Cactus-Like Plant Shows Promise as Treatment for Intractable Cancer Pain

By Pat Anson

Throughout history, humans have often turned to plants and herbs for pain relief. Poppy plants gave us opium, aspirin was derived from willow trees, and peppermint oil is used to relieve everything from migraines to joint pain. Turmeric, ginger, lavender, eucalyptus and capsaicin are staples in many topical analgesics.

Researchers at the National Institutes of Health (NIH) say a cactus-like shrub native to Morocco also shows promise as a treatment for severe cancer pain and other types of intractable pain.

In a small pilot study recently published in the journal NEJM Evidence, they reported that injections of resiniferatoxin (RTX), a molecule derived from resin spurge (Euphorbia resinifera), provided durable pain relief to patients with terminal end-stage cancer.

"The effects are immediate," lead author Andrew Mannes, MD, chief of the NIH Clinical Center Department of Perioperative Medicine, said in a press release. "This is a potential new therapy from a new family of drugs that gives people with severe cancer pain an opportunity to return some normality to their lives."

The study involved 19 patients with terminal end-stage cancer who did not get adequate pain relief from opioids and other pharmaceutical drugs. But after a single injection of RTX, their worst pain intensity fell by 38% and their use of opioids by 57%. Quality of life also improved, allowing the patients to reengage with family and friends in their final days.

NIH scientists believe RTX has the potential to treat other pain conditions, including other types of cancer pain, neuropathy, post-surgical pain, trigeminal neuralgia, and chronic nerve pain caused by chemotherapy.

"Targeting specific nerves brings many pain disorders into the range of RTX and allows physicians to tailor the treatment to the patient's pain problem. This interventional approach is a simple path to personalized pain medicine," said senior author Michael Iadarola, PhD, a research scientist in the NIH Clinical Center Department of Perioperative Medicine.

RTX acts similarly to capsaicin, the active molecule in chili pepper, by numbing nerve fibers in damaged tissue and blocking them from sending pain signals to the brain. RTX enters the TRPV1 ion channel in the peripheral nervous system, allowing an overload of calcium to flood into the nerve fiber. Patients are still able to feel mild sensations like touch, pressure and pin pricks, but more severe pain signals are blocked.

"Basically, RTX cuts the pain-specific wires connecting the body to the spinal cord, but leaves many other sensations intact," Iadarola said. "These TRPV1 neurons are really the most important population of neurons that you want to target for effective pain relief."

"What makes this unique from all the other things that are out there is that it is so highly selective," Mannes said. "The only thing it seems to take out is heat sensation and pain."

People in North Africa knew this thousands of years ago. The first written record of Euphorbia resinifera being used for pain control dates back to the time of the Roman Emperor Augustus, when dried latex from the plant was used as medicine.

The NIH is planning further studies of RTX in clinical trials.

A Non-Alcoholic Drink Can Help You Relax, Socialize and May Even Relieve Pain

By Madora Pennington

I am going for a month without drinking, not because I have a problem with alcohol or because alcohol is interfering with my life. I don't and it isn't.

I just got back from a long vacation, which included an 8-day all-inclusive cruise. We wanted to get our money’s worth. After weeks of drinking every day, it seemed only sensible to take a full break from alcohol. No one would argue that so much drinking is healthy.

I am not alone. You may have heard about the “sober curious” — those who abstain to see what socializing, stress, and life itself is like without alcohol. Young adults, overall, are drinking less alcohol. These trends are fueling the demand for non-alcoholic, yet interesting drinks that seem sophisticated or reminiscent of a cocktail.

But is there a non-alcoholic drink that also helps you relax and socialize? I found a company, Sentia Spirits, that makes beverages that enhance your body’s production of GABA

Don’t confuse GABA (gamma-aminobutyric acid) with the nerve pain medication gabapentin (Neurontin). GABA is a naturally occurring neurotransmitter that sends signals in the brain and spinal cord, while gabapentin is a synthetic variation of GABA. The medication acts similarly as GABA, but tends to cause many unwanted side effects. Benzodiazepines, SSRI antidepressants, muscle relaxers, and other drugs also affect GABA in the body.

Sentia’s beverages contain herbs and botanicals that improve mood, focus, calmness, and energy. Their concoctions taste more like bitters than a mocktail, but certainly provide an interesting experience for the palate.

I found them to be subtly relaxing, without the impairment of an alcohol-induced buzz.

GABA itself is also available in supplements that people take to relax and improve sleep. It may also help relieve pain. When GABA binds to pain receptors, it reduces the transmission of pain signals, potentially providing relief from various types of physical discomfort.

SENTIA SPIRITS

Research has found that low levels of GABA make it harder to keep negative emotions such as fear, anxiety and depression in check, and may also worsen chronic pain. As PNN has reported, Dr. Forest Tennant recommends GABA supplements for patients with intractable pain "to force damaged nerve tissue to correctly function and relieve pain.”  

As far as reasons for abstaining, alcohol worsens depression. And people with alcohol use disorder often have chronic pain, which means they could be self-medicating.

Using supplemental GABA or medications that promote it could be a useful strategy in managing the spiral of chronic pain on the body and brain. Many sources suggest taking GABA on an empty stomach to give it a better chance of reaching the brain.

Limiting alcohol intake might also be a wise choice for anyone. Certainly, finding ways to diminish stress and improve sleep should be part of pain management.

Sentia costs about $40 for a 500ml bottle, which is enough for 20 shot-sized servings. If you don't want it straight or want to make it look like a cocktail, you can mix it with tonic water.

Talk to your healthcare provider about your pain control regimen and how to improve it before taking GABA or any supplement.

I enjoyed my time of sobriety very much. I thought I would miss drinking, but did not. The sleepiness and haziness from a glass of wine is stronger than I realized, and it doesn’t make socializing more fun for me. I ended my sober curious time with a resolve to drink less overall.

Care and Control of Adhesive Arachnoiditis Depends on Water

By Dr. Forest Tennant

Chronic illness tends to decrease one’s desire to drink fluids. If you have Adhesive Arachnoiditis (AA), however, you must drink some fluids about every 2 hours while awake. Why?

AA is an inflammatory disease of the spinal canal in which cauda equina nerve roots become attached by adhesions to the arachnoid-dural membranes covering the spinal canal. 

