1

Trajectories of Headache Disability Treatment Response: Psychosocial and Clinical

Correlates

A thesis presented to

the faculty of

the College of Arts and Sciences of Ohio University

In partial fulfillment

of the requirements for the degree

Master of Science

Kristin N. Lewis

November 2009

© 2009 Kristin N. Lewis. All Rights Reserved.

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This thesis titled

Trajectories of Headache Disability Treatment Response: Psychosocial and Clinical

Correlates

by

KRISTIN N. LEWIS

has been approved for

the Department of Psychology

and the College of Arts and Sciences by

Bernadette D. Heckman

Assistant Professor of Psychology

Benjamin M. Ogles

Dean, College of Arts and Sciences

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ABSTRACT

LEWIS, KRISTIN N., M.S., November 2009, Psychology

Trajectories of Headache Disability Treatment Response: Psychosocial and Clinical

Correlates (89 pp.)

Director of Thesis: Bernadette D. Heckman

Using a naturalistic, longitudinal study design, 219 patients receiving treatment

for headache disorders completed psychosocial assessments and 30-day daily diaries that

assessed headache frequency, severity, and disability at pre-treatment and provided data

on headache-related disability at pre-treatment and 1-, 2-, and 6-month follow-up. Latent-

class trajectory analysis of the headache disability measure identified three treatment

trajectory groups: (1) a high-disability non-responder group; (2) a high-disability

responder group; and (3) a low-disability responder group.

Approved: _____________________________________________________________

Bernadette D. Heckman

Assistant Professor of Psychology

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ACKNOWLEDGMENTS

I would like to thank all those who have supported me throughout the process of

developing this project. First of all, I would like to thank my advisor, Dr. Bernadette

Heckman for her support, guidance, and patience throughout the process. I would also

like to thank my committee members, Dr. Ken Holroyd and Dr. Timothy Anderson, for

providing important suggestions, feedback, and support to help improve the quality of the

project and paper. For her invaluable guidance, input, and statistical savvy, I’d like to

thank Lina Hiwaman. For their important contributions to the final product, I would like

to thank several friends. Thanks, Gary Ellis, Christina Wei, Liza Mermelstein, Kadian

Sinclair and the Heckman lab for reading my drafts and providing helpful comments.

Thanks are also due to the entire Project INSIGHT Team for their commitment and

contributions to the project. Finally, I would like to thank my family, particularly my

sister Kim and my dad Jerry, and my friends for their consistent support, encouragement,

and patience.
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TABLE OF CONTENTS

Page

Abstract ............................................................................................................................... 3 

Acknowledgments............................................................................................................... 4 

List of Tables ...................................................................................................................... 7 

List of Figures ..................................................................................................................... 9 

Introduction ....................................................................................................................... 10 

Method and Participants ................................................................................................... 13 

Characteristics of Participants ...................................................................................... 13 

Procedures ..................................................................................................................... 13 

Study Inclusion Criteria ............................................................................................ 14 

Assessment Measures ............................................................................................... 15 

Data Analyses ........................................................................................................... 17 

Results ............................................................................................................................... 19 

Sample Characteristics .................................................................................................. 19 

Latent Growth Curve Analysis ..................................................................................... 19 

ANOVA and Chi-square Analyses ............................................................................... 21 

Multinomial Logistic Regressions ................................................................................ 22 

Predictors of the High-High versus Low-Poor Disability Trajectory Groups .............. 23 

Predictors of the High-Non versus Low-Poor Disability Trajectory Groups ............... 23 

Discussion ......................................................................................................................... 24 

References ......................................................................................................................... 31 

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Appendix A: Supplemental Text ...................................................................................... 59 

Disability ....................................................................................................................... 60 

Health Related Quality of Life...................................................................................... 61 

Social Cognitive Theory ............................................................................................... 64 

Appendix B: Study Measures ........................................................................................... 66 

Demographics ............................................................................................................... 67 

Multidimensional Scale of Perceived Social Support................................................... 73 

Prime MD ..................................................................................................................... 74 

Part of a 30-Day Diary .................................................................................................. 80 

Modified Migraine Specific Quality of Life ................................................................. 81 

Headache Disability Inventory ..................................................................................... 83 

Appendix C: Supplemental Analyses ............................................................................... 84 

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LIST OF TABLES

Page

Table 1: Levels of Disability and All Potential Demographic, Headache Characteristic

and Psychosocial Predictor Variables .............................................................................46

Table 2: Zero-order Pearson Correlations of All Potential Predictor Variables .............48

Table 3: HDI Latent Growth Curve Analysis Results: Model Fit Indices and Group

Descriptions ....................................................................................................................49

Table 4: Intent to Treat Values of the HDI by Trajectory Group for all Follow-up

Periods.............................................................................................................................50

Table 5: Results of T-tests Comparing the Intent to Treat Values of the Trajectory Groups

at the Baseline and 6MFU Assessment Points................................................................51

Table 6: Results of the Three Multinomial Logistic Regression Analyses Conducted for

Demographic, Headache Characteristic, and Psychosocial Predictors ...........................52

Table 7: Odds Ratios and Test Statistics of all Individual Predictors Included in the

Multinomial Logistic Regression Analyses ....................................................................53

Table 8: Means and Standard Deviations Obtained for all Measures in the Current and

Previous Studies ..............................................................................................................54

Table C-1. Levels of the HSQ and All Potential Demographic, Headache Characteristic,

and Psychosocial Predictors. ...........................................................................................85 

Table C-2. Results of LCGA: Model Fit Indices and Descriptions for all Headache

Specific Quality of Life Trajectory Groups. ...................................................................86 

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Table C-3: Results of Multinomial Logistic Regressions Predicting HSQ Responder

Group Membership .........................................................................................................87 

Table C-4. Results of Multinomial Logistic Regressions: Unique Predictors ................88 

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LIST OF FIGURES

Page

Figure 1: Study Design ...................................................................................................55

Figure 2: Proposed and actual HDI values .....................................................................56

Figure 3: Model of quality of life and the disablement process .....................................57

Figure 4: Model of quality of life ...................................................................................58

Figure C-1. Actual and proposed mean values of quality of life at baseline, 1 month

follow- up, 2 month follow-up, and 6 month follow-up. ................................................89 

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INTRODUCTION

In the United States, one-year prevalence estimates of chronic tension-type

headache (CTTH; 9 to 14%) and migraine headache (20 to 30%) have been documented

(Jensen & Stovner, 2008; Stovner et al., 2007). These disorders pose serious public health

problems, including high rates of physical impairment, employment absenteeism, reduced

work productivity, and diminished quality of life (Lipton, et al., 2007; Silberstein, et al.,

2007; Steiner et al., 2003; Stewart, Lipton, & Simon, 1996; Stewart et al., 1992). Given

the significant impact of headache disorders on one’s physical, social and emotional well-

being, it is important to understand how patients respond to contemporary headache

pharmacotherapies to prevent and/or manage headaches.

Numerous preventive pharmacological treatments have been indicated for

headache disorders. Prophylactic (i.e., preventive) pharmacotherapies have repeatedly

been shown to reduce the frequency and severity of a variety of chronic headache

conditions (Diener et al., 2007; Silberstein et al., 2004; Bettucci, 2006; Holroyd et al.,

2001). Propranolol, a beta-blocker, is the most frequently studied prophylactic migraine

treatment while amitriptyline, a tricyclic antidepressant, is the most frequently studied

treatment for CTTH (Speciali, Eckeli, & Dach, 2008; Castells, Delgado, & Escoda, 2008;

Ramadan, 2007; Loj & Soloman, 2006; Fumal & Schoenen, 2008; Lampl et al., 2006).

While several pharmacotherapies efficaciously treat headache disorders, a

significant proportion of patients (≈30%) do not respond successfully to these treatments

(Holroyd, 2002; Adelman, 2000; Diener et al., 2008). Little is known about this latter

group of patients. There are several potential outcome trajectories that patients may
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evince over the course of pharmacoptherapy. For example, some patients report rapid

improvements, some report more gradual changes, and others report no changes in their

headache activity after initiating new acute and prophylactic treatments (Heckman et al.,

2008; Holroyd et al., 2001).

Growth curve modeling provides an opportunity to identify statistically and

potentially clinically meaningful differences in longitudinal treatment outcome

trajectories in headache patients. Growth curve modeling has been utilized most

extensively in studies of learning, depression, and substance use, areas in which

subgroups of treatment outcomes are common (Gildengers et al., 2005; Murphy et al.,

2008; Amtmann, Abbott, & Berninger, 2008). For example, several 10-year longitudinal

studies of symptom severity in schizophrenic patients found symptom reductions in

approximately 75% of patients, symptom increases in 25% of patients, and symptom

stability in just a few patients (Levine & Rabinowitz, 2008; Rabinowitz et al., 2008;

Rabinowitz et al,, 2007). A distinct subset of children does not respond, or responds

slowly, to early reading interventions (Amtmann, Abbott, & Berninger, 2008). Finally,

anxiety declines in most female patients following an acute cardiac event but persists in a

significant subset of patients (≈30%; Murphy et al., 2008).The utilization of growth curve

modeling in these areas has enabled researchers to characterize heterogeneous response

patterns and identify factors predictive of treatment resistant depression (Levine &

Rabinowitz, 2008), long-term substance use behavior patterns (Xie, McHugo, & Drake,

2009), and children in need of more comprehensive early reading interventions

(Amtmann, Abott, & Berninger, 2008).

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The prophylactic medication treatment of headache disorders has been studied

extensively but suffers from a lack of diversity in treatment outcome measures. Most

research of this type relies on headache frequency and severity as outcome measures.

While these measures enable practitioners to evaluate treatment efficacy vis-à-vis

symptom improvement, they yield less information about one’s physical or functioning

well-being (Andrasik et al., 2005). It has long been posited that the experience of pain

includes not only the sensory experience of pain but also the emotional and functional

sequelae of sensory-related pain (Andrasik et al., 2005;Turk & Okifuji, 2002).

Headache disability may be an ideal outcome measure by which to assess

treatment outcomes because headache disability measures correlate positively and

significantly with headache frequency and severity (Jacobson et al., 1994) and capture

functional-, emotional-, and role-related activity overlooked by headache frequency and

severity measures (Magnusson, Riess, and Becker, 2004; Holroyd, 1999; Holroyd, Labus,

& Carlson, 2009). Increasingly, patients—and those who pay for medical treatments—

seek medical interventions that improve headache-related symptoms and improve one’s

physical, emotional and functional welfare.

