Journal of Psychosomatic Research 116 (2019) 83–92

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Journal of Psychosomatic Research

journal homepage: www.elsevier.com/locate/jpsychores

Illness perception in people with primary and secondary chronic headache T

in the general population
⁎
Espen Saxhaug Kristoffersena,b, , Christofer Lundqvista,c,d,e, Michael Bjørn Russella,c
a
Head and Neck Research Group, Research Centre, Akershus University Hospital, Lørenskog, Norway
b
Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
c
Institute of Clinical Medicine, Campus Akershus University Hospital, University of Oslo, Nordbyhagen, Norway
d
HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway
e
Department of Neurology, Akershus University Hospital, Lørenskog, Norway

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Chronic headache (headache ≥15 days/month) is a leading cause of disability. Illness perception,
Chronic migraine beliefs and cognitive models are likely central for patient understanding of their chronic pain condition and are
Chronic tension-type headache associated with treatment outcome. However, these factors are insufficiently described in chronic headache.
Common-sense model Objective: To describe illness perception, and to explore the effect of background variables and headache
Illness perception
characteristics on illness perceptions in primary and secondary chronic headaches in the general population.
Medication-overuse headache
Methods: 30,000 persons aged 30e44 from the general population were screened for chronic headache by a
Pain
Secondary headache mailed questionnaire. Those with self-reported chronic headache were interviewed by headache specialists. The
questionnaire response rate was 71%, and the interview participation rate was 74%. The International
Classification of Headache Disorders III was applied. Illness perception was assessed by the Revised Illness
Perception Questionnaire (IPQ-R). The statistical approach was exploratory.
Results: 405 of the 516 eligible participants (78%) completed the IPQ-R. Confirmatory factor analysis showed
good internal validity in chronic headache. People believed their chronic headache to be long-lasting, with
negative life consequences including emotional distress. Severe headache-related disability was associated with
more perception of chronicity, more perceived consequences, emotional load and illness identity and less illness
coherence. People with secondary chronic headache scored significantly higher on chronicity and life con-
sequences, and had less personal control than those with primary chronic headache.
Conclusion: Chronic primary and secondary headache is associated with a high symptom burden and chronicity
with large perceived negative consequences for daily living, suggesting multidisciplinary management may be
necessary.

1. Introduction
Migraine and tension-type headache are very frequent pain dis-
orders, public health problems and among the world leading causes of
disability according to the Global Burden of Disease study [1,2].
Chronic headaches (i.e. ≥ 15 days/month for three months
or ≥ 180 days/year) such as chronic tension-type headache (CTTH),
chronic migraine (CM) and medication-overuse headache (MOH) affect
people in their most productive phase of life, leading to activity lim-
itation, work absence and social burden for individuals, families, health
services and welfare systems [2,3]. In addition, as the overall pre-
valence of chronic headaches is 3–4%, chronic headaches contribute
substantially to disability and disease burden in the general population
[2,4,5].
Over the past decades, psychological and personality factors have
been suggested to be associated with pain disorders [6–8]. Living with a
disabling and/or frequent pain condition can trigger stress and psy-
chological distress. In addition, an underlying vulnerability for stress
may complicate pain. These thoughts are beginning to influence treat-
ment strategies and are used either in addition to pharmacological
treatment or as part of coping strategy-based treatments when phar-
macological treatment has not proven successful.
The Illness Perception Questionnaire (IPQ) has been developed
based on the common-sense model of illness [6,9]. According to this
model, all people with symptoms, injuries or disorders construct cog-
nitive models to make sense of their illness. The five core components of

⁎
Corresponding author at: Head and Neck Research Group, Research Centre, Akershus University Hospital, PO Box 95, 1478 Lørenskog, Norway.
E-mail address: e.s.kristoffersen@medisin.uio.no (E.S. Kristoffersen).