The arachnoid membrane is unique among tissues in the body as it doesn’t have its own blood supply. No arteries feed into it. Consequently, it depends on a “full tank” of spinal fluid that comes from the fluids you drink. Spinal fluid brings nutrients and medication to the arachnoid. It also bathes the inflamed area and washes away inflammatory waste and toxins.

Spinal fluid must be constantly kept at a high level. The body makes about 500 milliliters (17 ounces) of spinal fluid a day. If you are dehydrated due to lack of regular fluid intake, you may not make enough spinal fluid to control AA, including its pain.

Water Soak Every Day

Soaking in water daily is also important to control pain and inflammation from AA.

Water soaking is an age-old remedy for pain that is still worthwhile. It is believed to relieve pain by relaxing muscles and increasing blood flow to damaged areas of the body.  

Water soaking also extracts excess bioelectricity and inflammatory toxins that have accumulated due to inflammation and damage to the neurologic circuitry in the body. 

Here is a list of water soaking measures that are applicable to a person with AA: 

1. Stand in the shower and let water flow off your back, neck and legs.

2. Immerse your body up to your neck in a bathtub, hot tub, jacuzzi or pool.

3. Drape a warm, water-soaked towel over your back.

4. Soak your feet and ankles in warm water.

The soaks should be done for 5 to 15 minutes. Minerals or herbs can be put in foot baths. The most popular mineral preparation is Epsom Salts.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.   

Flexible Implant Could Be Alternative to Spinal Cord Stimulators

By Pat Anson

Spinal cord stimulators have long been fraught with problems. First developed in the 1960’s, the devices are surgically implanted near the spine to deliver mild electric impulses that block pain signals from traveling to the brain.

Although their design and technology have improved over the years, making them smaller, rechargeable and programmable, spinal cord stimulators (SCSs) still have high failure rates and poor safety records. Recent studies have also questioned their effectiveness in treating back pain.

Researchers at the University of Southern California have developed an alternative: a small, flexible, wireless, and battery-free implant that could overcome some of the limitations of SCSs.

NATURE ELECTRONICS

The experimental device, recently introduced in a paper published in Nature Electronics, is powered by a wearable ultrasound transmitter and uses machine learning algorithms to customize treatment for each patient. The implant is designed to bend and twist, unlike traditional stimulators that tend to be bulky and are hard-wired to batteries.

“Implantable percutaneous electrical stimulators… are expensive, can cause damage during surgery and often rely on a battery power supply that must be periodically replaced. Here we report an integrated, flexible ultrasound-induced wireless implantable stimulator combined with a pain detection and management system for personalized chronic pain management," wrote a team of researchers at USC’s Alfred E. Mann Department of Biomedical Engineering.

The researchers tested the wireless stimulator in laboratory rodents experiencing different levels of pain. They found the device accurately predicted the levels of stress experienced by the animals and adapted the electrical stimulation it delivered, easing most of their pain.

“We classify pain stimuli from brain recordings by developing a machine learning model and program the acoustic energy from the ultrasound transmitter and, therefore, the intensity of electrical stimulation," researchers said. "The implant can generate targeted, self-adaptive and quantitative electrical stimulations to the spinal cord according to the classified pain levels for chronic pain management in free-moving animal models."

The research team is planning further tests on other lab animals, with the goal of eventually testing the device in clinical trials on humans.

About 50,000 traditional spinal cord stimulators are implanted every year in the U.S., where they are promoted as alternatives to opioids and other pain treatments. However, a 2022 study found that SCSs do not reduce patient use of opioids, epidurals, steroid injections or radiofrequency ablation. About a fifth of patients experienced complications so severe the devices had to be removed or revised.

‘Zombie’ Nerve Cells Make Chronic Pain Worse

By Pat Anson

The zombies are at it again.

Weeks after researchers announced a new way to treat low back pain by targeting so-called zombie cells – a new study suggests that peripheral nerve pain could also be treated with drugs that target aging cells.

Senescent neurons are cells that stop dividing, but refuse to die and linger in the central nervous system. As people age, more and more of these “zombie cells” build up, secreting inflammatory agents that increase pain sensitivity and raise the risk of age-related diseases like arthritis, Alzheimer’s and Parkinson’s.

“Very little is known about underlying causes of pain experienced during aging. The prevalence of chronic pain in aging populations and the lack of effective and non-addictive treatments motivated this exploration into neuronal senescence as a potential mechanism,” Lauren Donovan, PhD, a research scientist at Stanford University, told PsyPost.

In studies on laboratory animals, Donovan and her colleagues at Stanford found that pain was amplified in older mice by senescent cells, which released inflammatory signals when the mice were injured. The same inflammatory reaction was found in younger mice, but was more pronounced in the older ones.

When the injured mice were treated with a drug called ABT263 – a compound that destroys senescent cells – the older mice showed less pain sensitivity and significant improvement in their weight-bearing behavior.

The younger mice treated with ABT263 showed only modest improvements in their pain-related behavior, which suggests that senescent cells play a significant role in causing chronic pain.

“The key takeaway for the average person is that as we age, some of our sensory neurons undergo a process called senescence, which may contribute to chronic pain,” said Donovan, who reported the findings in the journal Nature Neuroscience.

“In addition, we found that injury can exacerbate senescence in neurons, leading to an additive effect of aging and injury that may enhance pain. This research identifies a new potential target for treating chronic pain, especially in older individuals. It suggests that addressing cellular senescence in the nervous system can lead to new ways of managing pain and sensory dysfunction.”

Researchers at McGill University reported similar findings last month in studies on laboratory mice with damaged discs. When the mice were given drugs that targeted senescent cells in their spines, they experienced less pain and their bone quality improved.

Previous animal studies have shown that senolytic drugs can reverse osteoarthritis by eliminating senescent cells, giving the body a chance to repair and rejuvenate damaged cartilage.

The findings need to be replicated in humans, but they suggest that senolytic drugs that target zombie cells have the potential to prevent or even cure some age-related diseases.

Online Emotional Support Therapy Modestly Reduces Chronic Pain

By Pat Anson

An online support program designed to “retrain the emotional brain” modestly reduces chronic pain and helps patients keep their negative emotions in check, according to a small pilot study in Australia.