The current study sought to characterize statistically and clinically meaningful

headache treatment response trajectory categories using the treatment outcome measure

of headache disability and to identify headache characteristics and psychosocial variables

assessed prior to the initiation of new preventive pharmacotherapies that predicted

treatment trajectory group membership. The selection of psychosocial factors associated

with treatment trajectory group membership was guided by Social Cognitive Theory
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(SCT; Bandura, 1986). Using growth curve modeling, the current study characterized

treatment trajectory group membership and identified demographic (race, socioeconomic

status), headache-related (diagnosis, headache days, headache severity), and psychosocial

characteristics (headache specific self efficacy, locus of control, social support,

psychiatric comorbidity) associated with membership in treatment response trajectory

groups. Findings from the current study may enable headache treatment practitioners to

identify patients who are likely, or unlikely, to respond favorably to contemporary

prophylactic pharmacotherapies administered to patients in headache treatment clinics.

METHOD AND PARTICIPANTS

Characteristics of Participants

Data analyzed in the current study were collected from 219 patients who

presented at outpatient medical settings for treatment of episodic migraine, chronic

migraine, episodic tension-type headache, or chronic tension-type headache. Patients

were recruited from four outpatient headache treatment clinics in Cincinnati, Cleveland,

Columbus, and Toledo, OH.

Procedures

The study used a naturalistic longitudinal design and assessed participants using

pre-treatment, 1-, 2-, and 6-month follow-up visits that occurred during the course of the

participant’s routine care (Please see Figure 1). It is important to note that the follow-up

time periods used in this study were selected because they coincided with participants’

normally scheduled follow-up visits to these clinics. Patients were recruited by their

neurologist at the initial clinic visit. To recruit study patients, brochures and posters that
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described the study were distributed to participating treatment clinics for display and

distribution to potential participants. Eligible patients who expressed interest in the study

provided written informed consent in the treatment clinic.

Patients were initially assessed at pre-treatment and were again assessed at 1, 2,

and 6 month follow-up. This particular treatment schedule represents the natural course

of treatment recommended by patients’ physicians. Abortive medication was given to

patients at the initial visit if they were not already receiving acute treatment. Furthermore,

physicians made modifications to abortive regimens for patients already in receipt of such

treatment. At this visit, patients were diagnosed by their physicians using HIS criteria.

Patients were re-assessed during their second visit, which occurred 1-month after the

initial visit, to determine their need for preventive pharmacotherapy based on their

headache activity during the previous 30 days. At this juncture, preventive medication

was prescribed as clinically indicated. Finally, patients made follow-up visits at two and

six months after their initial visit.

Study Inclusion Criteria

The study employed the following inclusion criteria: (1) 18 years of age or older;

(2) self-identifying as African American or Caucasian; (3) satisfying IHS criteria for

either episodic migraine, chronic migraine, episodic tension-type headache, or chronic

tension-type headache; (4) the patient’s physician believed that he or she should begin a

new preventive pharmacotherapy; (5) proficiency in the English language; (6) the patient

was willing to postpone preventive treatment for one month (to assess headache activity

prior to the initiation of the new preventive pharmacotherapy; and (7) the patient
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completed the Headache Disability Inventory (HDI) at least once during the course of

treatment.

Assessment Measures

Demographic Characteristics. Patients provided data on their age, gender, race,

education, employment status, insurance status, and annual income through a self-report

questionnaire completed at the pre-treatment visit. To obtain a more comprehensive

estimate of each patient’s socioeconomic status, a principal components analysis (PCA)

created a composite SES score based on each patient’s “Number of Years of Education

Completed” and “Annual Income.”

Headache Diagnosis. During the initial patient-physician interaction, the

physician diagnosed the patient’s current headache disorder(s) using International

Headache Society (2003) criteria.

Headache Characteristics. Measures of headache activity were obtained via

participants’ self-report diary data completed from the pre-treatment visit to the 1 month

follow-up visit, and either mailed in to the research cite or returned to the physician.

Headache characteristics were determined by (a) the number of headache days during the

past month (frequency) and (b) average intensity of headaches over the month (severity).

Primary Care Evaluation for Mental Disorders (PRIME MD; Spitzer et al.,

1994). Patients’ psychiatric disorders were diagnosed using the PRIME-MD. The

PRIME-MD was administered to patients by trained research staff during a telephone

interview conducted within two days of the pre-treatment visit. The PRIME-MD yields a

subset of diagnoses included in the Diagnostic and Statistical Manual of Mental

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Disorders (DSM IV; Spitzer et al., 1994), including mood and anxiety disorders, as well

as alcohol (abuse/ dependence), eating disorders, and somatoform disorders. Previous

studies have found the PRIME-MD to be comparable to trained diagnostic interviews

(Spitzer et al., 1994; Please see appendix B). For the purposes of this study, psychiatric

comorbidity was assessed as: (1) anxiety diagnosis (i.e., “yes”/ “no”) and depression

diagnosis (“yes”/ “no”).

Headache Specific Locus of Control Scale (HSLC; Martin, Holroyd, & Penzien,

1990; VandeCreek & O'Donnell, 1992). The 33-item HSLC scale measured patients’

beliefs regarding factors that control their headaches. The HSLC scale contained three

locus of control (LOC) subscales that assessed the extent to which individuals believed

their headaches were controlled by their own efforts (Internal LOC subscale), chance

circumstances (Chance LOC subscale), and health care professionals (Health Care

Professional LOC subscale). Respondents rated the extent to which they agreed with each

LOC item using a five-point rating scale (1= “Strongly disagree” to 5=“Strongly agree”).

In the current study, coefficient alpha for each LOC subscale ranged from 0.82 to 0.85

and the test-retest reliabilities of the HSLC subscales over a three-week interval ranged

from 0.72 to 0.75. (Martin, Holroyd, & Penzien, 1990; Please see appendix B).

Headache Management Self-Efficacy Scale (HMSE; French et al., 2000). ).The

25-item HMSE scale assessed a patient’s perceived ability to prevent and manage their

headache activity. Patients rated the extent to which they agreed with each item using a

seven-point rating scale (1=“Strongly disagree” to 7=“Strongly agree”). In the current

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study, the HMSE scale demonstrated excellent internal consistency (α=.90; Please see

appendix B).

Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem,

Zimet, & Farley, 1988). The 12-item MSPSS scale measured patients’ perceived social

support from three sources: family; friends; and significant other(s). Each MSPSS item

used a seven-point Likert scale (1=“Very strongly disagree” to 7=“Very strongly agree”).

Higher scores indicate higher perceptions of social support. The MSPSS scale

demonstrated excellent psychometric characteristics in the current study (α=.91, test-rest

reliability=.93).

Headache Disability Inventory (HDI; Jacobson et al., 1994). The 25-item HDI

assessed the burden of chronic headaches on one’s emotional well-being and daily

functioning and served as the primary outcome measure in growth curve modeling

analyses. The HDI demonstrated excellent psychometric properties in the current study

(α=.92).

Data Analyses

Intent to Treat Analysis. An intent to treat (ITT) analysis was used in the current

study because it provides the most accurate representation of the population of interest,

unlike a completers-only approach that would, in all likelihood, yield a sample that is

biased on one or more variables. The ITT approach used data provided by participants

who received preventative medication, self-identified as being Caucasian or African

American, and who completed the HDI at any of the assessment time points during the
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study (n=219). Data on treatment completers versus non-completers is published

elsewhere (Heckman et al., 2008).

Mixed Modeling. The current analysis identified subgroups of patients with

similar courses of treatment response as measured by the HDI. To derive homogeneous,

empirically-based subgroups, mixed model latent regression modeling was conducted.

This analysis empirically clustered similar trajectories over time based on both the initial

disability score (intercept) and change in disability score over time (slope). The number

of groups and, therefore, the number of separate trajectories for which parameters

estimated was achieved by including a categorical latent variable in the model. Both

statistical and pragmatic criteria were used to determine the optimal shape and number of

groups. Following Muthen’s (2003) guidelines, the statistical criteria for determining the

model included the Bayesian Information Criteria (BIC), posterior probability, and

entropy. BIC, a goodness-of-fit measure, was used to assess the fit of a model with

multiple classes that accounted for the number of parameters estimated in the analysis.

Model fit was indicated by lower BIC values. Estimated conditional class probabilities

were utilized to compute entropy. Entropy measured how statistically distinguishable the

proposed classes were, with higher entropy values indicative of more distinguishable

classes. Additionally, the study team examined the pragmatic criteria of number of

groups, the meaningfulness and interpretability of the model, and the number of

participants in each group (Muthen, 2003, Lubke & Muthen, 2005). Data analyses for

mixed modeling were conducted using Mplus version 3.11 (Muthen & Muthen, 2004).
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Predictive Characteristics. Three multinomial logistic regressions were carried

out to explore factors that predicted and differentiated the trajectories. Demographic

factors included race/ethnicity (African-American or Caucasian-American) and

socioeconomic status (SES). Clinical factors included migraine or tension-type headache

diagnosis, chronic or episodic diagnosis, headache days, and headache severity at

baseline. Psychosocial variables included headache self-efficacy, locus of control, social

support, and psychiatric comorbidity.

RESULTS

Sample Characteristics

As shown in Table 1, the typical patient was Caucasian (67%), female (88%), and

36.7 years of age. Eighty percent of participants were diagnosed with migraine headache

and 20% were diagnosed with tension-type headache as their primary diagnosis. Forty-

seven percent of participants had an “episodic” headache diagnosis (i.e., episodic tension-

type headache, episodic migraine headache with and without aura) and 53% had a

chronic diagnosis (i.e., chronic tension-type headache, chronic migraine with and without

aura, chronic daily headache). On average, patients experienced headaches on 17.4 days

over a 30-day period.

Latent Growth Curve Analysis

Results from mixed modeling latent class analyses indicated that the best fitting

model was a linear, 3–class model. Table 2 shows fit indices and entropy of the growth

mixture models for linear and quadratic models with 1, 2, 3, and 4 classes. While the

BICs of the three best-fitting models were not significantly different from each other, the
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lowest BIC (which is preferable when evaluating model fit) was determined to be a

linear, 3-class model. The linear, 3-class model had an entropy value of 0.628, indicating

that the classes in the model were modestly distinguishable from each other. The average

class posterior probabilities ranged from .742-.874, indicating that the model accurately

predicted patients’ group classification 74 to 87% of the time.

