History of childhood maltreatment is associated with comorbid depression in women with migraine

The Role of Attachment Style, Adverse Childhood Experiences and Dissociation in Migraine

Migraine and chronic migraine are caused by a combination of modifiable and non-modifiable genetic, social, behavioral and environmental risk factors. Further research of possible modifiable risk factors for this headache disorder is merited, given its role as one of the leading causes of years lived with disability per year. The first aim of this online cross-sectional study was to investigate the psychosocial risk factors that predicted chronic migraine and severe migraine-related disability in 507 Irish and UK participants, focusing specifically on childhood maltreatment, attachment and tendency to dissociate, or experience depressed mood and/or anxiety. Additionally, this study aimed to examine variables that mediated the relationships between these psychosocial risk factors and migraine chronicity or severe migraine-related disability. Adjusted binary logistic regression revealed that shutdown dissociation (Odds Ratio [OR] 4.57, 95% Confidence Interval [CI] 2.66-7.85) and severe physical abuse (OR 4.30, 95% CI 1.44-12.83 had significant odds of predicting migraine chronicity, while depression (OR 3.28, 95% CI 1.86-5.77) significantly predicted severe migraine-related disability. Mediation analyses indicated that shutdown dissociation mediated the relationship between seven predictor variables and both chronicity and severe disability including possible predisposing factors emotional abuse, physical neglect, avoidant attachment and anxious attachment. These findings suggest that early life stressors (such as childhood trauma and avoidant attachment style), shutdown dissociation and depression may impact on migraine trajectory. To investigate whether these psychosocial factors are risk factors for migraine chronicity or disability, prospective research should be conducted in this area to account for fluctuations in migraine chronicity over time.

What is the link between migraine and psychiatric disorders? From epidemiology to therapeutics

The association between migraine and psychiatric disorders is well documented through numerous population-based studies. The results of these studies are coherent and show an increased risk of suffering from depression, bipolar disorders, numerous anxiety disorders, especially post-traumatic stress disorder. This raises the question of stress as a precipitating factor for migraine illness. Psychiatric comorbidity is even more frequent in chronic migraine than in episodic migraine patients. Many prospective studies have shown that psychiatric comorbidity could be considered as a risk factor for migraine chronicization. Psychiatric comorbidity is also responsible for an increase of the frequency of anti-migraine drug intake, a worsening of quality of life and a worsening of functional impairment. It is also responsible for an increase in the direct and indirect costs of migraine. The reason why psychiatric comorbidity is so high in migraineurs is not unambiguous. Multiple causal relationships and common etiological factors are linked. Recently, genome-wide association studies gave leads to a genetic common heritability between major depressive disorder and migraine. For clinicians, an important topic remains how to treat migraineurs with psychiatric comorbidity. These patients suffer frequently from severe migraine or refractory migraine. Antidepressant and anti-convulsive drugs can be useful, as well as psychological therapies. But moreover, it is of utmost importance to propose an integrated multidisciplinary approach to these difficult patients.

Functional difficulties mediate the association between exposure to adverse childhood experiences and headaches among children: Findings from a population-based study

BACKGROUND

Adverse childhood experiences (ACEs) are commonly observed in the general population and often have lasting neurological and physiological effects. Previous studies have found links between exposure to ACEs, headaches, and functional difficulties in adults. However, little is known about the mechanisms through which exposure to ACEs is associated with headaches among children.

OBJECTIVE

To examine the association between exposure to ACEs and headaches in children, and whether functional difficulties mediate this association.

METHODS

Data for this cross-sectional secondary analysis study came from the 2017-2018 National Survey of Children's Health. The sample analyzed in this study was 40,953 children who were between ages 3 and 17 years. We adjusted for the complexity of the sampling design and used structural equation modeling to examine the mediating effect of functional difficulties in the association between exposure to ACEs and headaches.