https://doi.org/10.1016/j.jpsychores.2018.12.001
Received 16 July 2018; Received in revised form 2 December 2018; Accepted 2 December 2018
0022-3999/ © 2018 Elsevier Inc. All rights reserved.
E.S. Kristoffersen et al.
this model are beliefs about the etiology of the illness, its symptoms and
labels, the personal consequences of the illness, how long it will last,
and if it may be controlled or cured [6]. These illness perceptions have
been suggested to determine how people act and respond. Thus, they
are probably important in guiding coping strategies and illness-related
behaviors such as treatment compliance [10,11]. Illness perceptions,
beliefs and cognitive models have been established in pain conditions
such as low back pain, fibromyalgia, complex widespread pain, os-
teoarthritis, orofacial pain, whiplash and sports injuries, but also in
cardiac and internal medicine diseases [12–22]. It has been shown that
such beliefs and perceptions about pain and causal factors may influ-
ence physical and mental health status [9,12–16,20,22]. Illness per-
ception is also associated with increased health care use and help-
seeking behavior [23,24]. Furthermore, illness perception may predict
the course of the disorder and treatment outcome [15,16,21,22,25–27].
It has been suggested that a high score on the Revised Illness Perception
Questionnaire (IPQ-R) scale consequences predicts higher pain-related
disability and psychological distress in chronic orofacial pain and
poorer outcome in low back pain and osteoarthritis after six months
follow-up [15,16,21]. As to headache disorders, only a few studies have
focused on different aspects of illness perception as assessed by dif-
ferent versions of the IPQ [28–34]. Furthermore, most of these studies
have recruited patients from more specialized care which may re-
present a selection of more severely affected patients. The IPQ-R has
been investigated for CM/MOH in a tertiary headache clinic and for
unclassified headache complaints in primary care, but never in the
general population [33]. In the primary care study, illness perception
was significantly different between patients treated in general practice
and those referred to neurologists with referred patients showing more
disease-related anxiety [33]. In addition, illness perception was a sig-
nificant predictor for negative headache outcomes and disability nine
months after the first consultation in general practice [35]. The
knowledge of the different chronic headaches from the general popu-
lation, diagnosed based on explicit and valid criteria, is sparse. The
Akershus study of chronic headache is an epidemiological study that
was constructed to fill this knowledge gap [4,5].
Many chronic headache patients are regarded as difficult to treat,
overuse over-the-counter medication, have low adherence to prophy-
lactic medication and use different complementary and alternative
medicine (CAM) strategies in seek of pain relief [36–38]. One way to
investigate what underlies such treatment strategies, choices and
coping behaviors may be to assess illness beliefs and perceptions.
Therefore, the aim of this study was to explore the different dimensions
of illness perception among people with primary and secondary chronic
headache from the general population. A secondary aim was to validate
the IPQ-R among people with chronic headaches.
2. Methods
2.1. Study design, population and variables
This was a cross-sectional epidemiological survey of 30,000 re-
presentative persons aged 30–44 drawn from the general population of
eastern Akershus County, Norway in 2005–2006. A postal ques-
tionnaire screened for possible chronic headache (≥15 days/last month
and/or ≥ 180 days/last year). Screening-positive subjects were invited
to a clinical interview at Akershus University Hospital.
The sample size was reduced to 28,871 because of error in the ad-
dress list (n = 1065), emigration (n = 32), multi-handicap (n = 28),
insufficient Norwegian language skills (n = 2), and death (n = 2). In
total, 71% (20,598/28,871) of the study population responded to the
screening questionnaire after two reminders.
Of 935 people with self-reported chronic headache, 53 persons did
not consent to further contact, and 30 persons did not speak Norwegian.
Among the 852 eligible, 139 declined participation and 80 could not be
reached by telephone. In total, 633 participated in clinical interviews
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Journal of Psychosomatic Research 116 (2019) 83–92
(490 as an ambulatory visit, 143 by telephone). The only exclusion
criterion was insufficient Norwegian language skills. Headache fre-
quency was assessed by days per month and days per 3 months.
Medication data were collected by self-reports during the interview.
The participants were asked to complete a medication list at home,
prior to the interview, or bring their medication to the consultation.
The number of days and dosage of medication intake per month were
recorded. The method has been described in detail elsewhere [4,5].
After the interview, the participants filled in a self-administered
questionnaire on socio-demographics, height, weight, smoking status,
physician contact (no, general practitioner (GP) or neurologist) and
CAM use (acupuncture, chiropractic, homeopathy, naprapathy, phy-
siotherapy, psychologist and psychomotor physiotherapy) due to
headache, and medication use for other conditions. The Migraine
Disability Assessment (MIDAS) measured headache related disability
[39]. Disability grade was scored according to MIDAS as minimal (0–5),
mild (6–10), moderate (11−20) or severe (≥21) [39].
As all included patients had chronic headaches (i.e. ≥ 15 days/
month for three months or ≥ 180 days/year), headache frequency was
further dichotomized into above the 75th percentile (≥80 days
/3 months) or below.
2.2. Headache classification
The International Classification of Headache Disorders II (ICHD-II)
was applied [40]. For the purpose of this paper, the diagnoses were re-
classified according to ICHD III [41]. Chronic headache was defined as
≥15 days/month for three months or ≥ 180 days/year. Those with
chronic headaches that would be classified as secondary exclusively due
to medication overuse were included as primary chronic headaches.
Chronic post-traumatic headache (CPTH) included head and whiplash
traumas. Cervicogenic headache (CEH) was classified according to the
criteria of the Cervicogenic Headache International Study Group, re-
quiring at least three criteria to be fulfilled, without requiring blockade
of the neck [42]. Headache attributed to chronic rhinosinusitis
(HACRS) was defined according to the criteria established by the
American Academy of Otolaryngology – Head and Neck Surgery adding
that the symptoms had persisted for 12 weeks or more [43].
2.3. Revised illness perception questionnaire
We used the Norwegian version of the IPQ-R to address illness
perceptions [12]. In our study, the terminology “my illness” was
changed to “chronic headache”. In total, 70 items are questioned in the
IPQ-R. In the identity dimension, participants were asked if they ex-
perienced any of 14 different symptoms (yes/no) and whether they
believed the different symptoms were related to their chronic headache
(yes/no). The agreement statements concern an acute/chronic timeline
(5 items), a cyclic timeline (4 items), the consequences of chronic
headache (6 items), positive beliefs about personal control (6 items),
positive beliefs about treatment control (5 items), illness coherence, i.e.
personal understanding of chronic headache (5 items), and emotional
representation, i.e. emotions caused by chronic headache (6 items).
Finally, there are 18 attribution items in four sub-dimensions: psycho-
logical attributions (6 items), risk factors (7 items), immunity factors (3