Many people with chronic pain also develop anxiety and depression, but are unable to get psychological treatment because they live in rural areas or have mobility issues, and don’t have easy access to a therapist.

“We’ve known now for some time that chronic pain is more than just ‘Ouch, it hurts.’ It’s more than a sensory experience, it’s incredibly emotional,” says lead author Nell Norman-Nott, PhD, a research fellow at the University of New South Wales and clinical trial manager at the NeuroRecovery Research Hub.

Norman-Nott and her colleagues enrolled 89 people with chronic pain in the “Pain and Emotion Therapy” program. Half of the patients participated in 8 weekly group sessions over Zoom, in which a therapist teaches them emotional skills such as distraction, breathing exercises, and relaxation and self-soothing techniques.

The other participants received the treatment they were already getting, such as medication or physical therapy, and served as a control group.

The study findings, published in JAMA Network Open, show that after 9 weeks there were moderate improvements in depression, anxiety and sleep in those that received online therapy. But there was no change in pain intensity compared to those in the control group.

However, after a 6-month follow-up period, participants reported a 10% reduction in their pain levels, as well as continued improvement in their emotions and sense of well-being.

One of them is Janelle Blight, who lives with chronic back pain, arthritis and neuropathic pain. For the first time in 30 years, she was able to reduce her morphine dose after getting online therapy.

“I’ve been on a lot of opioids and things like that, but I’ve had nothing or found no course that’s been able to help take away the pain or help control the pain at home,” said Blight. “By doing the course, I’ve been able to learn how to reduce my emotional side of my pain, which has helped my chronic pain in the end.”

During a briefing with reporters, researchers called the study a “major step forward in pain care.” But in the actual study, they said the 10% reduction in pain intensity after six months was not well understood and “should be treated with caution.” The improvement was dependent on participants continuing to use the emotional skills they developed during online therapy.

Researchers hope to build on what they’ve learned with a larger study involving 300 participants in 2026. Registrations are open (for Australians only) on the NeuroRecovery Research Hub website.

How Workplace Conditions Contribute to Chronic Pain and Mental Health Issues

By Pat Anson

If you are of a certain age – like me – you’ll remember when computers started entering the workplace in the 1980’s. There was a huge learning curve, but eventually work became faster and more efficient.

There was also a tradeoff: employees reported back and neck pain from sitting at keyboards all day, and carpal tunnel syndrome became a thing. Companies learned about the hazards of repetitive motion, and how chair height, limited desk space and poorly shaped computer mouses affected worker health, absenteeism and productivity. A new industry was born: ergonomics.

Flash forward 40 years and companies are now being urged to think about “emotional ergonomics” – how workplace stress contributes to anxiety, depression, burnout, and chronic pain.

“Physical pain is often a symptom of deeper, underlying stressors—from job pressures to mental health challenges. Addressing industrial ergonomics without considering emotional well-being is an incomplete strategy. The most forward-thinking companies recognize that true injury prevention must integrate both,” says Kevin Lombardo, CEO of the DORN Companies.

DORN has partnered with organizations that specialize in ergonomics, business psychology, and suicide prevention on a new white paper called “Emotional Ergonomics: How the Intersection of Industrial Ergonomics, Pain, and Mental Health Shapes Worker Wellbeing.”

The paper’s main findings are that workplace conditions deeply affect the physical and mental health of workers, and that organizations must address them together to have a healthy, high-performing workforce. Workplace stress affects 40% of employees in the United States and contributes to about $190 billion in added healthcare costs.

Unlike the 1980’s, when most jobs entailed a 40-hour work week and were performed outside the home, today’s knowledge-driven economy blurs the lines between professional and personal lives. Employees may get work-related emails or texts at all hours of the day and night, and a growing number work from home. This increases exposure to stress, cognitive demands, poor sleep habits, and the psychosocial risks that come with juggling work, family and personal time.

A recent study found that stress and anxiety have become the most common work-related injuries, accounting for over half (52%) of new cases. That trend is mirrored in Google searches for “burnout,” which have risen dramatically in the last 10 years.

“This research signals a necessary shift in how we approach workplace well-being. Emotional Ergonomics bridges the gap between physical safety and mental resilience, ensuring that employee health is not just a compliance checkbox but a business imperative. Organizations that fail to recognize this connection risk long-term workforce instability and financial strain,” says Dr. Sally Spencer-Thomas, President of United Suicide Survivors International.

Common psychosocial hazards in the workplace include:

• Excessive workload and time pressures

• Toxic relationships between coworkers and supervisors

• Hazing, bullying, harassment and discrimination

• Exposure to workplace accidents and trauma

• Low autonomy and limited decision-making

• Job insecurity

• Work-Life disruption

To address these issues, companies can adjust workloads and allow for more flexible scheduling; adopt health and wellness programs; train supervisors in empathetic communication skills; and allow for “quiet time” and space where workers can decompress from job strain.

The goal is to view workers not as cogs in a machine, but as individuals with different physical, emotional, and psychological needs. An “I’ve got your back” mentality in the workplace builds trust and helps employees feel valued.  

To learn more about the study findings and ways to build emotional ergonomics, you can sign up to watch a live webinar on Wednesday, May 21.

Drugs Targeting ‘Zombie Cells’ May Reduce Low Back Pain

By Pat Anson

Low back pain is one of the most common and difficult pain conditions to treat. Although it’s the leading cause of disability worldwide, a recent study found that only about 10% of pharmaceutical and non-surgical therapies for low back pain provide relief. More invasive treatments, such as spinal injections and nerve blocks, have also been found to be no more effective than a placebo.

In short, there’s not much evidence to support the use of many treatments commonly used for low back pain -- which makes a preclinical study on two potential treatments all the more interesting.

Low back pain is commonly caused by senescent cells, so-called “zombie cells” that build up in spinal discs as people age or when discs are damaged. Instead of dying off like normal cells, these aging cells linger in the spine, causing pain and inflammation.

In experiments on laboratory mice, researchers at McGill University found that two drugs – o-vanillin and RG-7112 -- can clear zombie cells from the spine, reduce pain and improve bone quality. O-vanillin is a natural compound, while RG-7112 is an FDA-approved cancer drug that shrinks tumors.

