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Childhood Emotional Abuse Linked to Adult Migraine
Pauline Anderson
December 29, 2014

Adults who experienced emotional abuse as children are more likely to have migraine than tension-type headache (TTH), a new study suggests.

The study also found that the odds of having migraine were even higher in adults subjected to two types rather than one type of maltreatment earlier in life.

This was among the first studies to use well-defined diagnostic criteria for migraine and to assess the effect of emotional abuse as well as emotional neglect and sexual abuse in a large population, said lead author Gretchen Tietjen, MD, professor and chair, neurology, University of Toledo Medical School, and director, Migraine Treatment and Research Center, University of Toledo, Ohio.

In light of these new study results, healthcare professionals may want to incorporate a validated questionnaire about adverse childhood experiences into their clinical assessment, as has Dr Tietjen.

"I find it very helpful because I'm taking care of the whole person," Dr Tietjen told Medscape Medical News. "Sometimes we see things that come out in adulthood that look like they tie back to early experiences in life."

Their findings were published online December 24 in Neurology.

Abuse vs Neglect
The study was a cross-sectional analysis of responses to the 2007 survey of the longitudinal, population-based American Migraine Prevalence and Prevention (AMPP) study. The analysis included 8305 adults with migraine (both episodic and chronic) and 1429 adults with episodic TTH.

Participants completed the Childhood Trauma Questionnaire, in which they recalled adverse experiences from childhood and adolescence. The study investigated the association between 3 types of such adverse childhood events (ACEs): emotional neglect, emotional abuse, and sexual abuse.

Dr Tietjen pointed out that abuse entails family members actively calling names, saying hurtful things, or making the child feel hated. In emotional neglect, family fails to make children feel important or loved or to provide a source of strength and support.

The study found that maltreatment rates were significantly higher in the migraine group than in the TTH group. This was true for each type of maltreatment: emotional neglect (24.5% vs 21.5%), emotional abuse (22.5% vs 16.7%), and sexual abuse (17.7% vs 13.3%). Overall, 34.2% of the ETTH group and 40.2% of the migraine group reported at least one form of maltreatment.

In models adjusted for sociodemographic variables, each type of maltreatment independently predicted higher relative odds of migraine (emotional neglect: odds ratio [OR], 1.23 [95% confidence interval (CI), 1.07 - 1.42]; emotional abuse: OR, 1.46 [95% CI, 1.25 - 1.71]; sexual abuse: OR, 1.35 [95% CI, 1.11 - 1.62]).

For emotional abuse, the result remained significant after additional adjustment for depression and anxiety (OR, 1.33 [95% CI, 1.13 - 1.57]), but this was not the case for emotional neglect or sexual abuse (although it also remained significant for any maltreatment).

"We found that even when we adjusted for depression and anxiety, there was still a 33% higher chance that those who had been emotionally abused would go on to have migraine rather than just sort of regular tension-type headaches," commented Dr Tietjen.

This, she added, suggests that it's not depression and anxiety causing the migraine but emotional abuse itself, although after adjustment, the much smaller number made the study less powerful.

Possible Pathways
People with depression and anxiety have a higher risk for headaches, but the question is how they're linked, said Dr Tietjen. "Is it that when you get abused, you get depressed and anxious and that leads to the headaches, or is it a different pathway where there's some type of changes that lead to migraine, and other changes that lead to depression and anxiety?"

Some evidence suggests that maltreatment early in life affects the brain. Dr Tietjen noted neuroimaging research that shows a link between parental verbal abuse and changes to the brain's white matter. Other research that compared the brains of people who committed suicide found fewer glucocorticoid receptors (stress receptors) in persons who had a history of childhood abuse compared with those who didn't.

"Abuse probably changes your neuroimmune system somewhat; it changes your stress response system, your sort of 'fight or flight' type of response, and it also changes your sympathetic nervous system," said Dr Tietjen. "So there are a lot of changes that occur that may predispose people to migraine."

The extent of brain changes may depend on the intensity of abuse and the type of abuse, added Dr Tietjen. It may also depend on the sex of the person who was abused, but that's difficult to determine because migraine occurs much more frequently in women. In this study, 80.4% of the migraine group was female.

