimena¨s, 1995).

Migraine results in the frequent use of health care providers, emergency rooms, and urgent care centers, as well as the use of large amounts of nonprescription and prescription medications (Celentano, Stewart, Lipton, & Reed, 1992). Both health care costs and indirect costs (i.e., absenteeism, reduced productivity, and lost workdays) add to the tremendous economic burden of migraine (Lipton, et al., 1997). Yet, little is known about the personal factors that influence the pain experience of migraineurs. The pervasiveness of migraine, the expense to the health care system, and the tremendous personal cost to migraineurs indicates the need for continued research that examines factors associated with both disability and quality of life experienced by migraineurs. In this report, variables that contribute to disability and quality of life in migraineurs are explored. The purpose of this study was to determine personal factors, illness-related factors, pain characteristics, the chronic pain experience, coping, and depressive symptomatology associated with the outcomes of disability and migraine-related quality of life in women with migraine headache.

THEORETICAL PERSPECTIVE FOR THE STUDY The conceptual framework of Moos and Schaefer (1984) was adapted by the first author to explain the hypothesized relationships among the variables included in the study: personal factors, illness-related factors, migraine headache pain, the chronic pain experience, coping, depressive symptomatology, disability, and migraine-related quality of life (Figure 1). The basis of this conceptual model is the crisis of chronic illness, in migraineurs, the uncertainty and unpredictability of migraine attacks that cause disequilibrium at various and unpredictable times. When an event upsets the normal patterns of behavior and lifestyle, habitual problem-solving mechanisms are used until balance is restored (Moos & Schaefer, 1984). When situations are so major that habitual problem-solving responses are inadequate, a crisis ensues and causes a state of turbulence, or disequilibrium (Moos & Schaefer, 1984). Even though migraine headaches have an intermittent and unpredictable nature, they produce debilitating moderate to severe pain episodes and accompanying symptoms. Effects of migraine headache have been reported by migraineurs between migraine episodes that result in continued disequilibrium, both during and between migraines. The long history of migraine in individuals can be viewed as consisting of recurrent crises, a series of crises, or as ongoing crises. The unpredictability of the occurrence of migraine headaches and of the effectiveness of treat-

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TABLE 1. Summary of the Study Instruments Scale MPQ-SF CPEI-H CSQ CES-D HDI MRQOL

No. of Items

Potential Range

Actual Range

Mean

15 10 48 20 25 47

0-45 0-100 0-288 0-60 0-100 0-188

0-42 3-100 12-217 0-60 0-100 20-188

17.15 48.65 106.25 14.91 46.22 90.19

SD 9.10 22.25 36.53 11.33 20.58 38.65

Cronbach’s ␣ 0.8165 0.8886 0.9071 0.9178 0.9110 0.9626

Abbreviation: SD, standard deviation.

ment and the disruption of migraineurs’ lives produces an ongoing uncertainty and disequilibrium. This framework includes factors, such as personal factors and illness-related factors, that may influence the person’s cognitive appraisal and selection of coping strategies (Moos & Schaefer, 1984). Living with chronic migraine headache pain is identified as the stimulus in this framework, whereas personal factors

and illness-related factors are hypothesized to affect the incidence, severity, and duration of migraine, the chronic pain experience, and the coping strategies used. Depressive symptomatology is depicted as affecting the following 3 variables: migraine headache, the chronic pain experience, and coping. In this adapted model, the outcomes are disability and migraine-related quality of life.

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FIGURE 1. y Theoretical framework: Influence of personal, illness-related factors, migraine pain, the chronic pain experience, coping, and depressive symptomatology on disability, and quality of life in women experiencing migraine pain. (Adapted and reprinted with permission from Moos and Schaefer, 1984 The crisis of physical illness: An overview and conceptual approach. In Moos and Schaefer [Eds.], Coping with physical illness: New perspectives, Plenum Medical Book Company).

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In this study, the following hypotheses were tested: personal and illness-related factors, pain characteristics, the chronic pain experience, coping strategies, and depressive symptomatology that will explain the majority of variance in migraine-related disability; and personal and illness-related factors, pain characteristics, the chronic pain experience, coping strategies, and depressive symptomatology that will explain the majority of variance in quality of life in migraineurs.