Figure 2 illustrates the proposed and actual disability trajectories for the each of

the three groups identified by the latent class analysis. Group 1 patients (n=74; 34%)

reported relatively high HDI scores at pre-treatment (mean=59.17) and evinced a non-

significant worsening of headache-related disability (i.e. HDI scores increased an average

of 0.645 points; Cohen’s d= -.11). Group 2 patients (n=24; 11%) reported the highest pre-

treatment HDI scores (mean=61.5) and evidenced the fastest decline in headache

disability over the 6 month follow-up period at a rate of 3.28 per follow-up period (a total

average decrease of 9.84; Cohen’s d=2.4). Group 3 patients (n=121; 55%) reported the

lowest pre-treatment HDI scores (mean=42.75) and exhibited gradually decreasing HDI

values over the 6 month follow-up period, with a total average decrease of 2.08 (Cohen’s

d =.52). Based on these findings, the three groups that emerged from the treatment

outcome analysis were classified as: (1) High-Disability, Nonresponders (i.e. Group 1,

which initiated treatment with an elevated level of disability and did not respond to

treatment); (2) High-Disability, Responders (i.e. Group 2, which initiated treatment with

a high level of disability but responded promptly to treatment); and (3) Low Disability,

Responders (i.e. Group 3, which started treatment with lower disability levels and

showed gradual responses to treatment (see Table 1, Figure 2, Table 3, and Table 4).
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ANOVA and Chi-square Analyses

Univariate ANOVAs and chi-square analyses tested for differences in

demographic, headache characteristic, and psychosocial variables between the disability

trajectory groups (See Table 1). The disability trajectory groups did not differ in age,

gender, ethnicity, having chronic vs. episodic headache diagnoses, having migraine vs.

tension-type diagnoses, or internal headache-specific locus of control (all ps > .10)

At pre-treatment, the three groups did differ in SES composite scores,

F(2,202)=3.02, p=.051, headache frequency, F(2,216)=4.38, p=.01, headache severity,

F(2,218)=5, p<.01, headache management self-efficacy, F(2,207)=12.07, p<.001, health

care professional locus of control, F(2,208)=8.87, p<.001, chance locus of control,

F(2,205)=23.53, p<.001, social support, F(2,209)=3.23, p=.04, having an anxiety

comorbidity, χ²(2)=22.27, p<.001, and having a depression comorbidity, χ²(2)=21.85,

p<.001.

Bonferroni corrected post-hoc comparisons found several differences between the

Low Disability-Responders Group and the High Disability-Non-Responders Group.

Specifically, compared to High Initial Disability, Non-Responders, Low Initial

Disability-Responders reported significantly higher SES composite scores (p < .05), ,

fewer headache days per month (p < .05), decreased headache severity (p < .05), less

health care professional locus of control, (p < .05), less chance locus of control (p < .05),

, greater headache management self-efficacy (p < .05), , and were less likely to have

comorbid anxiety or depressive disorder diagnoses (both ps < .05).

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Significant differences were also observed between Low Disability, Responders

and High Disability Responders. Compared to High Initial Disability Responders, Low

Initial Disability Responders reported less health care provider locus of control (p < .05),

decreased chance locus of control (p < .05), greater headache management self-efficacy

(p < .05), and were less likely to have comorbid anxiety and depression diagnoses (both

ps < .05).

Multinomial Logistic Regressions

Correlational analyses were conducted in order to assess for multicollinearity

between the independent variables (see Table 5). While significant correlations were

found between several of the independent variables, VIF and tolerance values indicated

that there was no multicollinearity among the independent variables (see Table 5).

Additionally, no predictors were correlated with one another at r> .80, further reducing

the possibility of multicollinearity (Tabachnik & Fidell, 2001).

As previously mentioned, ANOVA and chi-square analyses were conducted to

determine which predictor variables to include in the multinomial logistic regressions

(MLRs). Predictors that were correlated with the disability trajectory groups with Pearson

correlation significance levels below 0.20 were included in the MLR (Tabachnik &

Fidell, 2001). Race, chronic diagnosis or episodic diagnosis, migraine or tension-type

diagnosis, and internal headache specific locus of control were correlated with the

disability trajectory groups with Pearson significance levels above 0.20, and these

variables were excluded from the subsequent analyses (see Table 1). All other variables

were correlated with the trajectory groups at baseline at significance levels below .2 and
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were included in the MLRs. Three MLRs were conducted, one including demographic

characteristics (socioeconomic status), one including headache-related characteristics

(frequency and severity), and one including psychosocial characteristics (self-efficacy,

health care provider locus of control, chance locus of control, social support, anxiety

comorbidity, and depression comorbidity) were conducted to see which factors predicted

disability trajectory group membership. The demographic characteristic (χ²(2)=6.16;

p=.05), headache-related characteristic (χ²(4)=15.94; p<.01), and psychosocial

characteristic (χ²(12)=77.66; p<.001) MLRs were significant, indicating that as a group,

each set of factors included in the three regressions significantly predicted disability

trajectory group membership. No factors included in the analysis predicted membership

in the high-disability responders group over the high-disability nonresponders group.

Predictors of the High-High versus Low-Poor Disability Trajectory Groups

High-disability responder trajectory group membership was predicted over low-

disability responder trajectory group membership by higher health care provider locus of

control (OR=1.08; p<.05), higher chance locus of control (OR=1.1; p<.001), and the

presence of an anxiety comorbidity (OR=3.08; p<.05). Headache severity marginally

predicted high-disability responders trajectory group membership over low-disability

responders group membership (OR=1.07; p=.051; Please see Tables 6 and 7).

Predictors of the High-Non versus Low-Poor Disability Trajectory Groups

High-disability nonresponder trajectory group membership was predicted over

low-disability responder group membership by lower SES (OR=.66; p< .05), higher

headache frequency (OR=1.05, p=.05), higher headache severity (OR=3.47, p=.01),

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lower headache specific self efficacy (OR=.97, p<.01), higher health care provider locus

of control (OR=1.06, p<.05), higher chance locus of control (OR=1.07, p<.01), having

an anxiety disorder (OR=2.48, p<.05), and having comorbid depression (OR=2.32, p<.05;

Please see Tables 6 and 7).

DISCUSSION

Using mixture growth modeling techniques, the current study found: (1) three

distinct patterns of response to prophylactic headache treatments that were categorized as

high-disability nonresponders, high-disability responders, and low-disability responders;

(2) that demographic, headache, and psychosocial variables distinguished participants in

the two groups with high initial disability scores from those participants with low initial

disability scores; and (3) that none of the variables assessed in the current study (i.e.

demographic, headache-related, and psychosocial variables) distinguished participants

with high initial levels of disability who improved from those with high initial levels of

disability who did not improve.

Using criteria suggested by Muthen (2002) and Muthen and Muthen (2003), our

study identified two groups (high-disability nonresponders and high-disability

responders) who started treatment with a comparable level of increased disability and a

third group of participants ( low-disability responders group) that had significantly lower

levels of impairment at the onset of treatment. This is not altogether inconsistent with

previous research, which, when utilizing other statistical techniques, frequently suggests

the presence of a subset of patients that does not respond to treatment (≈30%), while most

other patients evince statistically and clinically meaningful reductions in headache

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symptoms (Holroyd, 2002; Adelman, 2000; Diener et al., 2008). Additionally, the level

of disability displayed in the two high disability groups when compared to the levels of

disability found in most national clinical research samples, suggests that these patients

are likely being missed in randomized clinical headache outcome studies (French, 2000;

Holroyd, Labus, & Carlson, 2009). For example, in treatment outcome studies on

patients with CTTH, the average baseline HDI score at treatment initiation was 38.42 and

39.42, respectively (Holroyd, Labus, & Carlson, 2009 & French, 2000, respectively).

These scores are much lower than the current study’s average of 51.83. It may be that

strict inclusion/exclusion criteria often used in clinical trials exclude headache patients

with high disability, who, for reasons such as psychiatric comorbidity, are not eligible for

the study. Future researchers should carefully consider the exclusionary criteria utilized,

as there appears to be a significantly impaired and poorly understood cluster of patients

who are not being examined (Tietjen et al., 2007).

When the demographic, headache-related, and psychosocial predictors of

disability trajectory group membership were examined, the three trajectory groups

appeared to collapse into two groups, a high disability and a low disability group. As

could be expected, the two high disability groups were predicted over the low disability

group by higher levels of headache frequency and severity and psychiatric comorbidity

(Cassidy et al., 2003; Von Korf et al., 1992; Terwindt et al., 2000; Lipton et al., 2001;

Jacobson et al., 1994; Heckman et al., 2008; Nicholson et al., 2007; Holroyd et al., 2000;

Lanteri-Minet et al., 2005; Breuner, Smith, & Womack, 2004; Tschennen et al., 1992;

Stewart & Lipton, 2002; Marcus, 2000). Additionally, a psychosocial profile including a
 26

high level of chance and health-care-provider locus of control, a low level of internal

locus of control, and a low level of self-efficacy predicted membership in the high-

disability groups. These findings are consistent with the extant literature (e.g. French et

al., 2000; Martin, Holroyd, & Penzien, 1990), and suggest that there may be two very

different clinical profiles of patients who enter treatment, a high initial disability and a

low initial disability group. Patients who entered treatment with high levels of disability

had heterogenous responses to treatment. While the majority of these patients did not

respond treatment, as might be expected based on previous research (Holroyd, 2002;

Adelman, 2000;Diener et al., 2008), a subset of this group responded quite well, and

attained a comparable although slightly higher disability level when compared to the low

disability group. Most of those patients who stayed in treatment showed significant

treatment response, while those who did not stay in treatment did not reduce their

headache-related disability. This result could be taken as a hopeful signal to headache

clinicians that patients with a challenging profile of clinical and psychosocial

characteristics have the potential to respond to treatment with dramatic reductions in the

impact of headache disorders on their functioning. However, as these patients were also

at a high risk for nonresponse to treatment, they may be good candidates for more intense

interventions, such as the combination of behavioral management and pharmacotherapy

(Rothrock, 2009). The psychosocial characteristics of these patients, such as high levels

of psychiatric comorbidity and low self-efficacy, may also make them potentially good

candidates for psychotherapy (Andrasik, Buse, & Grazzi, 2009). Psychotherapeutic

interventions may help to remediate the distress caused by anxiety and depression, which
 27

may have a relationship to headache disability (Andrasik, Buse, & Grazzi, 2009).

Additionally, as self-efficacy has been emerging in the literature as an important mediator

of headache disorder treatment outcome, behavioral management training should target

self-efficacy (Holroyd, Labus, & Carlson, 2009).

It is also important to note that the majority of patients initiated treatment with a

(relatively) lower level of disability, and while they improved at a statistically significant

level, the decreases in disability were fairly small. This is consistent with the limited

clinically representative research that has used headache disability as a measure of

headache treatment response (Heckman et al., 2009). Given the limited improvement

most patients experience in treatment, continued resources need to be directed towards

developing more effective headache treatments.

