Main symptoms associated with the catastrophizing in women with fibromyalgia and migraine

Objective To evaluate the main symptoms associated with catastrophizing in women with fibromyalgia and migraine. Methods We conducted an observational study with 26 women diagnosed with both fibromyalgia and migraine, aged between 30 and 60 yrs (46±8 yrs). The Pain Catastrophizing Scale was applied as a cut-off point of 30, dividing the volunteers into groups with (n=18) and without catastrophizing (n=8). We assessed the quality of sleep (Pittsburgh Sleep Quality Index), the presence of depression and anxiety (Beck's Depression and Anxiety Inventories), the quality of life perception (Fibromyalgia Impact Questionnaire-revised), the disability due to migraine (Migraine Disability Assessment), and the level of physical activity (International Physical Activity Questionnaire). Results The time of fibromyalgia did not differ (p=0.80) between the group with (8.54±4.88 yrs) and without catastrophizing (10.04±3.47 yrs). The Fibromyalgia Impact Questionnaire-revised scores were significantly higher (p=0.01) among women with catastrophizing (78.0±12.6) than those without (56.6±22.3). There was no difference between the groups (p>0.05) in relation to the other outcomes evaluated. Conclusion The presence of catastrophizing in women with fibromyalgia and migraine are associated with a worse perception of quality of life. Manuella Moraes Monteiro Barbosa Barros Departamento de Fisioterapia, Laboratório de Aprendizagem e Controle Motor, Universidade Federal de Pernambuco. Av. Jornalista Aníbal Fernandes, 173 Cidade Universitária, Recife – Pernambuco. Phone number: +55 81 2126-8492; +55 81 2126-8937. manu_mmbb@hotmail.com Received: May 27, 2020. Accepted: June 5, 2020. Edited by Marcelo Moraes Valença


Introduction
F ibromyalgia is a a broad-spectrum disease that has an average worldwide prevalence of 4.1% in women. 1 Over the years, the classification of fibromyalgia by the American College of Rheumatology has undergone improvements, ceasing to be characterized only by chronic widespread pain and the presence of tender points in anatomically specific regions, known as tender points. 2 Currently the classification takes into account the symptoms associated with this disease. 3,4 The etiology of fibromyalgia is not yet fully understood, but several The etiology of fibromyalgia is not yet fully understood, but several factors contribute to its development, including dysfunctions of the factors contribute to its development, including dysfunctions of the central and autonomic nervous system, neuroendocrine disorders, central and autonomic nervous system, neuroendocrine disorders, regulation of neurotransmitters, changes in the hypothalamic-pitui-regulation of neurotransmitters, changes in the hypothalamic-pituitary axis, and exposure to stressors. tary axis, and exposure to stressors. 5,6 5,6 Sensory stimuli transmitted Sensory stimuli transmitted to the central nervous system are processed in an altered manner, to the central nervous system are processed in an altered manner, resulting in generalized pain and changes in the painful threshold. resulting in generalized pain and changes in the painful threshold. 6,7 6,7 Fibromyalgia presents a complex picture that includes numerous Fibromyalgia presents a complex picture that includes numerous symptoms such as depression, anxiety, headache, cognitive, and symptoms such as depression, anxiety, headache, cognitive, and sleep disorders and negative impacts on quality of life. sleep disorders and negative impacts on quality of life. 8 8 In this In this context, migraine is a relevant symptom and represents the type of context, migraine is a relevant symptom and represents the type of headache most found in patients with fibromyalgia, whose preva-headache most found in patients with fibromyalgia, whose prevalence varies between 45% and 80%. lence varies between 45% and 80%. 9 9 In addition, the cognitive and emotional aspects related to the pain In addition, the cognitive and emotional aspects related to the pain experienced by fibromyalgia patients involve a catastrophizing experienced by fibromyalgia patients involve a catastrophizing thought, recognized as a negative state in the face of a painful thought, recognized as a negative state in the face of a painful experience. experience. 10 10 Depression is part of the factors that interfere with the Depression is part of the factors that interfere with the painful perception of fibromyalgia, but unlike catastrophization, it painful perception of fibromyalgia, but unlike catastrophization, it refers to sadness, discouragement, lack of interest, and unwilling-refers to sadness, discouragement, lack of interest, and unwillingness to perform activities that previously gave you pleasure. In ness to perform activities that previously gave you pleasure. In turn, catastrophizing is specifically related to thoughts and feelings turn, catastrophizing is specifically related to thoughts and feelings linked to the painful situation, such as fear, worry, inability to divert linked to the painful situation, such as fear, worry, inability to divert attention, and deal with pain. attention, and deal with pain. 11 11 There is still a lack of studies in the literature There is still a lack of studies in the literature 12-15 12-15 evaluating the pre-evaluating the presence of catastrophization however, it is known that this symptom sence of catastrophization however, it is known that this symptom is related to chronic pain, feelings of incapacity, is related to chronic pain, feelings of incapacity, 12 12 more severe de-more severe degrees of depression and anxiety, more migraine attacks, grees of depression and anxiety, more migraine attacks, 13 13 exercise exercise intolerance intolerance 14 14 and sleep disorders and sleep disorders 15 15 . Also, catastrophization can . Also, catastrophization can worsen the perception of these symptoms, which are also present worsen the perception of these symptoms, which are also present in fibromyalgia and migraine, making it necessary to evaluate them in fibromyalgia and migraine, making it necessary to evaluate them to guide the treatment of patients. to guide the treatment of patients.
Despite the above, the catastrophization of pain has not yet been Despite the above, the catastrophization of pain has not yet been analyzed in women with associated fibromyalgia and migraine. analyzed in women with associated fibromyalgia and migraine.
Thus, the present study aimed to assess the main symptoms as-Thus, the present study aimed to assess the main symptoms associated with catastrophization in women with fibromyalgia and sociated with catastrophization in women with fibromyalgia and migraine. migraine.

