==== Front Cureus Cureus 2168-8184 Cureus 2168-8184 Cureus Palo Alto (CA) 10.7759/cureus.39688 Neurology Psychiatry Psychology Pain-Related Cognitive Processes, Pain Interference, and Alexithymia in Patients With Primary Headaches Muacevic Alexander Adler John R Şentürk İlteriş Ahmet 1 Aşkın Turan Suna 2 Eyigürbüz Tuğba 3 Şentürk Erman 4 Kale İçen Nilüfer 3 1 Pain Management, Bağcılar Education and Research Hospital, İstanbul, TUR 2 Pain Management, Mersin City Education and Research Hospital, Mersin, TUR 3 Neurology, Bağcılar Education and Research Hospital, İstanbul, TUR 4 Psychiatry, NP Feneryolu Medical Center, Üsküdar University, İstanbul, TUR Suna Aşkın Turan sunaaskin1@gmail.com 30 5 2023 5 2023 15 5 e3968830 5 2023 Copyright © 2023, Şentürk et al. 2023 Şentürk et al. https://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from https://www.cureus.com/articles/159547-pain-related-cognitive-processes-pain-interference-and-alexithymia-in-patients-with-primary-headaches Objectives This study aims to investigate the effects of pain-related cognitive processes (PRCPs) and emotional state on pain-related disability (PRD) and pain interference (difficulty in performing daily routines, difficulty in engaging in social activities [the enjoyment of life], and the impact on work and/or school performance) in patients with primary headaches (PHs). Methodology PRCPs were evaluated with the Pain Anxiety Symptom Scale-20 (PASS-20), Pain Catastrophizing Scale (PCS), and Pain Belief Questionnaire (PBQ). Anxiety, depression, and alexithymia were investigated to assess the emotional state. PRD was assessed by Headache Impact Test-6 (HIT-6). Health-related quality of life (HRQoL) was evaluated under three headings: daily activities (with Short Form-36 [SF-36] Question [Q] 22), social activities (with Graded Chronic Pain Scale-Revised [GCPS-R] Q 4), as well as the working ability (with GCPS-R Q 5). Two separate models were constructed to identify the factors influencing PRD and HRQoL in PHP: M1 to reveal the factors affecting PRD and M2 to determine the independent factors affecting pain interference. In both models, correlation analysis was applied first and the significant data were then evaluated with regression analysis. Results A total of 364 participants (74 healthy controls [HCs] and 290 PHPs) completed the study. In M1, the following domains were significantly associated with PRD: cognitive anxiety (β = 0.098; 95% confidence interval [CI] = 0.001-0.405; P = 0.049); helplessness (β = 0.107; 95% CI = 0.018-0.356; P = 0.031); alexithymia (β = 0.077; 95% CI = 0.005-0.116; P = 0.033); depression (β = 0.083; 95% CI = 0.014-0.011; P = 0.025). In M2, factors associated with impairment in daily activities for PHP were as follows: duration of pain, pain intensity, alexithymia, escape-avoidance response, psychological anxiety, anxiety, and poor sleep quality (R = 0.770; R2 = 0.588). The independent factors affecting social activities for PHP were pain intensity and pain-related anxiety (R = 0.90; R2 = 0.81). Independent risk factors that affected the ability to work for PHP were pain intensity, cognitive anxiety, escape-avoidance response, and pain anxiety (R = 0.90; R2 = 0.81). Conclusions This study highlights the importance of cognitive and emotional processes that help increase our understanding of the patient with PHs. This understanding may help to reduce disability and improve the quality of life in this population by helping to guide multidisciplinary treatment goals. pain-related anxiety pain-related disability alexithymia pain interference headache ==== Body pmcIntroduction The prevalence of headache disorders among adults is estimated to be about 50%, and one-third or more of these adults have migraines. Headaches that last 15 days or more a month affect 1.7% to 4% of the world’s adult population [1]. The International Headache Society (IHS) classifies headaches into the following types: primary, secondary, and painful cranial neuropathies; other facial pains; and other headaches [2]. Because of their prevalence and effects on health-related quality of life (HRQoL), primary headache disorders (PHDs) such as migraines, tension-type headaches (TTHs), and trigeminal autonomic cephalgias (TACs) are significant for public health [3]. In recent years, research on the mechanisms of chronic pain has shifted beyond focusing solely on nociception toward a broader perspective that includes pain-related cognitive (PRC), motivational, and psychiatric factors and processes that may contribute to the development and maintenance of chronic pain. These factors have been demonstrated to play a significant role in headache-related disability and/or HRQoL [4-5]​​​​​​. Pain is a subjective perceptual phenomenon that affects cognitive functions, and cognitive factors influence pain expectation and assessment [6]. The cognitive process contributes directly to one’s thoughts and experiences regarding pain (e.g., the increased neural response to pain perception and pain anticipation associated with pain-related rumination) [7]. Patients’ intense expectations about pain and the repetition of negative processes caused by pain, fear of pain, or worry about the negative consequences of pain all contribute significantly to disability [8]. The fear-avoidance model explains the relationship between pain-related anxiety and impairment [9]. Pain catastrophizing, one of the cognitive variables, refers to beliefs about pain and is a repetitive way of thinking that is associated with decreased problem-solving ability and negative effects [10]. Catastrophizing is associated with increased disability and pain severity and is an important cognitive measure and prognostic indicator in patients with chronic pain. From this perspective, it can be said that catastrophizing is one of the primary objectives of cognitive behavioral therapy for patients with headaches [11-12]. Pain-related negative beliefs, such as being convinced of the permanence of pain and regarding pain as mysterious and unexplainable, make coping with the pain more difficult [13]. Specifically, migraineurs have higher levels of harm avoidance and persistence and lower levels of self-direction [12]. Patients with PHD frequently exhibit psychiatric comorbidities, with anxiety disorders and depression being the most prevalent. Psychiatric comorbidities are associated with poorer pain management outcomes [12-14]​​​​​​. Alexithymia is a cognitive-emotional disorder that has been associated with somatosensory amplification, which is a tendency to focus on benign or neutral somatic sensations due to difficulty in experiencing and expressing emotions. It is thought that individuals with alexithymia misinterpret somatic sensations in favor of physical signs of illness, focusing on somatic manifestations of emotional arousal, and that alexithymia is associated with greater pain intensity and disability [15]. Evaluating the relationship between cognition and pain is critical for understanding chronic pain syndromes and their psychosocial effects, attaining therapeutic goals, and improving treatment outcomes [6]. People filter environmental stimuli