While no clinical or psychosocial characteristic included in the analysis predicted

group membership between the two high-disability groups, a subsequent analysis

indicated that the high disability responders group had significantly (p<.05) lower rates of

dropping from the study (25% vs. 51%). This can be interpreted in multiple ways. It is

understandable that patients who enter treatment with high levels of disability and

improve rapidly would be more likely to maintain treatment adherence than those who

did not improve, or who improved gradually. However, participants who adhere to

treatment are also more likely to respond to treatment (Boes & Capobianco, 2005; Rains,

Lipchik, & Penzien, 2006), and may have been more likely to be in the high-disability

responders group. Alternatively, this may simply have been an artifact of the intent to

treat analysis, as the last HDI score received for the participants was carried forward,
 28

while patients’ actual treatment response may have been different. Future studies might

consider a brief follow-up with those patients who drop from treatment to assess

treatment outcomes.

While the current study did not find a statistical difference between the two high

initial disability groups on race, age, or SES, previous research conducted with this

sample found that patients who prematurely dropped from treatment were more likely to

be younger, African-American, and have lower levels of SES in Caucasian-Americans

(Heckman et al., 2008). Future studies might consider continuing to explore the

relationship between treatment adherence, premature treatment termination, and

treatment response. Additionally, treatment adherence appears to be an important

potential area for intervention in clinical settings.

The current study had several limitations. First, this is a secondary analysis of a

dataset that was collected for another purpose. Moreover, because all participating

headache treatment clinics were located in urban areas in Ohio, study results may not

generalize to other geographic locations. All data collected in the study, with the

exception of headache diagnoses, were self-report in nature and potentially subject to

problems related to social desirability, demand characteristics, and recall bias. Many of

the measures utilized in the study were not specific to preventive pharmacological

treatment, and were instead geared toward non-pharmacological headache self-

management. As a result, the findings in the current study may not be an accurate

reflection of the relationship between, for example, headache self-efficacy and preventive
 29

pharmacological treatment. In order to more accurately assess this relationship, measures

are needed to assess, for example, medication regimen self-efficacy.

While this study employed the pragmatic criteria outlined by Muthen (2003) to

select the model (i.e. number of groups, the meaningfulness and interpretability of the

model, and the number of participants in each group), there were multiple models that fit

the data. Therefore, justification could be made for alternative interpretations of the data.

Additionally, the current study utilized an intent-to-treat analysis in order to capture the

most representative sample of participants. However, utilization of a completers sample

would have most likely produced a different grouping of the participants that could

provide information about what predicts treatment response in a sample of patients who

tend to stay in treatment. While the study included a wide range of factors that have been

found to be important in the health and headache literatures, the list of potential

predictors was by no means exhaustive. Other factors such as co-occurring symptoms,

medication side-effects, and adherence to treatment regimens which were not measured

in the current study may have differentiated participants in the disability trajectory

groups.

In spite of the above limitations, the current study is the first to examine headache

treatment response patterns using latent growth curve methodology. This paper has

overcome some of the limitations of previous research, including its use of a prospective

design, a comprehensive outcome measure, and a clinically-representative sample. This

research identified the clinical profile (demographic, headache characteristic, and

psychosocial) of three groups of patients, each with similar disability trajectories. Two of
 30

these groups had a similar level of disability, headache days, headache severity, headache

management self-efficacy, chance and healthcare-professional locus of control, and rates

of psychiatric comorbidity, but strikingly different responses to treatment. These two

groups, the high-disability responders and high-disability nonresponders groups, differed

on most variables from the third group, the low-disability responders. However, the only

variable that distinguished the high-disability responders and high-disability

nonresponders groups was treatment adherence (as measured by dropping from the

current study). The results of the current study suggest that clinicians should pay

particular attention to those patients with high levels of disability at their initial visits, as

those patients are at a high risk for non-response to treatment. These patients are also

potentially good candidates for behavioral interventions, as they had a clinical profile

including high levels of psychiatric comorbidity, low levels of self-efficacy, and high

levels of health-care-provider and chance locus of control. Additionally, patients with

high levels of disability had high treatment dropout rates, suggesting that clinicians target

adherence interventions to participants with similar clinical profiles. These results also

imply that RCT’s may be missing those participants who enter treatment with high levels

of disability, who, due to high rates of psychiatric comorbidity, may be excluded.

Furthermore, research is needed to determine what factors may predict the difference

between those patients who start treatment with high levels of disability, stay in

treatment, and improve, and those who drop from treatment and do not improve.
 31

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 46

Table 1: Levels of Disability and All Potential Demographic, Headache Characteristic and Psychosocial Predictor Variables.

Total High-disability Nonresponders Low –disability Responders High-disability Responders

M SD N M SD N M SD N M SD N

Base HDI 51.83 11.3 205 61.84 7.5 67 43.75 7.7 114 62.33 6.7 24

1 MFU 49.02 11.8 125 60.72 8.3 54 41.31 7.2 103 57.64 7.2 22

2 MFU 46.97 11.4 98 58.59 6.8 41 40.43 7.7 86 51.4 10 20

6 MFU 45.18 11.2 76 61.11 6.5 36 39.03 6.7 77 41.11 8.2 18

Freq 17.38 7.8 180 19.11 7.9 55 15.93 7.7 102 19.7 6.8 23

Severity 1.68 .39 180 1.8 .45 55 1.6 .33 102 1.74 .39 23

Freq (M) 17.38 7.0 219 18.67 6.8 74 16.16 7.1 121 19.6 6.6 24

Severity (M) 1.68 .35 219 1.77 .4 74 1.61 .3 121 1.74 .4 24

B HSE 92.14 22.9 210 84.35 20.4 66 99.38 21.8 110 87.2 24.5 20

LOC HCP 34 7.8 211 35.94 8.2 65 31.56 7.4 115 36.54 5.3 24

LOC Int 33 8.5 211 32.77 9.1 69 31.56 8 116 34.9 7.6 22

LOC Chance 33.68 8.5 208 37.97 7.1 65 30.5 8.1 113 37.39 7.7 23

Social Sup 6 1 212 5.22 1.5 70 5.73 1.3 118 5.4 1.4 24

SES .01 .95 205 -.22 .93 66 .14 .95 116 .01 .89 23

Race (AA) 37% 81 219 45% 33 74 34% 41 121 29% 7 24

Chronic 43% 93 218 46% 34 74 40% 48 120 46% 11 24

 47

Migraine 72% 157 218 66% 49 74 74% 90 120 75% 18 24

Anx Com 46% 99 214 64% 47 73 32% 37 117 63% 15 24

Dep Com 54% 115 214 73% 53 73 39% 46 117 67% 16 24

Age 36.74 10.1 208 37.43 10.4 70 35.89 10.2 114 38.75 8.7 24

Gender (F) 88% 190 215 84% 62 71 87% 105 120 96% 23 24
 48

Table 2: HDI Latent Growth Curve Analysis Results: Model Fit Indices and Group
Descriptions.

Model Entropy BIC Par. Log Likelihood Group Percentage Group Group Quad.
Ns Intercept Slope Funct.
Linear 1 ___ 4678.642 8 -2317.765 219 ___ 50.9 -.8
group

Linear 2 .602 4675.42 11 -2308.07 153 70 46.3 -1.2

groups 66 30 60 .1
Linear 3 .628 4670.484* 14 -2297.519 74 34 59.2 .2
groups 121 55 42.7 -.7
24 11 61.5 -3.3
Linear 4 .65 4674.719 17 -2291.552 52 24 61.5 .6
groups 72 33 53.3 -.7
81 37 40.3 -.9
14 6 60.3 -3.8
Quadratic ___ 4670.774 12 -2303.053 219 ___ 52 -2.7 .3
1 group

Quadratic .595 4672.586 16 -2293.180 155 71 47.8 -3 .3

2 groups

64 29 61 -2 .3

Quadratic .629 4673.74 20 -2282.979 75 34 60.9 -2.5 .4

3 groups
22 10 61.7 -4.5 .2

122 56 43.8 -2.4 .2

Quadratic .666 4678.554 24 -2274.608 91 42 41.6 -2.2 .2

4 groups
34 16 66 -4.7 .8
19 9 61.8 -5.4 .3
75 34 55.6 -1.5 .2
 49

Table 3: Intent to Treat Values of the HDI by Trajectory Group for all Follow-up Periods.

Total Sample High-disability Low-disability High-disability

Nonresponders Responders Responders
M SD N M SD N M SD N M SD N
Baseline HDI 51.74 11.8 219 61.55 7.6 74 43.64 7.7 121 62.33 6.7 24
HDI 1 MFU 50.09 12.1 219 61.53 8 74 41.5 7.2 121 58.08 7 24
HDI 2 MFU 48.74 12.2 219 60.99 7 74 40.59 7.7 121 52.04 9.5 24
HDI 6 MFU 47.81 12.7 219 62.32 6.4 74 39.73 7.4 121 43.83 8.5 24
 50

Table 4: Results of T-Tests Comparing the Intent to Treat Values of the Three Disability
Trajectory Groups at Baseline and 6MFU.

Baseline 6 MFU
T Df Sig T Df sig
High-disability 15.85 193 <.001 21.87 193 <.001
Responders vs. Low-
disability Responders
Low-disability Responders -11.04 143 <.001 -2.43 143 .016
vs. High-disability
Nonresponders
High-disability -.45 96 .653 11.31 96 <.001
Responders vs. High-
disability Nonresponders
 51

Table 5: Zero-Order Pearson Correlation of All Potential Predictor Variables.

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13

1. Race _

2. SES -.16* _

3. Chronic .05 -.09 _

4. Migraine - .23** -.24** _

.19**

5. Frequency .16* -.24** .27** .11 _

6. Severity .2* -.19* .03 -.05 .21** _

7. Anxiety -.1 .13 -.05 -.09 -.2** -.05 _

8 . Depression - .03 -.12 -.02 -.2** -.12 .33** _

.19**

9. HSE -.11 .22** -.13 -.06 -.16* -.21** .09 .17* _

10. LOC Internal .1 -.01 -.05 .05 .10 -.04 -.25** -.12 .39** _

11. LOC HCP -.05 -.07 .03 .05 -.04 -.00 -.21** -.02 -.02 .22** _

12. Chance .05 -.25** .04 -.08 .11 .10 -.31** -.21** -.42** .04 .23** _

13. Soc. Sup. -.13 .21** -.16* -.04 -.22** .03 .07 .17* .1 -.11 .004 -.18* _
 52

Table 6: Results of the Three Multinomial Logistic Regression Analyses Conducted for
Demographic, Headache Characteristic and Psychosocial Predictors.

