The next question is what to do when the answer is yes.
"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."
If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.
Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."
Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "
Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."
Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.