“Our findings are exciting because it suggests we might be able to treat back pain in a completely new way, by removing the cells driving the problem, not just masking the pain,” said senior author Lisbet Haglund, PhD, a Professor in McGill’s Department of Surgery and Co-director of the Orthopaedic Research Laboratory at Montreal General Hospital.

Haglund and her colleagues found that o-vanillin and RG-7112 had a beneficial effect when taken separately, but their impact was greatest when they were taken together orally.  After just eight weeks of treatment, the drugs slowed or even reversed disc damage in mice.  

“We were surprised that an oral treatment could reach the spinal discs, which are hard to access and present a major hurdle in treating back pain,” said Haglund. “The big question now is whether these drugs can have the same effect in humans.”

O-vanillin belongs to a family of spicy and pungent natural compounds known as vanilloids, which are found in chili peppers and turmeric. Vanilloids are already used to control inflammation and reduce pain in topical patches like Qutenza.

O-vanillin was not originally intended to be part of the McGill study. But while testing other drugs, researchers decided to include o-vanillin to see whether it might be effective when taken orally. The results offer some of the first evidence that o-vanillin can clear out zombie cells. Analogs of RG-7112 were already known to do this in osteoarthritis and cancer research, but had not previously been used to treat back pain.

The McGill findings are published in the journal Science Advances. In future studies, Haglund’s team hopes to modify o-vanillin to help it stay in the body longer and become more effective. In addition to back pain, they believe the two drugs have the potential to treat other age-related diseases driven by senescent cells, such as arthritis and osteoporosis.

Physical Therapy Coverage Often Ends When Patients Still Need It

By Jordan Rau, KFF Health News

Mari Villar was slammed by a car that jumped the curb, breaking her legs and collapsing a lung. Amy Paulo was in pain from a femur surgery that wasn’t healing properly. Katie Kriegshauser suffered organ failure during pregnancy, weakening her so much that she couldn’t lift her baby daughter.

All went to physical therapy, but their health insurers stopped paying before any could walk without assistance. Paulo spent nearly $1,500 out of her own pocket for more sessions.

Millions of Americans rely on physical and occupational therapists to regain strength and motor skills after operations, diseases, and injuries. But recoveries are routinely stymied by a widespread constraint in health insurance policies: rigid caps on therapy sessions.

Insurers frequently limit such sessions to as few as 20 a year, a KFF Health News examination finds, even for people with severe damage such as spinal cord injuries and strokes, who may need months of treatment, multiple times a week. Patients can face a bind: Without therapy, they can’t return to work, but without working, they can’t afford the therapy.

Paulo said she pressed her insurer for more sessions, to no avail. “I said, ‘I’m in pain. I need the services. Is there anything I can do?’” she recalled. “They said, no, they can’t override the hard limit for the plan.”

A typical physical therapy session for a privately insured patient to improve daily functioning costs $192 on average, according to the Health Care Cost Institute. Most run from a half hour to an hour.

Insurers say annual visit limits help keep down costs, and therefore premiums, and are intended to prevent therapists from continuing treatment when patients are no longer improving. They say most injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority.

Atul Patel, a physiatrist in Overland Park, Kansas, and the treasurer of the American Academy of Physical Medicine and Rehabilitation, said insurers’ desire to prevent gratuitous therapy is understandable but has “gone too far.”

“Most patients get way less therapy than they would actually benefit from,” he said.

Hard caps on rehab endure in part because of an omission in the Affordable Care Act. While that law required insurers to cover rehab and barred them from setting spending restrictions on a patient’s medical care, it did not prohibit establishing a maximum number of therapy sessions a year.

More than 29,000 ACA health plans — nearly 4 in 5 — limit the annual number of physical therapy sessions, according to a KFF Health News analysis of plans sold last year to individuals and small businesses. Caps generally ranged from 20 to 60 visits; the most common was 20 a year.

Health plans provided by employers often have limits of 20 or 30 sessions as well, said Cori Uccello, senior health fellow at the American Academy of Actuaries.

“It’s the gross reality in America right now,” said Sam Porritt, chairman of the Falling Forward Foundation, a Kansas-based philanthropy that has paid for therapy for about 200 patients who exhausted their insurance over the past decade. “No one knows about this except people in the industry. You find out about it when tragedy hits.”

Even in plans with no caps, patients are not guaranteed unlimited treatment. Therapists say insurers repeatedly require prior authorization, demanding a new request every two or three visits. Insurers frequently deny additional sessions if they believe there hasn’t been improvement.

“We’re seeing a lot of arbitrary denials just to see if you’ll appeal,” said Gwen Simons, a lawyer in Scarborough, Maine, who represents therapy practices. “That’s the point where the therapist throws up their hands.”

‘Couldn’t Pick Her Up’

Katie Kriegshauser, a 37-year-old psychologist from Kansas City, Missouri, developed pregnancy complications that shut down her liver, pancreas, and kidneys in November 2023.

After giving birth to her daughter, she spent more than three months in a hospital, undergoing multiple surgeries and losing more than 40 pounds so quickly that doctors suspected her nerves became damaged from compression. Her neurologist told her he doubted she would ever walk again.

Kriegshauser’s UnitedHealthcare insurance plan allowed 30 visits at Ability KC, a rehabilitation clinic in Kansas City. She burned through them in six weeks in 2024 because she needed both physical therapy, to regain her mobility, and occupational therapy, for daily tasks such as getting dressed.

“At that point I was starting to use the walker from being completely in the wheelchair,” Kriegshauser recalled. She said she wasn’t strong enough to change her daughter’s diaper. “I couldn’t pick her up out of her crib or put her down to sleep,” she said.

The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms. “A huge amount of progress happened in that period after my insurance ran out,” she said.

In an unsigned statement, UnitedHealthcare said it covered the services that were included in Kriegshauser’s health plan. The company declined to permit an official to discuss its policies on the record because of security concerns.

A Shattered Teenager

Patients who need therapy near the start of a health plan’s year are more likely to run out of visits. Mari Villar was 15 and had been walking with high school friends to get a bite to eat in May 2023 when a car leaped over a curb and smashed into her before the driver sped away.

The accident broke both her legs, lacerated her liver, damaged her colon, severed an artery in her right leg, and collapsed her lung. She has undergone 11 operations, including emergency exploratory surgery to stop internal bleeding, four angioplasties, and the installation of screws and plates to hold her leg bones together.