Methods
This is an observational, cross-sectional study. The research was This is an observational, cross-sectional study.

Sample
The participants were recruited from the list of patients seen at the The participants were recruited from the list of patients seen at the fibromyalgia outpatient clinic of the rheumatology sector at Hospital fibromyalgia outpatient clinic of the rheumatology sector at Hospital

Procedures for data collection
By phone, the participants were invited to participate in the survey By phone, the participants were invited to participate in the survey and asked about the eligibility criteria. In the initial evaluation, a and asked about the eligibility criteria. In the initial evaluation, a semi-structured questionnaire was applied to obtain sociodemogra-semi-structured questionnaire was applied to obtain sociodemographic and clinical data. Then, they went through the evaluation of phic and clinical data. Then, they went through the evaluation of a neurologist who diagnosed the type of headache, based on the a neurologist who diagnosed the type of headache, based on the criteria of the International Classification of Headache Disorders, criteria of the International Classification of Headache Disorders, 3 3 rd rd edition -beta version. edition -beta version. 16 16 The presence of catastrophizing was assessed using the pain catas-The presence of catastrophizing was assessed using the pain catastrophizing scale. This instrument, validated and adapted to Portugue-trophizing scale. This instrument, validated and adapted to Portuguese (Cronbach alpha= 0.91), assesses the thoughts and feelings of the se (Cronbach alpha= 0.91), assesses the thoughts and feelings of the volunteers in the face of pain experience and consists of 13 items, volunteers in the face of pain experience and consists of 13 items, whose score ranges from 0-4, with 52 being the maximum score. whose score ranges from 0-4, with 52 being the maximum score. 17 17 The global score of 30 indicates that the individual has clinically The global score of 30 indicates that the individual has clinically relevant levels of catastrophization. relevant levels of catastrophization. 18 18 The sample was then divided The sample was then divided into two groups, one with catastrophization and one without. into two groups, one with catastrophization and one without.

Outcome Assessment
The questions ranging from 0-3 and is divided into seven components questions ranging from 0-3 and is divided into seven components related to sleep: subjective quality, latency, duration, habitual ef-related to sleep: subjective quality, latency, duration, habitual efficiency, changes and the use of sleep medications, and daytime ficiency, changes and the use of sleep medications, and daytime dysfunction. The total score was given by the sum of all components, dysfunction. The total score was given by the sum of all components, reaching a maximum of 21 points. reaching a maximum of 21 points. 19 19 The depression outcome was assessed by Beck Depression Inventory The depression outcome was assessed by Beck Depression Inventory The level of pain resulting from fibromyalgia was assessed using this The level of pain resulting from fibromyalgia was assessed using this questionnaire, which presents a specific scale related to pain, whose questionnaire, which presents a specific scale related to pain, whose domain of symptom intensity varies from zero to ten. domain of symptom intensity varies from zero to ten. 23 23 Migraine disability was assessed by the Migraine Disability As-Migraine disability was assessed by the Migraine Disability Assessment Test (MIDAS). From the sum of the scores, the volunteers sessment Test (MIDAS). From the sum of the scores, the volunteers were classified as minimal disability (0-5 points), mild (6-10 points), were classified as minimal disability (0-5 points), mild (6-10 points), moderate (11-20 points), and severe (> 20 points). moderate (11-20 points), and severe (> 20 points). 24 24 The level of physical activity was verified by the International Physi-The level of physical activity was verified by the International Physical Activity Questionnaire (IPAQ), in its short version. It consists of cal Activity Questionnaire (IPAQ), in its short version. It consists of four questions containing two sub-items that allowed measuring the four questions containing two sub-items that allowed measuring the frequency, duration of activities, intensity during the week, and also frequency, duration of activities, intensity during the week, and also the periods of inactivity of the participants. Among the categories the periods of inactivity of the participants. Among the categories provided by IPAQ, it was possible to classify the volunteers as very provided by IPAQ, it was possible to classify the volunteers as very active, active, irregularly active and sedentary, through data related active, active, irregularly active and sedentary, through data related to the frequency and duration reported by them. to the frequency and duration reported by them. 25 25