items), and accident or chance (2 items). Agreement was indicated on a
five-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neither
agree or disagree, 4 = agree and 5 = strongly agree.
2.4. Illness perceptions in other pain populations
We used previously published IPQ-R values to compare our sample
with other pain conditions. The following populations were used for
comparison:
1) Unclassified headache from primary care [33]. Patients (n = 240)
E.S. Kristoffersen et al.
who consulted their GP for headache as their main problem were
recruited from 18 general practices in the UK. The mean age was
39 years and 71% were female.
2) Acute pain [12]. Patients (n = 35) were recruited from a private
physiotherapy practice in New Zealand. The mean age was 36 years
and 43% were female.
3) Unspecified chronic pain [12]. Patients (n = 63) were recruited
from hospital based chronic pain clinics in New Zealand. The mean
age was 54 years and 59% were female.
4) Fibromyalgia [13]. Patients (n = 51) were recruited from the Dutch
Fibromyalgia patient association. The mean age was 44 years, 92%
were female and the duration of disease on average 10 years.
5) Chronic widespread pain [14]. Patients (n = 152) were recruited
from a pain and rehabilitation centre at a university hospital in
Sweden. The mean age was 46 years, 91% were female and the
duration of disease on average 16 years.
6) Chronic low back pain [15]. Patients (n = 1591) were recruited
from general practices in UK. The mean age was 44 years and 59%
were female.
7) Osteoarthritis [16]. Patients (n = 241) were recruited from rheu-
matologists, orthopaedic surgeons, and GPs in the Netherlands. The
mean age was 59 years and 82% were female.
2.5. Statistical analysis
For descriptive data, proportions, means and SDs or 95% confidence
intervals (CI) are given. The different chronic headache diagnoses were
compared using the t-test (continuous data) or the χ2 test (categorical
data).
A confirmatory factor analysis for this population was performed
using the latent variable analysis (lavaan package) for R (https://www.
r-project.org/) with the originally reported dimensions of the IPQ-R
[44]. Fit indexes and covariance between dimensions are presented.
MedCalc (https://www.medcalc.org/calc/comparison_of_means.
php) was used to compare the IPQ-R mean (SD) values across dif-
ferent studies.
We used an exploratory multivariable linear regression model
(single block) to evaluate the effect of gender, age, education, type of
headache, medication overuse, headache frequency, disability and
other chronic pain on the different dimensions of IPQ-R (as dependent
variable).
Significance levels were set at p ≤ .05, using two-sided test. As the
study and statistical approach was exploratory by nature, no corrections
for multiplicity were done. We used SPSS version 25.0 for all analyses
except for the confirmatory analysis and the comparison across dif-
ferent studies.
2.6. Ethical issues
The Regional Committee for Medical Research Ethics and the
Norwegian Social Science Data Services approved the study. All parti-
cipants gave informed consent.
3. Results
3.1. Sample characteristics
In total, 117 of the 633 subjects who underwent clinical interview
did not meet criteria for chronic headache, thus, 516 participants were
eligible. 405 of the 516 eligible participants (78%) completed the IPQ-
R. Responders and non-responders did not differ in age, gender, years
lived with headache, other chronic pain conditions or in the distribu-
tion of headache diagnoses (data not shown). Respondents were 37.5
(SD 4.3) on average, 320 (79%) were female, 111 (28%) had attained
education > 15 years, and they had had headache for 15.8 (9.3) years
on average. Three hundred and sixteen (78%) had primary chronic
85
Journal of Psychosomatic Research 116 (2019) 83–92
headache (31 had CM, 282 had CTTH and 3 had new daily persistent
headache). Among the 89 (22%) with secondary chronic headache, 45
had CPTH/CEH, 38 had HACRS and six had other secondary chronic
headaches. In total, 194 (48%) had co-occurrence of migraine, 189
(47%) had medication overuse, 31% had a headache fre-
quency ≥ 80 days per month and 56% scored in the highest (severe)
MIDAS disability. Sixty-nine (17%) had other chronic pain conditions
and 213 (53%) had high psychological distress.
3.2. Internal validation
Confirmatory factor analysis of the original 7 dimensions showed
good fit indexes (comparative fit index 0.842, Tucker-Lewis index
0.827, root mean square error of approximation 0.065 90%CI
0.061–0.069, standardized RMS residual 0.074), thus providing partial
internal validation of the IPQ-R in the present chronic headache po-
pulation. In general, there were low levels of interaction between the
dimensions with evidence of somewhat more substantial interaction
between timeline and consequences (covariance 0.224), timeline –
emotional (0.133), consequences – illness coherence (−0.181), con-
sequences – emotional (0.527), personal control – treatment (0.114)
and illness coherence – emotional (0.371) (all p-values are < 0.001).
3.3. IPQ-R in chronic headaches
People with primary and secondary chronic headache experienced a
high mean symptom load of 6.2 and 6.9 symptoms, respectively. Five of
the 14 identity symptoms were directly related to their headache and
the most common related symptoms reported were other pain (82%),
fatigue (75%), dizziness (56%), loss of strength (54%) sleep difficulties
(51%) and nausea (47%).
The main differences in IPQ-R scores were found between primary
and secondary chronic headache (Table 1). People with secondary
chronic headache reported worse perceptions and beliefs than those
with primary chronic headache with more illness identity (6.6 vs. 5.8,
p = .05), more chronicity (23.9 vs. 21.8, p = .001), larger consequences
of (18.9 vs. 17.4, p = .003), and less personal control over the disease
(18.8 vs. 19.9, p = .03). In addition, they reported more accident (6.2
vs. 5.0, p < .001), less risk factor (13.0 vs. 14.6, p = .03) and less
psychological (12.8 vs. 16.1, p < .001) attributions than those with
primary chronic headache.
For people with chronic headache and medication overuse, personal
control was lower (19.1 vs. 20.1, p = .017), negative emotions higher
(17.9 vs. 16.6, p = .017) and the illness identity higher (6.5 vs. 5.5,
p = .002) than for those without medication overuse.
In the whole population of chronic headaches, having a high
headache disability load was independently associated with a more
illness identity (6.4 vs. 5.0, p < .001), more chronicity (23.3 vs. 20.5,
p < .001), larger consequences of (19.0 vs. 15.6, p < .001), and more
negative emotions (18.3 vs. 15.3, p < .001) and less illness coherence
(18.0 vs. 19.3, p = .006). In addition, those with high disability re-
ported more accident (5.5 vs. 4.7, p < .001) attributions than those
with no to moderate disability.
The main findings in the exploratory linear regression models were
that female gender, severe headache disability and high headache fre-
quency were associated with a worsening in most of the illness per-
ception sub-dimensions for primary chronic headaches (Table 2). Fe-
male gender was associated with more symptoms and higher
psychological attributions, but fewer consequences, better personal and
treatment control, and a greater understanding of the illness as com-
pared to men (Table 2). Headache disability was associated with higher
chronicity, consequences and emotional scores, more chance or acci-
dent attribution and with less disease coherence. Headache fre-
quency ≥ 80 days/3 months was associated with a chronic timeline,
consequences and accident or chance attribution (Table 2). Co-occur-
rence of other chronic pain was associated with an increased chronicity
E.S. Kristoffersen et al. Journal of Psychosomatic Research 116 (2019) 83–92

