The work by Gretchen Tietjen, MD, and colleagues in the recently published manuscript “Adverse Childhood Experiences Are Associated With Migraine and Vascular Biomarkers” is the first study to examine the association of biomarkers for endothelial dysfunction, migraine, and adverse childhood experiences in the same population. This study, which received the American Headache Society’s Harold G. Wolff Award, provides insight into the complex interactions between experience, behavior, and biology with respect to these conditions.
Sadly, childhood abuse and maltreatment is common in all countries, cultures, and sociodemographics. Clinical and population-based studies have established that rates of childhood maltreatment and abuse are higher among persons with migraine than among those without. This finding was replicated in Dr. Tietjen’s study of 100 females with migraine and 41 female controls.
Among women with migraine, scores on the Adverse Childhood Experiences (ACE) questionnaire were highest among women with continuous headache and chronic migraine. In addition, the authors found that women who had experienced childhood adversity had a higher risk for biomarkers of coagulation (eg, elevated vWF activity), inflammation (eg, elevated hsCRP), and oxidative stress (eg, lower NOx) biomarkers, which have been linked to stroke. The majority of these relationships remained significant after adjusting for sociodemographics and stroke risk factors.
The authors’ finding that the experience of childhood adversity is related to an early age of migraine onset and high headache frequency suggests a possible causal or stress–diathesis relationship between adverse childhood maltreatment and migraine. Early-life stress may predispose individuals to changes in sympathetic nervous system reactivity and the hypothalamo–pituitary–adrenocortical (HPA) axis. Childhood adversity also may cause attenuated development of the left prefrontal cortex, amygdala, and hippocampus, all of which play important roles in pain, stress, and emotion. ACEs may also affect the immune system through the sympathetic nervous system and the HPA axis, thus putting those who experience ACEs at risk of health challenges throughout life.
Adverse Childhood Experiences: Prevalence and Comorbidities
In 2009, the US Department of Health and Human Services’s Administration for Children and Families received more than two million reports of suspected child abuse, which is most likely an underestimation of the actual number of cases. In the same year, 1,760 children were estimated to have died in the US because of child abuse or neglect. The Federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as, at minimum, “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.” These ACEs include the following items:
- • Abuse (eg, emotional, physical, or sexual abuse)
- • Neglect (emotional or physical neglect)
- • Household dysfunction (eg, domestic violence, substance abuse, mental illness, parental separation or divorce, or an incarcerated household member).
In addition to the relationship between ACEs and migraine, childhood maltreatment and abuse are also related to increased rates of fibromyalgia, chronic pain conditions, cardiac conditions, irritable bowel disease, depression, anxiety, borderline personality disorder, substance abuse disorders, panic disorder, obsessive compulsive disorder, dissociative disorder, and conduct disorder. Childhood abuse may also lead victims to abuse others (ie, revictimization) or and harm themselves (eg, cutting, burning, or suicide attempts).
Based on the elevated rates of ACEs among persons with migraine, healthcare professionals (HCPs) who treat patients with migraine should be mindful that the latter may have a history of ACEs. HCPs also should be aware of the possible effects and comorbidities related to ACEs. If deemed appropriate, assessment of a history of ACEs may be conducted as part of written questionnaires (eg, the Childhood Trauma Questionnaire and the ACEs study questionnaire) or in verbal discussion during history taking or follow-up visits.
All assessment and discussion should be conducted in private, and limits of confidentiality should be discussed. Patients vary widely in their desire and willingness to discuss a history of ACEs. These discussions will likely require extra time, compassion, and may necessitate a referral to a mental healthcare professional, especially in the case of comorbid depression, anxiety, post-traumatic stress disorder (PTSD), personality disorder, current or ongoing abuse, self-harm behavior, or suicidal ideation. (See the “National Consensus Guidelines on Identifying and Responding to Domestic Violence and Intimation in Health Care Settings” for more information and suggestions on handling current abuse).
Psychological Treatment of ACEs, PTSD, and Related Comorbidities
Events that cause feelings of intense fear, helplessness, or horror may cause individuals to develop PTSD. Autonomic nervous system dysregulation plays a role in PTSD and migraine. Several psychological and behavioral therapies, administered during and after a traumatic experience, have been shown empirically to help individuals cope with the effects of the experience. The treatments also may help treat comorbid psychological conditions or behaviors, including PTSD, self-harm behaviors, depression, and anxiety. These treatments include cognitive behavioral therapy (CBT), dialectic behavioral therapy (DBT), relaxation therapies, and biofeedback.