Statistical Analysis
The data were analyzed using the Statistical Package for Social The data were analyzed using the Statistical Package for Social

Results
Of the 29 women evaluated, one was excluded for having another type of headache and two for not completing the questionnaires. The general characterization of the sample of the 26 included participants (45.9 ± 7.9 years) and the clinical level of pain catastrophization is shown in Table 1. There was no difference between the groups regarding the time of diagnosis of fibromyalgia. Table 2 shows the characteristics of the sample in relation to the associated symptoms. The presence of migraines had a serious impact on the daily and professional life of half of the sample. When observing the psychological characteristics of the studied population, it was possible to identify that 76.93% of the volunteers had a degree of depression from mild to moderate and 65.39% reported a moderate to severe degree of anxiety.
Fibromyalgia Impact Questionnaire-Revised scores were significantly higher (p = 0.01) among women with catastrophization (78.0 ± 12.6) than those without (56.6 ± 22.3). There was no difference between groups (p> 0.05) in relation to the other outcomes assessed ( Table 2).

Discussion
In the present study, only the perception of quality of life was associated with the presence of catastrophization in women with fibromyalgia and migraine. Despite the lack of association in relation to the other outcomes studied, the results of our study are of great clinical relevance, as they demonstrate that catastrophization can worsen the perception of function, global impact, and intensity of symptoms in patients with fibromyalgia and migraine, generating negative repercussions in the quality of life of this population. In addition, this is a pioneering study, since the catastrophizing of pain has not yet been analyzed in women with associated fibromyalgia and migraine.
In the present study, more than half of women with fibromyalgia and migraine exhibited clinically relevant levels of pain catastrophization, differing from the results of another study 13 , in which only a quarter of the sample, composed of migrant women, presented this symptom. In this way, it is possible that the presence of associated fibromyalgia and migraine, which share similar pathophysiological pathways 7,10 , has contributed to greater susceptibility to pain, potentiating changes in central processing and generating greater impact on catastrophizing symptoms.
Another relevant aspect, frequently cited in the literature, is that catastrophization provides a more intense experience of pain in patients with chronic pain. 14 For this reason, women with the presence of associated fibromyalgia and migraine were expected to experience greater pain intensity and changes in pain threshold. 6,7 Despite this, in our study, no great variations were observed in the intensity of pain due to migraine and fibromyalgia.
On the other hand, our study showed that fibromyalgia and migraine women with catastrophization had greater impacts on the perception of quality of life. It is known that both fibromyalgia 8 and migraine 26 promote negative impacts on patients' quality of life. Thus, the associ-ation between different disabling clinical conditions could aggravate catastrophizing symptoms, making it difficult for the patient to deal with the painful situation. 11 It is also often cited that women with fibromyalgia are less physically active than healthy women 27 , which could be explained by the fear that fibromyalgia patients have that physical activity could worsen their symptoms. 28 In addition, people with high levels of catastrophization may have worse physical performance 14 , probably due to intolerance to pain-related activity.
Another common association is the presence of catastrophization, sleep disorders 15 , and more severe degrees of depression and anxiety. 13 Despite the findings, in our study the catastrophizing group did not present lower levels of physical activity and no association was observed with worsening migraine impact, sleep disorders, depression, and anxiety. It is possible that the lack of association between the variables studied in the present research is related to the small sample size.
The results of the present study have some limitations. As it is an observational study, it is not possible to establish cause-and-effect relationships in this research. In addition, the small sample size makes it impossible to perform statistical analysis with multiple linear regression, which would make it possible to verify the influence of dependent variables with catastrophization. *Student t-test. Data are presented as mean ± standard deviation or n (%). BMI -Body Mass Index.

Conclusion
The presence of catastrophization in women with fibromyalgia and migraine is associated with a worsening perception of quality of life.