Table 1
Mean (SD) Revised Illness perception questionnaire (IPQ-R) dimension scores for people with different chronic headaches.
Chronic Chronic New daily All primary Chronic post- Headache attributed All secondary All chronic
migraine tension-type persistent chronic traumatic/ to chronic chronic headaches
N = 31 headache headache headaches cervicogenic rhinosinusitis headaches N = 405
N = 282 N=3 N = 316 headache N = 38 N = 89
N = 45

Illness identity 6.9 (3.1) b 5.7 (2.9) 8.0 5.8 (2.9) b 6.8 (2.8) a 6.4 (2.7) 6.6 (2.7) 6.0 (2.9)
Timeline (acute/chronic) 24.4 (4.6) 21.5 (5.1) 22.3 21.8 (5.1) a 25.2 (4.3) 22.7 (4.8) 23.9 (4.9) 22.2 (5.1)
Timeline (cyclical) 14.7 (3.8) 14.4 (3.4) 11.0 14.4 (3.4) 14.0 (3.2) 13.3 (4.3) 13.7 (3.6) 14.3 (3.5)
Consequences 18.4 (4.0) 17.3 (4.2) 19.0 17.4 (4.2) b 19.8 (3.5) 18.3 (4.2) 18.9 (4.1) 17.8 (4.2)
Personal control 18.7 (4.0) 20.0 (4.2) 22.0 19.9 (4.2) a 19.1 (4.8) 18.6 (3.8) 18.8 (4.3) 19.7 (4.2)
Treatment control 16.0 (2.8) 16.4 (3.2) 17.7 16.4 (3.1) 15.5 (3.2) 16.6 (3.0) 15.9 (3.2) 16.3 (3.1)
Emotional 18.4 (5.5) 16.9 (5.9) 19.3 17.1 (5.9) 18.0 (5.6) 17.4 (4.2) 17.5 (5.0) 17.2 (5.7)
representations
Illness coherence 18.2 (4.3) 18.5 (4.3) 14.3 18.4 (4.3) 19.0 (5.0) 17.8 (4.6) 18.6 (4.8) 18.5 (4.4)
c b
Psychological 16.9 (5.7) 16.0 (5.6) 17.3 16.1 (5.6) 11.8 (5.5) 14.8 (4.4) 12.8 (5.3) 15.4 (5.7)
attributions
a
Risk factors attributions 16.2 (4.7) 14.5 (4.5) 14.3 14.6 (4.5) b 11.7 (4.4) b 15.1 (4.5) 13.0 (4.7) 14.3 (4.6)
Immune attributions 6.0 (2.2) 5.8 (2.3) 6.0 5.8 (2.3) 5.3 (2.4) a 6.5 (2.4) 5.8 (2.5) 5.8 (2.4)
Accident/chance 4.7 (1.9) 5.0 (2.1) 5.0 5.0 (2.1) c 7.7 (1.7) c 4.6 (2.1) 6.2 (2.5) 5.2 (2.2)
attributions

a
p < .05 for CM compared to CTTH, CPTH/CEH compared to HACRS, Primary chronic headache compared to Secondary chronic headache.
b
p < .01 for CM compared to CTTH, CPTH/CEH compared to HACRS, Primary chronic headache compared to Secondary chronic headache.
c
p < .001 for CM compared to CTTH, CPTH/CEH compared to HACRS, Primary chronic headache compared to Secondary chronic headache.

and illness identity, but not with any other IPQ-R dimensions (Table 2).
The IPQ-R illness identity dimension was the outcome associated with
most of the predictors. Medication overuse was associated with the
illness identity and the risk factor attribution dimension, whereas
whether the primary headache was CM or CTTH only affected the
timeline with more chronicity in CM.
For secondary chronic headaches associations between the different
variables and outcomes were less clear (Table 3). Female gender was
associated with more chronicity, higher personal control, better illness
coherence and less psychological and immune attributions than males.
Those with severe disability had stronger illness identity and beliefs of
more consequences than those with no to moderate disability. A high
headache frequency was associated with more chronicity and con-
sequences than for those with < 80 headache days/3 months. Medica-
tion overuse was associated with more symptoms, but better illness
coherence among those with secondary chronic headaches. The sec-
ondary headache subtype was associated with risk factor attribution
with CEH/CPTH predicting higher accident/chance attribution while
HACRS predicted higher predisposing factor attribution.
3.4. Physician contact and CAM use
Those who had consulted their GP for headache (n = 321) had a
longer perceived timeline (22.5 vs. 21.2, p = .03) than those without
such contact (n = 83). Those who had been referred to neurologist
(n = 88) had higher illness identity (6.6 vs. 5.8, p = .043), more
chronicity (23.7 vs. 22.1, p = .009) and more perceived consequences
(19.2 vs. 17.4, p = .001) than those only treated by their GP (n = 233).
Those who had used CAM for their headache (n = 266) had higher
illness identity (6.4 vs. 5.1, p < .001), more chronicity (23.0 vs. 20.8,
p < .001), more perceived consequences (18.2 vs. 16.8, p = .002),
more personal control (20.0 vs. 19.1, p = .033), and higher emotional
representation (17.8 vs. 16.1, p = .005) than those who had not tried
CAM for their headache (n = 138).
3.5. IPQ-R in chronic headaches compared to other pain conditions
Table 4 shows the comparison of chronic headache mean IPQ-R
dimension scores across other studies of pain patients [12–16,33].
Chronic headaches differed from acute pain with another pattern of all
(except emotional representation) dimension scores. The study on
unselected headaches shows similar patterns but lower chronicity and
less illness coherence than chronic headache. Some difference in illness
identity, consequences, personal and treatment control, emotional re-
presentations, psychological, risk factor and immune attributions may
also be discerned between arthritis pain and chronic headaches. Pa-
tients with chronic low back pain had fewer symptoms, shorter per-
ceived timeline, better personal and treatment control, less psycholo-
gical attribution, but more accident/chance attribution and less illness
coherence. Unspecified chronic pain, chronic widespread pain and fi-
bromyalgia give more similar IPQ-R dimension patterns to chronic
headaches.
4. Discussion
This is the first study using the IPQ-R in chronic headaches in the
general population, and to our knowledge, the largest population-based
study of illness perception in any chronic pain condition. Chronic
headache sufferers attributed as many as 5 other symptoms to their
headache and believed their chronic headache to be long lasting, with
negative consequences for their lives including emotional distress.
Those with secondary chronic headache scored significantly higher on
chronicity and consequences for their lives and felt less personal control
than people with primary chronic headache.
People with CM reported a higher risk factor attribution than those
with CTTH. In the same way, people with HACRS reported a higher risk
factor attribution than those with CPTH/CEH. Furthermore, accident/
chance attributions were more common among those with CPTH/CEH
than those with HACRS. The ICHD-III includes attributed-related cri-
teria in relation to many secondary headaches (including CPTH and
HACRS), thus predictors and outcomes may overlap and complicating
the interpretation.
Interestingly, another population-based study from Norway found
that the total symptom load was strongly associated with the patient's
self-reported health and functional status [45]. Patients reporting sev-
eral symptoms often represent a challenge to the health care system and
as in the present study, also a primary care study from the UK, found
the number of symptoms as collected by the illness identity subscale to
be a predictor for referral to neurologist for headache patients [33].
Those who had tried CAM for their chronic headache in the present
study scored higher on illness identity, chronicity, consequences and
emotional representation than those who had not tried CAM. This