RESULTS

Based on parent reports, we found that 4.1% (1697/40,953) of the children reported frequent or severe headaches, and 9.5% (3906/40,953) were exposed to three or more ACEs. About one in four children (23.4%; 9601/40,953) had at least one functional difficulty. The results show that exposure to ACEs was directly positively associated with functional difficulties (β = 0.16, p < 0.001, 95% CI = 0.15-0.17), and functional difficulties were in turn positively associated with headaches (β = 0.17, p < 0.001, 95% CI = 0.12-0.22). The Sobel test of indirect effect showed that functional difficulties partially mediated the association between exposure to ACEs and headaches (β = 0.027, p < 0.001, 95% CI = 0.022-0.029). Also, older children and children with brain injury were more likely to report experiencing headaches.

CONCLUSIONS

The findings from this study suggest an association between exposure to ACEs and headaches among children, and functional difficulties partially mediate this association.

Impact of abuse on migraine-related sensory hypersensitivity symptoms: Results from the American Registry for Migraine Research

BACKGROUND AND OBJECTIVES

Prior studies have established an association between a history of abuse and the development of migraine. This cross-sectional observational study explored the relationship between self-reported abuse history with migraine-related sensory hypersensitivity symptoms.

METHODS

In total, 588 adult patients with migraine from the American Registry for Migraine Research completed questionnaires: Generalized Anxiety Disorder-7, Patient Health Questionnaire-2 for depression, Photosensitivity Assessment Questionnaire, Hyperacusis Questionnaire, and Allodynia Symptom Checklist. Using four binary screening questions, patients were asked to self-report if they believed they had suffered emotional, physical, or sexual abuse in their lifetime. Differences in questionnaire scores between groups with and without a history of abuse were determined. Regression models adjusted for age, sex, and basic headache features analyzed the relationship between abuse history and sensory hypersensitivity symptoms. Moderation analysis explored the role of headache frequency in this relationship. Mediation analysis assessed the indirect (Mediated) effect (IE) of abuse on sensory hypersensitivity through depression or anxiety. Additional models analyzed relationships between sensory hypersensitivity symptoms and abuse subtypes or the number of abuse subtypes.

RESULTS

Of 588 participants, 222 (38%) reported a history of abuse. Patients with a history of abuse reported statistically significantly greater average headache frequency (7.6 vs. 4.7 days, p = 0.030). Patients with a history of abuse also reported higher average or median questionnaire scores: anxiety (7.6 vs. 4.7, p < 0.001, d = 0.56), depression (1.7 vs. 1.3, p = 0.009, d = 0.24), photophobia (0.54 vs. 0.44, p < 0.001, d = 0.32), hyperacusis (19.6 vs. 14.9, p < 0.001, d = 0.49), ictal allodynia (6.0 vs. 3.0, p < 0.001, d = 0.46), and interictal allodynia (1.0 vs. 0.0, p < 0.001, d = 0.30). After controlling for patient age, sex and years lived with headache, abuse maintained a significant association with every sensory hypersensitivity measure. Headache frequency significantly moderated the relationship between a history of abuse with increased ictal allodynia (p = 0.036). Anxiety significantly mediated the relationships between abuse with photophobia (IE = 0.03, 95% CI = 0.01-0.04), hyperacusis (IE = 1.51, 95% CI = 0.91-2.24), ictal allodynia (IE = 0.02, 95% CI = 0.01-0.04), and interictal allodynia (IE = 0.02, 95% CI = 0.01-0.06). Depression significantly mediated the relationship between abuse with photophobia (IE = 0.02, 95% CI = 0.01-0.03) and with hyperacusis (IE = 0.45, 95% CI = 0.11-0.88). The association between the individual subtypes of abuse and the number of subtypes of abuse with sensory hypersensitivity symptoms varied.

CONCLUSION

A history of abuse is associated with greater migraine-related sensory hypersensitivity symptoms. To reduce the impact of abuse on migraine symptoms, future studies should explore mechanistic connections between abuse and migraine-associated symptoms.

Identifying and managing refractory migraine: barriers and opportunities?