based on the mental patterns formed by their experiences and formulate expectations accordingly, and their reactions and feelings are influenced by how events are perceived and interpreted rather than by the events themselves [16]. From this perspective, when a person has a headache, they experience emotional responses and form certain thoughts and/or images in their mind. The current study aims to determine whether there is a significant relationship between various factors such as sociodemographic data, pain characteristics (duration, frequency, intensity, etc.), pain-related cognitive process (PRCP - pain-related anxiety, catastrophic thoughts, and pain beliefs), emotional status (alexithymia, depression, and anxiety), and pain outcomes (pain disability and pain interfering with the quality of life [QoL]). Materials and methods Ethics committee Approval for the study was obtained from the Istanbul Bağcılar Training and Research Hospital Clinical Research Ethics Committee (2021.01.1.06.006). Participants For this prospective study, data were obtained from three outpatient clinics (pain medicine, headache polyclinic, and neurology) at two centers (Istanbul Bağcılar Training and Research Hospital and Istanbul Cam and Sakura City Hospital). Those who presented to the clinics with complaints of headaches for at least three months were invited to enroll in the study. The diagnosis of PH was per the International Classification of Headache Disorders, Third Edition (ICHD-3) beta [2] criteria, and psychiatric examination of the participants was conducted per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5VR) criteria [17]. All participants provided their written informed consent. Exclusion criteria were as follows: confirmed cognitive and psychological dysfunction (from examination of telemedicine records and personal history), other systemic medical disorders associated with chronic pain (e.g., rheumatoid arthritis, fibromyalgia, and cancer-related pain), head and/or neck injury, a history of substance abuse, the use of antidepressants-anxiolytic drugs for headache prophylaxis, and usage of painkillers to relieve headaches more than 10 days a month (to exclude medication overuse headaches), below 18 years old or 75 years old or more. In addition, a healthy control (HC) group was formed in the study comprising adults in comparable age groups who did not experience headaches or who had a headache fewer than three times per month that did not require treatment. The same exclusion criteria were applied to the control group. The following details were recorded: demographic information, pain characteristics, duration of pain in months, headache location, duration of the attack, the presence of aura, accompanying symptoms (nausea/vomiting, photophobia, or phonophobia), any prior treatment, and the number of days per month they took analgesics. Scales Pain Variables Pain intensity: The Numeric Rating Scale (NRS) was applied. Participants were instructed to select an integer (between 0 and 100) that most accurately described the level of pain. Scores between 50 and 70 were regarded as moderate, and those between 80 and 100 were regarded as high. Headache-related disability: Headache Impact Test-6 (HIT-6) is a six-item self-reported questionnaire used to assess headache-related disability. It assesses the impact that headaches have had on psychological, cognitive, occupational, and social functioning over the previous four weeks. Scores range from 36 to 78, and scores above 60 indicate that headache has a very serious impact on functioning [18]. Pain grading: Graded Chronic Pain Scale-Revised (GCPS-R) was used. The six-item scale is used to measure chronic pain, which is divided into three severity categories: mild (Grade 1), bothersome (Grade 2), and high impact (Grade 3). High-impact chronic pain (HICP) is characterized by persistent pain that interferes with work, social life, and self-care [19]. Pain-Related Cognitive Processes Pain-related anxiety: Pain-related anxiety was analyzed with the Pain Anxiety Symptom Scale-20 (PASS-20). This scale evaluates four aspects of pain-related anxiety: cognitive anxiety, escape/avoidance actions, fear of pain, and physiological symptoms of anxiety. PASS-20 is graded on a six-point Likert-like scale, with 0 being never and 5 being always. Higher scores indicate greater pain anxiety [20]. In our study, we utilized a five-point Likert scale (0 [never] to 4 [always]) because it was simpler to comprehend. Catastrophic thoughts. The Pain Catastrophizing Scale (PCS) was used to measure pain-related catastrophic thoughts. It consists of three subscales: helplessness (Qs 1-5 and 12), magnification (Qs 6, 7, and 13), and rumination (Qs 8-11). Using a five-point Likert scale, evaluations (0 = not at all to 4 = always) are made. It is rated from 0 to 52 points, and a higher score corresponds to a higher level of pain-related catastrophic thoughts [21]. Beliefs: The Pain Belief Questionnaire (PBQ) was utilized. This measure has two subgroups: organic beliefs and psychological beliefs. Organic beliefs evaluate the perceived source of pain as well as the perceived physical harm or physiological discomfort that threatens its control. Psychological beliefs analyze internal elements and emotions that influence pain experience. Higher scores indicate a worse perception of pain and more negative beliefs [22]. Emotional Processes Depression: The Beck Depression Inventory (BDI) is a 21-item assessment of the severity of depression. Each item is graded between 0 and 3 on a four-point Likert-like scale. Higher scores indicate more severe depressive symptoms [23]. Anxiety: The Beck Anxiety Inventory (BAI) is a 21-item scale for measuring the degree of anxiety. Each item is graded from 0 to 3 on a four-point Likert-like scale [24]. Alexithymia: Toronto Alexithymia Scale-20 (TAS-20) has three subscales: difficulty identifying feelings (DIFs), difficulty describing feelings to other people (DDF), and a stimulus-bound, externally oriented thinking (EOT) style. Alexithymia is present if the overall TAS-20 score is greater than 60, and possible alexithymia is present if the total score is between 52 and 60 [25]. QoL and Pain Interference Sleep quality: The Pittsburgh Sleep Quality Index (PSQI) is a questionnaire designed to measure sleep quality and disruptions. Scores on the PSQI vary from 0 to 21 points. A total score of 5 or higher is a sensitive and specific indicator of poor sleep quality [26]. HRQoL: The short form-36 (SF-36) was applied. It comprises eight subscales (physical function, pain, limitation due to physical problems, limitation due to emotional problems, emotional well-being, social function, energy fatigue, and general health perception). The scale provides not just a single total score but also individual scores for each of the eight subscales. Subscales assess HRQoL on a scale of 0 to 100, with 0 indicating poor and 100 indicating high HRQoL [27]. Pain interference: Pain interference was assessed in three categories: daily activities (SF-36 Q 22), social activities (GCPS-R Q 4), and working ability (GCPS-R Q 5). Allodynia Cutaneous allodynia: The 12-item Allodynia Symptom Checklist (ASC-12) is a tool used to assess cutaneous allodynia. ASC-12 scores range from 0 to 24, with 3 to 5 suggesting mild allodynia, 6 to 8 indicating moderate allodynia, and 9 and higher indicating severe allodynia [28].  