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Table 2
Exploratory linear regression analyses of the different IPQ-R dimensions for all primary chronic headaches.
Timeline (acute/chronic) Timeline (cyclical) Consequences Personal control Treatment control Emotional Illness coherence
representations

Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value

Female vs. male* 0.38 (−0.98; 1.74) 0.58 0.14 (−0.82; 0.78 −0.95 (−2.04; 0.09 1.45 (0.29; 2.60) 0.014 1.00 (0.10; 0.029 1.21 (−0.41; 0.14 2.07 (0.91; 3.24) < 0.001
1.10) 0.13) 1.91) 2.83)
Age −0.27 (−1.56; 1.03) 0.68 −0.85 (−1.77; 0.07 0.80 (−0.24; 0.13 0.12 (−0.98; 0.83 −0.45 (−1.31; 0.30 0.78 (−0.76; 0.32 −0.57 (−1.67; 0.31
0.06) 1.83) 1.23) 0.41) 2.32) 0.53)
Education ≤15 years vs. > 15 years* 0.51.(−0.77; 1.79) 0.44 0.40 (−0.51; 0.39 0.51 (−0.51; 0.32 −1.45 (−2.54; 0.009 −0.76 (−1.62; 0.08 0.20 (−1.33; 0.80 −0.71 (−1.80; 0.20
1.30) 1.54) −0.36) 0.09) 1.72) 0.38)
CTTH vs. CM* −2.17 (−4.31; 0.047 0.78 (−0.73; 0.31 0.71 (−1.00; 0.41 1.12 (−0.71; 0.23 0.67 (−0.74; 0.35 0.62 (−1.93; 0.63 −0.54 (−2.36; 0.56
−0.03) 0.29) 2.43) 2.94) 2.07) 3.16) 1.28)
Medication overuse vs. no overuse* 0.36 (−0.82; 1.53) 0.55 0.72 (−0.11; 0.09 0.29 (−0.65; 0.55 −0.48 (−1.49; 0.35 0.34 (−0.44; 0.39 1.14 (−0.26; 0.11 0.57 (−0.43; 0.27
1.55) 1.232) 0.52) 1.12) 2.54) 1.57)
Headache frequency > 75 vs. < 75 2.61 (1.34; 3.87) < 0.001 −0.08 (−0.97; 0.87 1.34 (0.33; 0.009 −0.79 (−1.87; 0.15 −0.80 (−1.64; 0.06 0.51 (−1.00; 0.51 −0.67 (−1.75; 0.22

87
percentile* 0.82) 2.36) 0.29) 0.04) 2.01) 0.40)
Severe disability vs. no to moderate* 2.10 (0.96; 3.24) < 0.001 0.85 (0.04; 0.039 2.94 (2.02; < 0.001 −0.74 (−1.71; 0.14 −0.50 (−1.25; 0.20 3.20 (1.84; < 0.001 −1.96 (−2.93; 0.001
1.65) 3.85) 0.23) 0.26) 4.55) −0.96)
Other chronic pain vs. no* 2.51 (0.97; 4.05) 0.002 −1.07 (−2.15; 0.06 1.21 (−0.02; 0.06 0.34 (−0.97; 0.61 −0.75 (−1.76; 0.15 0.85 (−0.98; 0.36 0.71 (−0.60; 0.29
0.02) 2.44) 1.65) 0.27) 2.69) 2.02)

Illness identity Psychological attributions Risk factors attributions Immune attributions Accident/chance attributions

Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value

Female vs. male* 1.39 (0.51; 2.28) 0.002 2.15 (0.50; 3.79) 0.011 0.07 (−1.19; 1.34) 0.91 −0.23 (−0.91; 0.44) 0.50 −0.45 (−1.03; 0.13) 0.13
Age 0.26 (−0.55; 1.07) 0.52 −0.60 (−2.16; 0.96) 0.45 0.08 (−1.12; 1.27) 0.90 0.19 (−0.46; 0.84) 0.56 −0.31 (−0.87; 0.24) 0.27
Education ≤15 years vs. > 15 years* −1.18 (−2.02; −0.33) 0.007 −0.57 (−2.10; 0.97) 0.47 −0.89 (−2.06; 0.27) 0.13 −0.12 (−0.76; 0.52) 0.71 0.05 (−0.50; 0.60) 0.86
CTTH vs. CM* −0.30 (−1.68; 1.08) 0.67 −1.28 (−3.81; 1.25) 0.32 −1.04 (−3.01; 0.94) 0.30 0.03 (−1.04; 1.09) 0.96 0.30 (−0.61; 1.21) 0.52
Medication overuse vs. no overuse* 0.89 (0.12; 1.66) 0.024 0.58 (−0.84; 2.00) 0.42 2.33 (1.25; 3.41) < 0.001 0.30 (−0.29; 0.88) 0.32 0.29 (−0.22; 0.79) 0.27
Headache frequency > 75 vs. < 75 percentile* 0.74 (−0.08; 1.56) 0.08 −0.99 (−2.49; 0.52) 0.20 −0.80 (−1.97; 0.36) 0.18 −0.02 (−0.65; 0.62) 0.96 0.92 (0.38; 1.46) < 0.001
Severe disability vs. no to moderate* 0.85 (0.10; 1.60) 0.027 0.63 (−0.75; 2.01) 0.37 0.95 (−0.09; 2.00) 0.07 0.48 (−0.09; 1.05) 0.10 0.53 (0.04; 1.02) 0.035
Other chronic pain vs. no* 0.99 (0.00; 1.98) 0.049 −0.71 (−2.55; 1.14) 0.45 0.98 (−0.42; 2.39) 0.17 −0.04 (−0.81; 0.73) 0.92 0.35 (−0.35; 0.99) 0.35
Journal of Psychosomatic Research 116 (2019) 83–92
 E.S. Kristoffersen et al.

