Globally, 40% of the population is affected by headache disorders, making it one of the most prevalent neurological disorders.1 Headaches are among the most common medical complaints, impacting a younger population than many other chronic conditions. The Healthcare Cost and Utilization Project’s Nationwide Emergency Sample from 2011 showed that between the ages of 20 and 44 years, headaches were among the top 5 reasons for presentation to the emergency department.2 About 13% of the American population suffers from migraine,3 which ranks within the top 10 most disabling disorders in many countries.4 Headache disorders affect one’s work productivity, interpersonal relationships, and mental health.1
Despite its prevalence, people with headache disorders face many barriers in acquiring effective care, with lack of knowledge placed as the principal barrier, leading to the underdiagnosis and undertreatment of headache disorders.1 Delaying effective interventions can increase the frequency and severity of headache disorders, potentially leading to the chronification of headaches.5 Assessing the efficacy of treatment is imperative to the treatment of headache disorders.
Pain is a dominant symptom of headaches and migraines, although it can be a difficult feature for patients to describe. Pain scales, such as asking a patient to rate their pain on a scale from 1 to 10, attempt to give patients a way to communicate the level of pain they are feeling. This number can have its benefits, as it is simple and can be a measure that health care workers use over time to track changes in pain severity, although it can have its drawbacks.
One of the main drawbacks to pain scales is the subjective nature of pain. What one patient describes as an 8 of 10 could be what another patient describes as a 5 of 10 due to different pain tolerances. Other factors and stressors can influence what a patient reports, making the scale subjective to circumstances that a pain scale is not intended to measure.
Using this number to communicate, a patient might report pain above or below what they perceive, accounting for how the health care team would perceive this number and direct treatment accordingly. Social factors can play a role, where someone might report an augmented number to reflect how they want their loved ones to perceive their pain management, whether higher for the sake of empathy or lower to attempt to reflect a better-managed state.
Chronic and recurrent conditions like headaches and migraines are not accurately expressed by single responses on a pain scale. With single pain ratings, a comprehensive view of a patient’s condition is reduced to a number given in a single instance, despite the changing nature of pain that can lead it to fluctuate higher or lower.
Despite these drawbacks, which many health care workers are familiar with, pain rating scales are still common practice when assessing pain severity in acute and chronic cases. This decision largely comes from the leverage of insurance companies, who want to see a quantified number to describe a patient’s condition. Governing bodies can further perpetuate the use of pain rating scales. The Center for Medicare and Medicaid Services uses the percentage of older patients who received a Pain Assessment Value Set to determine pain as a measure of quality.6 Governing bodies have the capability to combat this, such as the United States Department of Human and Health Services stating in their Pain Management Best Practices Report that initiatives to report pain through pain scores have led to aggressive treatment to lower the number and have consequently increased opioid use.7
Clinical trials employ other measures to detect more comprehensive changes in someone’s condition, such as the APPRAISE (NCT03927144) trial,7 which utilizes the Patient’s Global Impression of Change (PGIC) scale. The PGIC scale encompasses a broader description of change compared to a pain scale, including symptoms, emotions, and quality of life. The Functional Pain Scale is a reliable and validated tool that can help with the assessment of pain by asking the patient the level of interference pain has with daily activities of life.8