REVIEW OF THE LITERATURE Migraine headache is defined as recurring headache, with or without aura, that lasts for 1 to 3 days, is often accompanied by other symptoms, such as photophobia, phonophobia, nausea, and vomiting, and interrupts or prohibits the daily activities of an individual to a significant extent (Headache Classification Committee of the International Headache Society [IHS], 1988). Migraine is an unpredictable, chronic condition, with no known cure or completely effective treatment, that affects every aspect of the migraineur’s life, including psychological and social functioning, employment, and enjoyment of life events (Stang & Osterhaus, 1993). Migraineurs develop a variety of responses to migraine and coping strategies to try to manage this condition. Coping has been defined as the use of purposeful efforts and behavioral and cognitive techniques to manage the negative impact of stressful life events (Holmes & Stevenson, 1990; Lazarus & Folkman, 1984). Coping is a person’s constantly changing cognitive and behavioral efforts to attempt to manage specific external and/or internal demands that are appraised as taxing or exceeding the person’s resources (Lazarus & Folkman, 1984). In this study, pain is conceptualized as the source of stress (ter Kuile, Spinhoven, Linssen, & van Houwelingen, 1995). Coping is conceptualized as purposeful efforts to manage the impact of pain (ter Kuile et al., 1995) and any effort that a person makes to reduce, tolerate, or minimize pain (Weir, Browne, Roberts, Tunks, & Gafni, 1994). This includes both cognitive and behavioral approaches. Some coping strategies used by migraineurs reported in previous studies include the use of negative coping strategies (Martin & Theunissen, 1993) and avoidance behaviors (Scharff, Turk, & Marcus, 1995), coping self-statements, and the reinterpretation of pain sensations (Haythornthwaite, Menefee, Heinberg, & Clark, 1998). Depression can refer to an affect, a symptom, or a syndrome (Dworkin & Giltin, 1991; Gupta, 1986). Depression as a symptom is a feeling state of sadness or unhappiness, and depression as a syndrome is charac-

terized by an abnormal mood and encompasses others signs and symptoms (Dworkin & Giltin, 1991). In previous studies of chronic pain patients, those whose scores classified them as depressed were those patients who reported using passive coping strategies, such as catastrophizing, and had an external locus of control (Jensen, Turner, Romano, & Karoly, 1991). Depression was found to be more tied to the ability to function than the experience of pain (Ho, Ong, & Lee, 1997). Perceived control over pain and perceived interference in functioning were found to mediate the relationship between pain severity and depression (Jensen et al., 1991). Depression may compound physical disability and threaten emotional well-being (Faucett, 1994). Confusion about whether depression is a precursor to or result of chronic pain and the nonexistent, inconsistent, or imprecise definitions of depression in the migraine literature have led to difficulty in comparing studies and difficulty coming to conclusions regarding the results of the studies. The literature regarding migraine pain and depression is contradictory and controversial. Several hypotheses linking depression and migraine headache in the literature suggest either a bidirectional relationship between the 2 constructs, dissimilar causes, or common causes of their co-occurrence. However, the majority of chronic pain patients are not clinically depressed (Jensen et al., 1991) and have generally normal psychological adjustment (Rains, 1999-2000). Disability has been broadly defined by the World Health Organization (1980) as any restriction of or lack of ability to perform an activity in the manner or within the range considered normal, including restrictions in performing conventional activities such as self-care, social relations, and work. Assessment of disability should provide an estimate of the impact a particular condition or symptom has on the patient’s perception of his or her ability to function normally in daily life (Jacobson, Ramadan, Norris, & Newman, 1995). On average, migraine headaches are more disabling, more painful, and of longer duration than other types of headaches (Edmeads, 1993; Stewart et al., 1994). Migraine was found to interfere even more with recreational and social activities than work-related activities (Pryse-Phillips et al., 1992; Stewart et al., 1994). Although pain may be the most important aspect of migraine for the individual sufferer, headache-related disability is the most important determinant of migraine’s societal impact measured in economic terms (Lipton et al., 1995). Most previous studies have used lost workdays as the sole measure of migraine-related disability (Lipton et al., 1995; Stewart et al., 1994), which does not present a full picture of disability in