The term refractory migraine has been used to describe persistent headache that is difficult to treat or fails to respond to standard and/or aggressive treatments. This subgroup of migraine patients are generally highly disabled and experience impaired quality of life, despite optimal treatments. Several definitions and criteria for refractory migraine have been published, but as yet, an accepted or established definition is not available. This article reviews the published criteria and proposes a new set of criteria. The epidemiology, pathophysiology and management options are also reviewed.

The exploration of mechanisms of comorbidity between migraine and depression

Migraine comorbid with depression is common and is often encountered in clinical practice. The comorbidity may lead to more serious conditions with other symptoms and a longer duration of treatment and it may impose heavy economic and social burdens, directly or indirectly, on patients and their families. Numerous studies have been published on the association of migraine with depression. Numerous literature have showed that the comorbidity may have a common complicated pathogenic mechanism involving biopsychosocial characteristics, including abnormal brain development and shared genetic basis, as well as neurotransmitters, sex hormones and stress. In addition, some studies have identified the multiple, bidirectional relationship between migraine and depressive disorder. We searched the literature for the possible common mechanisms between migraine and depression and classified the research results.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

Negative Short-Term Outcome of Detoxification Therapy in Chronic Migraine With Medication Overuse Headache: Role for Early Life Traumatic Experiences and Recent Stressful Events

Background: Early traumatic experiences and Stressful episodes appear to be associated to the development and perpetuation of chronic pain disorders and to dependence-related behaviors. Objective: The present study evaluated whether these factors can be predictors, together with psychiatric conditions, of the outcome of a detoxification treatment in patients suffering from chronic migraine and medication-overuse headache in a 2-month follow-up. Methods: Consecutive patients undergoing a detoxification program as therapy for treating chronic migraine and medication overuse headache at the Pavia Headache Center were analyzed. During this program, lasting about 1 week, all patients received the standard CARE in-patient withdrawal protocol, which consisted in discontinuing abruptly the overused drug(s) and receiving daily detoxification therapy. Data on childhood traumatic events and recent stressful ones were analyzed by means of the Childhood Trauma Questionnaire and Stressful life-events Questionnaire. Psychiatric conditions were evaluated using the Structured Clinical Interview for Diagnostic and Statistical Manual of mental disorders. Results: A total of 166 (80% females; mean age 44.7) patients completed the follow-up at 2 months after the detoxification program: of these 118 (71%) (78% females; mean age 44.7) stopped overuse and reverted to an episodic pattern of headache (Group A); 19 (11%) (89% females; mean age 41.3) kept overusing and maintained a chronic pattern of headache (Group B); and 29 (18%) (79% females; mean age 46.9) stopped overuse without any benefit on headache frequency (Group C). At the multivariate analyses, a higher number of early life emotional distress (Odds Ratio 11.096; p = 0.037) arose as a prognostic factor for the outcome in Group B, while major depression during life-time (Odds Ratio 3.703; p = 0.006) and higher number of severe stressful episodes in the past 10 years (Odds Ratio 1.679; p = 0.045) were prognostic factors for the outcome of Group C. Conclusions: Data suggest that early life traumas and stressful events have a negative impact on the outcome of the detoxification program in subjects overusing acute medication for headache. The history of emotional childhood traumas is associated to the failure to cease overuse, whereas recent very serious life events are associated to the persistence of headache chronicity.

The Association Between Childhood Traumatic Events and Headache-Related Parameters in Patients with Migraine: A Cross-Sectional Study in Turkish Population

Introduction

The aim of this study is to investigate the association between childhood traumatic events and headache-related clinical parameters in migraine patients.

Methods

95 patients diagnosed with migraine and 50 healthy controls were included in the study. A socio-demographic form, the Childhood Trauma Questionnaire (CTQ), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were completed by all participants. Additionally, the Visual Analog Scale (VAS) and the Migraine Disability Assessment Test (MIDAS) were applied to migraine patients.