Villar spent nearly a month in Shirley Ryan AbilityLab’s hospital in Chicago. She was discharged after her mother’s insurer, Blue Cross and Blue Shield of Illinois, denied her physician’s request for five more days, making her more reliant on outpatient therapy, according to records shared by her mother, Megan Bracamontes.

Villar began going to one of Shirley Ryan’s outpatient clinics, but by the end of 2023, she had used up the 30 physical therapy and 30 occupational therapy visits the Blue Cross plan allowed.

Because the plan ran from July to June, she had no sessions left for the first half of 2024.

MARI VILLAR AND HER THERAPIST

“I couldn't do much,” Villar said. “I made lots of progress there, but I was still on crutches.”

Dave Van de Walle, a Blue Cross spokesperson, said in an email that the insurer does not comment on individual cases. Razia Hashmi, vice president for clinical affairs at the Blue Cross Blue Shield Association, said in a written statement that patients who have run out of sessions should “explore alternative treatment plans” including home exercises.

Villar received some extra sessions from the Falling Forward Foundation. While her plan year has reset, Villar is postponing most therapy sessions until after her next surgery so she will be less likely to run out again. Bracamontes said her daughter still can’t feel or move her right foot and needs three more operations: one to relieve nerve pain, and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right.

“Therapy caps are very unfair because everyone’s situation is different,” Villar said. “I really depend on my sessions to get me to a new normalcy. And not having that and going through all these procedures is scary to think about.”

Rationing Therapy

Most people who use all their sessions either stop going or pay out-of-pocket for extra therapy.

Amy Paulo, a 34-year-old Massachusetts woman recovering from two operations on her left leg, maxed out the 40 visits covered by Blue Cross Blue Shield of Massachusetts in 2024, so she spent $1,445 out-of-pocket for 17 therapy sessions.

Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg — the difference a consequence of juvenile arthritis. Her recovery was prolonged, she said, because her femur didn’t heal properly after one of the operations, in which surgeons cut out the middle of her femur and put a rod in its place.

“I went ballistic on Blue Cross many, many times,” said Paulo, who works with developmentally delayed children.”

Amy McHugh, a Blue Cross spokesperson, declined to discuss Paulo’s case. In an email, she said most employers who hire Blue Cross to administer their health benefits choose plans with “our standard” 60-visit limit, which she said is more generous than most insurers offer, but some employers “choose to allow for more or fewer visits per year.”

Paulo said she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she’ll need more help after an upcoming operation on her leg.

“We had to plan to save my visits for this surgery, as ridiculous as it sounds,” she said.

Medicare Is More Generous

People with commercial insurance plans face more hurdles than those on Medicare, which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document medical necessity. This year the limits are $2,410 for physical and speech therapy and $2,410 for occupational therapy.

Private Medicare Advantage plans don’t have visit or dollar caps, but they often require prior authorization every few visits. The U.S. Senate Permanent Subcommittee on Investigations found last year that MA plans deny requests for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other medical services.

Therapists say many commercial plans require prior authorization and mete out approvals parsimoniously. Insurers often make therapists submit detailed notes, sometimes for each session, documenting patients’ treatment plans, goals, and test results showing how well they perform each exercise.

“It’s a battle of getting visits,” said Jackee Ndwaru, an occupational therapist in Jacksonville, Florida. “If you can’t show progress they’re not going to approve.”

An Insurer Overruled

Marjorie Haney’s insurance plan covered 20 therapy sessions a year, but Anthem Blue Cross Blue Shield approved only a few visits at a time for the rotator cuff she tore in a bike accident in Maine. After 13 visits in 2021, Anthem refused to approve more, writing that her medical records “do not show you made progress with specific daily tasks,” according to the denial letter.

Haney, a physical therapist herself, said the decision made no sense because at that stage of her recovery, the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion.

“I went through those visits like they were water,” Haney, now 57, said. “My range was getting better, but functionally I couldn’t use my arm to lift things.”

Haney appealed to Maine’s insurance bureau for an independent review. In its report overturning Anthem’s decision, the bureau’s physician consultant, William Barreto, concluded that Haney had made “substantial improvement” — she no longer needed a shoulder sling and was able to return to work with restrictions. Barreto also noted that nothing in Anthem’s policy required progress with specific daily tasks, which was the basis for Anthem’s refusal.

“Given the member’s substantial restriction in active range of motion and inability to begin strengthening exercises, there is remaining deficit that requires the skills and training of a qualified physical therapist,” the report said.

Anthem said it requires repeated assessments before authorizing additional visits “to ensure the member is receiving the right care for the right period of time based on his or her care needs.” In the statement provided by Stephanie DuBois, an Anthem spokesperson, the insurer said this process “also helps prevent members from using up all their covered treatment benefits too quickly, especially if they don’t end up needing the maximum number of therapy visits.”

In 2023, Maine passed a law banning prior authorization for the first 12 rehab visits, making it one of the few states to curb insurer limitations on physical therapy. The law doesn’t protect residents with plans based in other states or plans from a Maine employer who self-insures.

Haney said after she won her appeal, she spaced out the sessions her plan permitted by going once weekly. “I got another month,” she said, “and I stretched it out to six weeks.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Mindfulness and Cognitive Behavioral Therapy Reduce Chronic Low Back Pain

By Pat Anson

Have you tried cognitive behavioral therapy (CBT) or mindfulness? Did they help relieve your pain?

Chronic pain sufferers have been telling us for years that neither form of psychotherapy worked for them. Yet many physicians continue to recommend CBT and/or mindfulness as a safer alternative to opioids and other pain medications.

Does either therapy actually work? And, if so, which one works better?

In the largest head-to-head study of its kind, a team of researchers compared the effectiveness of CBT with mindfulness in 770 patients with chronic low back pain. Unlike previous studies, these patients had fairly high pain levels (an average of 6.1 on a zero to 10 pain scale) and they were taking opioids for at least three months.

The study wasn’t short-term either. Participants were regularly surveyed about their pain levels, physical function, quality of life, and opioid use for up to a year.     

“The people in this study had quite severe back pain that interfered with their life and was bad enough to need opioid medication. Usually, in that condition, people don’t really get better over time on their own,” said co-lead author Bruce Barrett, MD, a Professor of Family Medicine and Community Health at the University of Wisconsin-Madison.