In summary, standard questionnaires [29,30] were completed in this recommended order by the participants: pain frequency (SF-36 Q 21), pain intensity (NRS), pain disability (HIT-6), pain interference (SF-36, GCPS-R, and PSQI), PRCP (PASS-20, PCS, and PBQ), HRQoL (SF-36 and PSQI), emotional status (BDI, BAI, TAS-20, and SF-36), and allodynia (ASC-12) (Figure 1). Figure 1 Diagram of scales used for variables. Figure credits: All the authors of this study. aPain frequency was calculated by the SF-36 Q 21. bPain intensity was calculated with NRS. cDepression was calculated with BDI. dAnxiety was calculated with BAI. eAlexithymia was calculated with TAS-20. fDaily activities were calculated by SF-36 Q 22. gSocial activities were calculated with GCPS-R Q 4. hWorking ability with GCPS-R Q 5. M1 (red lines): Correlation analysis pathway to reveal factors affecting PRD. (To determine the factors affecting PRD PV, PRCP and ES were first evaluated in the correlation analysis and then the results of the regression analysis were revealed after the significant data.) M2 (blue lines): Correlation analysis pathway to reveal PI (The steps applied in M1 were also applied in M2). TAS-20, Toronto Alexithymia Scale-20; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; Q, question; SF-36, Short Form-36; PV, pain variables; PRCP, pain-related cognitive process; PASS-20, Pain Anxiety Symptom Scale-20; PCS, Pain Catastrophizing Scale; PBQ, Pain Belief Questionnaire; ES, emotional state; PRD, pain-related disability; HIT-6, Headache Impact Test-6; PI, pain interference; M1, Model 1; M2, Model 2; NRS, Numeric Rating Scale; GCPS-R, Graded Chronic Pain Scale-Revised Hypothesis and models We hypothesized that negative thoughts and/or images may affect current and future headache experiences, may evoke negative emotions, and may cause the individual to focus excessively on their physical limitations and pain experience, thereby increasing their pain perception. Based on this hypothesis, two models were devised: M1 to reveal factors affecting pain-related disability (PRD) and M2 to determine independent factors that affect pain interference were constructed. In both models, all variables were first evaluated by correlation analysis. Statistically significant data were then included in regression analysis. Multiple linear regression analysis was used to clarify the cause-and-effect relationship between the scales. Statistical analysis IBM SPSS version 23 (IBM Corp., Armonk, NY, USA) was used to conduct statistical analysis. The findings are presented as a sum of numbers (N) and percentages (%) or mean ± standard deviation (SD). The normality of numerical variables was examined using the Kolmogorov-Smirnov test. The Kruskal-Wallis test was used on non-normally distributed variables, and Bonferroni correction M was applied while performing the Mann-Whitney U test to determine the significance of pairwise differences. The percentages of categorical variables were compared between the groups by using the chi-square (X2) test, and post hoc analysis was done as necessary. The Mann-Whitney U test was performed to compare the variables of individuals with and without headaches. The strength of the associations between the dependent variable and several independent variables was measured using the multiple regression coefficients (R). The multiple explanatory coefficients (R2) values indicate how well the independent variable explains the dependent variable, and this was required to be high for a model to be considered adequate. The F statistic had to be significant, and the standard error (SE) of the regression equation had to be modest for the model to be considered significant. When the standard error was high, R2 was tested to determine whether the model was adequate. Results Comparison of demographic data and pain variables Of the 364 participants who completed the study, 74 (20.3%) were HCs. In 290 PHPs, chronic migraine (CM) (76, or 20.8%) and episodic migraine without aura (EMWOA) (57, or 15.6%) were the most common diagnoses. Table 1 summarizes the comparisons between PHP and HCs in terms of demographic data and pain variables. Demographic Data There was a statistical difference between patients with primary trigeminal neuralgia (pTN) and the other groups in terms of mean age and age groups (X2 = 33.29; P < 0.001). The proportion of male participants was higher in the TAC group (X2 = 22.7; P = 0.002). In terms of employment, marital status, and the presence of chronic disease, there was a statistical difference between pTN patients and other groups (P < 0.050). There were no differences between the groups in other demographic data. Pain Variables Participants with headaches reported a mean pain duration of 74.79 ± 91.31 months of pain, and HCs reported a mean duration of 4.51 ± 10.92 months of pain (Z = −11,707; P < 0.001). Pain disability and intensity: A long disease duration and high headache frequency were significantly associated with headache-related disability (r = 0.550; P < 0.001). The PHP group had a pain intensity on the NRS of 7.18 ± 2.06, and the HCs had a pain intensity of 1.71 ± 1.64 (Z = −12.538; P < 0.001). In the PHP, the calculation of PRD was 63.82 ± 7.57, and 121 (33.2%) participants reported having very severe headaches. As expected, the pain load was higher in PHPs compared to the control group. Pain interference: Daily activities (SF-36 Q 22) scores were 47.32 ± 25.46 for the PHP group and 85.81 ± 20.30 for HCs (Z = −10.074; P < 0.001). The social activities (GCPS-R Q 4) score was 6.72 ± 2.74 in PHPs and 1.8 ± 2.25 in HCs (Z = −10.678; P < 0.001). Working ability (GCPS-R Q 5) scores were 6.63 ± 2.72 in the PHP group and 1.66 ± 1.98 in HCs (Z = −11.098; P < 0.001). Sleep quality scores were 8.28 ± 3.62 in the PHP group and 4.93 ± 2.39 in HCs (Z = −7.413; P < 0.001) (data not shown in Table 1). Table 1 Demographic characteristics of the participants. Values are presented as mean ± standard deviation or number (%). aBMI calculated using the formula kg/m2. bThe period from the beginning of the complaints to the present (months). cPain intensity was calculated by the NRS. dPain-related disability was calculated by HIT-6. ePain interference was evaluated under four headings: daily activities with SF-36 Q 22; social activities with GCPS-R Q 4; working ability with GCPS-R Q 5; sleep quality with PSQI. fAllodynia was calculated by ASC-12. ASC-12, Allodynia Symptom Checklist-12; SF-36, Short Form-36; HC, healthy control; EMWA, episodic migraine with aura; EMWOA, episodic migraine without aura; CM, chronic migraine; ETTH, episodic tension-type headache; CTTH, chronic tension-type headache; pTN, primary trigeminal neuralgia; TOS, trigeminal autonomic cephalgia; BMI, body mass index; DM, diabetes mellitus; HT, hypertension; TD, thyroid dysfunction; CAD, coronary artery disease; NRS, numeric rating scale; HIT-6, Headache Impact