January 8, 2010 — A large, new, multicenter survey has found that childhood abuse is highly prevalent among migraine patients and that migraine patients with a history of early-life abuse have significantly more comorbid pain conditions, including irritable bowel syndrome (IBS) and fibromyalgia (FM), compared with those without such a history.
The research appeared in Headache: The Journal of Head and Face Pain, published on behalf of the American Headache Society.
The study, the largest to date to look at early abuse in a migraine population, was conducted by the Women’s Issues Section Research Consortium of the American Headache Society. It included 1348 patients (88% women; mean age, 41 years) with migraine at 11 outpatient headache centers in the United States and Canada.
Using electronic questionnaires, researchers collected sociodemographic information, including age, sex, race, household income, educational level, and substance abuse. They assessed childhood abuse using the Childhood Trauma Questionnaire, a 28-item, self-reported measure of 5 categories of abuse: physical, sexual, and emotional abuse and physical and emotional neglect. Depression was assessed using the Patient Health Questionnaire and anxiety using the Beck Anxiety Inventory.
Headache disorder was determined using the International Classification of Headache Disorders, 2nd Edition, criteria.
Maltreatment Prevalence
The research appeared in 3 separate articles. In the first article, researchers discussed the prevalence of childhood maltreatment. They found that 58% of participants endured childhood abuse or neglect. Emotional abuse was reported most commonly (38%) and in higher severity (12% with “severe to extreme” abuse) than other abuses, such as physical and sexual abuse.
Emotional abuse is “very, very common” in this headache population, said the lead study author, Gretchen E. Tietjen, MD, professor and chair, Department of Neurology, University of Toledo, Ohio. “The rate was higher than previously reported, and it was surprising.”
In population studies, only about 10% of respondents report emotional abuse, she said.
Emotional abuse is relatively difficult to define and has only recently been recognized as a distinct entity, said Dr. Tietjen. This abuse, which can occur on a daily basis and often reflects a poor family environment, may have more dire and long-lasting consequences than other types of abuse.
Neglect, too, has received scant attention in studies even though it is the category of child maltreatment most frequently recorded by child protection agencies.
This part of the study also showed that more than 33% of respondents reported abuse in adulthood, predominantly (70%) between the ages of 18 and 30 years. Physical abuse in adulthood was reported by 20% and sexual abuse by 22%. “From an alternative perspective, of those reporting childhood maltreatment, 43% were revictimized in adulthood,” the study authors write.
Migraine Characteristics
The second article reviewed migraine characteristics and the differences among episodic headache (fewer than 15 headaches a month), frequent headache, and episodic headache that developed into chronic headache. About 40% of participants had migraine with aura, 34% had chronic migraine, and 26% a transformation from episodic to chronic headache.
After adjusting for all variables, including current depression and anxiety, only emotional abuse was associated with chronic migraine (odds ratio, 1.77) and transformational headaches (odds ratio, 1.89). “Having chronic headaches, or a headache all day every day, and transforming from episodic to chronic were tied not as much to the other abuses but to emotional abuse,” said Dr. Tietjen.
Patients who had experienced childhood emotional abuse also tended to develop migraines earlier, at a median of 16 vs 19 years of age for those without such abuse, she said.
Pain Conditions
The third analysis investigated the relationship between childhood abuse and comorbid pain conditions, including IBS, FM, chronic fatigue syndrome (CFS), interstitial cystitis, arthritis, endometriosis, uterine fibroids, and pelvic pain and cramps.
Comorbid pain conditions were common among participants — 25% had arthritis, 31% had IBS, 16% had CFS, and 10% had FM. Some 61% had at least 1 comorbid pain condition, 18% had 2, and 13% had 3 or more pain conditions. Those reporting emotional abuse or physical neglect had significantly more comorbid pain conditions compared with those without these childhood traumas.
“What was interesting and what makes one infer that there may be a causal relationship is the fact that the more severely abused you were and the more different types of abuse you had, the more different pain conditions you had,” said Dr. Tietjen.
The associations of maltreatment and pain were independent of depression and anxiety, both of which were highly prevalent in this population (28% had current depression and 56% had current anxiety). “This suggests that although depression is strongly associated with, and may be a sequela of, childhood maltreatment, emotional abuse and physical neglect each independently contributes to enhanced pain experience,” write the study authors.
From Stress to Headache
What is not clear is how childhood abuse may eventually lead to migraines and other pain conditions. Maltreatment at an early age could cause changes in areas of the brain, including the hippocampus and amygdala, and alter stress responses, said Dr. Tietjen. An alteration in cortisol in childhood “changes forever your stress response,” she noted. These changes may not be evident in childhood but develop over time, she said.
It is impossible to determine how an individual will react to the stress of abuse. It could depend on the severity of abuse, who the abuser was (whether it was a trusted family member or merely an acquaintance), and the age at which the abuse began, said Dr. Tietjen.
It also could depend on genetic makeup. Stress may actually change DNA to make a person more susceptible to the traumatic fallout of abuse. On the other hand, genes may make some people more resilient to the effects of stress.
“It’s probably a very complicated makeup of a lot of different genes and a lot of different things in the environment” that predisposes some people to develop pain and headache after exposure to stress, said Dr. Tietjen.
What might tie abuse and various pain syndromes together is what Dr. Tietjen called “central sensitization,” where stress pushes the central nervous system into overdrive. One of the characteristics of this state of central sensitivity is allodynia. Past research has shown that patients with migraine-related allodynia are more likely to have IBS, CFS, and other pain-related syndromes, said Dr. Tietjen.
Preventing Painful Conditions
However, there may be a way to prevent pain-related manifestations of childhood exposure to abuse. Dr. Tietjen believes that cognitive behavioral therapy, which teaches patients to better handle stress, could prevent painful conditions. She used the example of a 20-year-old woman with a history of abuse who comes in with a migraine. Treating that patient with cognitive behavioral therapy may prevent progression to chronic migraine or prevent FM, IBS, or other conditions that typically develop at a slightly later age.
“Cognitive behavioral therapy might be a good therapy under that circumstance because it changes the body’s response to stress. If you have an abnormal response to stress because of your past experiences, maybe this can help normalize your response.”
According to background information included in the articles, childhood maltreatment is a major public health problem. In the United States, there are nearly 1 million substantiated reports of physical and sexual abuse of children each year. Most reported cases involve neglect, followed by physical abuse then sexual abuse.