Participants were divided into two groups and trained by experienced therapists in either mindfulness or CBT, before being told to practice them at home daily for at least 30 minutes. Patients trained in mindfulness learned how to “deconstruct” their pain to make it seem less important, while those trained in CBT learned coping, behavioral and relaxation skills.

The study findings, published in JAMA Network Open, show that CBT and mindfulness were equally effective, leading to modest improvements in pain, function and quality of life. The benefits persisted and grew stronger over 12 months, with most participants reducing or even stopping their opioid use.

After a year, the average pain level in the mindfulness group fell to 5.4, while those in the CBT group were reduced to 5.5 on the zero to 10 scale. That’s about a 10% improvement.

“Both mindfulness and cognitive behavioral therapy were shown to be safe, effective treatments, providing lasting benefits for people with opioid-treated chronic back pain. These evidence-based behavioral therapies should be standard of care available to our patients,” wrote lead author Aleksandra Zgierska, MD, a Professor of Family and Community Medicine at Penn State College of Medicine.

Although participants were not explicitly encouraged to reduce their use of opioids, patients in both groups did. Researchers say that was a direct result of their training, which taught them how to cope better with pain and decrease their opioid use on their own.

“These therapies aren’t a total cure, but they teach people how to develop the inner resources they need to cope with chronic pain and to live a better life,” said co-author Eric Garland, PhD, a Psychiatry Professor at the University of California San Diego. “Mindfulness is a self-regulated tool that comes from within, unlike surgery or medication where something is being done to you from the outside. By learning these techniques, patients continue to experience lasting benefit,”

A recent study at UC San Diego using advanced brain imaging found some of the first physical evidence that mindfulness lowers pain intensity by reducing neural activity in parts of the brain associated with pain and negative emotions.

Magic Mirror on the Wall, Do I Look Healthy in This Selfie?

By Madora Pennington

What if gazing into your smartphone’s camera did more than make content for your Instagram? What if it could assess your health?

By analyzing the blood flow in your face, an app claims to do just that.

Your facial blood flow says a lot about you --- whether you are at rest, concentrating, happy or sad. And thanks to advances in artificial intelligence, it can also assess the state of your health.

The Anura MagicMirror uses transdermal optical imaging technology to gage cardiac and blood flow activity. It then processes this information to assess your overall health, as well as your risk of developing chronic conditions like diabetes, hypertension, and cardiovascular disease.

The app, which can be downloaded on a smartphone, records the face for thirty seconds. The facial blood flow — imperceptible to the human eye — is then compared to AI models from tens of thousands of individuals. From this data, it churns out individual health feedback. While not as accurate as having a blood pressure cuff or blood test, Anura makes an educated guess about your health indicators.

How accurate is Anura?

“All measurements have been validated using medical grade devices and following established scientific research protocols.  We have ten peer reviewed papers published in scientific journals detailing the methods and procedures used and the corresponding results,” says Marzio Pozzuoli, CEO of NuraLogix, which developed the Anura MagicMirror.

I downloaded a free version of the app – called Anura Lite -- and tried it for myself.

I have Ehlers-Danlos Syndrome, a connective tissue disorder, so I have “invisible” health challenges that don’t easily fall under the gaze of this app.

Anura focuses on the main issues that affect everyone: heart health, metabolic health, and mental health — which are leading indicators for chronic conditions that can end in death: cardiovascular disease, hypertension, diabetes and stroke. 

The app collects data on 30 different health parameters, including your breathing, blood pressure, heartbeat, vascular capacity, body mass index, facial skin age, waist-to-height ratio, body shape index, and mental stress index.

With this data, it then estimates the risk of cardiovascular disease, diabetes, fatty liver disease, and stroke over the next ten years.

The app also asked about my gender, age, weight and height, so I’m assuming it used this self-reported information to answer some of its questions about my health. Here are some of the scores the app gave my health and general wellness:

True, I don’t have a high BMI and am not overweight, so I’m not at high risk for metabolic disease. I already knew that.

I do have heart issues, but they are monitored and managed by my cardiologist -- successfully, it seems, if we believe Anura.

I felt relaxed when I used the app, and the MagicMirror reassuringly agreed.

One thing it got wrong was my skin age. It’s been a while since I was 31. I confess that to get my age lower, I put on makeup and laid on my back for the facial scan. I hope this didn’t affect the overall results. I am always risking my mental health when I focus the painfully high-definition iPhone camera on myself.

For metric junkies, Anura might be as fun as popping on the scale every morning or using a Fitbit.

The app doesn’t have a pain score, but for a patient with chronic pain or illness, it might be insightful to do a scan in times of physical or mental stress to see what, if anything, could be learned and addressed.

Currently, NeuroLogix is finding customers for its technology in the life insurance industry. Instead of accepting the assertions of an applicant at face value or requesting medical records and lab tests, an app like Anura could provide a health assessment more quickly – and cheaply — to the insurer.

It is easy to imagine a place for technology like this in telehealth, where a doctor has no opportunity to put a blood pressure cuff or pulse oximeter on a patient. Clinicians could then gather health data through a remote scan, improving the quality of remote telehealth appointments.

Telehealth is of enormous benefit to disabled people and the elderly, especially in rural areas without easy access to medical care or specialists. That is, if the technology proves reliable. For now, NeuroLogix admits its health assessments are “only estimates and are not a substitute for the judgment of the healthcare professional.”

But in the future, with more research, it might be possible to measure pain by using technology like this instead of relying on flawed methods like the pain scale. Pain is a subjective experience that currently has no objective and reliable way to measure, because it varies from person to person. MagicMirror may someday give us an alternative.

Why Are Doctors Reluctant to Recommend Mobility Aids?

By Crystal Lindell 

There’s a common thought process among doctors when it comes to opioid pain medications. 

They usually don’t prescribe them unless you specifically ask for them, because they don’t want to “encourage” you to use them. But also, if you do ask for opioids, then they label you as a drug seeker and assume you’re looking for “the easy way out” or to get high.

In short, most doctors try very hard to avoid giving patients opioids, unless they want to treat addiction with Suboxone – which ironically contains the opioid buprenorphine.

While I strongly disagree with every part of that thought process, in that situation doctors at least have the excuse that they have to worry about the DEA and losing their medical licenses. 

