Evidence indicates that pain avoidance behaviors are often heightened after recent pain events and can be disrupted when people experience uncontrollable stress. “This disruption can lead to maladaptive behaviors, including passivity and deconditioning, and can cause negative effects, such as anxiety and depressive moods,” explains Wiebke Gandhi, PhD. “Despite this clinical importance, motivational aspects of pain avoidance are still understudied in humans, and their neural mechanisms remain vastly unknown.”

 

How Pain Avoidance Behaviors Change

For a study published in Pain, Dr. Gandhi and colleagues examined neural networks underlying the influence of successful and unsuccessful pain avoidance on subsequent pain avoidance behavior using fMRI in 15 participants with episodic migraine and 17 without it. “We wanted to see how people changed in their pain avoidance behaviors after experiencing a previous unsuccessful attempt despite trying hard,” Dr. Gandhi says. “We also sought to determine whether these changes might be further influenced by long-term experiences with not being able to control pain.”

Pain avoidance behavior was assessed using an adaptation of an incentive delay task. In each round of the task, participants tried to avoid a painful stimulus and receive a nonpainful one instead. “Our study compared healthy people with patients who suffered from unavoidable migraine attacks 1-15 days per month,” says Dr. Gandhi. “In addition, we explored what happens in the brain while people mentally prepare for pain avoidance and whether pain avoidance was associated with differences in the ability to cope with pain. This may be especially important for patients with migraine.”

 

Pain Avoidance Behavior Compromised With Previous Unsuccessful Attempts

Pain avoidance behavior was compromised when the previous avoidance attempt was unsuccessful. “When participants tried hard to avoid previous pain but were unable to do so, they consequently had a reduced ability to avoid the next upcoming pain,” Dr. Gandhi says. “People with and without migraine showed this effect, but it was more pronounced in those with migraine.”

After unsuccessful pain avoidance on the preceding trial, patients with migraine had fewer pain avoidance behaviors. This reduction in behavior was associated with higher helplessness scores only among participants with migraine (Figure). “The individual helplessness score positively correlated with a greater reduction in pain avoidance behavior following unsuccessful avoidance attempts,” says Dr. Gandhi. “This means that patients with stronger signs of maladaptive coping (ie, helplessness) were more impacted in their ability to avoid pain when the previous attempt was unsuccessful.”

Participants with migraine also had lower activation of their right posterior parietal cortex (PPC) after unsuccessful pain avoidance when compared with those without migraine. “The PPC is typically associated with being able to attend to relevant external stimuli,” Dr. Gandhi says. “Patients with migraine might not maintain the attention needed to avoid upcoming pain when they were previously unsuccessful in their pain avoidance attempts. Out of several brain regions negatively associated with more helplessness, only PPC activation predicted the subsequent ability to avoid pain. This highlights its link to both pain avoidance behavior and individual pain coping ability.”

 

Increase Focus on Addressing Helplessness in Chronic Pain  

Findings from the study imply that an interaction of the experience of clinical pain and the individual ability to cope with it compromises pain avoidance. “The differences observed between patients with and without migraine were driven by coping ability of migraine patients,” says Dr. Gandhi. “Patients reporting high levels of helplessness when dealing with their migraine pain had much stronger deficits in pain avoidance behaviors as soon as they had an unsuccessful attempt. This implies they give up trying more quickly when a previous attempt went unrewarded. Based on this finding, it’s important to focus on helplessness in chronic pain and the need to increase perceived controllability over their condition to counteract feelings of being helpless.”

According to Dr. Gandhi, attention training to increase focus on external stimuli and away from self-screening may improve pain management in the future. “Attention training has been successful in reducing anxiety in patients with cancer and may be applicable to migraine,” she says. “In addition, attention training may prevent or reverse anxiety before helplessness and its long-term consequences fully develop.”