Test-6; Q, question; GCPS-R, Graded Chronic Pain Scale-Revised; PSQI, Pittsburgh Sleep Quality Index   HC (n = 74) EMWA (n = 31) EMWOA (n = 57) CM (n = 76) ETTH (n = 35) CTTH (n = 41) pTN (n = 21) TOS (n = 29) X2 P Age (years) 38 ± 11.34 35.96 ± 10.35  36.91 ± 10.68 38.72 ± 13.03  33.80 ± 12.48  40.85 ± 11.63  58.90 ± 17.19  36.72 ± 11.05 33.296 0.001 Age range (years) 18-35 30 (40.5%) 14 (45.2%) 21 (36.8%) 29 (38.2%) 19 (54.3%) 10 (24.4%) 3 (14.3%) 14 (48.3%) 39.106 0.001 35-50 34 (45.9%) 13 (41.9%) 30 (52.6%) 31 (40.8%) 12 (34.3%) 21 (51.2%) 4 (19%) 8 (27.6%) 50-65 9 (12.2%) 4 (11.9%) 6 (10.5%) 14 (18.4%) 4 (11.4%) 8 (19.5%) 3 (14.3%) 7 (24.1%) ≥65 1 (1.4%) 0 (0%) 0 (0%) 2 (2.6%) 0 (0%) 2 (4.9%) 11 (52.4%) 0 (0%) Gender Women 41 (55.4%) 22 (71%) 45 (78.9%) 60 (78.9%) 28 (80%) 29 (70.7%) 14 (66.7%) 13 (44.8%) 22.7 0.002 Men 33 (44.6%) 9 (29%) 12 (21.1%) 16 (21.1%) 7 (20%) 12 (29.3%) 7(33.3%) 16 (55.2%) BMIa 24.14 ± 4.41 25.63 ± 4.65 25.92 ± 5.43 24.65 ± 4.63 25.68 ± 5.25 26.91 ± 4.95 26.38 ± 5.67 24.13 ± 4.44 12.785 0.078 Working status Working 52 (70.3%) 12 (38.7%) 28 (49.1%) 28 (36.8%) 15 (42.9%) 17 (41.5%) 3 (14.3%) 19 (65.5%) 109.607 0.001 Left job 3 (4.1%) 6 (19.4%) 9 (15.8%) 9 (11.8%) 4 (11.4%) 11 (26.8%) 3 (14.3%) 2 (6.9%) Never 10 (13.5%) 11 (35.5%) 17 (29.8%) 27 (35.5%) 14 (40%) 10 (24.4%) 6 (28.6%) 3 (10.3%) Retired 3 (4.1%) 1 (3.2%) 1 (1.8%) 4 (5.3%) 0 (0%) 2 (4.9%) 9 (42.9%) 4 (13.8%) Student 6 (8.1%) 1 (3.2%) 2 (3.5%) 8 (10.5%) 2 (5.7%) 1 (2.4%) 0 (0%) 1 (3.4%) Education level Course 3 (4.1%) 2 (6.5%) 3 (5.3%) 3 (3.9%) 1 (2.9%) 3 (7.3%) 4 (19%) 0 (0%) 50.642 0.055 Primary 8 (10.8%) 8 (25.8%) 18 (31.6%) 20 (26.3%) 10 (28.6%) 11 (26.8%) 5 (23.8%) 3 (10.3%) Middle school   7 (9.5%) 5 (16.1%) 6 (10.5%) 11 (14.5%) 4 (11.4%) 7 (17.1%) 4 (19%) 1 (3.4%) High school   17 (23%) 8 (25.8%) 13 (22.8%) 26 (34.2%) 11 (31.4%) 13 (31.7%) 4 (19%) 14 (48.3%) University 39 (52.7) 8 (25.8) 17 (29.8%) 16 (21.1) 9 (25.7) 7 (17.1) 4 (19%) 11 (37.9%) Marital status Single 24 (32.4%) 10 (32.3%) 15 (26.3%) 20 (26.3%) 14 (40%) 9 (22%) 1 (4.8%) 14 (48.3%) 51.152 0.005 Married 44 (59.5%) 21 (67.7%) 37 (64.9%) 51 (67.1%) 18 (51.4%) 27 (65.9%) 16 (76.2%) 15 (51.7%) Widow 1 (1.4%) 0 (0%) 2 (3.5%) 3 (3.9%) 1 (2.9%) 3 (7.3%) 4 (19%) 0 (0%) Divorced 5 (6.8%) 0 (0%) 2 (3.5%) 2 (2.6%) 0 (0%) 2 (4.9%) 0 (0%) 0 (0%) Living together 0 (0%) 0 (0%) 1 (1.8%) 0 (0%) 2 (5.7%) 0 (0%) 0 (0%) 0 (0%) Chronic diseases None 57 (77%) 17 (54.8%) 35 (61.4%) 44 (57.9%) 25 (71.4%) 27 (65.9%) 8 (38.1%) 22 (75.9%) 105.391 0.001 DM 5 (6.8%) 3 (9.7%) 1 (1.8%) 2 (2.6%) 3 (8.6%) 4 (9.8%) 2 (9.5%) 0 (0) HT 5 (6.8%) 1 (3.2%) 1 (1.8%) 8 (10.5%) 2 (5.7%) 1 (2.4%) 9 (42.9%) 2 (6.9%) TD 0 (0%) 1 (3.2%) 9 (15.8%) 4 (5.3%) 3 (8.6%) 1 (2.4%) 1 (4.8%) 1 (3.4%) CAD 2 (2.7%) 0 (0%) 2 (3.5%) 4 (5.3%) 1 (2.9%) 1 (2.4%) 0 (0%) 0 (0%) Asthma 1 (1.4%) 2 (6.5%) 6 (10.5%) 6 (7.9%) 0 (0%) 2 (4.9%) 1 (4.8%) 1 (3.4%) COPD 0 (0%) 0 (0%) 1 (1.8%) 2 (2.6%) 0 (0%) 1 (2.4%) 0 (0%) 2 (6.9%) Others 4 (5.4) 7 (22.6) 2 (3.5) 6 (7.9) 1 (2.9) 4 (9.8) 0 (0) 1 (3.4) Smoking (Yes) 36 (48.6%) 11 (35.5%) 11 (19.3%) 23 (30.3%) 9 (25.7%) 16 (39%) 9 (42.9%) 12 (41.4%) 15.717 0.028 Pain durationb 4.51 ± 10.92 90.00 ± 93.10 98.86 ± 105.67 95.52 ± 105.53 46.08 ± 57.59 60.77 ± 94.38 44.76 ± 55.34 37.37 ± 37.63 148.741 0.001 Pain intensityc (Total) 1.71 ± 1.64 7.70 ± 1.14 6.45 ± 2.08 7.92 ± 1.75 5.25 ± 2.13 7.54 ± 1.65 8.04 ± 1.90 7.62 ± 2.19 194.274 0.001 Pain disabilityd (Total) 42.12 ± 7.93 64.60 ± 6.33 64.94 ± 5.43 66.13 ± 8.10 60.51 ± 6.39 65.20 ± 9.26 61.47 ± 5.78 59.44 ± 7.85 172.093 0.001 Pain interferencee Daily activities 85.81 ± 20.30 39.16 ± 23.38 52.63 ± 20.42 42.75 ± 24.78 58.57 ± 24.95 51.42 ± 24.95 46.42 ± 26.55 42.24 ± 30.69 115.077 0.001 Social activities 1.83 ± 2.25 7.16 ± 1.78 6.07 ± 2.72 7.21 ± 2.73 5.05 ± 2.42 7.14 ± 2.57 7.33 ± 3.41 8.00 ± 2.03 135.077 0.001 Working ability 1.66 ± 1.98 7.60 ± 1.71 5.75 ± 2.80 7.07 ± 2.56 4.85 ± 2.85 6.97 ± 2.53 7.66 ± 2.61 7.62 ± 2.36 147.886 0.001 Sleep quality 4.93 ± 2.39 7.80 ± 2.70 7.80 ± 3.54 8.71 ± 3.74 7.02 ± 3.13 8.00 ± 3.91 8.76 ± 3.92 9.75 ± 3.95 65.500 0.001 Allodyniaf (Total) 1.23 ± 2.67 3.06 ± 4.11 2.17 ± 3.00 3.65 ± 4.66 0.91 ± 1.59 1.42 ± 2.03 2.47 ± 3.98 1.79 ± 3.21 28.593 0.001 Comparison of PRCPs and emotional status Table 2 summarizes the relationship between PRCPs and emotional status. Table 2 Assessment of the cognitive process. Values are presented as mean ± standard deviation. aPain-related catastrophizing thoughts were calculated with PCS. bPain-related anxiety was calculated with PASS-20. cPain beliefs were calculated with PBQ. dAnxiety was calculated with BAI. eDepression was calculated with BDI. fAlexithymia was calculated with TAS-20. gMental health was calculated with SF-36. hEmotional role difficulty was calculated with the SF-36. TAS-20, Toronto Alexithymia Scale-20; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; PBQ, Pain Beliefs Questionnaire; SF-36, Short Form-36; PASS-20, Pain Anxiety Symptom Scale-20; PCS, Pain Catastrophizing Scale; HC, healthy control; EMWA, episodic migraine with aura; EMWOA, episodic migraine without aura; CM, chronic migraine; ETTH, episodic tension-type headache; CTTH, chronic tension-type headache; pTN, primary trigeminal neuralgia; TOS, trigeminal autonomic cephalgia   HC (n = 74) EMWA (n = 31) EMWOA (n = 57) CM (n = 76) ETTH (n = 35) CTTH (n = 41) pTN (n = 21) TOS (n = 29) X2 P Pain-related catastrophizing thoughtsa Rumination 3.36 ± 3.53 9.41 ± 4.35 8.91 ± 4.55 10.43 ± 4.45 6.34 ± 4.60 9.80 ± 4.32 11.66 ± 2.74 9.89 ± 4.26 107.764 0.001 Magnification 2.16 ± 2.04 5.54 ± 2.71 5.45 ± 2.98 6.55 ± 2.85 3.62 ± 2.52 5.14 ± 2.83 7.57 ± 1.83 6.34 ± 2.68 115.056 0.001 Helplessness 3.97 ± 3.51 11.38 ± 5.59 11.31 ± 5.81 14.14 ± 6.22 7.88 ± 6.02 12.14 ± 6.46 14.85 ± 4.09 13.55 ± 5.85 126.305 0.001 Total 9.50 ± 8.14 26.35 ± 11.16 25.68 ± 12.23 31.13 ± 12.40 17.85 ± 11.91 27.09 ± 12.31 34.09 ± 6.92 29.79 ± 10.78 134.044 0.001 Pain-related anxietyb Cognitive anxiety 5.00 ± 4.34 12.38 ± 4.22 12.28 ± 4.50 12.80 ± 4.82 9.37 ± 4.86 12.36 ± 4.65 13.66 ± 5.14 13.44 ± 5.25 107.179 0.001 Fear 3.25 ± 3.47 8.83 ± 4.49 8.82 ± 4.79 10.38 ± 4.83 6.22 ± 4.08 9.56 ± 4.07 13.61 ± 4.87 12.79 ± 5.12 127.933 0.001 Physiological anxiety 1.55 ± 2.39 7.96 ± 4.42 6.10 ± 5.12 8.65 ± 5.34 3.97 ± 3.76 6.07 ± 4.60 11.85 ± 5.08 10.31 ± 6.11 128.181 0.001 Escape avoidance 6.54 ± 4.76 12.38 ± 4.46 12.17 ± 3.71 11.80 ± 4.84 9.37 ± 4.79 11.56 ± 4.48 14.38 ± 4.00 13.24 ± 4.34 78.665 0.001 Total 16.35 ± 12.30 41.58 ± 13.26 39.38 ± 13.77 43.64 ± 15.00 28.94 ± 14.12 39.56 ± 13.31 53.52 ± 15.57 49.79 ± 17.23 145.693 0.001 Pain beliefsc Organic beliefs 25.32 ± 7.01 21.03 ± 4.58 21.86 ± 6.20 20.35 ± 6.27 23.80 ± 5.94 20.29 ± 6.22 18.42 ± 4.63 19.24 ± 4.86 40.672 0.001 Psychogenic beliefs 9.75 ± 4.85 9.16 ± 3.05 8.36 ± 3.90 8.46 ± 3.80 9.28 ± 3.82 9.31 ± 3.74 8.61 ± 3.20 9.58 ± 3.31 6.385 0.496 Anxietyd (Total) 8.64 ± 6.26 22.12 ± 14.24  18.03 ± 12.75  23.69 ± 14.20  14.94 ± 9.36  18.46 ± 12.97 19.04 ± 14.18  17.41 ± 10.19 60.602 0.001 Depressione (Total) 9.14 ± 5.40 16.61 ± 10.47 13.49 ± 10.06  20.36 ± 11.14  16.54 ± 12.37  17.80 ± 8.80 25.09 ± 12.31  23.10 ± 11.04  71.620 0.001 