The insufficiency of a simple stress question in assessing stress for chronic daily headache in clinical practice

Abstract

Background: In managing chronic daily headaches (CDH), a comprehensive approach is necessary to evaluate stress, a closely linked factor. However, limited time and costs often lead to the use of a simple stress question in clinical settings. This study aims to assess the validity of using a simple stress question for CDH patients and explore its implications for clinical practice.

Methods: We recruited 103 patients with CDH who completed structured self-administered questionnaires, including a simple stress question ("Have you had any stress or concerns in the last 4 weeks?") and validated Korean versions of questionnaires for depression, anxiety, insomnia, and the Brief Encounter Psychosocial Instrument (BEPSI). A headache specialist conducted clinical interviews. The stress group consisted of patients who acknowledged overt stress (answering "yes" to the simple question) and covert stress (initially answering "no" but later admitting during the interview). Results showed no statistical difference between the subgroups, so they were combined as the "acknowledged stress" group.

Results: Out of 103 patients, 54.4% had chronic migraine, 45.6% had chronic tension-type headache, and 66 patients (64.1%) acknowledged experiencing stress. No significant differences were found in demographic and clinical characteristics, BEPSI stress assessment, or depression, anxiety, and insomnia profiles between patients with overt stress (n = 51) and covert stress (n = 15). The average BEPSI score was 2.3 ± 0.9, with 45.6% of patients exceeding the criteria (>2.4). Two (5.4%) patients in denial of stress had scores above the BEPSI criteria. Among patients below the criteria of BEPSI, 21 acknowledged stress, while 35 denied stress, with no significant differences observed.

Conclusions: This study suggests the limitations of relying solely on a simple stress question for assessing stress in patients with CDH in clinical practice. It is possible to encounter covert stress, include individuals who do not exhibit noticeable stress, and misclassify stress levels. To overcome these limitations, it is necessary to foster a supportive environment for open communication on stress and implement a comprehensive assessment strategy when needed.

Keywords: Brief Encounter Psychosocial Instrument (BEPSI); Chronic daily headache; Covert stress; Simple stress question; Stress assessment.