χ² df P val

Demographics (SES) 6.16 2 .046

Clinical Characteristics 16.01 4 .003

Frequency 5.88 2 .053

Severity 7.52 2 .023

Clinical Characteristics (M) 15.94 4 .003

Frequency (M) 6.06 2 .048

Severity (M) 7.27 2 .026

Psychosocial Characteristics 77.66 12 <.001

Anxiety Dx 7.53 2 .023

Depression Dx 5.27 2 .072

HSE 7.15 2 .028

LOC-Chance 12.49 2 .002

LOC-HCP 7.55 2 .023

Social Support .94 2 .625

 53

Table 7: Odds Ratios and Test Statistics of all Individual Predictors Included in the
Multinomial Logistic Regression Analyses.
High-disability Nonresponders vs. High- Low-disability Responders vs. High- Low-disability Responders vs. High-
disability Responders disability Responders disability Nonresponders
Odds Wald P Odds ratio Wald p Odds ratio Wald p
Ratio
Clinical Characteristics (imputed mean)

Frequency .98 .41 .52 .94 3.80 .05 .96 3.76 .05

Severity 1.37 .22 .64 .41 1.71 .19 .30 6.67 .01

Psychosocial Characteristics

Anxiety Dx 1.20 .10 .75 3.07 4.13 .04 2.57 5.79 .02

Depression Dx .66 .57 .45 1.62 .77 .38 2.47 5.18 .02

HSE .99 .95 .33 1.01 .86 .35 1.02 6.81 .01

LOC-Chance .99 .18 .68 .91 6.57 .01 .92 9.03 >.01

LOC-HCP .98 .28 .60 .92 4.63 .03 .94 5.36 .02

Social Support .96 .04 .84 1.10 .25 .62 1.14 .93 .34

Demographics

SES .76 1.09 .30 1.16 .35 .55 1.53 5.76 .02

Clinical Characteristics

Frequency .99 .17 .69 .94 3.48 .06 .96 3.86 .05

Severity 1.52 .42 .52 .44 1.68 .20 .29 6.94 .01
 54

Table 8: Means and Standard Deviations Obtained for all Measures in the Current Study
Compared with Previous Studies.

Measures Mean SD Prior Studies Sample M SD

HDI- 51.83 11.8 French et al., 329 Patients seeking 39.42 19.46
treatment for
2000 headache disorders
Baseline 38.42 18.53
169 patients seeking
Holroyd, treatment with CTTH
Labus, &
Carlson, 2009
HDI- 45.38 11.9 _ _ _ _

Outcome

HMSE 92.14 22.9 French et al., 329 Patients seeking 110.29 20.9
treatment for
2000 headache disorders
LOC- 33 8.5 Martin, College student 40.19 7.52
headache sufferers
Holroyd, &
Internal Penzien, 1990
329 Patients seeking 8.00
French et al., treatment for 36.36
headache disorders
2000
LOC- 33.68 8.5 Martin, College student 28.01 7.84
headache sufferers
Holroyd, &
Chance Penzien, 1990 329 Patients seeking
30.85 8.11
treatment for
French et al., headache disorders

2000
LOC-HCP 34 7.8 Martin, College student 23.45 8.04
headache sufferers
Holroyd, &
Penzien, 1990 329 Patients seeking
28.88 6.24
treatment for
French et al., headache disorders

2000
MSPSS 6 1 Zimet, 275 college students 5.80 .86
Dahlem,
Zimet, &
Farley, 1988
 55

Baseline 1-MO 2-MO FU 6-MO FU

FU Visit Visit Visit

0 1 2 3 4 5 6 7

30-Day MONTHS
Headache Diary

Preventive Therapy
is initiated

Figure 1. Prospective design: participants were assessed at baseline, 1-, 2-, and 6-month
follow-up visits that occur during the course of each participant’s care at four
collaborating clinic sites.
 56

Figure 2. Average headache disability inventory scores as proposed by the growth curve
model and as reported by participants at all four assessment points for the three disability
trajectory groups.
 57

Explanatory Variables

Contextual Factors Resources Barriers Health Promoting

Behaviors

QoL
Pathology Impairment Functional Disability
Limitations

Disablement Process

Figure 3. Conceptual models of the disablement process and contributions to quality of

life outcomes. Adapted from Stuifbergen, Brown, and Phillips (2009) and Verbrugge and
Jette (1994).
 58

Figure 4. Model of quality of life, reproduced from Phillips and Stuifbergen (2009).
 59

APPENDIX A: SUPPLEMENTAL TEXT

 60

Disability

The theory of disability has evolved over time from a biomedical model to a

biopsychosocial model. In the biomedical model of disability, the disability is a distinct,

objective condition (Smart & Smart, 2006). This model separates the medical condition

from the person and the environment, and can increase the stigmatization of persons with

disabilities by identifying and categorizing them by their disability. The biomedical

model also leads to the “try harder” syndrome, in which the responsibility for the degree

of “success” in adapting to the disability lies in the individual (Smart & Smart, 2006).

Later models of disability recognized the importance of the environment (both

social and physical) and aspects of the individual aside from the disability (Nagi, 1976).

These models recognized that individuals fulfill various functions in their environment,

and acknowledge that aspects of the environment, including prejudice and stigma, can

exacerbate or create disability (Smart & Smart, 2006; Nicholson et al., 2007).

Currently, the most commonly utilized of model of disability is the World Health

Organization’s International Classification of Functioning, Disability, and Health (ICF;

Masala & Petretto, 2008). This model can be summarized as the interaction between the

person, the health condition, and the environment (Masala & Petretto, 2008). When this

interaction is positive, it is considered functioning, and when it is negative, it is

considered disablement (Masala & Petretto, 2008; Andrasik, 2005). This model is

consistent with the movement in behavioral medicine towards the biopsychosocial model

of illness, which acknowledges the importance of personal and environmental factors

(Nicolson, Houle, Rhudy, & Norton, 2007).

 61

Most research has focused on how individual characteristics relate to disability.

For example, Phillips and Stuifbergen (2009) used structural equation modeling (SEM) to

evaluate predictors of disability in patients with fibromyalgia or multiple sclerosis. The

authors used a biosocial model of disability and examined the relationship between age,

education, duration of illness, depressive symptoms, social support, economic adequacy,

functional limitations, and disability (see Figure 3). The authors found a similar fit for

both the participants with Fibromyalgia and Multiple Sclerosis, and that both intra-

individual and extra individual factors partially mediated the role of functional limitations

on disability. A comprehensive model of disability in headache disorders has not been

created.

Health Related Quality of Life

Health related quality of life (HRQL) has been examined in many chronic

illnesses such as pulmonary arterial hypertension (Shafazand, et al., 2004), human

immunodeficiency virus (Swindells et al., 1999) and chronic pain (Blyth et al., 2001;

Boardman et al., 2003; Jensen et al., 2007). From these studies, it can be concluded that

the more a patient’s illness restricts him/her physically and emotionally, the more likely

he/she is to report being dissatisfied with his/her HRQL.

There are a variety of factors that have been related to quality of life in patients

with chronic illnesses. For example, research that looked at the quality of life of patients

living with HIV found that social support and problem-focused coping were significantly

associated with better HRLQ (Swindells et al., 1999). This suggests that in addition to the

direct physical and emotional impact of an illness, there are psychosocial factors that may
 62

moderate patients’ perception of their quality of life. Therefore, it is not only important to

consider the physical impact that a disease has on the patient’s life, but also thorough

consideration should be given to psychosocial factors such as support network and coping

strategies in tailoring treatment for a particular patient.

Health-related quality of life may also be affected by socioeconomic factors. In

their study that looked at the HRQL in hypertensive patients exposed to a pharmacy

intervention, Cote and colleagues (2005) found that compared to those not given the

intervention, participants in the treatment group and who had higher socioeconomic

status (SES) reported improvement in the HRQL, whereas low SES participants in the

treatment group did not report such benefits. The authors concluded that pharmacists’

interventions can have both a negative and a positive impact on the HRQL of individuals

treated with antihypertensive medication, depending on income level.

Several attempts have been made to create more comprehensive models of the

factors related to quality of life for specific chronic illnesses. In one specific example,

Stuifbergen, Brown, and Phillips (2009) examined predictors of quality of life and

disability using a comprehensive model of quality of life for people with multiple

sclerosis (see figure 4). The conceptual model included contextual factors, resources,

barriers, and health promoting behaviors as explanatory variables, while pathology,

impairment, functional limitations, and disability represented the disablement process.

The model had a significant fit, and barriers, social support, health promoting behaviors,

and functional limitations were significant predictors of quality of life.

 63

Headache and QoL. Dahlof and Solomon (1998) conceptualized HRQL as

representing the net effects of an illness and its therapy on a patient’s perception of his or

her ability to have a useful and fulfilling life. The key components of this

conceptualization are the patients’ perception of the direct effects of the illness and

his/her perception of the effects of the intervention used to remedy the illness. The

patients’ perception of his/her quality of life is dependent on the degree to which the two

domains restrict his/her ability to function normally. For headache sufferers, the

debilitating effects of both the illnesses and therapy are costly.

Studies have reported that headache sufferers have a lower health-related quality

of life than individuals with other chronic illnesses such as hypertension and diabetes

(Osterhaus, Townsend, Gandek, & Ware, 1994). Most studies that have examined the

impact of headache on HRQL have been conducted with clinical populations. These

samples tend to consist of patients with more frequent and severe headaches. Few studies

have looked at the impact of migraine on HRQL in a community sample (Lipton et al.,

2000). One study conducted in the Netherlands showed that subjects with migraine in the

community had significantly lower scores on measures of HRQL than matched control

groups (Terwindt et al., 2000). Lipton (1998) also reported a negative correlation

between headache disability in migraineurs and HRQL. As disability from headache

increased, migraineurs reported lower HRQL. These findings reflect the detrimental

impact of headaches on an individual’s ability to function as a contributing member of

society.
 64

Social Cognitive Theory

Bandura’s social cognitive theory (SCT) built on social learning theory (Miller &

Dollard, 1941), and integrated cognitive factors. The theory assertsthat social and

environmental factors influence individuals through cognitive and psychological

mechanisms (Bandura, 1986). The unique contribution of social learning theory to

understanding and explaining behavior is the “continuous reciprocal interaction between

cognitive, behavioral, and environmental determinants” (Bandura, 1977, p. vii). It was

influential in promoting the notion that people are both the products and the producers of

their environment (Bandura, 1989).

Among the important personal (or cognitive) factors outlined by Bandura that

have been frequently studied in the health literature is self-efficacy (Bandura, 1994;

Rosenstock, Strecher, & Becker, 1988; Baranowski et al., 2002). Self-efficacy is defined

as an individual’s belief in their ability to take specific actions to accomplish a certain

goal (Bandura, 1994; Rosenstock, Strecher, & Becker, 1988).