I’ve also noticed that many doctors have the same thought process when it comes to prescribing and/or recommending mobility aids like walking canes, crutches and wheelchairs. 

They don’t like to suggest them to patients because they don’t want to “encourage” their use. However, on the other end, if a patient does ask for them, doctors also bristle at that. They seem to think that mobility aids are, like opioids, “the easy way out.” 

Of course, there’s nothing easy about either opioids or mobility aids. If a patient has gotten to a point where they feel the need to use either one, chances are they are needed. 

I noticed these anti-mobility aid attitudes among doctors myself, when I had pain from a bone spur on my heel. My doctors never suggested crutches, and I had to figure out for myself that not using my foot was the only thing that seemed to help relieve the pain. I had some crutches at home from a previous injury, and using them allowed me to still function while also not putting weight on my foot. They also allowed my body to heal. 

Years ago, when my fiancé had a severe hip injury, he had to go out and buy his own cane because his doctors had not even suggested one, much less prescribed one – despite the very clear need. 

Online you’ll find multiple Reddit threads of patients expressing frustration at how doctors approach mobility aids. About a year ago in the “Mobility Aids” section of Subreddit, a poster asked, “Why are doctors so hesitant to let patients use mobility aids?”

“I use forearm crutches because I struggle to walk sometimes because of how much my pain hurts and my doctor thinks I have [an] autoimmune disorder that causes this pain which I'm getting more testing for but he goes ‘you're 19 you don't need mobility aids.’ But I have literally fallen over before. Laid in bed in agony barely able to move. Cried from how much it hurts and so much more yet they want to deny me what helps me get around?”

The post then has multiple responses from readers lamenting that they have had the same experience with doctors.

“I’ve had the same issues with doctors and just got mobility aids on my own, not through a doctor. I don't understand why doctors avoid it though because there’s been days at a time where I couldn’t leave my bed and it was hard to go anywhere or do anything on bad days [and] even on good days I still have troubles,” one poster wrote.

There is research that seems to confirm those fears.

A recent study in The Lancet found demographic, socioeconomic and social barriers impacted how much access people had to "mobility assistive products" or MAPs. They surveyed 12,080 people over age 50 in England and found that 42% had an unmet need for a mobility aid. 

Researchers found that women were more likely to have difficulty accessing mobility aids when they have a need for them. They also found that older patients who were unemployed or had a low education level had more trouble accessing MAPs.

Interestingly, having a romantic partner also increased the chances of having an unmet need for a mobility aid, whereas being single actually made patients more likely to have them. My guess is that single people are more likely to advocate for access to mobility aids, because they don’t have a partner at home to help them with daily tasks.  

Other studies have shown a prejudice toward patients with mobility aids among doctors. 

For example, a 2023 study published in the National Library of Medicine looked at physicians' attitudes about caring for disabled patients. They interviewed doctors in focus groups and found many had medical offices that presented “physical barriers to providing health care for people with disabilities, including inaccessible buildings and equipment.”

Some doctors openly admitted the lack of accessibility in their clinics. For example, one rural primary care physician said, “I know for a fact our building is not accessible.” 

If a doctor doesn’t even offer an accessible building to patients, odds are that they don’t prioritize mobility aids for the patients either. 

It seems that doctors assume that if patients start using a mobility aid, they’ll end up using it for the rest of their lives. But in my case and my fiance’s case, that’s not what happened. We both used them short term, and stopped as soon as we were healthy enough to do so. 

Regardless, who cares if people use mobility aids for the rest of their lives? Would that be such a bad thing? Being alive and independent with mobility aids is preferable to being confined at home and/or losing your independence. 

Perhaps some doctors see patients with mobility aids as a failure on their part. After all, if a patient needs them, then the doctor must not be doing enough to treat them. 

Mobility aids are exactly what the name implies – an aid that gives people more mobility, and by extension, more independence and freedom. They can greatly improve someone’s quality of life, whether they are used long or short-term. 

There’s no reason for doctors to gate-keep mobility aids, other than their own ablest bias. If they actually want to help patients, they should be suggesting them a lot more often. 

Virtual Nature Scenes May Help Relieve Minor Pain

By Crystal Lindell

Nature scenes may help relieve minor acute pain – even if you only “see” the nature scene in a virtual reality program. That’s according to new research published this week in, appropriately, the journal Nature Communications. 

Researchers administered mild electric shocks to cause a pain response in 49 healthy volunteers, and then showed them a virtual reality scene that was either a nature scene of a lake, an urban cityscape, or an indoor office setting.  

The researchers then used both brain scans and self-reported pain reactions to analyze whether any of the scenes reduced pain. 

NATURE COMMUNICATIONS

They found that areas of the brain that handle physical pain signals were less active when people saw the virtual nature scene. Self-reported pain also was lower in the nature vs. urban and indoor settings. 

I will admit that, at first, I didn’t want to believe that “virtual nature scenes” could have the same mental effect as actual, living nature. But then I quickly realized that I did enjoy virtual nature scenes, fake or not. 

Every morning, after watching the news, I open the YouTube app on my Roku and select a calming nature scene to play on the TV throughout the day. In the winter, it’s a roaring fire; in the spring, a calming rainy scene; in the summer, ocean waves; and in the fall, autumn leaves rustling. 

While I’m not sure if any of the YouTube nature scenes help my physical pain, I do think they help calm my anxiety – in the same way that watching the news usually increases my anxiety. 

Of course, the mostly Austrian research team couldn’t resist slipping in a little anti-opioid messaging, writing: 

“Besides advancing our basic knowledge, such research may have considerable importance for efforts to complement pharmaceutical treatment approaches, with their well-documented negative side effects and addictive properties.”

While I’m glad they used the word “complement” instead of “replace,” it’s their mention of “negative side effects and addictive properties” that makes it clear that they do want this research to eventually lead to non-opioid pain treatments. 

But when you actually look at the study, you’ll see that it very specifically looks only at minor, acute pain. So this research should not be used to reduce pain medications for people with chronic pain. 

I’m not accusing the authors of wanting that, since they clearly think more studies are necessary. But in our current opioid-phobia environment, I do have concerns about doctors seeing the study headline and giving patients “go look at a lake” advice to reduce medication-based pain treatments.