Alexithymiaf Difficulty describing feelings 10.41 ± 3.79 12.12 ± 3.94 11.94 ± 3.40 13.06 ± 4.18 11.42 ± 3.55 12.36 ± 3.20 10.00 ± 2.60 9.34 ± 3.07 35.546 0.001 Difficulty identifying feelings 12.95 ± 5.44 16.48 ± 6.75 14.84 ± 5.60 18.07 ± 6.76 14.82 ± 6.11 17.39 ± 6.32 12.71 ± 3.93 13.13 ± 4.96 39.830 0.001 Externally oriented thinking 19.45 ± 8.22 19.96 ± 6.17 19.45 ± 6.88 22.30 ± 6.58 21.11 ± 6.18 20.56 ± 5.70 16.09 ± 5.12 15.20 ± 4.78 33.030 0.001 Total 42.83 ± 15.46 48.58 ± 14.56 46.24 ± 13.45 53.44 ± 15.43 47.37 ± 13.13 50.31 ± 12.91 38.81 ± 9.85 37.69 ± 11.95 41.949 0.001 Mental healthg 66.64 ± 19.00 45.41 ± 13.56  50.59 ± 19.67  46.71 ± 17.82  49.37 ± 18.76 48.58 ± 18.40  47.81 ± 17.36  45.51 ± 13.62  56.139 0.001 Emotional role difficultyh 74.77 ± 36.93 44.08 ± 44.21 49.70 ± 39.40 39.47 ± 39.14 60.95 ± 39.17 50.44 ± 42.84 41.36 ± 42.02 36.78 ± 36.01 37.455 0.001 Pain-Related Cognitive Processes Catastrophic thoughts: In this category, the helplessness score was 12.24 ± 6.21 in the PHP group and 3.97 ± 3.51 in HCs (Z = −9.904; P < 0.001). The PCS total scores were 27.45 ± 12.38 in the PHP group and 9.50 ± 8.14 in HCs (Z = −10.143; P < 0.001). Pain-related anxiety: Cognitive anxiety was scored as 12.30 ± 4.84 in the PHP group and 5.00 ± 4.34 in HCs (Z = −9.640; P < 0.001). The score for fear of pain was 9.76 ± 4.99 in the PHP group and 3.2 (SD = 3.47) in HCs (Z = −9.575; P < 0.001). The total pain-related anxiety scores for PHP were 41.56 ± 15.68 and 16.35 ± 12.35 for HCs (Z = −10.549; P < 0.001). Pain-related beliefs: There was a significant difference between the group with PH and HCs with respect to pain-related organic beliefs (Z = −5.09; P < 0.001). However, there was no significant difference in terms of psychogenic beliefs between the groups (P = 0.393). Emotional Status As expected, scores for general anxiety and depression were greater in the PHP group than in HCs. In terms of anxiety, the PHP group scored 19.65 ± 13.09 and the HCs group scored 8.64 ± 6.26 (Z = −7.019; P < 0.001). For depression, the PHP group scored 18.40 ± 11.24, while the HCs group scored 9.14 ± 5.40 (Z = −6.622; P < 0.001). Differences were observed in the evaluation of alexithymia between PHP and HCs: for DDF, between CM and HCs (X2 = 35.546; P < 0.050 by post hoc tests); for DIF (all the above acronyms not previously defined), between CM and HCs (X2 = 39.830; P < 0.050 by post hoc tests); for EOT, between TACs and HCs (X2 = 33.030; P < 0.050 by post hoc tests); and total scores, between CM and HCs (X2 = 41.949; P < 0.050 by post hoc tests). There was no significant difference in the EOT subscale for the assessment of alexithymia between the PHP and HCs groups (P = 0.902). There was a significant difference between PHP and HCs for mental health (SF-36; Z = −7.286; P < 0.001), while for emotional role difficulty, there was a significant difference between HCs and EMWA, HCs and CM, and HCs and TAC patients (P < 0.050 with post hoc tests). Hypothesis and models Some data such as age, pain frequency, attack duration, and pain beliefs were not included in the models as only data that were significant in the preliminary correlation analysis were used in the regression modeling. Model 1 The regression model of M1 was generated using the stepwise technique with the data that were significant in the correlation analysis, and M1 was significant (F = 4.47; P = 0.350; D-W value = 1.99). In the results of the regression analysis, a significant positive correlation was found in the variables indicated for PRD: BMI (β = 0.079; 95% confidence interval [CI] = 0.026-0.341; P = 0.022), pain duration (β = 0.126; 95% CI = 0.008-0.027; P < 0.001), pain intensity (β = 0.366; 95% CI = 1.039-1.832; P < 0.001), cognitive anxiety (β = 0.098; 95% CI = 0.001-0.405; P = 0.049), helplessness (β = 0.107; 95% CI = 0.018-0.356; P = 0.031), alexithymia (total) (β = 0.077; 95% CI = 0.005-0.116; P = 0.033), depression (β = 0.083; 95% CI = 0.014-0.011; P = 0.025), and sleep latency (β = 0.084; 95% CI = 0.185-1.824; P = 0.016). A negative connection was observed between general health perception and PRD (β = −0.083; 95% CI = −0.089 to −0.003; P = 0.035; R = 0.80) (Table 3). Table 3 The effects of sociodemographic data, pain characteristics, pain-related cognitive processes, and alexithymia on pain-related disability. aBMI calculated using the formula kg/m2. bThe period from the beginning of the complaints to the present (months). cPain intensity was calculated by NRS. dCognitive anxiety is a subscale of PASS-20. eHelplessness is a subscale of PCS. fAlexithymia was calculated with TAS-20. gDepression was calculated with BDI. hGeneral health was calculated with SF-36. iSleep latency was calculated with PSQI. NRS, Numeric Rating Scale; TAS-20, Toronto Alexithymia Scale-20; BDI, Beck Depression Inventory; SF-36, Short Form-36; PASS-20, Pain Anxiety Symptom Scale-20; PCS, Pain Catastrophizing Scale; PSQI, Pittsburgh Sleep Quality Index; CI, confidence interval; β, beta; BMI, body mass index   Unstandardized coefficients Standardized coefficients t P 95% CI for B   B SE β     Lower bound Upper bound Constant 39.171 2.253   17.383 0.001 34.739 43.603 BMIa 0.184 0.080 0.079 2.293 0.022 0.026 0.341 Pain durationb 0.017 0.005 0.126 3.650 0.001 0.008 0.027 Pain intensityc 1.435 0.202 0.366 7.117 0.001 1.039 1.832 Cognitive anxietyd 0.203 0.103 0.098 1.975 0.049 0.001 0.405 Helplessnesse 0.187 0.086 0.107 2.171 0.031 0.018 0.356 Alexithymief (total) 0.060 0.028 0.077 2.146 0.033 0.005 0.116 Depressiong 0.088 0.039 0.083 2.252 0.025 0.164 0.011 General healthh –0.046 0.022 –0.083 –2.114 0.035 –0.089 –0.003 Sleep latencyi 1.004 0.417 0.084 2.411 0.016 0.185 1.824 Model 2 The same procedure was followed for pain interference, and a regression analysis model was created for M2. Simple linear regression analysis results for social activities were significant (F = 4.57; P = 0.033; D-W value = 2.15). Social activities: Between pain intensity and social activities (β = 0.208; 95% CI = 0.143-0.321; P < 0.001) and between pain-related anxiety (total) and social activities (β = 0.066; 95% CI = 0.001-0.023; P = 0.033), there were significant positive associations (R = 0.90; R2 = 0.81). Working ability: Regression analysis results for workability were significant (F = 4.95; P = 0.027; D-W value = 1.86). Positive correlations for workability were observed for the following: pain intensity (β = 0.154; 95% CI = 0.083-0.259; P < 0.001), cognitive anxiety (β = 0.091; 95% CI = 0.001-0.107; P = 0.048), escape-avoidance response (β = 0.100; 95% CI = 0.010-0.119; P = 0.019), and pain anxiety (total) (β = 0.127; 95% CI = 0.012-0.034; P < 0.001). There was a negative correlation between social functioning and workability (β = −0.056; 95% CI = −0.014 to −0.001; P = 0.027; R = 0.90; R2 = 0.81). Daily activities: Regression analysis model results within daily activities were significant (F = 4.52; P = 0.004; D-W value = 2.10). Significant negative correlations for daily activities were found for the following: pain duration (β = −0.098; 95% CI = −0.060 to −0.010; P = 0.006), pain intensity (β = −0.165; 95% CI = −0.845 to −2.564; P < 0.001 ), alexithymia (β = −0.085; 95% CI = −0.332 to −0.021; P = 0.026), escape-avoidance response (β = −0.204; 95% CI = −1.709 to −0.738; P < 0.001), psychological anxiety (β = −0.186; 95% CI = −0.523 to −1.543; P = < 0.001), anxiety (β = −.130; 95% CI = −0.515 to −0.106; P = 0.003), and sleep quality (β = −0.100; 95% CI = −6.077 to −1.258; P = 0.003; R = 0.770; R2 = 0.588) (Table 4). Table 4 Relationships between sociodemographic data, pain characteristics, pain-related cognitive processes and, emotional state with pain interference. aPain intensity was calculated with NRS. bPain anxiety was calculated with PASS-20. cCognitive anxiety is a subscale of PASS-20. dEscape is a subscale of PASS-20. eSocial functioning was calculated with SF-36. fThe period from the beginning of the complaints to the present (months). gAlexithymia was calculated with TAS-20. hPsychological anxiety is a subscale of PASS-20. iAnxiety was calculated with BAI. jSleep quality with PSQI. NRS, Numeric Rating Scale; TAS-20, Toronto Alexithymia Scale-20; BAI, Beck Anxiety Inventory; SF-36, Short Form-36; PASS-20, Pain Anxiety Symptom Scale-20; PCS, Pain Catastrophizing Scale; PSQI, Pittsburgh Sleep Quality Index; CI, confidence interval; β, beta   Unstandardized coefficients Standardized coefficients t P 95% CI for B   B SE β     Lower Bound Upper Bound Social activities Constant –0.124 0.188   –0.659 0.510 –0.494 0.246 Pain intensitya 0.232 0.045 0.208 5.110 0.001 0.143 0.321 Pain anxietyb 0.012 0.006 0.066 2.139 0.033 0.001 0.023 Working ability Constant 0.309 0.335   0.923 0.357 –0.349 0.967 Pain intensity 0.171 0.045 0.154 3.812 0.001 0.083 0.259 Cognitive anxietyc 0.054 0.027 0.091 1.983 0.048 0 0.107 Pain anxiety (total) 0.023 0.006 0.127 4.117 0.001 0.012 0.034 Escaped 0.065 0.027 0.100 2.348 0.019 0.010 0.119 Social functioninge –0.007 0.003 –0.056 –2.224 0.027 –0.014 –0.001 Daily activities Constant 7.462 6.538   1.141 0.255 –5.396 20.321 Pain durationf –0.035 0.013 –0.098 –2.747 0.006 –0.060 –0.010 Pain intensity –1.704 0.437 –0.165 –3.901 0.001 –0.845 –2.564 Alexithymieg (total) –0.177 0.079 –0.085 –2.235 0.026 –0.332 –0.021 Escape –1.224 0.247 –0.204 –4.958 0.001 –1.709 –0.738 Psychological anxietyh –1.033 0.259 –0.186 3.986 0.001 –0.523 –1.543 Anxietyi –0.310 0.104 –0.130 –2.989 0.003 –0.515 –0.106 Sleep qualityj –3.668 1.225 –0.100 –2.994 0.003 –6.077 –1.258 Discussion This prospective study, conducted in headache and pain outpatient clinics in two distinct centers in Turkey, analyzed pain characteristics, PRCPs, and emotional status in PHPs in comparison to the control group and determined the effects of these variables on PRD and HRQoL. Comparison of patients with PHs and HCs As predicted [31], the mean age of patients with pTN was higher than that of other groups; therefore, the proportion of retirees, the marriage rate, and the presence of comorbidities differed between those with pTN and other groups. Again, the ratio of men to women was greater in the TAC group. Other sociodemographic parameters did not show significant differences between other diagnostic categories, which may be a result of the relative homogeneity of these groups. There was a statistically significant difference between the PHP and the control group in terms of pain characteristics (duration, frequency, intensity, and disability), PRCP (all subscales and total scores except psychogenic pain beliefs), emotional status (depression, anxiety, and alexithymia), and HRQoL. These findings support earlier research [32-36]. Interestingly, in our study, we found a difference between patients with TACs and HCs for EOT, while there was only a difference between patients with CM and the control group for subscales of alexithymia other than EOT (DDF and DIF) and alexithymia total scores. Recent research has found that the effects of the EOT subscale were either less pronounced or non-existent compared to those of other alexithymia subscales [15]. The authors hypothesized that this was due to the poor psychometric qualities of the EOT, particularly for non-Western cultures. In addition, they suggested that chronic pain and DIF may be more closely related. We were unable to draw any comparisons because there is no study in the literature analyzing EOT in a group with TACs. Our opinion is that more research is required to assess scales for the traits of alexithymia in PHPs. Determination of factors affecting PRD and pain interference in patients with PHs We developed two separate models (M1 and M2). HIT-6 was used to assess headache-related disability for M1. HIT-6 assesses the likelihood that social functioning, role function, vitality, cognitive functioning, and psychological distress are characteristics that may influence headache frequency and intensity [18,37].  Pain interference is a measurement of the degree to which pain interferes with physical, cognitive, emotional, and recreational activities, as well as enjoyment of life [38]. In this context, the dependent variables for M2 are daily activities, social activities, and working ability. Previous studies have found different results for BMI and headache disability, emphasizing that associations should be supported by larger studies [39-40]. We found only BMI as an independent risk factor for disability among sociodemographic data in M1. Pain behavior, disability, and general psychological distress may increase as pain progresses from the acute phase to the chronic phase. On the other hand, adjustment to pain and disability may occur over time [41]. There are conflicting results in the literature regarding relationships between pain duration (story) and PRD and pain interference [42-43]. We found pain duration to be an independent risk factor for PRD in M1 and daily activities in M2. The effects of high pain intensity on disability and pain experience were investigated, and its possible contribution to pain management was emphasized because baseline pain intensity is amenable to intervention [44-45].  Increased pain intensity is associated with increased healthcare burden and costs, in addition to worsening HRQoL [46]. The primary goal of pain management is to increase physical function while reducing pain [36]. In our regression models (M1 and M2), pain intensity was one of the strongest predictors of PRD and pain interference. We draw attention to basic pain intensity as it is manageable (measures and treatment methods). Sleep disturbance is common in PHPs, and there are associations between poor sleep quality and pain disability [47]. We found a relationship between sleep latency and disability. Sleep latency is the technical term for the length of time it takes to fall asleep. Sleep latency was found to be normal or longer in migraine patients compared to the normal population [48]. It would be appropriate to compare our data in further studies with larger samples. Those who attribute more meaning to their pain and have intense anxiety about their pain may show higher levels of disability. Such thought processes can be modified in psychotherapeutic interventions [49]. The fear-avoidance model explains how pain-related anxiety contributes to disability [9]. Pain-related anxiety symptoms