Abuse, Maltreatment, and PTSD and Their Relationship to Migraine
Research has shown that sexual, physical and especially emotional abuse creates a predisposition to headache. Individuals with migraine may have experienced abuse in early life. Childhood maltreatment, referred to as “Adverse Childhood Experiences” (ACEs), is associated with an earlier onset of migraine and a tendency for episodic migraine to become chronic. Identification of an abusive history may influence the assessment and treatment of presenting health concerns. Further, providing resources to those being abused can result in improved outcomes. Abuse may be defined in a variety of ways, including but not limited to:
A willful act carried out with the intent of causing pain or injury. Examples: slapping, hitting, kicking, striking, pinching or pushing.
Emotional abuse and neglect
Willful act executed to cause emotional pain, injury, or mental anguish. Examples: neglect, threats, harassment, controlling behavior, attempts to isolate and bullying.
Nonconsensual sexual activity.
Any cruelty inflicted upon a child including sexual activity (whether consensual or not). Children can also experience abuse by witnessing violence within the family, having a dysfunctional family and other traumatic experiences such as household substance abuse or having a family member in jail.
Abuse or neglect of an individual 65 years of age or older.
Abuse of physically or mentally disabled individuals.
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, as it is believed that the majority of cases are not reported.
It is estimated that between 20% and 30% of women and 7.5% of men in the United States have been physically and/or sexually abused by an intimate partner at some point in their adult lives. From 1993 to 1998, victimization by an intimate partner accounted for 22% of the violent crime experienced by females. It is the leading cause of serious injury for women, and approximately 818,000 elderly Americans were victims of domestic abuse in 1994. Adults abusers may have witnessed abuse as a child.
How Abuse Leads to Migraine
Being a victim of abuse, or a witness to abuse, is stressful. This is particularly true when one is young, and dependent on one’s family. In some homes, abuse, particularly verbal abuse, is so common that a child may never have experienced a more nurturing environment. In many instances, maltreated children cannot identify a trusted adult in whom to confide. Sometimes children who report abuse are either not believed or are made to feel at fault. It is not difficult to imagine how a stressful early life might lead to depression and anxiety, as well as a lack of confidence.
Stress is the most widely recognized trigger for migraine attacks. For instance, many people report that experiences such as a deadline at work, a fight with a family member, or a sick child at home bring on an attack. But can stress experienced as a child make one more prone to migraines later in life? Although there is not direct proof, there are now more than ten published studies that suggest that persons who report having experienced childhood abuse are considerably more likely to experience headaches in adulthood than those who have had carefree childhoods. Furthermore, the worse the abuse is the higher the likelihood of developing headache, as well as other pain conditions. To further understand how stress causes headache, researchers have studied both the long and short-term effects of stress on body function.
Autonomic nervous system response
Stress may affect the autonomic (or “automatic”) nervous system. This part of the nervous system controls the “fight or flight” response that is the body’s natural response to danger. It is controlled by the hypothalamus, pituitary and adrenal glands. Relaxation therapies can counteract the “fight or flight” response. They engage the parasympathetic branch of the nervous system that controls the “relaxation response.”
The relaxation response can often be started through deep breathing or focusing on a pleasant image or memory. Free instructions and audio relaxation exercises are available at dawnbuse.com as well as many apps on iTunes and other sources.
Acute stress causes different organs to release a variety of hormones that ultimately lead the release of cortisol, a steroid hormone. Cortisol is produced in the adrenal gland, which sits on top of the kidney, and it is released into the blood stream in response to stress. In the short term, the greater the stress, the higher the levels of cortisol. But with long-term stress experienced by those growing up in an abusive home, cortisol responses may rise and then eventually decline.
This may represent a breakdown of the body’s ability to produce a normal hormone response to stress, similar to a broken thermostat being unable to regulate the heat. Lower than normal cortisol levels have also been found in other pain conditions that have been linked to childhood abuse, such as fibromyalgia (muscle pain) and pelvic pain. Lower cortisol levels may actually increase the bad effects related to daily stress. For example, being stressed interferes with the body’s immune system, including one’s ability to fight off infection. Over time, lower cortisol levels may also result in chronic inflammation, a state that has been linked to heart disease. Studies have shown that adults experiencing child abuse are more likely to have inflammation and also to experience heart attacks.