Perceived self-efficacy has been studied in relation to long-term health behaviors

and has been predictive of behaviors and outcomes in chronic illnesses such as asthma,

arthritis, chronic obstructive pulmonary disease, and diabetes (Allen, Becker, & Swank,

1991; Bandura, 1977). Research examining the relationship between health-promoting

and health-impairing behaviors and self-efficacy beliefs have found a negative

relationship between perceived self-efficacy and health-related behaviors such as

frequenting bathhouses and bars and engaging and in risky sexual practices, and a

positive relationship between perceived self efficacy and condom use in adolescents and
 65

adults (McKusick et al., 1985; DiClemente et al., 1992; Jemmott, Jemmott, & Fong,

1992; Bandura, 1994).

 66

APPENDIX B: STUDY MEASURES

 67

Demographics.

(1) What is your gender?

o Male What is your DOB__/__/__Age___
o Female
(2) What ethnic background or race do you consider yourself?
o White/Non-Hispanic
o Hispanic/Latino
o African American/Non-Hispanic
o African American-Hispanic
o Asian or Pacific Islander
o Native American
o Other__________(Specify)

(3) What is the highest grade or year of school that you have completed?

 6  7  8  9  10  11  12  13  14  15  16  17  18  19  20+
Elementary High School Trade/College Graduate School

(4) What is your current employment status? (Mark all that apply)
o Working full-time ( 35 or more hours per week)
o Working part-time ( fewer than 35 hours per week)
o Unemployed
o Student (either full or part-time
o Social Security Disability
o Applying for Social Security
o Other (Please
explain:_____________________________________)

(5) What figure is closest to your current annual income?

o $0-$20,000
o $20,001-$40,000
o $40,001-$60,000
o $60,001-$80,000
o $80,001-$100,000
o Over $100,000

(6) Do you have insurance? (Please select all that apply)

o HMO
o PPO
o Private
o SSI/SSD
o Out of pocket
 68

Headache Management Self-Efficacy Scale

Instructions: You will find below a number of statements related to headaches.

Please read each statement carefully and indicate how much you agree or
disagree with the statement by circling a number next to it. Use the following
scale as a guide.

Strongly Moderately Slightly Neither Slightly Moderately Strongly

Disagree Disagree Disagree Agree Agree Agree Agree
nor Disagree
1 2 3 4 5 6 7

(1) I can keep even a bad headache from disrupting my day

By changing the way I respond to the pain…………………….1 2 3 4 5 6 7
(2) When I’m in some situations, nothing I do will
Prevent headaches……………………………………………...1 2 3 4 5 6 7
(3) I can reduce the intensity of a headache by relaxing…………...1 2 3 4 5 6 7
(4) There are things I can do to reduce headache pain……………..1 2 3 4 5 6 7
(5) I can prevent headaches by recognizing headache triggers…….1 2 3 4 5 6 7
(6) Once I have a headache, there is nothing I can do to control it...1 2 3 4 5 6 7
(7) When I’m tense, I can prevent headaches by controlling
my tension……………………………………………………. 1234567
(8) Nothing I do reduces the pain of a headache………………... 1234567
(9) If I do certain things every day, I can reduce the number of
headaches I will have………………………………………….. 1 2 3 4 5 6 7
(10) If I can catch a headache before it begins, I can stop it………... 1 2 3 4 5 6 7
(11) Nothing I do will keep a mild headache from turning
into a bad headache……………………………………………. 1 2 3 4 5 6 7
(12) I can prevent headaches by changing how I respond to stress… 1 2 3 4 5 6 7

(13) I can do things to control how much my headaches

interferes with my life………………………………………………1 2 3 4 5 6 7
(14) I cannot control the tension that causes my headaches……………..1 2 3 4 5 6 7
(15) I can do things that will control how long a headache lasts………...1 2 3 4 5 6 7
(16) Nothing I do will keep a bad headache from disrupting my day……1 2 3 4 5 6 7
(17) When I’m not under a lot of stress, I can prevent many headaches…1 2 3 4 5 6 7
(18) When I sense a headache is coming, there is nothing
I can do to stop it…………………………………………………. 1 2 3 4 5 6 7
(19) I can keep a mild headache from disrupting my day by
changing the way I respond to the pain………………………….. 1 2 3 4 5 6 7
(20) If I am under a lot of stress, there is nothing I can do to
prevent headaches………………………………………………… 1 2 3 4 5 6 7
(21) I can do things that make a headache seem not so bad……………. 1 2 3 4 5 6 7
 69

(22) There are things I can do to prevent headaches……………………1 2 3 4 5 6 7

(23) If I am upset, there is nothing I can do to control
the pain of a headache……………………………………………..1 2 3 4 5 6 7
(24) I can control the intensity of headache pain………………………..1 2 3 4 5 6 7
(25) I can do things to cope with my headaches………………………...1 2 3 4 5 6 7
 70

Headache Specific Locus of Control

The HSLC is a 33 item questionnaire that has responses ranging from 1 (strongly
disagree) to 5 (strongly agree). The HSLC consists of 3 subscales: Health Care
Professionals Locus of Control, Internal Locus of Control, and Chance Locus of
Control
Note that to create a total I/E score items on either the Internal subscale or
on the two External subscales (Health Care Professionals & Chance) need to be
reverse scored. In previous reports using this scales items on the Internal subscale
have been reverse scored so that higher scores indicate a more external LOC.

1.Scoring the 2. Scoring the 3. Scoring the

Health Care
Professionals
subscale: calculate
the sum for items
6, 8, 10, 12, 14, 15,
16, 22, 24, 27, 30.
Internal subscale: Chance subscale:
calculate the sum calculate the sum
for items 2, 4, 5, 7, for items:
11, 17, 19, 21, 26, 1,3,9,13,18,20,
28, 32. 23,25,29,31,33.

Instructions: This is a questionnaire designed to determine the way in which

people view certain important headache-related issues. Each item is a belief
statement with which you may agree or disagree. Beside each statement are
numbers which correspond to a scale on which you may rate the extent to which
you agree or disagree with each item. The values range from "Strongly Disagree"
= 1 to "Strongly Agree" = 5. Circle the number that represents the extent to
which you disagree or agree with the statement. Please make sure that you
answer every item and that you circle only one number per item. This is a
measure of your personal beliefs; there is no right or wrong answers.
1 = Strongly Disagree
2 = Moderately Disagree
3 = Neutral
4 = Moderately Agree
5 = Strongly Agree

1. When I have a headache, there is nothing I can do to affect

its course ................................................................................................ 1 2 3 4 5

2. I can prevent some of my headaches by avoiding certain

stressful situations ................................................................................... 1 2 3 4 5

3. I am completely at the mercy of my headaches ..................................... 1 2 3 4 5

 71

4. I can prevent some of my headaches by not getting emotionally

upset ........................................................................................................ 1 2 3 4 5

5. If I remember to relax, I can avoid some of my headaches ................... 1 2 3 4 5

6. Only my doctor can give me ways to prevent my headaches ................. 1 2 3 4 5

7. My headaches are sometimes worse because I am overactive ............... 1 2 3 4 5

8. My headaches can be less severe if medical professionals

(doctors, nurses, etc.) take proper care of me ........................................ 1 2 3 4 5

9. My headaches are beyond all control ..................................................... 1 2 3 4 5

10. My doctor's treatment can help my headaches ....................................... 1 2 3 4 5

11. When I worry or ruminate about things, I am more likely to get

headaches ................................................................................................ 1 2 3 4 5

12. Just seeing my doctor helps my headaches ............................................. 1 2 3 4 5

13. No matter what I do, if I am going to get a headache, I will

get a headache ......................................................................................... 1 2 3 4 5

14. Having regular contact with my physician is the best way for
me to control my headaches .................................................................... 1 2 3 4 5

15. When I have headaches, I should consult a medically trained

professional ............................................................................................. 1 2 3 4 5

16. Following the doctor's medication regimen is the best way for
me not to be laid-up with a headache ...................................................... 1 2 3 4 5

17. When I drive myself too hard, I get headaches ....................................... 1 2 3 4 5

18. Luck plays a big part in determining how soon I will recover
from a headache ..................................................................................... 1 2 3 4 5

19. By not becoming agitated or overactive, I can prevent many

headaches ................................................................................................ 1 2 3 4 5

20. My not getting headaches is largely a matter of good fortune ................ 1 2 3 4 5

21. My actions influence whether I have headaches ..................................... 1 2 3 4 5

22. I usually recover from a headache when I get proper medical

help ......................................................................................................... 1 2 3 4 5
 72

23. I'm likely to get headaches no matter what I do ..................................... 1 2 3 4 5

24. If I don't have the right medication, my headaches will be a

problem ................................................................................................... 1 2 3 4 5

25. Often I feel that no matter what I do, I will still have headaches ........... 1 2 3 4 5

26. I am directly responsible for getting some of my headaches .................. 1 2 3 4 5

27. When my doctor makes a mistake, I am the one to suffer

with headaches ........................................................................................ 1 2 3 4 5

28. My headaches are worse when I'm coping with stress ............................ 1 2 3 4 5

29. When I get headaches, I just have to let nature run its course ................ 1 2 3 4 5

30. Health professionals keep me from getting headaches ........................... 1 2 3 4 5

31. I'm just plain lucky for a month when I don't get headaches .................. 1 2 3 4 5

32. When I have not been taking proper care of myself, I am

likely to experience headaches ................................................................ 1 2 3 4 5

33. It's a matter of fate whether I have a headache ....................................... 1 2 3 4 5

 73

Multidimensional Scale of Perceived Social Support

Instructions: Read each statement carefully. Indicate how you feel about each statement
by circling the appropriate number suing the following scale:
1 = Very strongly disagree
2 = Strongly disagree
3 = Mildly disagree
4 = Neutral
5 = Mildly agree
6 = strongly agree
7 = very strongly agree
(1) There is a special person who is around when I am in need…………1 2 3 4 5 6 7
(2) There is a special person with whom I can share joys and sorrows….1 2 3 4 5 6 7
(3) My family really tries to help me…………………………………. 1 2 3 4 5 6 7
(4) I get the emotional help and support I need from my family……... 1 2 3 4 5 6 7
(5) I have a special person who is a real source of comfort to me……. 1 2 3 4 5 6 7
(6) My friends really try to help me…………………………………... 1 2 3 4 5 6 7
(7) I can count on my friends when things go wrong……………………1 2 3 4 5 6 7
(8) I can talk about my problems with my family……………………….1 2 3 4 5 6 7
(9) I have friends with whom I can share my joys and sorrows…………1 2 3 4 5 6 7
(10) There is a special person in my life who cares about my feelings….1 2 3 4 5 6 7
(11) My family is willing to help me make decisions……………………1 2 3 4 5 6 7
(12) I can talk about my problems with my friends……………………...1 2 3 4 5 6 7
 74

Prime MD

Instructions

1. Within each module, proceed sequentially from question to question unless

instructed either to skip to another question or to EXIT from the module.
Remember: Always proceed to the next question unless you are instructed to go
elsewhere.

