Adults with migraines and chronic headaches that are related to childhood maltreatment may require different therapeutic approaches than adult patients without histories of abuse.
OJAI, CA—Children who experience physical and emotional abuse or neglect are more likely to have migraines and headaches as adults, according to research presented at the Fourth Annual Headache Cooperative of the Pacific. These patients may benefit from cognitive behavioral therapies that specifically address the trauma of adverse childhood experiences.
Dawn C. Buse, PhD, Director of Behavioral Medicine at the Montefiore Headache Center and Assistant Professor in the Department of Neurology at Albert Einstein College of Medicine in New York City, presented findings connecting childhood abuse to posttraumatic stress disorder (PTSD), headache, and migraine, along with potential treatment options.
“There are strong data demonstrating that persons who were abused or mistreated as children have increased comorbidity for migraine as adults, as well as several other medical and psychiatric disorders,” Dr. Buse said. “Since we know that rates of childhood abuse and trauma and PTSD are common among persons with migraine, health care providers who treat migraine sufferers must be aware of the signs of both, and they should not be afraid to address these issues with patients, including assessment and referral for treatment when appropriate. In addition, persons with childhood abuse and PTSD have heightened rates of depression and anxiety. Therefore, it is important to be aware of the symptoms of these disorders and also to refer for treatment when appropriate.”
Dose-Response Relationship Between Abuse and Headache
“Childhood maltreatment is a nonspecific risk factor for a range of different psychologic and behavioral problems, including revictimization and abuse against self and others,” Dr. Buse said. Psychiatric comorbidities resulting from adverse childhood experiences include PTSD, depression, anxiety, panic disorder, borderline personality disorder, self-harm behaviors, and substance abuse. Medical comorbidities include migraine, fibromyalgia, chronic pain disorders, and an increased risk for cardiovascular events.
Dr. Buse reviewed findings from several studies that identified a dose-response relationship between childhood adverse events (which include neglect, household dysfunction, and physical, sexual, and emotional abuse) and adult headache or migraine. In the Adverse Childhood Experiences (ACEs) study, researchers analyzed clinical data from nearly 18,000 adults in the Kaiser Health Plan in San Diego and observed a graded relationship between number of types of ACEs and risk for frequent headache or migraine in adulthood. “Each experience of ACE raised the risk for frequent headaches, and this risk was increased more than twofold in persons with an ACE sum score of greater than or equal to 5, compared with persons with a score of 0,” Dr. Buse reported.
Another study that gathered data from 11 headache centers in the United States and Canada also found a graded relationship between the number of adverse childhood experiences and these negative outcomes, Dr. Buse commented. “Tietjen and colleagues found that physical abuse, emotional abuse, and neglect were significantly correlated with migraine, and were even more common among persons with chronic migraine compared with episodic migraine. Among 1,348 persons with migraine, a staggering 21% reported experiencing physical abuse as a child and 25% reported experiencing sexual abuse. The samples in both of these studies are representative of patients seen in headache clinics,” she reported. “This means that one in four patients encountered in a headache clinic may have a history of physical or sexual abuse in childhood.”
Not all persons who experience abuse or other traumatic experiences develop PTSD. In a prospective study of 105 children who were mistreated before age 12 and assessed at age 29, 23% of those who had been sexually abused and 19% of those who had been physically abused met criteria for PTSD, which include exposure to a traumatic event that is persistently re-experienced through nightmares, intrusive thoughts or memories, or flashbacks. In addition, there are attempts to avoid stimuli related to the original event, and hyperawareness and sensitivity or numbing of awareness.
PTSD (resulting from any event) is correlated with an increased risk for episodic migraine and chronic daily headache, according to investigators who examined data from the National Comorbidity Survey Replication. In turn, patients with migraine and headache had higher prevalence rates of PTSD. In all these studies, a substantial portion of adult patients reported experiencing abuse and neglect during childhood, Dr. Buse noted, stressing that these experiences cannot be ignored when treating patients with migraine and headache.
Altering the Brain’s Response to Stress
Dr. Buse reported that there is growing evidence that genes are involved in either increased vulnerability or resilience in response to early stressful experiences. Most likely, the way that individuals respond to stressful experiences is influenced by a gene-environment interaction. She also presented data suggesting that epigenetics may be involved. “Early stressful experiences may become hard-coded into the genome, creating a memory of events that leads to impaired health at a later date,” Dr. Buse explained. “Chronic maltreatment early in life may alter the brain’s response to stress via the hypothalamus-pituitary-adrenal system, which may predispose persons to migraine. A recent study of inflammatory blood markers in adults showed higher levels in those persons who had been exposed to maltreatment in childhood, suggesting a potential mechanism of action. For these reasons, biofeedback and cognitive behavioral therapies that help patients become aware and gain control over the autonomic nervous system can be especially beneficial.”