Migraine Headache

migraineurs. Also, previous researchers typically focused on the consequences of a single migraine headache rather than the overall impact of the illness (Stewart et al., 1994). Headache during work has been reported as completely disabling for 17% to 70% of migraine sufferers (Lipton, 1995a; Micieli et al., 1995; Pryse-Phillips et al., 1992). Disability in migraineurs greatly affects social and family activities (Lipton, 1995a; Micieli et al., 1995; Pryse-Phillips et al., 1992), with 60% of migraineurs stating that migraine had a significant impact on their families (Smith, 1997). Even those participants with migraine with moderate as opposed to severe pain reported substantially diminished functioning and well-being as compared with the general population (Osterhaus, Townsend, Gandek, & Ware, 1994). Disability is particularly important to measure because it is a direct measure of life impact and a direct consequence of other headache features including pain intensity, attack duration, and number of migrainous symptoms (Stewart et al., 1994). All of the aforementioned variables can dramatically influence the quality of life of a migraineur. Quality of life refers to individual’s appraisals of and satisfaction with current functioning versus what the person believes to be ideal or achievable (Taylor, Jones, & Burns, 1998). A long pain history and ineffective treatment of pain, such as with migraine headaches, is associated with poor quality of life (Skevington, 1998). The acute morbidity associated with migraine often has devastating effects on quality of life and role expectations (Osterhaus et al., 1994). Migraine’s unpredictability and uncontrollability, and the inability to anticipate or prevent attacks, causes interruptions in normal daily activities and impairs quality of life (Jhingran et al., 1996). Migraineurs were found to be significantly more functionally impaired than patients with diabetes, hypertension, osteoarthritis, and back pain (Solomon, 1997). Generally, quality of life is found to be poorer in migraineurs than in control groups (Dalho ¨ f & Dimena¨s, 1995; Durham et al., 1998; Michel, Dartigues, Lindoulsi, & Henry, 1997). Although headache is among the most common pain complaint seen by physicians, the measurement of health-related quality of life in headache patients has only recently been attempted (Solomon, 1997). Although there have been many journal articles about migraine and quality of life in the last 10 years, they have mainly focused on the effect of various new medications on migraine headaches. The literature suggests a much greater effect on migraineurs’ quality of life than previously thought, both during and between migraine headaches.

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METHODS Design and Sample An exploratory, correlational design was used in this study. The final sample size consisted of 247 women who met the IHS (Headache Classification Committee of the IHS, 1988) criteria for migraine headache and agreed to participate in the study by returning their completed questionnaires. Questionnaires were sent to 509 eligible individuals. Out of 260 completed and returned questionnaires, 247 (56% response rate) were useable. Thirteen participants were excluded, 4 for their pregnancy status and 9 for returning questionnaires with insufficient data to determine their migraine headache status with the IHS criteria (1988). Inclusion criteria that guided the selection of participants for the final sample were women who: (1) self-reported migraine headaches; (2) met the IHS (1988) criteria for the classification of migraine headache; (3) reported having headaches for longer than the previous 3 months (indicating chronic pain; Merskey & Bogduk, 1994); (4) were 18 to 66 years of age; (5) were able to speak, read, and understand English; (6) were not pregnant; and (7) were willing to participate in the study, as shown by the return of their completed questionnaires. Procedure The university Institutional Review Board committee approved the procedures used in this study. The sample was obtained through a survey sampling company, which compiled lists of potential participants through mail and telephone surveys of individuals who identified themselves as migraine sufferers. The study sample was selected from a total of 2,308 potential participants by using stratified, random sampling and by recruiting with mailed survey techniques (Dillman, 1978). The first author sent an initial introductory letter explaining the study to 509 potential participants. Educational material about migraine was included with this letter as an incentive to participate in the study. The first copy of the booklet of questionnaires and an explanatory letter were sent 1 week later. The explanatory letter provided more complete information about the study, its purpose, the risks and benefits of participation in the study, how the data were to be used, and the process of informed consent. Another educational pamphlet was included with these materials, again as an incentive. The first reminder was a brief postcard indicating that the questionnaires had not been returned and how important it was to do so. The second copy of the booklet of questionnaires, with a follow-up letter, was