2. Diagnoses are boxed.

3. EXIT means to exit from the module you are in. Then proceed either to the next
module that needs to be evaluated or to the Summary Sheet on the last page.

INTRODUCTION TO PATIENT:

Now, I’ll be asking you some questions to help me understand any other symptoms you might be having. I’ll be making some notes
as we go along.

PSYCHIATRIC HISTORY:

A. Have you ever seen your doctor about difficulty with nerves, tensions, or depression?
□ If yes, what, when, how long, treatment?_______________________________
___________________________________________________________________
___________________________________________________________________
□ No

B. Do you currently have any difficulties with nerves, tension, or depression?

□ Yes, what? ______________________ (ask below questions 1,2, and 3)
□ No

If participant responded yes to question B, query for the following:

1. Has your doctor ever prescribed you tablets for this difficulty?
□ Yes, what________________ □ No

If answer yes to question 1, ask following question. If not, go to question 3.

2. Are you still currently taking medication for this problem?
□ Yes, what_________________ □ No

3. Are you currently seeing a counselor/therapist for this difficulty?

□ Yes □ No
 75

MOOD MODULE

For the last 2 weeks, have you had any of the following problems nearly every day?

1. Trouble falling or staying asleep, or sleeping too much? Yes No

2. Feeling tired or having little energy? Yes No

3. Poor appetite or overeating? Yes No

4. Little interest or pleasure in doing things? Yes No

5. Feeling down, depressed, or hopeless? Yes No

6. Feeling bad about yourself – or that you are a failure Yes No

or have let yourself or your family down?

7. Trouble concentrating on things, such as reading the Yes No

newspaper or watching television?

8. Being so fidgety or restless that you were moving

around a lot more than usual?
If no: What about the opposite – moving or Yes No
speaking so slowly that other people could have noticed?
Count as Yes if Yes to either question, or if
psychomotor agitation or retardation observed
during the interview.

9. In the last 2 weeks, have you had thoughts that you Yes No
would be better off dead or of hurting yourself in
some way? If yes: Tell me about it.

10. Are answers to five or more of #1 to #9 Yes (one of

which is #4 or #5)? Yes- No

MOOD MODULE cont.

11. Have you ever had a time when you were either much
more down or depressed, or had even less interest or
pleasure in doing things?
If yes: At that time, did you have many of the problems
that I just asked you about, like trouble sleeping,
concentrating, feeling tired, poor appetite, little
interest in things? Yes- No
Count as Yes only if, in the past, patient probably had
Five of symptoms #1 to #9 and acknowledges some
Current depressed mood or little interest or pleasure.

12. Over the last 2 years, have you often felt down or
depressed, or had little interest or pleasure in doing things?
Count Yes only if Yes to: Was that on more than Yes No-
half the days over the last 2 years?

13. In the last 2 years, has that often made it hard for you Yes- No
to do your work, take care of things at home, or get along
with other people?

14. Was major depression (including partial remission)

Diagnosed at #10 or #11? Yes- No

15. Are answers to two or more of #1 to #9 Yes (one of

 76
which is #4 or #5)? Yes- No-

16. Did a doctor ever say you were manic-depressive or

give you Lithium or Depakote? Yes- No
If yes: When was that? Do you know why?
____________________________________
____________________________________

17. Are current depressed symptoms probably due to

the biological effects of a physical disorder, Yes- No-
medication, or other drug?

ANXIETY MODULE

18. During the PAST MONTH have you had an anxiety attack
(suddenly feeling fear or panic)? Yes No-

19.You indicated that you had an anxiety attack this

month. Has this ever happened before? Yes No-

20.Does the attack sometimes come suddenly out of

the blue? If unclear: In situations where you don’t
expect to be nervous or uncomfortable? Yes No-

21.Have you worried a lot about having another attack

or worried that there was something wrong with you? Yes No-
Count as Yes if ever present.

Think about your last really bad attack.

Go to #33 as soon as you have checked four symptoms that occurred during the patient’s last bad attack.

22. ‫ ٱ‬Were you short of 26. ‫ ٱ‬Did you feel as if you 29. ‫ ٱ‬Did you feel dizzy,
breath? were choking? unsteady, or faint?

23. ‫ ٱ‬Did your heart race, 27. ‫ ٱ‬Did you have hot 30. ‫ ٱ‬Did you pound, or skip?
flashes or chills? have tingling or
numbness in part
of your body?

24. ‫ ٱ‬Did you have chest
pain or pressure?
25. ‫ ٱ‬Did you sweat?
28. ‫ ٱ‬Did you have nausea, 31. ‫ ٱ‬Did you tremble or
or an upset stomach, shake?
or the feeling that you
were going to have
diarrhea?
32. ‫ ٱ‬Were you afraid you
were dying?

33. Are four or more of #22 to #32 checked? Yes- No-

 77

ANXIETY MODULE cont.

34a. Have you felt nervous, anxious, or on edge on more

than half the days in the last month? Yes No

34b. Have you been worrying about a lot of different

things on more than half the days in the last month? Yes- No-

In the last month, have you often been bothered by any of these problems?

35. ‫ ٱ‬Feeling restless so 37. ‫ ٱ‬Muscle tension, 39. ‫ ٱ‬Trouble concentrating

that it is hard to sit aches, or soreness? on things, such as
still? reading or watching
TV?

36. ‫ ٱ‬Getting tired 38. ‫ ٱ‬Trouble falling asleep 40. ‫ ٱ‬Becoming easily
very easily? or staying asleep? annoyed or irritated?

41. Are three or more of #35 to #40 checked? Yes No-

42. In the last month, have these problems made it hard

for you to do your work, take care of things at home, Yes No-
or get along with other people?

43. In the last 6 months, have you been worrying a great

deal about different things?
Count as Yes only if also Yes to: Has this been on Yes No-
more than half the days in the last 6 months?

44. When you are worrying this way, do you find that you
can’t stop? Yes- No-

45. Has Panic Disorder or Anxiety Disorder NOS been

Diagnosed? Yes No-

46. Are current anxiety symptoms probably due to

biological effects of a physical disorder, Yes- No-
medication, or other drug?

Alcohol Module

47. Do you drink alcohol? Yes No-

During the PAST MONTH…

48. Have you thought you should cut down on your

your drinking of alcohol? Yes No

49. Has anyone complained about your drinking? Yes No

50. Have you felt guilty or upset about your drinking? Yes No

51. Was there ever a single day in which you had more
drinks of beer, wine or liquor? Yes No

52. Has a doctor ever suggested that you stop drinking

 78
because of a problem with your health? Yes No

Count as Yes if has continued to drink in the last

6 months after doctor suggested stopping.

Have any of the following happened to you more than one time in the last 6 months?

53. Were you drinking, high from alcohol, or hung over

while you were working, going to school, or taking Yes No
care of other responsibilities?

54. What about missing or being late for work, school,

or other responsibilities because you were drinking or
hung over? Yes No

55. What about having a problem getting along with other

people while you were drinking? Yes No

56. What about driving a car after having several drinks

or after drinking too much? Yes No

57. Is at least one of #48 to #52 Yes- OR- do responses

for questions #53 to #56 indicate patient has Yes- No-
probably had a significant problem with alcohol
within the past 6 months?

EATING DISORDER MODULE

58. During the PAST MONTH, have you been bothered by

your eating being out of control? Yes No-

59. Did you often eat, within any 2-hour period, what most
people would regard as an unusually large amount Yes No-
of food?
60. When you eat this way, do you often feel that you
Can’t control what or how much you eat? Yes No-

61. Has this been as often, on average, as twice a week

for the last 3 months? Yes No-

62. Do you often make yourself vomit, or take more than

twice the recommended dosage of laxatives, to avoid Yes No-
gaining weight after eating this way?

63. Has this been as often, on average, as twice a week for

for the last 3 months? Yes- No

64. Do you often fast- no eat anything at all for at least

24 hours- or exercise for more than an hour specifically Yes No-
in order to avoid gaining weight after eating this way?

65. Has this been as often, on average, as twice a week for

the last 3 months? Yes- No-

Summary Sheet

Patient ID#_________________

Summary Diagnosis
 79
Check all the diagnoses made in the modules.
‫ ٱ‬No diagnosis made in any modules

Mood

‫ٱ‬ Major Depressive Disorder (296.20)

‫ٱ‬ Partial Remission of Major Depressive Disorder (296.25)
‫ٱ‬ Dysthymia (300.4)
‫ٱ‬ Minor Depressive Disorder (311)
‫ٱ‬ R/O Bipolar Disorder ( if confirmed: 296.50)
‫ٱ‬ R/O Depressive Disorder Due to Physical Disorder, Medication, or Other Drug
(If confirmed and due to physical disorder: 293.83)
(If confirmed and due to medication or other drug: 295.84)

Anxiety

‫ٱ‬ Panic Disorder (300.01)

‫ٱ‬ Generalized Anxiety Disorder (300.02)
‫ٱ‬ Anxiety Disorder NOS (300.00)
‫ٱ‬ R/O Anxiety Disorder Due to Physical Disorder, Medication, or other Drug
(If confirmed and due to physical disorder: 293.89)
(If confirmed and due to medication or other drug: 292.89)

Alcohol

‫ ٱ‬Probable Alcohol Abuse/Dependence

(If confirmed Alcohol Abuse: 305.00)
(If confirmed Alcohol Dependence: 303.9)

Eating Disorder

‫ ٱ‬Binge Eating Disorder (307.50)

‫ ٱ‬Bulimia Nervosa, Purging Type (307.51)
‫ ٱ‬Bulimia Nervosa, Nonpurging Type (307.51)
 80

Part of a 30-Day Diary

 81

Modified Migraine Specific Quality of Life

The purpose of this scale is to identify difficulties that you may be experiencing because
of your headaches. Please circle yes, sometimes, or no to each item. Answer each item
as it pertains to your headache only.