Childhood abuse may make people more vulnerable to other pain syndromes, too, including fibromyalgia and irritable bowel syndrome. Studies showing that ACEs are linked to biomarkers of inflammation in adulthood suggest a possible mechanical pathway, said the authors.

Some people develop "central sensitivity," where having one pain syndrome puts them at risk for others "because the central nervous system is dysfunctional and kind of revved up," said Dr Tietjen.

Epigenetics ? the interaction of genes with the environment ? may be at play in the relationship between childhood abuse and adult migraine. It's possible, said Dr Tietjen, that abuse changes how DNA works, so that it has an increased effect on stress responses.

"It may be that environmental things that happen in your life can change which genes are upregulated and which genes are down-regulated, so it changes the packaging."

Family Fabric
But what is it about emotional abuse that makes it seemingly more conducive to migraine than other types of abuse or neglect? Research shows that emotional abuse can be particularly stressful, especially if it's ongoing, said Dr Tietjen.

"When people have emotional abuse, unfortunately it sometimes tends to be within the fabric of the family. So you might live with that every day of your life."

Sexual abuse, in contrast, might occur only intermittently, she said. "And if you're supported by your family, it might be easier to get through than something like emotional abuse where it may be your family doing it to you."

Although this study didn't determine the effect of timing of abuse initiation, other research of headache in general suggests that the psychiatric effects of abuse that occurs before age 12 years differ from the effects of abuse occurring after that age.

"Some studies have shown that the age at which the abuse occurred and also the family's response to the abuse ? if subjects get a lot of support from their family, for example ? has an effect. If the family is the problem, it looks like emotional abuse may have a different sort of effect, maybe a more profound effect, on some people."

The study also showed that the odds of migraine compared with TTH were greater in patients with two compared with only one ACE, even after adjustment for depression and anxiety (OR, 1.37 [95% CI, 1.12 - 1.68]). This provides evidence of a "dose response" effect in the relationship between ACEs and migraine, said Dr Tietjen.

In her own practice, Dr Tietjen asks every patient with migraine to answer 10 questions taken from the Adverse Childhood Experiences questionnaire that address personal experiences of abuse but also experiences of witnessing abuse.

She has noted that patients with a strong abuse history often are more refractory to antidepressant medication and may need referral. "I try to get them help to get some of their comorbidities, like anxiety and depression, better treated," she said. "I'm a strong believer in cognitive-behavioral therapy. There are lots of data showing that it can be very effective in treating migraine."

Further Therapy
This type of therapy, as well as meditation and "guided therapy," can help patients control their reaction to stress, and perhaps the hormonal changes that occur as a response to that stress, she said.

The current study didn't include physical abuse because of space limitations in the AMPP study survey. In addition, physical abuse requires more investigation into whether, for example, the headache is linked to the childhood physical abuse or the concussion that resulted.

The study was also limited by the self-reported data for many variables and the lack of controls without headache.

"Future studies comparing both migraine and TTH participants to no headache controls will be of interest," commented B. Lee Peterlin, DO, director, Johns Hopkins Headache Research, and associate professor, neurology, Johns Hopkins University, Baltimore, Maryland in an accompanying editorial.

The study is "well-described and analyzed" and is "an important contribution to advancing our understanding of the association between ACE and headache disorders," said Dr Peterlin.

"In particular, it highlights the importance of identification of ACE in both migraine and TTH participants as this can help guide treatment strategies and future research."

The study was supported by the National Headache Foundation. Dr Tietjen has received funding for research from GlaxoSmithKline. She serves on the editorial board of Headache, has reviewed for the National Institute of Neurological Disorders and Stroke (NINDS) and the Migraine Research Foundation, owns common stock in Johnson & Johnson and Stryker, served as an advisory board member, and received honoraria from MAP Pharmaceuticals and the American Headache Society. Dr Peterlin has received funding from NIH/NINDS and the Landenberger Foundation (a grant for a study unrelated to the current manuscript), serves as an associate editor for the journals Headache and BMC Neurology, and receives investigator-initiated research support from GSK and Luitpold Pharmaceuticals for studies unrelated to the current manuscript.

Neurology. Published online December 24, 2014. Abstract Editorial
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