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then sent to the participants. Several weeks after this, the second and final reminder to return the questionnaires was sent to the participants. Thank-you notes and a final educational pamphlet were then sent to the participants. The final results of the study were sent to each participant after the study was completed. The approximate total time required by the participants to complete the booklet of questionnaires was between 1 and 1.5 hours. Instruments The participants completed a total of 6 instruments that measured the study variables, as well as a demographic questionnaire (Table 1). This demographic data collection sheet was used in a previous study by the authors (Kolotylo & Broome, 2000). The Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias, and Facial Pain, formulated by the Headache Classification Committee of the IHS (1988), was used to determine the existence of migraine headache in the participants who returned the questionnaires. The McGill Pain Questionnaire-Short Form (MPQSF; Melzack, 1987) was used to specify the subjective pain experience, and it consists of 3 components. The participants rated their pain with 15 descriptors, 11 sensory and 4 affective, which were rated on a descriptive-scaled response format (yes, no, mild, moderate, and severe). Higher scores indicated greater reported subjective pain. Also, typical and usual migraine pain were measured with 2 numeric-scaled format items. The internal consistency was 0.81 for the total scale in this study. The Chronic Pain Experience Instrument-Headache (CPEI-H; G. C. Davis, unpublished manuscript, 1995) is a 10-item, self-report instrument that was used to determine how a person responded to living with the chronic pain experience and how the participants responded generally to their headache pain. The response format was a 0 (strongly agree) to 10 (strongly disagree) numeric scale. The total score on the CPEI-H ranged from 0 to 100, with higher scores indicating a more negative response to living with chronic pain. For the purpose of clarity, the responses were altered so that a negative correlation indicates a more negative chronic pain experience. The internal consistency of the total instrument was 0.88 in this study. Coping strategies were measured with the Coping Strategies Questionnaire (CSQ; Rosenstiel & Keefe, 1983). This instrument is a 50-item, self-report measure used to determine the extent to which chronic pain patients use cognitive and behavioral coping strategies. In this study, the CSQ was used to determine how often the participants used a coping strat-

egy when they experienced migraine headache pain. The CSQ has 48 items that measure how often coping strategies were used (0 ⫽ never, 3 ⫽ sometimes, 6 ⫽ always) and 2 pain control effectiveness ratings to measure the participants’ perceived control over pain (0 ⫽ no control, 3 ⫽ some control, 6 ⫽ complete control) and perceived ability to decrease pain (0 ⫽ cannot decrease pain at all, 3 ⫽ can decrease pain somewhat, 6 ⫽ can decrease pain completely). The total score ranged from 0 to 288, with higher scores indicating more frequent use of coping strategies. Higher scores on the items measuring coping effectiveness indicated more perceived control over pain and a greater perceived ability to decrease pain. Cronbach’s ␣ for the total instrument was 0.90 in this study. Depressive symptomatology was measured with the Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977). This 20-item, self-report measure of depressive symptoms has a 4-point alternate choice response format. Total scores on the CES-D range from 0 to 60, with a score of 16 or greater indicating the presence and persistence of depressive symptoms. Internal consistency for this instrument in this study was 0.91 The Henry Ford Hospital Disability Inventory (HDI; Jacobson, Ramadan, Aggarwal, & Newman, 1994) is a 25-item measure of self-perceived headache disability used to quantify the impact of headache on daily living. The HDI has a 3-point alternate choice response format (4 ⫽ yes, 2 ⫽ sometimes, 0 ⫽ no). Total instrument scores were used and ranged from 0 to 100. Higher scores indicated higher levels of selfperceived disability. Cronbach’s ␣ for the total instrument in this study was 0.91. The Migraine-Related Quality of Life Questionnaire (MRQOL; Cavallini, Micieli, Bussone, Rossi, & Nappi, 1995) was used in this study to evaluate general health and the person’s ability to actively function in society. In this study, the participants were asked to complete the questionnaire with reference to a typical migraine headache. The MRQOL measured quality of life, both during and between migraine headaches, with responses from 0 (no) to 4 (yes, and it bothered me a great deal). Higher scores on this instrument indicated a greater effect on, or decreased, quality of life. For the purpose of clarity, responses were altered so that negative signs indicated a decreased quality of life. The internal consistency was 0.96 for the total scale in this study. In previous research, developers of the MRQOL reported several findings that provide preliminary support for the validity of the scale (Cavallini et al., 1995). In a study of the impact of headache pain in 4,000 headache sufferers, scores on the MRQOL discrimi-

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TABLE 2. Correlation Matrix of the Study Instruments Scales

CPEI-H

CSQ

CES-D

HDI

MRQOL

MPQ-SF CPEI-H CSQ CES-D HDI

⫺0.31*

0.15 ⫺0.21*

0.26* ⫺0.42* 0.17*

0.40* ⫺0.72* 0.22* 0.58*

⫺0.47* ⫺0.69* ⫺0.17* ⫺0.61* ⫺0.81*

* p ⬍ .01.

nated between chronic daily headache (CDH) and episodic headache (EH) patients. CDH patients reported significantly more frustration and irritability, whereas headache interfered more with the social life of those with EH. MRQOL scores also reflected greater compromise during the interictal period of headache for both groups.