are more consistent for disability in patients with chronic pain than general anxiety symptoms [50]. In this study, we showed that not general anxiety but cognitive anxiety (difficulty concentrating on other things), which is one of the PASS-20 subscales, contributes to the development of headache-related disability and is associated with the ability to work. Cognitive anxiety was shown to be the most important determinant of the fear-response pattern in patients with chronic low back pain [51]. The authors suggested that the cognitive anxiety scale could help identify patients who may benefit from exposure treatment for back pain. Cognitive processes encompass the thoughts, beliefs, attributions, and attitudes someone may experience. Cognitions influence whether a patient engages in behaviors that reduce the likelihood of a headache attack, treatment adherence, how they cope with a headache attack, and consequently headache-related disability [32]. The fact that cognitive anxiety resulting from headache-related cognitive distortions is the most important predictor of headache-related disability in this study reinforces the importance of restructuring unrealistic beliefs in routine treatment. Cognitive distortions about headache management and treatment can be replaced by more realistic beliefs with cognitive restructuring, and then possible maladaptive behaviors are reorganized. Thus, individuals would be preoccupied with learning more adaptive ways of managing headaches rather than with unattainable goals like eradicating such beliefs. Behavioral therapy is suggested to be as effective as pharmacological treatments, not only for the treatment of headaches but also for maintaining a lifelong response to headache treatment, and it is effective in reducing anxiety sensitivity and decreasing anxiety related to pain sensations [52]. Especially in migraineurs, catastrophic thoughts appear to be an indicator of dysfunction and lower quality of life, independent of other psychological variables (such as anxiety and depression) [12]. We identified helplessness from catastrophizing thoughts as one indicator of PRD. Helplessness reflects the inability to cope with pain, and its important (compared to other subscales of the PCS) role between pain and disability levels has been emphasized [44,53]. Another interesting finding in our study is that alexithymia is more effective than anxiety for headache-related disability. The coexistence of chronic pain and depression is common; alexithymia is also significantly associated with depression and may predispose to depression, and depression may mediate chronic pain and alexithymia [54].  Although we observed that alexithymia and depression are risk factors for PRD, whether depression mediates alexithymia was not evaluated in this study. Pain-related anxiety contributes significantly to the functional limitations of those affected by headaches [55]. Here, we established a link between pain-related anxiety and pain interferences. It has been reported that patients with chronic pain, which significantly affects their daily activities, tend to reduce their participation in exercises and therapies, and avoidance behavior should be targeted in treatment planning [56]. Also, a pathway from anxiety sensitivity and headache severity to fear of pain and further into avoidance and escape behavior was demonstrated in patients with headaches [55]. We established relationships between escape-avoidance responses and pain interference. We also detected a relationship between physiological anxiety (PASS-20 subscales) and daily activities. Physiological anxiety is the subscale most associated with sleep problems [57]. Sleep disturbance is associated with more severe headaches and pain interventions [47]. We did not establish a relationship between catastrophizing thoughts and pain interference as we did for pain-related anxiety. Our results should be supported by larger studies. Several limitations exist in this study. The use of a self-administered questionnaire can result in questions being misunderstood, increasing the possibility of subjective responses. However, the evaluation of the sample by a neurologist and a psychiatrist contributed to the validation of the screening results. In addition, prophylactic drugs can directly affect the emotional state and outcomes. Patients who received prophylactic treatment were not included in the study, leading to the possibility of selection bias. Again, selection bias may occur with the invitation method to enroll subjects from clinics. Finally, generalization of outcomes may not be appropriate for the elderly; therefore, caution is recommended in this age group. Conclusions We found the effects of PRCP in PHP on disability and HRQoL to be significant. We emphasize that PRCPs should be considered in treatment goals, such as the identification and management of anxiety and depression. Our findings assist in the multidisciplinary evaluation and treatment of the needs of patients affected by PHs. Human Ethics Animal Ethics Consent was obtained or waived by all participants in this study. The Istanbul Bagcilar Training and Research Hospital Clinical Research Ethics Committee issued approval 2021.01.1.06.006. This study was performed in line with the principles of the Declaration of Helsinki. The Istanbul Bagcilar Training and Research Hospital Clinical Research Ethics Committee (2021.01.1.06.006) has approved the study. Written Informed consent was obtained. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. The authors have declared that no competing interests exist. ==== Refs References 1 World Health Organization. Headache Disorders 8 2022 2016 http://World Health Organization. Headache disorders. 2016. https://www.who.int/news-room/fact-sheets/detail/headache-disorders.[Accessed august 15, 2022] 2 The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia Headache Classification Committee of the International Headache Society (IHS) 629 808 33 2013 23771276 3 The global burden of headache: a documentation of headache prevalence and disability worldwide Cephalalgia Stovner Lj Hagen K Jensen R 193 210 27 2007 17381554 4 Emotional and motivational pain processing: current state of knowledge and perspectives in translational research Pain Res Manag Becker S Navratilova E Nees F Van Damme S 5457870 2018 2018 30123398 5 Quality of life differs among headache diagnoses: analysis of SF-36 survey in 901 headache patients Pain Wang SJ Fuh JL Lu SR Juang KD 285 292 89 2001 11166485 6 Cognition and pain: a review Front Psychol Khera T Rangasamy V 673962 12 2021 34093370 7 Psychosocial approaches to pain management: an organizational framework Pain Jensen MP 717 725 152 2011 21168972 8 The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain Pain McCracken LM Zayfert C Gross RT 67 73 50 1992 1513605 9 Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art Pain Vlaeyen JWS Linton SJ 317 332 85 2000 10781906 10 Pain catastrophizing as repetitive negative thinking: a development of the conceptualization Cogn Behav Ther Flink IL Boersma K Linton SJ 215 223 42 2013 23978106 11 Depression and anxiety in pain Rev