Results

Positive correlations were found between emotional abuse, physical abuse, physical neglect, CTQ total scores, and headache frequency (r=0.33, r=0.24, r=0.26 and r=0.28 respectively) in migraine patients. A positive correlation was found between physical neglect and headache duration (r=0.28). Positive correlations were also found between emotional abuse and physical neglect, and MIDAS total scores (r=0.22 and r=0.23, respectively). Emotional abuse and CTQ total scores were associated with younger mean age of headache onset (r=-0.24 and r=-0.23).

Conclusion

Childhood traumatic events are associated with more frequent and more severe headache episodes, and younger headache onset in migraine patients.

Untangling the Association Between Migraine, Pain, and Anxiety: Examining Migraine and Generalized Anxiety Disorders in a Canadian Population Based Study

OBJECTIVE

The aims of this study were to investigate: (1) the prevalence and unadjusted and adjusted odds of 12-month generalized anxiety disorder (GAD) among adults with migraine in comparison to those without migraine; (2) If debilitating pain and/or limitations in instrumental activities of daily living (IADLs) are mediators of the migraine-GAD association; and (3) Factors associated with past year GAD among adults with migraine.

METHODS

Secondary data analysis of the nationally representative 2012 Canadian Community Health Survey-Mental Health (CCHS-MS), a population-based survey of community dwellers with a response rate of 68.9%. The first subsample included those with (n = 2232) and without migraine (n = 19,270), and the second subsample was restricted to those with migraine (n = 2232). GAD was based on the WHO-CIDI scale.

RESULTS

Fully, 6% of those with migraines had past year GAD in comparison of 2.1% of those without migraine (P < .001). The socio-demographically adjusted odds of past year GAD were two and a half times higher among those with migraine than those without (OR= 2.46; 95% CI = 2.00, 3.02). A path analysis indicated that debilitating pain and limitations in IADLs were mediators in the relationship between migraine and GAD. In the sample restricted to migraineurs, the factors associated with higher odds of 12-month GAD included having a university degree, having low income, being without a confidant, and being male.

CONCLUSIONS

Generalized anxiety disorder is robustly associated with migraine and targeted outreach and interventions are warranted.

Risk factors of chronic daily headache or chronic migraine

Chronic daily headache (CDH) is a common neurological condition that affects 1-4 % of the general population. Most individuals with CDH originally suffered from episodic headaches, but over time, this developed into CDH. Although the pathophysiology of CDH is not fully understood, recent clinical and epidemiological studies suggest some risk factors that are associated with an increased risk of transformation from episodic headaches. If risk factors can be identified, they could provide a base for aggressive preventive intervention and thus decrease the transformation from episodic headaches to eventual CDH. In this article, we review and summarize the current data on risk factors for CDH.

A Review of Select Centralized Pain Syndromes: Relationship With Childhood Sexual Abuse, Opiate Prescribing, and Treatment Implications for the Primary Care Physician

Pain can be broadly divided into 3 classes, including nociceptive or inflammatory pain (protective), neuropathic (pathological, occurring after damage to the nervous system), or centralized (pathological, due to abnormal function but with no damage or inflammation to the nervous system). The latter has been posited to occur when descending analgesic pathways are attenuated and/or glutamatergic transmission is facilitated. Additionally, this "pain prone phenotype" can be associated with early life trauma and a suboptimal response to opiates. This article will review the relationships between centralized pain syndromes (ie, fibromyalgia, chronic low back pain), childhood sexual abuse, and opiate misuse. Finally, treatment implications, potentially effecting primary care physicians, will be discussed.

Recalled maltreatment, migraine, and tension-type headache: results of the AMPP study

OBJECTIVE

To examine the relationship of recalled adverse childhood experiences (ACEs) with migraine and episodic tension-type headache (ETTH).

METHODS

We conducted a cross-sectional analysis of ACEs among 2007 American Migraine Prevalence and Prevention Study survey respondents with ETTH and migraine. We modeled headache type using logistic regression adjusting for sociodemographic variables (age, race, sex, income), depression, and anxiety, and headache day frequency using ordinal logistic regression with a proportional odds model.

