Abuse, Post Traumatic Stress Disorder and Migraine

Abuse, Post-Traumatic Stress Disorder and Migraine
Gretchen E. Tietjen, MD and Dawn C. Buse, PhD
Key Points:
  1. Abuse is common worldwide and can be physical, sexual or emotional.
  2. Victims and perpetrators of abuse can be any age, gender, or ethnic group.
  3. The abused have higher rates of migraine than people without abuse.
  4. Some victims develop post traumatic stress disorder (PTSD) manifested by flashbacks, nightmares, increased anxiety, and avoidance of reminders of the event.
  5. There is a strong link between migraine, abuse, and PTSD.
  6. Psychological therapies are the mainstay of treatment; cognitive-behavioral therapies have the most evidence supporting their use; certain types of antidepressants may also be helpful.
  7. If you or someone you know is a victim of current or ongoing abuse call the National Domestic Hotline: 1-800-799-SAFE or law enforcement now.
Childhood Maltreatment and Migraine
Sadly, abuse is common. Abuse can happen to someone of any age, gender, and race, by someone of any age, gender, and race. Child abuse is especially heartbreaking. In 2009 alone, the U.S. Health And Human Services - Child Protective Services received more than 2 million reports of suspected child abuse. This number is likely lower than what actually occurs. It is believed that the majority of cases are not reported. In that same year, it was estimated that 1,760 children died in the US due to child abuse or neglect. The Federal Child Abuse Prevention and Treatment Act (CAPTA) of 2003 defines child abuse and neglect. It states this to be: "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm." The US Department of Health and Human Services- Child Welfare Information Gateway calls these events "Childhood aversive experiences." These include:
• Abuse
– Emotional Abuse
– Physical Abuse
– Sexual Abuse
• Neglect
– Emotional Neglect
– Physical Neglect
• Household Dysfunction
– Mother Treated Violently
– Household Substance Abuse
– Household Mental Illness
– Parental Separation or Divorce
– Incarcerated Household Member
See http://www.childwelfare.gov for more information.
Childhood maltreatment or abuse predicts many other possible problems. These occur both during childhood and adulthood. Problems include medical and psychological conditions. They sometimes include harm to others (called "revictimization" or inflicting abuse upon others). They sometimes include harm to oneself, such as cutting, burning oneself, or suicide attempts. These behaviors can last well into adulthood. Many persist throughout life if not treated. Several studies demonstrate that childhood injury or abuse makes it more likely to develop migraine later in life. The more severe the abuse, the stronger the link grows. These headaches are also more likely to be frequent and disabling. Severe abuse is also linked to other conditions, including chronic pain, fibromyalgia and irritable bowel disease.
Chronic maltreatment early in life alters the brain’s response to stress. This may make it more likely to have migraine. A study of inflammatory blood tests suggests a mechanism for the link. In this study, adults showed higher levels of biomarkers in the bloodstream when exposed to abuse in childhood. Genes are also important in this process. Genes are responsible for how a person and their body respond to early stressful experiences. It is also possible that early stressful experiences may become hard-coded into DNA. This creates a memory of events that leads to impaired health at a later date.
Post Traumatic Stress Disorder and Migraine
Childhood maltreatment, abuse or violence may lead to post-traumatic stress disorder (PTSD) at a later age. PTSD is a condition that results from exposure to an event that caused feelings of intense fear, helplessness, or horror. Many traumatic stressors exist. These include natural disasters and transportation accidents. Others are physical and sexual assault such as rape and exposure to war or combat. Finding out about a traumatic event or about the violent death of a loved one may also lead to PTSD. The main symptoms of PTSD include 1) re-experiencing the traumatic event through flashbacks or nightmares; 2) avoiding reminders of the trauma; 3) increased anxiety and emotional arousal such as feeling irritable, jumpy, or being easily startled; and 4) feeling detached from others or emotionally "numb". Other symptoms may include feeling angry, guilty, hopeless, and experiencing physical aches and pains, including headache.
Studies show a connection between PTSD and migraine. PTSD occurs in about 10% of the general population. It is present in about 25% of patients in a headache clinic. About 50% of combat veteran clinic patients have headache. In one study of PTSD and migraine, nearly 60% reported physical or sexual abuse as the cause. Not unexpectedly, the presence of PTSD complicates migraine. In persons with migraine, headache frequency and headache-related disability are greater than in those without PTSD. Interestingly, in a study of the PTSD-migraine link, men with migraine were 3 times more likely to have PTSD than women with migraine.