FINDINGS Demographic Characteristics of the Participants The participants in this study were largely white (85.2%), with most between the ages of 24 and 44 years (49.4%; mean ⫽ 43.45) and 45 and 66 years (46.9%) and married (72.5%). Slightly more than half of the sample reported an income level of less than $51,000 (51.0%), and slightly less than half (49.0%) reported income greater than $51,000 per annum. One third (32.7%) of the sample were college graduates or had attended graduate school. Forty percent of the sample reported having completed some college, a quarter reported having completed high school (25.7%), and 1.6% reported grade school education. Most of the participants reported a family history of migraine (70.3%). Most of the respondents (69.4%) reported that a physician had diagnosed them with migraine without aura. Women in this sample were not currently pregnant, and all met the IHS criteria for migraine without aura. The majority of the sample lived in an urban setting (85.5%), lived with others (90.7%), and worked outside of the home or was students (84.4%). Pain Experience of Migraineurs Migraineurs reported that their worst mean migraine pain intensity in the past 6 months was 9 on a scale from 0 (no pain) to 10 (pain as bad as could be). On average, migraine pain in the past 6 months was reported as 6 on a pain intensity scale of 0 (no pain) to 10 (pain as bad as could be). Typically, migraines were

reported as occurring monthly (41.5%), although 25.3% of the women reported weekly migraines. Migraine headaches were most often reported as persisting for a number of hours (53.4%), although some participants (38.7%) reported that their migraines lasted for days. Participants reported that migraine episodes began anywhere from the age of 5 to 58 years, and the number of years suffered from migraine was reported as being from 1 to 54 years. Relationship Between Pain Factors and Migraine All of the correlations among the study instruments (except 2) were significant, although the relationships were not always strong. In Table 2, correlations are presented that varied in strength from weak-positive (0.17) to strong-negative relationships (-0.81). The strongest associations were: (1) between the chronic pain experience (CPEI-H) and disability (-0.72), indicating higher disability was associated with a negative chronic pain experience; (2) between depressive symptomatology (CES-D) and disability (HDI, 0.58), indicating a higher depression score was associated with a higher disability score; (3) between the chronic pain experience (CPEI-H) and quality of life (MRQOL, -0.69), indicating that a negative response to the chronic pain experience was associated with decreased quality of life; (4) between depressive symptomatology (CES-D) and quality of life (MRQOL, -0.61), indicating that higher depression scores were associated with decreased quality of life; and (5) between disability (HDI, -0.81) and quality of life (MRQOL), indicating increased disability scores were associated with decreased quality of life. Predictors of Disability and Quality of Life Two hierarchical regressions were used to test 2 hypotheses. For the purpose of this study, disability and quality of life were viewed as 2 related but different constructs. Therefore, the first hypothesis tested the

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predictive power of selected variables in disability scores in women with migraine headache. The second hypothesis tested the predictive power of selected variables in quality-of-life scores in women with migraine headache. First Hypothesis: Disability. In the first hypothesis, which included all of the variables from the theoretical framework (Figure 1), the variables were entered into the equation in the order they appeared in the framework. A total of 62.9% of the variance was explained by several factors in the model. Of the personal and illness-related factors, only use of prophylactic medications for migraine headache was entered into the regression equation, and it accounted for 6.5% of the variance in disability (F [1, 224] ⫽ 15.61, p ⬍ .001). The depressive symptomatology variable was entered second and accounted for 28.3% of the variance in disability (F [2, 223] ⫽ 59.53, p ⬍ 0.001). The next block of predictor variables included pain intensity, duration, and frequency and accounted for 3.3% of the variance in disability (F [5, 220] ⫽ 27.12, p ⬍ .001). The remainder of the independent variables were entered in the order in which they appear in the theoretical framework. The total migraine headache pain accounted for 4.7% of the variance in disability (F [6, 219] ⫽ 27.28, p ⬍ .001). The chronic pain experience contributed another 20.0% of the variance in disability (F [7, 218] ⫽ 52.57, p ⬍ .001). Coping strategies added only 0.1% of the variance in disability (F [8, 217] ⫽ 46.05, p ⬍ .001). When considering the ␤ weights of the use of prophylactic medication for migraine headache, pain intensity, pain duration, pain frequency, and coping strategies, it was noted that the predictive power of the regression equation was not significantly improved by the addition of these variables. These variables were therefore deleted from the predictor group. The total accounted variance in disability (HDI) by the depressive symptomatology, migraine headache pain, and chronic pain experience predictor variables was 62.9%. Depressive symptomatology and the chronic pain experience contributed the majority of the percentage of variance of disability in this regression equation. An additional contributing variable was migraine headache pain. Second Hypothesis: Quality of Life. In the second hypothesis, all of the variables from the theoretical framework were entered as predictor variables to attempt to explain the variance in migraine-related quality of life. Of the personal and illness-related factors, only the use of prophylactic medications for migraine headache was entered, and it accounted for 6.1% of the variance in migraine-related quality of life (F [1, 223] ⫽ 15.19, p ⬍ .001). Depressive symptomatology