RESULTS

Participants had migraine (n = 8,305) or ETTH (n = 1,429). Rates of ACEs were significantly higher among respondents with migraine than ETTH for emotional neglect (24.5% vs 21.5%), emotional abuse (22.5% vs 16.7%), and sexual abuse (17.7% vs 13.3%). Odds of migraine vs ETTH were significantly higher for those reporting 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), or sexual abuse (OR = 1.35, 95% CI 1.11-1.62) when adjusted for sociodemographics. Results remained significant only for emotional abuse when adjusting for depression and anxiety (OR = 1.33, 95% CI 1.13-1.57). Odds of migraine were higher with 2 (OR 1.52, 95% CI 1.25-1.86) vs 1 (OR 1.17, 95% CI 1.00-1.36) ACE, which held after adjusting for depression and anxiety. All forms of maltreatment were associated with higher headache day frequency category in migraine but results lost significance after adjusting for depression and anxiety.

CONCLUSIONS

ACEs are associated with a higher risk of migraine vs ETTH. Attenuation of the influence of ACEs by depression and anxiety suggests confounding or mediation, although results for emotional abuse were generally maintained.

Psychiatric comorbidity of chronic daily headache: focus on traumatic experiences in childhood, post-traumatic stress disorder and suicidality

The fifth edition of the Diagnostic and Statistic Manual (DSM-5) reclassified some mental disorders recently. Post-traumatic stress disorder (PTSD) is in a new section termed "trauma- and stressor-related disorder". Community-based studies have shown that PTSD is associated with a notably high suicidal risk. In addition to previous findings of comorbidity between chronic daily headache (CDH) and both depressive disorders and anxiety disorders, recent data suggest that frequency of childhood maltreatment, PTSD, and suicidality are also increased in CDH. CDH patients with migraine aura are especially at risk of suicidal ideation. Research suggests that migraine attack, aura, frequency, and chronicity may all be related to serotonergic dysfunction. Vulnerability to PTSD and suicidality are also linked to brain serotonin function, including polymorphisms in the serotonin transporter gene (5-HTTLPR). In the present review, we focus on recent advances in knowledge of traumatic experiences in childhood, PTSD, and suicidality in relation to migraine and CDH. We hypothesize that vulnerability to PTSD is associated with migraine attack, migraine aura, and CDH. We further postulate that these associations may explain some of the elevated suicidal risks among patients with migraine, migraine aura, and/or CDH. Field studies are required to support these hypotheses.

Childhood trauma and dissociation in tertiary care patients with migraine and tension type headache: a controlled study

OBJECTIVE

The aims of this study were: i) to compare the severity of somatoform and psychoform dissociation and childhood trauma among migraine patients, tension-type headache patients (TTH), and healthy controls; and, ii) to identify any relationships between headache characteristics and dissociative symptoms and traumatic childhood experiences among tertiary care patients with headache.

METHODS

The study sample consisted of 79 patients with migraine, 49 patients with TTH and 40 healthy controls. They completed the socio-demographic form, Childhood Trauma Questionnaire (CTQ), Dissociative Experiences Scale (DES), and the Somatoform Dissociation Questionnaire (SDQ).

RESULTS

The average score for childhood emotional abuse was significantly higher in the TTH and migraine patients than in healthy controls; mean scores for emotional neglect and physical abuse were higher in TTH patients than healthy controls; and the total CTQ score was higher in TTH patients than in either migraine patients or healthy controls. Average DES scores were significantly higher in TTH patients versus migraine patients and controls; and SDQ scores were higher in both headache groups than in controls. Headache duration and severity were found to be significantly related to childhood abuse scores among migraine but not TTH patients.

CONCLUSION

Our findings support the evidence of a relationship between childhood trauma and migraines, and suggest that childhood traumatic events are common and deleteriously effect migraine characteristics. Also our study suggests that childhood trauma may have a role in TTH. Significant differences in the DES and SDQ scores between groups may be explained by the differences in childhood trauma experiences.