1. Because of my headaches, I feel handicapped………………No Sometimes Yes

2. Because of my headaches, I feel restricted in

performing my routine daily activities………………………No Sometimes Yes

3. No one understands the effect that my headaches

have on my life………………………………………………No Sometimes Yes

4. I restrict my recreational activities (e.g., sports, hobbies)

because of my headaches……………………………………No Sometimes Yes

5. My headaches make me angry………………………………No Sometimes Yes

6. Sometimes I feel that I am going to lose control

because of my headaches…………………………………...No Sometimes Yes

7. Because of my headaches, I am less likely to socialize……… No Sometimes Yes

8. My spouse (significant other), or family and friends, have

no idea what I am going through because of my headaches….No Sometimes Yes

9. My headaches are so bad that I feel I am going

to go insane……………………………………………………No Sometimes Yes

10. My outlook on the world is affected by my headaches………No Sometimes Yes

11. I am afraid to go outside when I feel that a headache

is starting……………………………………………………..No Sometimes Yes

12. I feel desperate because of my headaches……………………No Sometimes Yes

13. I am concerned that I am paying penalties at work

or at home because of my headaches…………………………No Sometimes Yes

14. My headaches place stress on my relationships with

family or friends………………………………………………No Sometimes Yes

15. I avoid being around people when I have a headache…………No Sometimes Yes

16. I believe my headaches are making it difficult

 82

for me to achieve my goals in life……………………………No Sometimes Yes

17. I am unable to think clearly because of

my headaches…………………………………………………No Sometimes Yes

18. I get tense (e.g. muscle tension) because of

my headaches…………………………………………………No Sometimes Yes

19. I do not enjoy social gatherings because of

my headaches…………………………………………………No Sometimes Yes

20. I feel irritable because of my headaches………………………No Sometimes Yes

21. I avoid traveling because of my headaches…………………….No Sometimes Yes

22. My headaches make me feel confused………………………No Sometimes Yes

23. My headaches make me feel frustrated………………………No Sometimes Yes

24. I find it difficult to read because of my headaches……………No Sometimes Yes

25. I find it difficult to focus my attention away

from my headaches and on other things………………………No Sometimes Yes
 83

Headache Disability Inventory

Instructions: The purpose of this scale is to identify difficulties you may be experiencing
because of your headaches. Please circle yes, sometimes, or not to each item. Answer
each item as it pertains to your headache only.
(1) Because of my headaches, I feel handicapped……..No Sometimes Yes
(2) Because of my headaches, I feel restricted in
Performing my routine daily activities…………….... No Sometimes Yes
(3) No one understands the effect that my headaches
have on my life………………………………………. No Sometimes Yes
(4) I restrict my recreational activities (e.g., sports, hobbies)
Because of my headaches…………………………. No Sometimes Yes
(5) My headaches make me angry……………………..No Sometimes Yes
(6) Sometimes I feel that I am going to lose control
Because of my headaches…………………………. No Sometimes Yes
(7) Because of my headaches, I am
less Likely to socialize................................................. No Sometimes Yes
(8) My spouse (significant other), or family and friends, have
No idea what I am going through because
of my headaches…………………………………….… No Sometimes Yes
9. My headaches are so bad that I feel am going
to go insane………………………..……………..…No Sometimes Yes
10. My outlook on the world is
affected by my headaches…………………………..…No Sometimes Yes
(11) I am afraid to go outside when I feel that a headache
Is starting………………….…………………….. No Sometimes Yes
(12) I feel desperate because of my headaches……….No Sometimes Yes
(13) I am concerned that I am paying penalties at work
Or at home because of my headaches…………… No Sometimes Yes
(14) My headaches place stress on my relationship with
Family or friends……………………………… No Sometimes Yes
(15) I avoid being around people when I
have a headache……………………………….…… No Sometimes Yes
(16) I believe my headaches are making it difficult
For me to achieve my goals in life………………. No Sometimes Yes
(17) I am unable to think clearly because of
Headaches………………………………………. No Sometimes Yes
(18 I get tense (e.g. muscle tension) because of
My headaches……………………………………. No Sometimes Yes
(19) I do no enjoy social gathering because of my
Headaches……………………………………….. No Sometimes Yes
(20) I feel irritable because of my headaches……… No Sometimes Yes
(21) I avoid traveling because of my headaches…… No Sometimes Yes
(22) My headaches make me feel confused………… No Sometimes Yes
(23) My headaches make me feel frustrated………… No Sometimes Yes
(24) I find it difficult to read because
of my headaches……………………………..…… No Sometimes Yes
(25) I find it difficult to focus my attention away
From my headaches and on other things…………..No Sometimes Yes
 84

APPENDIX C: SUPPLEMENTAL ANALYSES

 85

Table C-1. Levels of the HSQ and All Potential Demographic, Headache Characteristic,
and Psychosocial Predictors.

Group 1 Group 2 Group 3

M SD N M SD N M SD N M SD N
Base HSQ 46.32 15.06 214 38.45 10.47 138 55.95 10.76 43 66.7 8.27 33

1 MFU 40.67 15.02 185 32.83 10.22 119 53.49 11.79 39 56.7 11.1 27

2 MFU 35.28 15.29 149 29.79 11.21 98 49.16 16.62 31 40.7 15.5 20

6 MFU 32.62 14.69 132 26.41 8.1 85 56.64 9.53 28 25 6.87 19

Freq 17.38 7.8 180 15.51 7.73 118 20.54 6.9 37 21.56 6.1 25

Severity 1.68 .39 180 1.6 .36 118 1.9 .42 37 1.73 .27 25

Freq (M) 17.38 7.0 221 15.8 7.12 140 19.87 6.2 47 20.65 5.7 32

Severity (M) 1.68 .35 221 1.61 1.12 140 1.86 .38 47 1.72 .3 32

B HSE 92.14 22.9 210 96.94 22.73 136 81.7 21.3 43 85.58 19.3 31

LOC HCP 33.49 7.8 211 33.31 7.6 137 33.24 9.5 42 34.59 6 32

LOC Int 32.19 8.5 211 32.08 7.73 136 30.44 11.9 43 35.03 6.7 32

LOC 33.68 8.5 208 31.34 8.22 134 37.91 7.5 43 37.94 7.6 31

Chance

Social Sup 5.53 8.4 214 5.81 1.12 139 5.04 1.6 43 4.97 1.73 32

SES .01 .95 207 .19 .93 135 -.38 .87 39 -.31 .9 33

Race (AA)* 37% 81 219 32 45 141 53 25 47 39 13 33

Chronic 43% 93 218 42 59 141 44 20 46 46 15 33

Migraine 72% 157 218 77 109 141 63 29 46 61 20 33

Anx Com 46% 99 214 39 53 136 56 26 47 65 20 31

Dep Com 54% 115 214 43 58 136 68 32 47 81 25 31

Age 36.76 10.1 210 36.65 10.2 136 37.39 10.9 41 36.42 9.4 33

Gender (F) 88% 190 215 91 128 141 79 34 43 91 30 33

 86

Table C-2. Results of LCGA: Model Fit Indices and Descriptions for all Headache
Specific Quality of Life Trajectory Groups.

Model Entropy BIC N Log Group Percent Group Group Quadratic

Parameters Likelihood Ns Intercept Slope Function
Linear 1 ___ 5462.8 9 -2707.1 221 ___ 44.3 -1.8
group

Linear 2 .652 5447.7 12 -2691.5 41 19 54.1 .4

groups 180 82 41.2 -2.5
Linear 3 .643 5447.89 15 -2683.5 141 64 36.4 -1.7
groups 47 21 52.9 .4
33 15 61.2 -6
Linear 4 .707 5452 18 -2677.8 125 57 34.9 -1.7
groups 39 18 60.4 -5.9
3 1 70.4 1.1
54 24 50.4 .1
Quadratic ___ 5417.02 11 -2678.8 221 ___ 46.4 -6.6 .8
1 group

Quadratic .644 5407.02 15 -2663.03 178 81 43.2 -7.2 .7

2 groups

43 19 56.4 -4.9 .8

Quadratic .679 5432.85 16 -2673.24 5 2 66.8 -31.5 4.9

3 groups
94 43 57.1 -11.4 1.3

122 55 36.8 -1.4 .1

Quadratic .666 4678.554 24 -2274.61 13 6 67.4 -17.4 2.8

4 groups
106 48 35.5 -4 .4
62 28 57.6 -14.5 1.6
40 18 49.1 1.5 -.2
 87

Table C-3: Results of Multinomial Logistic Regressions Predicting HSQ Responder

Group Membership

χ² df P val

Full Model 83.9 18 <.001

Demographics 18.65 4 .001

Race 2.53 2 .282

SES 14.14 2 .001

Clinical Characteristics 36.68 6 <.001

Frequency 15.34 2 <.001

Severity 15 2 .001

Migraine vs. TTH .246 2 .88

Clinical Characteristics (M) 37.98 6 <.001

Frequency (M) 12.92 2 .002

Severity (M) 16 2 <.001

Migraine vs. TTH 3.36 2 .187

Psychosocial Characteristics 63.82 12 <.001

Anxiety Dx 2.55 2 .280

Depression Dx 5.83 2 .054

HSE 3.36 2 .186

LOC-Chance 8.13 2 .017

LOC-Internal 3.83 2 .148

Social Support 9.61 2 .008

 88

Table C-4. Results of Multinomial Logistic Regressions: Unique Predictors

High Non-responders vs. High High- Low Moderate-responders vs. High High- Low Moderate-responders vs. High Non-
responders responders responders
Odds Wald P Odds ratio Wald p Odds ratio Wald p
Ratio

Demographics

SES 1.86 6.56 .01 .94 .04 .85 .51 8.42 .004

Race 1.15 .12 .73 .63 .93 .34 .55 2.54 .111

Clinical Characteristics

Frequency .90 9.51 <.01 .98 .34 .56 1.09 7.86 <.01

Severity .44 1.48 .22 3.51 3.11 .08 7.92 13.5 <.01

Mig vs. TTH .78 .25 .62 .84 .09 .76 1.08 .02 .88

Clinical Characteristics (Inputted Means)

Frequency .98 .41 .52 .91 8.81 <.01 .93 6.51 .01

Severity 4.15 4.02 .05 .5 1.1 .29 .12 14.43 <.01

Mig vs. TTH 1.21 .15 .70 .61 1.28 .26 .50 2.95 .09

Psychosocial Characteristics

Anxiety Dx 1.00 .00 .99 .55 1.45 .23 .54 1.89 .17

Depression Dx 1.01 .17 .68 .37 3.89 .05 .46 3.16 .08

HSE 1.00 .01 .91 1.02 2.05 .15 1.02 2.28 .13

LOC-Internal .94 3.66 .06 .96 1.58 .21 1.03 .86 .36

Social Support 1.00 .00 .99 1.47 5.71 .02 1.47 7.35 <.01
 89

Figure C-1. Actual and proposed mean values of quality of life at baseline, 1 month
follow- up, 2 month follow-up, and 6 month follow-up.