was then entered after the personal and illness-related predictor, and it accounted for 31.4% of the variance in migraine-related quality of life (F [2, 232] ⫽ 69.55, p ⬍ .001). Of the pain characteristics, only migraine pain intensity and pain frequency were entered, and they accounted for 3.8% of the variance in migrainerelated quality of life (F [4, 230] ⫽ 40.48, p ⬍ .001). The remaining independent variables were then added into the regression equation in the order represented in the theoretical framework. Migraine headache pain accounted for 8.1% of the variance in migraine-related quality of life (F [5, 229] ⫽ 27.19, p ⬍ .001), and the chronic pain experience accounted for 15.4% of the variance in migraine-related quality of life (F [6, 228] ⫽ 69.86, p ⬍ .001). Use of prophylactic medication for migraine headache, pain intensity, pain frequency, and coping strategies did not significantly improve the predictive power of the regression equation (determined with ␤ weights) and were, therefore, deleted from the predictor group. The total accounted-for variance in migraine-related quality of life by the depressive symptomatology, migraine headache pain, and chronic pain experience predictor variables was 64.8%. In this hypothesis, only depressive symptomatology contributed a large amount to the variance of the criterion variable, quality of life. Other variables contributing to the explained percentage were migraine headache pain and the chronic pain experience. Figures 2 and 3 illustrate the standardized ␤ weights of the predictor variables in both regression equations.

DISCUSSION The purpose of this study was to determine the association of predictor variables to outcome variables, disability, and quality of life. The theoretically based predictor variables in this study had not been tested previously to determine the amount of variability they account for in the outcome variables. In both regression equations, the predictor variables that significantly improved the predictive power of the regression equation were depressive symptomatology, migraine headache pain, and the chronic pain experience. Many personal and illness-related factors that were related to migraine pain in certain previous literature, such as income, ethnicity, and education, were not related to migraine pain in this study. Pain characteristics in this study were not correlated with several of the other study variables. Yet, pain characteristics of this sample were similar to migraine samples in previous studies (Henry et al., 1992; Lipton 1995a; Micieli et al., 1995). Participants in this study

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FIGURE 2. y Regression model: Influence of migraine headache pain, the chronic pain experience, control over pain, and depressive symptomatology on disability in women experiencing migraine pain.

responded negatively to living with chronic head pain and used different types of coping strategies at differing rates of frequency than in other research, depending on the type of chronic pain patients with which they were compared. This sample also reported increased depressive symptomatology (43.2%) over migraineurs going to pain clinics (about one third). Aspects of disability, that is affecting social, family, and work life, were greater than or similar to that of migraineurs in previous research. Previous samples were recruited from clinics and ambulatory centers. The participants in this study were self-diagnosed migraineurs and volunteered to be included in the survey company lists of migraineurs, which may have affected the nature of the responses. Further, the use of mailed surveys in their home environment rather than in a clinic or clinician’s office, with the assurance of anonymity and confidentiality, may have affected the nature of the responses. The high level of education and

affluent nature of the sample may have affected the sample’s responses and the generalizability of the findings. The theoretical framework was partially supported by this study. Migraine headache pain, the chronic pain experience, and depressive symptomatology were the significant predictor variables for both disability and quality of life in migraineurs. In the present study, as in previous research, increased frequency of pain was correlated with decreased disability, and increased intensity and duration of pain were correlated with increased disability. Yet, there was a range of intensity and duration of migraine headache, with many women having frequent but moderate pain with their migraine. These women may have learned to deal with their migraines differently because of the more moderate (albeit more frequent) nature of their pain. However, for those whose pain was severe and lasting, the effect on ability to function was consider-