Pain Woo AK 8 12 4 2010 12 Applying a biopsychosocial model to migraine: rationale and clinical implications J Headache Pain Rosignoli C Ornello R Onofri A 100 23 2022 35953769 13 Pain beliefs and the use of cognitive-behavioral coping strategies Pain Williams DA Keefe FJ 185 190 46 1991 1749641 14 Factors associated with depression in patients referred to headache specialists Neurology Jelinski SE Magnusson JE Becker WJ 489 495 68 2007 17296914 15 Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis Pain Aaron RV Fisher EA de la Vega R Lumley MA Palermo TM 994 1006 160 2019 31009416 16 Bilişsel Terapi Temel İlkeler ve Uygulama, pp. 39-45 Türkçapar MH 39 45 Ankara, Turkey HYB Basım Yayın s: 2008 17 Diagnostic and Statistical Manual of Mental Disorders (DSM-5VR) Association AP Philadelphia, PA, USA American Psychiatric Association 2013 18 A six-item short-form survey for measuring headache impact: the HIT-6 Qual Life Res Kosinski M Bayliss MS Bjorner JB 963 974 12 2003 14651415 19 Graded chronic pain scale revised: mild, bothersome, and high-impact chronic pain Pain Von Korff M DeBar LL Krebs EE Kerns RD Deyo RA Keefe FJ 651 661 161 2020 31764390 20 A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity Pain Res Manag McCracken LM Dhingra L 45 50 7 2002 16231066 21 The Pain Catastrophizing Scale: development and validation Psychol Assess Sullivan MJ Bishop SR Pivik J 524 532 7 1995 22 The Pain Beliefs Questionnaire: an investigation of beliefs in the causes and consequences of pain Pain Edwards LC Pearce SA Turner-Stokes L Jones A 267 272 51 1992 1491853 23 An inventory for measuring depression Arch Gen Psychiatry Beck AT Ward CH Mendelson M Mock J Erbaugh J 561 571 4 1961 13688369 24 An inventory for measuring clinical anxiety: psychometric properties J Consult Clin Psychol Beck AT Epstein N Brown G Steer RA 893 897 56 1988 3204199 25 The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure J Psychosom Res Bagby RM Parker JD Taylor GJ 23 32 38 1994 8126686 26 The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research Psychiatry Res Buysse DJ Reynolds CF 3rd Monk TH Berman SR Kupfer DJ 193 213 28 1989 2748771 27 SF-36 health survey update Spine (Phila Pa 1976) Ware JE Jr 3130 3139 25 2000 11124729 28 Cutaneous allodynia in the migraine population Ann Neurol Lipton RB Bigal ME Ashina S 148 158 63 2008 18059010 29 Measurement in pain medicine BJA Education Bendinger T Plunkett N 310 315 16 2016 30 Assessment of patients with chronic pain Br J Anaesth Dansie EJ Turk DC 19 25 111 2013 23794641 31 Trigeminal neuralgia: basic and clinical aspects Curr Neuropharmacol Araya EI Claudino RF Piovesan EJ Chichorro JG 109 119 18 2020 31608834 32 Psychological risk factors in headache Headache Nicholson RA Houle TT Rhudy JL Norton PJ 413 426 47 2007 17371358 33 The role of fear of pain in headache Headache Black AK Fulwiler JC Smitherman TA 669 679 55 2015 25903510 34 The impact of pain-related emotions on migraine Sci Rep Kim S Bae DW Park SG Park JW 577 11 2021 33436778 35 Quality of life in primary headache disorders: a review Cephalalgia Abu Bakar N Tanprawate S Lambru G Torkamani M Jahanshahi M Matharu M 67 91 36 2016 25888584 36 Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation Pain Karayannis NV Sturgeon JA Chih-Kao M Cooley C Mackey SC 1063 1068 158 2017 28221284 37 Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine Cephalalgia Yang M Rendas-Baum R Varon SF Kosinski M 357 367 31 2011 20819842 38 Development of a PROMIS item bank to measure pain interference Pain Amtmann D Cook KF Jensen MP 173 182 150 2010 20554116 39 Migraine and body mass index categories: a systematic review and meta-analysis of observational studies J Headache Pain Ornello R Ripa P Pistoia F Degan D Tiseo C Carolei A Sacco S 27 16 2015 25903159 40 Prognostic factors for chronic headache: a systematic review Neurology Probyn K Bowers H Caldwell F Mistry D Underwood M Matharu M Pincus T 291 301 89 2017 28615422 41 Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain Pain2000 Peters ML Sorbi MJ Kruise DA Kerssens JJ Verhaak PF Bensing JM 181 192 84 42 Predicting factors of pain duration in patients with chronic pain: a large population-based study Anesth Pain Med Majedi H Amini MH Yousefshahi F Khazaeipour Z Majedi M Rahimi M Orandi A 0 10 2020 43 Pain characteristics and incidence of functional disability among community-dwelling older adults PLoS One Makino K Lee S Bae S Jung S Shinkai Y Chiba I Shimada H 0 14 2019 44 High-impact chronic pain: evaluation of risk factors and predictors Korean J Pain Şentürk İA Şentürk E Üstün I Gökçedağ A Yıldırım NP İçen NK 84 97 36 2023 36581599 45 Baseline pain intensity is a predictor of chronic pain in individuals with distal radius fracture J Orthop Sports Phys Ther Mehta SP MacDermid JC Richardson J MacIntyre NJ Grewal R 119 127 45 2015 25573007 46 The longitudinal relationships between pain severity and disability versus health-related quality of life and costs among chronic low back pain patients Qual Life Res Mutubuki EN Beljon Y Maas ET Huygen FJ Ostelo RW van Tulder MW van Dongen JM 275 287 29 2020 31531837 47 Migraine and sleep disorders: a systematic review J Headache Pain Tiseo C Vacca A Felbush A 126 21 2020 33109076 48 Sleep Patterns Changes Depending on Headache Subtype and Covariates of Primary Headache Disorders In: Neurophysiology - Networks, Plasticity, Pathophysiology and Behavior Domaç FM Uludüz D Özge A London Intech 2022 49 Chronic pain in the Republic of Ireland--community prevalence, psychosocial profile and predictors of pain-related disability: results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, part 1 Pain Raftery MN Sarma K Murphy AW De la Harpe D Normand C McGuire BE 1096 1103 152 2011 21450402 50 The assessment of anxiety and fear in persons with chronic pain: a comparison of instruments Behav Res Ther McCracken LM Gross RT Aikens J Carnrike CL Jr 927 933 34 1996 8990544 51 Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model Pain Glombiewski JA Riecke J Holzapfel S Rief W König S Lachnit H Seifart U 547 554 156 2015 25599236 52 Application of behavioral therapies in adult and adolescent patients with chronic migraine Neurol Sci Weeks RE 0 7 34 2013 53 Rumination, magnification, and helplessness: how do different aspects of pain catastrophizing relate to pain severity and functioning? Clin J Pain Craner JR Gilliam WP Sperry JA 1028 1035 32 2016 26783987 54 Correlations between alexithymia and pain severity, depression, and anxiety among patients with chronic and episodic migraine Psychiatry Clin Neurosci Yalug I Selekler M Erdogan A Kutlu A Dundar G Ankarali H Aker T 231 238 64 2010 20602723 55 Anxiety sensitivity, fear, and avoidance behavior in headache pain Pain Norton PJ Asmundson GJ 218 223 111 2004 15327826 56 Pain-related fear, disability, and the fear-avoidance model of chronic pain Curr Opin Psychol Zale EL Ditre JW 24 30 5 2015 25844393 57 Sleep problems in pain patients entering tertiary pain care: the role of pain-related anxiety, medication use, self-reported diseases, and sleep disorders Pain Miettinen T Sverloff J Lappalainen OP Linton SJ Sipilä K Kalso E 0 20 163 2022