Table 3
Exploratory linear regression analyses of the different IPQ-R dimensions for all secondary chronic headaches.
Timeline (acute/chronic) Timeline (cyclical) Consequences Personal control Treatment control Emotional representations Illness coherence

Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value

Female vs. male* 2.63 (0.02; 0.048 1.26 (−0.92; 0.25 1.18 (−0.86; 0.25 3.29 (0.63; 0.016 1.10 (−0.95; 0.29 −1.19 (−4.31; 0.45 3.59 (0.71; 0.015
5.72) 3.45) 3.21) 5.96) 3.16) 1.94) 6.47)
Age 0.16 (−2.69; 0.91 1.23 (−1.15; 0.30 1.19 (−1.03; 0.29 −2.29 (−5.20; 0.12 −0.76 (−3.00; 0.50 1.55(−1.87; 4.96) 0.37 −2.74 (−5.89; 0.09
3.02) 3.62) 3.41) 0.63) 1.49) 0.40)
Education ≤15 years vs. > 15 years* 0.13 (−2.31; 0.92 0.41 (−1.63; 0.69 2.05 (0.15; 0.035 −1.42 (−3.91; 0.26 0.31 (−1.61; 0.75 2.77.(−0.15; 5.68) 0.06 −1.08 (−3.77; 0.43
2.57) 2.45) 3.95) 1.08) 2.22) 1.61)
CPTH/CEH vs. HACRS* 1.11 (−1.22; 0.34 1.63 (−0.32; 0.10 0.31 (−1.51; 0.73 1.99 (−0.40; 0.10 −1.22 (−3.05; 0.19 0.81 (−1.99; 3.60) 0.57 0.63 (−1.95; 0.63
3.45) 3.58) 2.13) 4.37) 0.61) 3.20)
Medication overuse vs. no overuse* −1.12 (−3.36; 0.32 0.77 (−1.10; 0.42 0.15 (−1.59; 0.87 −0.88 (−3.16; 0.44 0.69 (−1.07; 0.43 1.59 (−1.08; 4.26) 0.24 2.64 (0.18; 0.036
1.11) 2.63) 1.89) 1.40) 2.45) 5.10)
Headache frequency > 75 vs. < 75 2.61 (0.18; 0.036 −3.25 (−5.27; 0.002 1.21 (−0.69; 0.21 −0.22 (−2.70; 0.86 −0.02 (−1.89; 0.99 −0.80 (−3.71; 0.58 2.22 (−0.46; 0.10
percentile* 5.04) −1.22) 3.10) 2.26) 1.92) 2.10) 4.90)

88
Severe disability vs. no to moderate* 0.70 (−1.70; 0.56 1.93 (−0.06; 0.06 3.52 (1.66; < 0.001 −0.04 (−2.47; 0.98 1.30 (−0.58; 0.17 0.52 (−2.33; 3.37) 0.72 0.01 (−2.63; 1.00
3.09) 3.93) 5.38) 2.40) 3.17) 2.64)
Other chronic pain vs. no* 0.73 (−2.28; 0.63 −0.72 (−3.23; 0.57 −1.50 (−3.85; 0.21 0.27 (−2.80; 0.86 −1.04 (−3.40; 0.38 −2.55 (−6.15; 0.16 −1.04 (−4.36; 0.53
3.73) 1.80) 0.84) 3.35) 1–32) 1.04) 2.27)

Illness identity Psychological attributions Risk factors attributions Immune attributions Accident/chance attributions

Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value Coeff (95%CI) p-value

Female vs. male* −0.72 (2.58; 1.15) 0.44 −3.15 (−6.19; −0.10) 0.04 −2.07 (−4.79; 0.65) 0.13 −2.48 (−3.92; −1.05) 0.001 −0.54 (−1.64; 0.57) 0.34
Age 1.38 (−0.60; 3.35) 0.17 1.46 (−1.96; 4.89) 0.40 −0.93 (−3.97; 2.11) 0.54 0.48 (−1.12; 2.08) 0.55 0.26 (−0.97; 1.50) 0.67
Education ≤15 years vs. > 15 years* 0.96 (−0.83; 2.75) 0.28 0.86 (−2.12; 3.83) 0.57 −0.77 (−3.37; 1.83) 0.55 0.58 (−0.79; 1.95) 0.40 −0.14 (−1.20; 0.92) 0.79
CPTH/CEH vs. HACRS* −0.28 (−2.02; 1.47) 0.75 −3.31 (−6.08; −0.54) 0.02 −4.73 (−7.17; −2.28) < 0.001 −1.95 (−3.24; 0.67) 0.004 3.39 (2.39; 4.38) < 0.001
Medication overuse vs. no overuse* 1.50 (−0.10; 3.11) 0.07 1.12 (1.53; 3.78) 0.40 −1.14 (−3.51; 1.22) 0.34 0.82 (−2.07; 0.42) 0.19 −0.07 (−1.03; 0.89) 0.89
Headache frequency > 75 vs. < 75 percentile* 0.96 (−0.80; 2.73) 0.28 −1.06 (−3.92; 1.81) 0.46 −1.59 (−4.11; 0.94) 0.21 0.04 (−1.29; 1.37) 0.95 0.46 (−0.57; 1.48) 0.38
Severe disability vs. no to moderate* 2.22 (0.52; 3.91) 0.012 0.39 (−2.47; 3.24) 0.79 1.88 (−0.61; 4.37) 0.14 0.60 (−0.71; 1.91) 0.36 0.15 (−0.86; 1.16) 0.76
Other chronic pain vs. no* −0.49 (−2.73; 1.74) 0.66 −1.03 (−4.66; 2.59) 0.57 1.14 (−2.04; 4.31) 0.48 0.72 (−0.95; 2.39) 0.39 0.03 (−1.26; 1.32) 0.96
Journal of Psychosomatic Research 116 (2019) 83–92
 E.S. Kristoffersen et al.