Headache and physical and sexual abuse among Jewish and Arab adolescents in Israel

The purpose of the present study was to evaluate the relationship between headaches and physical and sexual abuse. A self-administered, anonymous questionnaire was presented to 2088 tenth grade students in Northern Israel. Participants were Jews and Arabs between the ages of 15 to 16 years. Arab adolescents comprised 55% of the analyzed sample and adolescent Jews 45%. With regard to gender, 56% of participants were females. Of the Arab participants, 18.6% reported having frequent headaches, less than that reported in the Jewish group (27.9%). Jewish girls who were physically abused during childhood had a higher prevalence of frequent headaches (55% vs 33% P < .001). Jewish students who reported being sexually abused had higher headache prevalence as well (44.4% vs 27.3% P = .05). In conclusion, adolescents who reported to have been physically or sexually abused report a higher prevalence of headache compared to their peers.

History of abuse and its relationship to pain experience and depression in women with chronic pelvic pain

OBJECTIVE

We sought to determine the relationship among a history of physical or sexual abuse, pain experience, and depressive symptoms among women with chronic pelvic pain (CPP).

STUDY DESIGN

This was a cross-sectional study of women who presented to a tertiary referral center for evaluation of CPP (N = 273). All participants completed standardized questionnaires to assess a history of physical or sexual abuse, pain severity, pain disability, and depressive symptoms. Subjects were grouped by abuse category and compared to CPP participants without history of abuse. Multinomial logistic regression models were used to determine the association between adolescent or adult and childhood physical or sexual abuse with pain intensity, pain-related disability, and depressive symptoms.

RESULTS

Logistic regression analyses indicated that, after controlling for age and education, none of the abuse categories was associated with pain severity. However, adolescent or adult sexual abuse predicted greater pain-related disability (odds ratio, 2.39; 95% confidence interval, 1.05-5.40), while both adolescent or adult physical and sexual abuse were associated with higher levels of depression (both P < .05). Level of education was significantly associated with pain intensity, pain disability, and depression.

CONCLUSION

For our sample of women with CPP, a history of abuse during childhood or adulthood was not associated with differences in pain intensity, but adolescent or adult sexual abuse was associated with greater pain-related disability. A history of physical abuse or sexual abuse appears to hold a stronger relationship with current depressive symptoms than pain experience for women with CPP. Educational achievement holds a robust relationship with pain morbidity and depression for this population.

Post-Traumatic Stress Disorder in Migraine Patients: Migraine, Trauma and Alexithymia

INTRODUCTION

In recent studies, it has been suggested that there is a relationship between migraine headaches and post-traumatic stress disorder (PTSD). The PTSD has not been diagnosed by a clinician in these studies; the evaluation has been carried out by the screening scales. Besides, it has also been asserted that there was relationship of alexithymia with migraine and other chronic painful disorders. In this study, our aim was to investigate the prevalence of clinically-diagnosed PTSD and alexithymic features among migraine patients.

METHODS

Sixty consecutive migraine patients sent from neurology clinic and 60 healthy controls having similar features constituted the sample of this study. SCID-I/CV PTSD module and the Clinician-Administered PTSD Scale (CAPS) was administered to the sample. The subjects also filled in the socio-demographic data form and the Toronto Alexithymia Scale (TAS). The level of pain perceived by the migraine patients was evaluated using a Visual Analog Scale (VAS).

RESULT

17 subjects (28%) in the migraine group and 5 individuals (8.3%) in the control group were diagnosed with PTSD. Hence, PTSD was found to be statistically significantly higher in the migraine group. 25 persons in the migraine group (41.6%) and 12 in the control group (20%) scored above the TAS cutoff score in terms of alexithymic features. Alexithymia was found to be statistically significantly higher in the migraine group). In the migraine group, VAS scores of the ones with PTSD were statistically significantly higher compared to that in ones without PTSD. 94% of the persons diagnosed with PTSD in the migraine group reported that their migraine headaches started after a traumatic experience. In the migraine group, no statistically significant correlation was detected between CAPS and VAS scores in subjects with PTSD.