Ideally, research like this would be used responsibly, inspiring healthcare providers to add more natural elements to places like doctor’s offices and even nursing homes – whether those nature elements are virtual, digital or physical paintings. 

Previous research has found that patients recovering from surgery used fewer analgesics and recovered faster if their hospital window gave them a view of trees, rather than a brick wall.

However, I remain extremely doubtful that this type of research will ever result in finding a way to use nature elements as an effective pain treatment in any way that even reduces the need for pain medication.

Physical Activity Helpful for Women with Chronic Pelvic Pain

By Pat Anson

About 1 in 7 women worldwide suffer from a gynecological or chronic pelvic pain disorder (CPPD) such as endometriosis or uterine fibroids – conditions that often don’t respond well to medical treatment.

With their pain and other symptoms poorly treated or even misdiagnosed, it’s not surprising then that many women with CPPDs suffer from depression, anxiety and a poor quality of life.

A new study at the Icahn School of Medicine at Mount Sinai suggests that moderate physical activity like brisk walking or aerobic exercise can improve the mental health of women who have a CPPD.

"Chronic pelvic pain disorders are incredibly complex and burdensome for those affected, yet we still have very few effective treatment strategies," says lead author Ipek Ensari, PhD, an Assistant Professor of Artificial Intelligence and Human Health at the Icahn School. "Our research suggests that physical activity could be an important tool for improving mental health in these patients, offering them a proactive way to enhance their well-being."

Ensari and her colleagues followed 76 women with CPPDs over 14 weeks using mobile health technology, collecting over 4,200 days’ worth of data. The mean average age of the women was 35. Nearly half (43%) said their mental health was only fair or poor, and 28% had previously been diagnosed with anxiety or a mood disorder.

Participants self-reported their mental health, physical functioning, and pain levels weekly on an app (ehive), while Fitbit devices measured their daily physical activity.

The study findings, recently published in the Journal of Pain Research, show a strong association between physical activity and good mental health. Women who did not reach recommended levels of physical activity had higher pain levels and poorer mental health, while those who were physically active had better mental health and physical functioning.  

One key finding was that the benefits of physical activity appear to accumulate over time, rather than provide immediate relief.

"We were particularly intrigued to find that the positive effects of exercise seem to lag by a few days, meaning the mental health benefits may build up gradually," said Ensari. "This insight is vital for both patients and health care providers, as it underscores the importance of consistency in physical activity."

The study is believed to be the first to use data collected in real time on the positive effects of physical activity on the mental health of women with CPPDs. It also demonstrates the potential of artificial intelligence and mobile health technology in chronic disease management.

“By using innovative data modeling techniques, we can better understand how lifestyle factors like physical activity interact with health conditions and pave the way for more personalized treatment approaches," says Girish Nadkarni, MD, Chair of the Windreich Department of Artificial Intelligence and Human Health at the Icahn School.

Endometriosis can have a profound impact on a person’s life. A recent study found that over two-thirds of women with endometriosis missed school or work due to pain from the condition. Women with endometriosis may struggle to keep up with their classes, friends, homework or extracurricular activities. It can also cause pain during sex, putting a strain on romantic relationships.  

Pink Tinted Glasses May Help Reduce Migraines

By Madora Pennington

To see the world through “rose-colored glasses” is to look on the bright side, ignoring the bad. This phrase is also used to describe someone who is naive or easily fooled. But real rose-colored glasses may have an actual use: reducing migraines.

Celebrity talent judge Simon Cowell recently revealed he wears them to stop his migraine attacks, which he believes are triggered by photophobia, a sensitivity to light brought on by spending long hours under bright studio lights while taping Britain’s Got Talent.

A migraine is more than just a headache. The pain can be so severe, a person cannot function. In addition to severe throbbing, often on one side of the head. Some people may have nausea, vomiting and visual disturbances, like flashes of light or a lessening of their visual field. Other migraineurs report odd tingling sensations or difficult speaking.

If you suffer from migraines, it will come as no surprise that a change in light could make a difference. More than 90% of migraine sufferers say that light can provoke a migraine attack, especially fluorescent lights.

simon cowell on ‘britain’s got talent’

There have been a few studies that suggest rose-colored glasses help migraines. A lens with a pink tint called FL-41 blocks blue and some amber and green lights on the color spectrum. This can prevent or provide relief to those who find fluorescent lights to be particularly troubling. Interestingly, one study noted that FL-41 tinted glasses also reduced eyelid twitching knows as blepharospasm and improved blinking.

Pink tinted lenses have been known as a possible migraine treatment as far back as 1991, but many patients and doctors have never heard of it. A study done then had migraineur children — kids who suffer migraines — try glasses with either a rose tint or a blue lens for 4 months. Only the children who used the pink glasses had fewer migraines. On average, the kids’ migraines were reduced from 6.2 per month to 1.6 per month.

Migraine medication is considered effective if it reduces migraines by half. So, by comparison, the pink lenses were very successful. Unlike with medication, no side effects were noted in the study on children. But one can imagine how cute those kiddos looked in their pink shades.

There is a possible explanation for why rose-colored spectacles could alleviate or prevent migraines.  It is known that migraineurs have alterations in visual signaling when suffering a migraine attack. A study using functional fMRIs showed that specially tinted lenses normalized visual activity in the brain.

A pink lens is best for reducing problematic visual stimulation. The FL-41 lens, acting as a light filter, lowers visual processing, attention and engagement. This makes a difference because it is the inappropriate increase in visual stimulation that causes or worsen migraines. I tried a pair for my last migraine and the relief was significant and immediate.

If you suffer from migraines like me, rose-tinted glasses would be an easy, inexpensive way to try to lessen your migraines. FL-41 glasses can be purchased on Amazon for as little as $25. Another option is to have an optician add an FL-41 film to your prescription glasses.

But, as always, buyer beware.

Dr. Alexander Solomon, an ophthalmologist with the Pacific Neuroscience Institute, recommends choosing a pink lens carefully. Rose-colored lenses are not the same as FL-41 lenses.

“Even among sites claiming they are selling FL-41 lenses, the quality and overall transmission of the lens may not be carefully regulated,” said Solomon.

It’s important to remember that eye strain caused by lights is only one possible cause of migraines. There can be other environmental triggers or combinations of triggers. Caffeine, stress, alcohol, skipping meals, strong smells, and even changes in weather are other known culprits.