Table 4
Comparison of primary and secondary chronic headache subjects' mean (SD) IPQ-R scores to other populations [12,14–16,20,33].
Present study Other study populations

All primary chronic All secondary All chronic Unclassified headache Acute pain Unspecified chronic Fibromyalgia Chronic widespread Chronic low Osteoarthritis
headaches chronic headaches headaches from primary care N = 35 pain N = 51 pain back pain N = 241
N = 316 N = 89 N = 405 N = 237 N = 63 N = 152 N = 1591

Illness identity1 5.8 (2.9) 6.6 (2.7) 6.0 (2.9) 7.1 (4.9)a,h 2.8 (1.7)a,d,g 6.2 (2.4)f 5.5 (2.4)c,f 8.0 (2.5)a,d,g 4.0 (2.4)a,d,g 5.3 (2.5)c,d,h
Timeline (acute/chronic) 21.8 (5.1) 23.9 (4.9)a 22.2 (5.1) 20.0 (0.3)a,d,g 13.4 23.1 (4.4) 25.4 (3.9)a,g 26.6 (3.7)a,d,g 19.6 (5.8)a,d,g 25.4 (3.7)a,e,g
(5.4)a,d,g
Timeline (cyclical) 14.4 (3.4) 13.7 (3.6) 14.3 (3.5) 12.3 (0.2)a,d,g 9.4 (2.6)a,d,g 12.9 (3.9)h 15.0 (3.3)c,f 14.0 (3.7) 13.0 (3.4)a,g 14.3 (3.1)
Consequences 17.4 (4.2) 18.9 (4.1)b 17.8 (4.2) 17.9 (0.3)d 14.2 23.5 (3.9)a,d,g 19.3 (4.1)i19.5 21.6 (4.4)a,d,i 17.3 (5.5)e 16.8 (4.6)d,h
(4.4)a,d,g (4.2)
Personal control 19.9 (4.2) 18.8 (4.3)c 19.7 (4.2) 18.3 (0.3)a,g 22.9 18.4 (4.0)i 15.7 (3.2) 17.7 (4.0)c,f,g 20.5 (3.8)c,d,g 18.8 (3.5)b,h
(3.5)a,d,g
Treatment control 16.4 (3.1) 15.9 (3.2) 16.3 (3.1) 16.6 (0.2)e 19.4 14.2 (3.4)b,e,g 16.2 (5.1) 14.1 (3.4)a,d,g 17.0 (3.4)b,e,g 13.9 (2.8)a,d,g
(3.3)a,d,g

89
Emotional representations 17.1 (5.9) 17.5 (5.0) 17.2 (5.7) 17.8 (0.3) 16.1 (4.0) 19.8 (4.2)b,e,g 15.9 (3.4)a,d,g 18.7 (5.3)h 16.7 (5.2) 14.3 (5.2)a,d,g
Illness coherence 18.4 (4.3) 18.6 (4.8) 18.5 (4.4) 16.4 (0.3)a,d,g 9.3 (3.0)a,d,g 13.4 (4.8)a,d,g 14.7 (5.8)c,f 17.6 (5.3)i 13.8 (5.0)a,d,g 17.9 (4.1)
Psychological attributions 16.1 (5.6) 12.8 (5.2)a 15.4 (5.7) NA 8.9 (3.0)a,d,g 12.5 (5.2)a,g 15.1 (3.6)e NA 11.9 (4.1)a,f,g 12.6 (4.3)a,g
Risk factors attributions 14.6 (4.5) 13.0 (4.7)b 14.3 (4.6) NA 12.3 (3.8)b,i 15.3 (4.8)e 7.4 (2.0)a,d,g NA 15.0 (4.1)d,h 17.8 (3.3)a,d,g
Immune attributions 5.8 (2.3) 5.8 (2.5) 5.8 (2.4) NA 4.0 (1.4)a,d,g 6.0 (2.5) 5.5 (1.7) NA 5.3 (1.9)a,f,g 6.7 (2.0)a,d,g
Accident/chance 5.0 (2.1) 6.2 (2.5)a 5.2 (2.2) NA 8.0 (1.9)a,d,g 6.5 (1.8)a,g NA 6.0 (1.9)a,g 4.9 (1.6)d
attributions