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FIGURE 3. y Regression model: Influence of migraine headache pain, the chronic pain experience, control over pain, and depressive symptomatology on quality of life in women experiencing migraine pain.

able. Although not reported in this article, many of the qualitative responses spontaneously reported by these women on the questionnaire support this statement. Interestingly, contrary to one previous study, pain intensity was not a significant predictor in this sample of chronic pain patients (Stewart et al., 1994), whereas frequency and duration were. Depressive symptomatology and the chronic pain experience explained most of the variance in disability in this sample. In the previous literature, wide variability in disability from migraine has also been reported (Lipton et al., 1995). In patients with other pain conditions, disability has been strongly associated with depression (Hagglund, Haley, Reveille, & Alarcon, 1989). In the present study, disability and depression were moderately correlated. Even though less than half of the sample in this study (43.2%) has scores classifying them as depressed, as measured by the CES-D (Radloff, 1977), this percentage was higher than expected in a com-

munity-based sample. Previous studies have reported that among clients who attended pain clinics, only one third were depressed (Jensen et al., 1991). The higher incidence of depression in this sample may be due to the type of instruments used, the settings of the participant’s participation, and the anonymity and confidentiality of the responses and likely explains why such a high degree of variance in disability was explained by depression. The incapacitating, severe pain and accompanying symptoms of migraine and lifestyle changes required in the attempt to prevent or control migraine can leave migraineurs feeling more disabled. In the present study, more interference in family and social activities were reported than in previous studies, which is a reflection of the community-based sample (Pryse-Phillips et al., 1992; Micieli et al., 1995). Perhaps the unhurried nature in the way the data were collected in this study lead to these differences (e.g., in their own homes). Disability has not been a typical

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end point in research studies (Lipton et al., 1995), and there is disagreement in the literature regarding the amount of disruption caused by migraine headache. The findings of this study suggest depressive symptomatology, the chronic pain experience, and pain characteristics are primary considerations in the study of women with migraine headache. Given the strong explanatory and predictory nature of several variables in this study, specifically depression, disability, and quality of life, there is a critical need for intervention research. Although most women with migraine still do not consult with physicians regarding their migraine headaches, those that do seem to be prescribed more adequate migraine-specific medication, such as triptans or ergotamines, for their migraine headaches. Although there continue to be reports of these medications not always being effective, when a person does not respond to one of these medications they may still get a positive response from another (Tepper, 1999). However, their mood disturbances associated with their chronic pain, such as depression, have not been adequately addressed. Assessment of migraine headache and depression and the use of higher dosages of antidepressants to treat depression and migraine headache (prophylactically) could help the patient by treating 2 comorbid conditions at the same time (i.e., depression and migraine headache) (Tepper, 2000). Future research is necessary regarding a 2-pronged approach to the treatment of migraine, both pharma-

cologic and nonpharmacologic. Women need to be taught self-care strategies, such as the use of nonpharmacologic treatments between migraine attacks. These could include biofeedback, relaxation, self-hypnosis, imagery, and other cognitive behavioral therapies. Over time, these therapies may decrease the frequency and intensity of migraine headache. Patient education is also necessary regarding the use of prophylactic medication for frequent migraine headaches and the need to take appropriate medication in a timely manner when a migraine episode occurs. Nurses can be supportive of women with migraine by believing their description of pain, even though there is not a quantitative test to prove migraine’s existence, and by encouraging appropriate medical assessment and consistent use of appropriate medications. Nurses can also teach nonpharmacologic interventions and support their use. Support of the patient by believing that they have pain will help immensely, as will assisting women to construct headache diaries to determine headache triggers and lifestyle changes that may be necessary. Nurses are in the unique position to be patient advocates. Nurses are cognizant of migraine headache and its comorbidities, can complete headache histories, and can be aware of and assess for depression, disability, and affects on quality of life. They also have the experience to teach self-care strategies and encourage adherence with effective and thoughtful medical regimens for women with migraine headaches.

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