MRI studies in adults, even young adults, who have experienced childhood abuse show that there are changes in the brain structures that process what is heard and seen. They connect this information to the structures that have a role in regulating emotions. This network of structures is known as the limbic system. Age at the time of abuse is probably important as different regions of the brain have particular periods when they are most sensitive to the effects of stress. Interestingly, recent studies in adults with migraine show many of the same areas to be affected.
Research has shown persons carrying certain genes are more susceptible to the effects of early life stress. Even more surprising is new evidence that the stressful experiences turn on and off certain genes and these gene changes (called epigenetics) may persist and have an effect on health later in life. It is also possible that these changes could actually be passed on to the next generation.
Treatment of History of Abuse and PTSD
Cognitive behavioral therapies (CBT) have the best evidence for treating the effects of 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. For more information about psychological and behavioral treatments for survivors of abuse and PTSD see: Association for Behavioral and Cognitive Therapies (ABCT): www.abct.org. In addition, everyone can benefit from learning and practicing relaxation techniques such as deep breathing, meditation and visual imagery.
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 their benefit. Studies in animals suggest that treatment with SSRIs may actually reverse some of the effects of maltreatment on the stress response. Other medications 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.
What You Can Do
Tell your Physician About Your Abuse History AND any Ongoing Abuse
In assessing your health concerns and planning your course of care, it is beneficial for your healthcare provider to know if you are currently being abused, feel in danger of being abused, or have been abused in the past. He or she may also assess if you have PTSD, depression, anxiety and other related conditions.
Is the History of Abuse Important Even if it Occurred as a Child?
As it may be linked to many medical and psychological problems, early abuse is indeed important. Significant stress occurring early in life may lead to a hypersensitive response to stress later in life. For some, stress is the most important trigger for migraine. Migraine may also be aggravated by the depression and anxiety that so often follow abuse.
What If You Are Currently Being Abused?
Your healthcare provider can guide you to resources offering psychological support and, when needed, personal safety. In addition, resources for help are listed at the end of this article. If you are currently in danger, ask for help. Place these calls from a phone where you will safe from your abuser(s). If your children are being abused, inform your healthcare team so that they can assist you immediately.
How Can You Best Deal With Abuse?
Your healthcare providers can guide you to resources offering psychological support and, when needed, personal safety. If you are currently in danger, ask for help. If you attempt to “forget” about prior abuse or deny that it ever happened, you are not working through the problem, but ignoring it. Talking to a mental health professional such as a psychologist, psychiatrist, or licensed clinical social worker, speaking to an abuse advocate, or calling an abuse hotline may help you cope, and put you in the right direction toward healing. From a perspective of treating your headache, therapies help with stress management may be beneficial such as biofeedback and relaxation training. Most importantly, do not be ashamed or embarrassed to ask for help. You are not alone. Help is available.
Domestic Violence Resources
- National Domestic Violence Hotline: Tel: 1-800-799-SAFE (7233) or TTY 1-800-787-3224 or visit their website at ndvh.org
- National Sexual Assault Hotline: Tel: 1-800-656-4673 or visit their website at rainn.org
- Futures without Violence: visit their website at futureswithoutviolence.org/section/_get_help or
call 1-800-799-SAFE (7233)
- National Clearinghouse on Abuse in Later Life:ncall.us/
- National Organization for Victim Assistance (NOVA)Tel: 1-800-879-6682 or visit their website at trynova.org
- National Resource Center on Domestic Violence
- Manweb, a website with information for battered men: batteredmen.com
- Child Welfare Information Gateway: childwelfare.gov/responding/reporting.cfm
- National Center on Elder Abuse: Tel: 302-831-3525 or visit their website at ncea.aoa.gov
To find a mental healthcare professional and/or learn more about Cognitive Behavioral Therapies and other treatments for survivors of abuse and PTSD, visit:
- American Psychological Association (APA): apa.org
- Association for Behavioral and Cognitive Therapies (ABCT): abct.org
Instructions and audio relaxation exercises are available at dawnbuse.com as well as many free and paid apps and podcasts on iTunes and other sources.
Elliott A. Schulman, MD, Professor, Lankenau Institute of Medical Research, Adjunct Clinical Professor, Jefferson School of Medicine
Dawn C. Buse, PhD, Director of Behavioral Medicine, Montefiore Headache Center, Associate Professor, Albert Einstein College of Medicine, Assistant Professor, Ferkauf Graduate School of Psychology
Gretchen E. Tietjen, MD, Professor and Chair, Department of Neurology, University of Toledo Director, University of Toledo Headache Research and Treatment Center
This article is a legacy contribution from the American Headache Society Committee for Headache Education (ACHE) and the Fred Sheftell, MD Education Center.
