title: The role of fear of pain in headache.
abstract: BACKGROUND
  Recurrent headache sufferers are often fearful of pain, which disrupts thought processes, interferes with daily activities, and may maintain headache-related disability through avoidance and associated negative reinforcement.
  
  
  OBJECTIVE
  The aim of this cross-sectional study was to (1) examine differences in fear of pain (FOP) between headache sufferers and non-headache controls; (2) examine differences in FOP across primary headache diagnostic groups; (3) assess the extent to which FOP predicts headache variables (eg., severity, frequency, disability); and (4) determine whether FOP mediates the relationship between pain severity and headache-related disability.
  
  
  METHODS
  The sample consisted of 908 young adults (M age = 19.5 years; 64.9% female). Of those, 237 (26.1%) met the diagnostic criteria for episodic tension-type headache (TTH), 232 (25.6%) for episodic migraine (167 [18.4%] without aura and 65 [7.2%] with aura), 38 (4.2%) for chronic migraine, and 19 (2.1%) for chronic TTH; 382 (42.1%) served as non-headache controls.
  
  
  RESULTS
  FOP differed among groups, with headache sufferers reporting greater FOP than those without headache; migraineurs typically endorsed greater FOP than those with TTH. Among those with headache, FOP significantly predicted headache severity (R(2)  = 6.1%) and frequency (R(2)  = 4.5%), and accounted for more variance in disability (R(2)  = 17.5%) than gender, anxiety, and depression combined (13.8%). Pain severity and disability were strongly associated (r = 0.61, P < .001), and FOP partially mediated this association (indirect effect point estimate = 0.38; 95% confidence interval: 0.23-0.57).
  
  
  CONCLUSIONS
  FOP differentiates migraineurs from those without headache and plays a significant role in primary headache, particularly in headache-related disability. Findings build upon and extend those from previous chronic pain studies and highlight the need for longitudinal and experimental studies to further explore this construct in headache.
authors.affiliation: Department of Psychology, University of Mississippi, Oxford, MS, USA.
authors.forename: Anna Katherine
authors.initials: AK
authors.lastname: Black
authors.affiliation: Department of Psychology, University of Mississippi, Oxford, MS, USA.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Fulwiler
authors.affiliation: Department of Psychology, University of Mississippi, Oxford, MS, USA.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Smitherman
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005239:Fear / Q000523:psychology*; D005260:Female; D006261:Headache / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology*; D055815:Young Adult
keywords: disability; fear of pain; headache; mediator; migraine; tension-type headache