1
n = 240 for primary, n = 60 for secondary, and n = 300 for all chronic headaches.
a
p < .001 compared to all primary chronic headaches.
b
p < .01 compared to all primary chronic headaches.
c
p < .05 compared to all primary chronic headaches.
d
p < .001 compared to all secondary chronic headaches.
e
p < .01 compared to all secondary chronic headaches.
f
p < .05 compared to all secondary chronic headaches.
g
p < .001 compared to all chronic headaches.
h
p < .01 compared to all chronic headaches.
i
p < .05 compared to all chronic headaches.
Journal of Psychosomatic Research 116 (2019) 83–92
E.S. Kristoffersen et al.
finding may be explained by the fact that people with more severe
headache try several different treatments compared to those with an
adequate pain control [37].
Patients with MOH have in other studies been described as having
more impulsivity, more somatic symptoms and higher levels of anxiety/
depression [46–49]. Thus, the findings of more negative emotions, less
personal control and a higher number of other symptoms among people
with MOH in the present study are in accordance with other studies
[46–48]. In a recent cohort study following the MOH patients from the
present sample over time, those who managed to terminate their
overused medication and reverted to episodic headache had sig-
nificantly shorter perceived timeline despite the actual time since
headache debut was similar in the two groups [50]. In addition, those
who reverted to episodic headache had significantly higher illness co-
herence than those who failed. These results, as well as our results, here
suggest the need for further longitudinal cohort studies focusing on the
different diagnostic groups over time. Such studies may contribute to-
wards a better understanding of how illness perception may play in and
possible shed more light on direction of causality.
The fact that secondary chronic headache was associated with a
worse illness perception than primary chronic headache is a new
finding and may be a marker of a more complex headache situation.
More symptoms attributed to the headache, larger consequences and
less personal control over the disease may reflect a cognitive model
based on the understanding that secondary headaches are caused by
external factors.
It is not possible to ascertain the direction of any of these associa-
tions which may, of course, be bidirectional. One study that used eco-
logical momentary assessment suggested that psychological stress could
trigger acute exacerbations of TTH [51]. Furthermore, psychological
distress is associated with primary chronic headache and secondary
chronic headaches [52,53]. However, in a vicious circle with a near-
daily headache and severe disability, many different aspects of life may
be affected in a bi-directional direction. Thus, different cognitive ex-
planation models and coping behaviors have been suggested [54–57].
Illness perception has been suggested to be of importance in illness-
specific behaviors such as treatment adherence [10,58]. The low
treatment and personal control found in the present study may con-
tribute to the low adherence to prophylactic headache medication
among headache sufferers [38]. Furthermore, perceived negative con-
sequences of headache have been found to be a much stronger predictor
for unsuccessful outcome than more likely factors such headache fre-
quency, headache disability, mood disorders and satisfaction with the
GP [35]. Thus, cognitive-behavioural approaches may be appropriate
for some of these patients which are often regarded as treatment re-
sistant. However, this is not unique for chronic headaches, but probably
applies also to other chronic pain conditions where pain coping is a
potential treatment target [7,8,57].
In the present study, co-occurrence of other chronic pain was only
associated with increased perception of chronicity and the number of
other symptoms attributed to headache. Based on the significant dif-
ferences in the IPQ-R dimensions for various chronic pain conditions, it
is possible to speculate that various types of pain contribute to, and/or
maintain different aspects of illness perceptions and cognitive models.
As an example, some of these pain conditions are purely symptomatic
diagnoses (chronic unspecified pain, fibromyalgia and chronic wide-
spread pain) whereas osteoarthritis has objective findings as a part of
the diagnosis.
A meta-analysis of patients with well-classified disorders has shown
that a strong illness identity in terms of number of attributed symptoms,
long timeline perspective (chronicity), perceived consequences, high
emotional representations and less personal control are associated with
serious and more negative health outcomes [54]. In line with these
findings, a large primary care study of low back pain reported that low
experienced symptom control, expectations of chronicity and perceived
severe consequences all significantly affected the outcome six months
90
Journal of Psychosomatic Research 116 (2019) 83–92
later [15]. Based on the comparable results in the same IPQ-R dimen-
sions as the present study, people with primary and secondary chronic
headaches are probably at risk of reduced physical and mental health. It
is known that anxiety, depression, gastro-intestinal complaints, mus-
cular-skeletal problems and other chronic pain disorders are associated
with and risk factors of chronic headache, and probably contribute to
the high disease burden and disability reported [1,47].
Whether or not it is possible to treat illness perception in itself is a
matter of debate. A recent study found that cognitive patient education
in low back pain initiated an improvement in illness perception [59].
Furthermore, another study of low back pain found that a reduction in
illness perception was associated with a reduction in depression and
pain-related behaviour. However, the clinical implication of this is
uncertain, as the causal relationship and direction of the factors cannot
be ascertained in that study design [56]. Furthermore, the common-
sense model suggests that illness perceptions change continuously due
to new information and personal experiences, which may suggest that
these factors could be affected by treatment, although others, in con-
trast, have shown that at least some dimensions are stable over time
[6].
Although illness perceptions have been shown to be associated with
treatment outcomes in osteoarthritis, headache and low back pain, the
clinical usefulness in chronic headaches such as CM, CTTH and MOH
needs further research.
Future studies should examine whether the improvement of illness
perceptions through specific psychological, cognitive or educational
interventions may promote a better adaptation to living with chronic
and disabling headache.
4.1. Strengths and limitations
Our population-based study was large, and the participation rate
was high.
The IPQ-R is the most used and validated illness perception ques-
tionnaire. The score is associated with important health outcomes.
Furthermore, the IPQ-R has been suggested to be valid in other chronic
pain conditions [9,15,20]. Our internal validation by confirmatory
factor analysis in our population suggests that the IPQ-R can be used
also in this setting, and that it may add additional information.
The 30–44 years age range in our study was chosen because the
prevalence of chronic headache is higher in this group than in younger
people, whereas co-morbidity of other diseases and medication use is
lower than in older age groups [60]. This age range may limit gen-
eralization of findings to the general adult population as older people
with more comorbidity may have different perceptions of the impact of
headache on their lives.
Face-to-face interviews by headache experts, as in the present study,
provide more valid headache diagnoses than questionnaire-based stu-
dies [61].
The majority of the participants completed a full diagnostic inter-
view conducted by a headache expert albeit with a smaller portion by
telephone. The headache diagnoses were not significantly different in
these two groups of participants and no significant difference between
data collected at the clinic and by telephone by a trained headache
expert was reported in a previous study [62]. Since two physicians
conducted the investigations, inter-observer variation is a possibility.
However, the headache diagnoses were equally frequent by both phy-
sicians, suggesting that inter-observer variation was low. The overall
sample size limited the number of variables that could be analyzed as
potential confounders, and this also lead us to dichotomize some vari-
ables for use in the analyses. Even though the sample size of secondary
chronic headache is relatively small and conferred some challenges due
to reduced power in the statistical analyses, it is the largest population
based sample reported so far. It may be argued that this potential power
problem should have limited the number of predictors in the regression
analyses, but we chose to use the same predictors in the analyses for
E.S. Kristoffersen et al.
both primary and secondary chronic headaches to be able to compare
these groups. The study in itself was exploratory and hypotheses gen-
erating as no other studies have investigated the IPQ-R in chronic
headaches from the general population. Thus, we found it most ap-
propriate to present unadjusted results and no corrections for multiple
comparisons were done.
Finally, the cross-sectional design in the present study does not
permit any conclusions about causality in the relationship between
chronic headache and IPQ-R.
We used pain populations from other studies for comparison, as no
control groups were included in the present study. These populations
were not population-based, were recruited from different settings and
with partly other age groups. This may, of course, affect the compar-
isons which should thus be interpreted with caution.
To conclude, people with chronic headache report a high symptom
burden and hold perceptions of a long-lasting disorder with psycholo-
gical attributions and large perceived negative consequences for daily
living. There is emerging evidence that patients` illness perceptions are
important determinants of function, disability and outcome. Our evi-
dence, as presented here, suggests that especially for patients with
secondary chronic headaches as well as for those with the highest
headache-related disability, treatment focusing on such perceptions and
on coping behaviour may be important. This implies that treatment
involving multidisciplinary, cognitively and coping focused treatment
and patient education may be promising for these patients.
Competing interest
All authors have completed the Unified Competing Interest form at
http://www.icmje.org/coi_disclosure.pdf All authors declare that they
have no competing interest.
Authors' contributions
MBR had the original idea for the study and planned the overall
design together with CL. All authors were involved in the planning and
interpretation of the data analysis. ESK conducted the data analysis and
prepared the initial draft. All authors have commented on, revised and
approved the final manuscript.
Acknowledgments
Kjersti Aaseth and Ragnhild Berling Grande conducted the clinical
interviews.
Funding
This study was supported by grants from the South East Norway
Regional Health Authority and Institute of Clinical Medicine, Campus
Akershus University Hospital, University of Oslo.
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