Last Updated 6/4/2013
Advice for Loved Ones
Howard Jacobs, MD
“There is no such thing as fun for the whole family.” –Jerry Seinfeld
Most Migraine sufferers will tell you that their migraines are worsened by stress. Stress can come from a number of sources, but the ones that seem to be on the top of the list are school, work, and family. Though all three are tremendously significant, it is infinitely easier to change a classroom, school, or even job than it is to change one’s family.
Whether it be marital discord, money concerns, or parent-teen conflict, family issues have a tremendous impact on the migraineur, and ignoring this is likely to result in less than successful migraine therapy.
On the flip side, having a supportive, understanding family can be an enormous help to the migraine sufferer…to an extent. Unfortunately, we find that very often with our adolescent patients, the parents are too focused on the migraine. So called “helicopter parents” who are hovering over their teen with repeated inquiries about their pain. In my clinic, I had one parent ask her 16-year-old son how he was feeling four times in a 15-minute visit. This kind of attention only serves to increase the focus on a problem that we are trying to minimize.
Often, having the whole family involved in the therapeutic process is the answer. It may mean scheduling visits at a time that spouses or parents are available and it may involve family counseling. People often find the prospect of family counseling threatening. It really should not be viewed as such. Seldom do people take classes on being a spouse or a parent before having to be one. Processes that seem right and become family habit sometimes are detrimental in ways not obvious to those involved.
Making the effort to work on sources of family stress and how the family responds to them while learning to be supportive without being overbearing can be the key to improving the life not only of the migraineur, but the whole family.
Howard Jacobs, MD, Pediatrician, Department of Pediatrics, University of Maryland, Baltimore, MD.
Impact on Work
FMLA for Migraine
The 20th anniversary of the federal Family and Medical Leave Act (FMLA) this year (2013) seems like a perfect opportunity to provide a basic overview of the law, and how it can help migraine patients.
The FMLA was enacted by Congress in 1993 to protect workers who become ill themselves, who become parents (either through adoption or birth), or who have ill family members in need of care. The FMLA applies to private, local, state and federal employees as long as certain requirements are met. The requirements are:[The FMLA provides employees who are covered by the law with up to 12 weeks of unpaid leave in a 12-month time period for the following circumstances:[Note that FMLA leave is unpaid. While you may be able to use paid leave otherwise available to you during this time to maintain your income, such as sick or vacation leave, the most significant protection of the FMLA is maintaining your employment status when you need to be gone from work for covered purposes. The other big benefit of the FMLA is that your employer must maintain your employer-provided health insurance benefits during your leave. Finally, covered employees are generally entitled to return to a position with the same pay, benefits, duties, and terms as before the leave was taken.
Your ability to use vacation or sick leave concurrently with your FMLA leave depends entirely on your employer’s policies and your ability to comply with them. This usually comes up with regard to the notice required in employer leave policies. Even if you can’t use your paid time off, if you’re entitled to FMLA leave, you can take it.
One incredibly beneficial aspect of the law for both episodic and chronic migraine patients is that the 12 weeks of leave can be taken all together or periodically as need. It can also be taken on a part-time basis.
As an employee seeking to take advantage of FMLA leave, you must give your employer at least 30 days notice if the reason for needing leave is foreseeable. You must provide as much notice as is practicable if the reason you’re seeking FMLA leave is unforeseeable.
Finally, employers can require doctor certification of your condition initially and a re-certification every six months for conditions of an ongoing nature.
FMLA leave is an important protection for the migraine patients covered by it. In particular, for those migraineurs who find their employer-provided leave being eaten up by missed days of work and still need more time off due to the debilitating nature of migraine disease, the FMLA can be an important safety net.
Diana Lee is an attorney, Migraine patient advocate and educator and Migraineur. She blogs at SomebodyHealMe.com and Migraine.com. She runs a bimonthly Migraine Chat that provides support and information for migraine patients and a monthly Headache and Migraine Disease Blog Carnival for other headache disorders bloggers.
© Diana Lee, 2013
Last updated February 9, 2013.