PTSD Therapy
The process that links migraine and PTSD is not known. PTSD may affect the autonomic (or "automatic") nervous system. This part of the nervous system controls the "fight or flight" response. This is the body’s natural response to danger. It is controlled by the hypothal-amus, pituitary and adrenal glands. Relaxation therapies can counter- act the "fight or flight" response. They engage the parasympathetic branch of the nervous system which controls the "relaxation response". The relaxation response can often be started through deep breathing or focusing on a pleasant image or memory. PTSD also affects the brain’s corpus callosum, a bundle of nerve fibers that connect the right and left sides of the brain. In PTSD, the corpus callosum shrinks.
Cognitive behavioral therapies (CBT) have the best evidence for treating the effects of PTSD and abuse. CBT can be helpful both during and immediately following a traumatic experience, or years later to help one cope with the after effects. CBT can be used in adults, children, elderly or disabled persons. There are several subtypes of CBT with scientific data supporting their use for PTSD. Cognitive therapy involves identifying and managing distressing trauma-related thoughts and abnormal patterns of thinking. Exposure therapy involves reducing the fear associated with traumatic experiences. This occurs through repeated confrontation combined with relaxation. This can be for feared places, situations, memories, thoughts, and feelings. Stress inoculation therapy involves developing skills for managing stress and anxiety. Types of skills include deep breathing, muscle relaxation, assertiveness training, role playing, thought stopping, and positive thinking. In eye movement desensitization and resensitization (EMDR) therapy, a person focuses on emotionally disturbing material. At the same time they focus on an external stimulus. This is usually eye movements, hand tapping, or sounds. For people who struggle with self-harm behaviors, dialectic behavior therapy (DBT) is especially helpful. Behaviors include self-cutting or suicidal thoughts or actions. DBT is also useful for those making dangerous or unhealthy life choices. DBT combines the basic principles of CBT with relaxation training, mindfulness mediation, and other proven interventions.
For help finding a mental health provider who uses these therapies see the recommendations below. In addition, everyone can benefit from learning and practicing relaxation techniques such as deep breathing, meditation and visual imagery. There are many tools such as workbooks and self-guided audio resources available.
The role of medication for the treatment of PTSD is less firmly proven. Selective Serotonin Reuptake Inhibitors (SSRIs) are a group of antidepressant medications. They are often prescribed for PTSD, but there is debate over the benefit. Studies in animals suggest that treatment with SSRIs may actually reverse some of the effects of maltreatment on the stress response. Other medications which are currently being investigated for the treatment of PTSD include beta-blockers (e.g. propranolol), Prazocin, and Ketamine. It is not recommended to take benzodiazepines, such as Valium, Ativan or Xanax, because they are not effective in treating PTSD and can be addictive.
  • Abuse is common in the US and around the world and can be physical, sexual or emotional.
  • Victims and perpetrators of abuse can be any age, gender, or ethnic group.
  • The abused have higher rates of migraine than those without abuse.
  • Some victims of abuse and other horrible events develop post traumatic stress disorder (PTSD).
  • Symptoms of PTSD include flashbacks, nightmares, anxiety, and avoidance of reminders of the event.
  • The occurrence of PTSD is 3 to 4 times more common in persons with migraine than those without migraine.
  • The brain-body stress response is altered in PTSD, and there may actually be changes in the structure of the brain as a result of PTSD.
  • Psychological therapies are the mainstay of treatment for PTSD and coping with the effects of abuse. Cognitive-behavioral therapies (CBT) have the most evidence supporting their use. Certain types of antidepressants (SSRIs) may also be helpful, either individually or in conjunction with psychotherapy.
  • Dialectic behavior therapy (DBT) can be helpful for someone who has difficulty with relationships or participates in self-harm or risks behaviors.
  • If you or someone you know is currently being abused call the National Domestic Hotline: 1-800-799-SAFE or law enforcement immediately. Help is available.
  • If you have been a victim of abuse and/or have PTSD consider treatment.
  • Talk to your healthcare provider, or to find a mental health care professional (psychologist, psychiatrist, or social worker) visit the following websites:
    • American Psychological Association (APA): www.apa.org
    • Association for Behavioral and Cognitive Therapies (ABCT): www.abct.org
    • Do a provider search by: "psychologist" or "psychiatrist": www.achenet.org
Gretchen E. Tietjen, MD, Professor and Chairman of Neurology, University of Toledo, Toledo OH; and Dawn C. Buse, PhD, Assistant Professor, Albert Einstein College of Medicine, Director of Behavioral Medicine, Montefiore Headache Center, Bronx, NY.


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