There is a lot of discussion, both in the media and in the medical literature, of the direct medical costs of chronic headaches which is a prototypical form of chronic pain. However, one thing that often gets overlooked is the indirect costs of these conditions. By indirect costs I mean, for example, lost productivity/income from work absences secondary to pain and/or increased costs for care of children and significant others secondary to an inability to perform these tasks oneself. Moreover, and perhaps most significantly, there are the psychological, emotional and physiologic tolls that chronic pain such as chronic headaches/migraines take on patients. In a fascinating study back in 2003, Susan Turner-Bowker surveyed over 7500 people with various health conditions and specifically analyzed a metric known as the health-related quality of life (HRQOL). What she discovered was that migraineurs’ HRQOL was similar to those patients suffering from congestive heart failure, hypertension and diabetes – all devastating illnesses. These results highlight the fact that chronic pain such as chronic headaches/migraines have significant negative impacts on functional health and well-being.
Unfortunately, the data correlating chronic pain with negative physiologic effects continues to mount. Just this week, a study in JAMA Internal Medicine looked at a cohort of over 10,000 elderly patients and followed them for a period of over 12 years. Remarkably, the people in this study who said that they were persistently troubled by moderate or severe pain demonstrated a nearly 10% faster decline in memory function over the subsequent 10 years. In addition, the statistical analysis implied that these same people would have a 16% higher relative risk of inability to manage other medications and an almost 12% higher relative risk of inability to manage their financial situation independently. It was therefore concluded that persistent pain was associated with accelerated memory decline and an increased probability of dementia. These numbers are significant because it has been estimated that as many as 1 in 3 elderly people experience chronic pain. The results seen with this current study are likely multifactorial, but may include the use of medication for pain, whether opioids or even NSAIDs (e.g. ibuprofen, Aleve) both of which have been shown in other studies to be associated with dementia risk. Alternatively, it has been suggested that the cognitive dysfunction associated with chronic pain may be secondary to diminished ability to focus on other functions as a result of the need to manage the discomfort, an effect that has been particularly noticeable on short-term memory. Another possible explanation may be that the stress associated with chronic pain may lead to cognitive decline via cortisol-based mechanisms.
While this particular study focused on elderly patients, it is reasonable to wonder whether or not the same mechanisms leading to cognitive decline suggested in this study also have effects on younger patients. I wonder, for example, if chronic pain beginning that begins at an earlier age leads to an earlier onset of cognitive dysfunction such as dementia. In either case, there is clearly a need to do more for patients than we are currently doing. Perhaps using conventional therapies as well as “thinking outside the box” at other possible causes for pain (e.g. peripheral nerve pathology) will allow us to manage these illnesses more effectively with less of a pharmacopeia. The ray hope from studies such as this one comes in the possibility that there is so much potential for benefit in overall health as well as quality of life even with small improvements in our understanding of these conditions.