CONCLUSION

In migraine patients, PTSD and alexithymic features have been found higher than in the healthy controls. Further studies are needed to search whether the practices aimed at treating the PTSD and alexithymic features can contribute to the treatment of migraine headaches or not.

Migraine and depression: bidirectional co-morbidities?

Even if the bidirectional co-morbidity between migraine and depression has been supported by epidemiological and genetic studies, many aspects of this association have not been completely understood. This may be due to the heterogeneous character of migraine and depression as well as to their multifactorial pathogenesis. In this review, we have briefly reported the more recent findings published about the co-morbidity between migraine and depression by discussing the above reported issues and the relative clinical and therapeutic implications.

Trauma exposure versus posttraumatic stress disorder: relative associations with migraine

BACKGROUND

Recent research has uncovered associations between migraine and experiencing traumatic events, the latter of which in some cases eventuates in the development of posttraumatic stress disorder (PTSD). However, existing studies have not attempted to explore the relative associations with migraine between experiencing trauma and suffering from PTSD.

OBJECTIVES

The aim of this cross-sectional study was to assess the predictive utility of trauma exposure vs PTSD in predicting migraine status and headache frequency, severity, and disability.

METHODS

One thousand fifty-one young adults (mean age = 18.9 years [SD = 1.4]; 63.1% female; 20.6% non-Caucasian) without secondary causes of headache provided data from measures of headache symptomatology and disability, trauma and PTSD symptomatology, and depression and anxiety. Three hundred met diagnostic criteria for migraine and were compared on trauma exposure and PTSD prevalence with 751 participants without migraine.

RESULTS

Seven hundred twenty-eight participants (69.3%) reported experiencing at least 1 traumatic event consistent with Criterion A for PTSD, of whom 184 also met diagnostic criteria for PTSD. Migraineurs were almost twice as likely as controls to meet criteria for PTSD (25.7% vs 14.2%, P < .0001) and reported a higher number of traumatic event types that happened to them personally (3.0 vs 2.4, P < .0001). However, experiencing a Criterion A event only was not a significant predictor of migraine either alone (odds ratio [OR] = 1.17, P = nonsignificant) or after adjustment for covariates. By comparison, the OR of migraine for those with a PTSD diagnosis (vs no Criterion A event) was 2.30 (P < .0001), which remained significant after controlling for relevant covariates (OR = 1.75, P = .009). When using continuous variables of trauma and PTSD symptomatology, PTSD was again most strongly associated with migraine. Numerous sensitivity analyses confirmed these findings. PTSD symptomatology, but not the number of traumas, was modestly but significantly associated with headache frequency, severity, and disability in univariate analyses.

CONCLUSIONS

Consistently across analyses, PTSD was a robust predictor of migraine, whereas trauma exposure alone was not. These data support the notion that it is not exposure to trauma itself that is principally associated with migraine, but rather the development and severity of PTSD symptoms resulting from such exposure.

A population-based longitudinal community study of major depression and migraine

OBJECTIVE

To examine whether major depressive episodes (MDEs) are associated with an increased risk of migraine in the general population and to examine whether migraine is associated with an increase risk of MDE.

BACKGROUND

Population-based cross-sectional studies have consistently reported an association between migraine and depression. However, longitudinal studies about this potentially bidirectional association are inconsistent.

METHODS

This retrospective cohort study used 12 years of follow-up data from the Canadian National Population Health Survey (15,254 respondents, age >12). Stratified analysis, logistic regression, and proportional hazard modeling were used to quantify the effect of migraine on subsequent MDE status and vice versa.

RESULTS

After adjusting for sex, age, and other chronic health conditions, respondents with migraine were 60% more likely (HR 1.6, 95% confidence interval 1.3-1.9) to develop MDE compared with those without migraine. Similarly adjusting for sex and age, respondents with MDE were 40% more likely (HR 1.4, 95% confidence interval 1.0-1.9) to develop migraine compared with those without MDE. However, the latter association disappeared after adjustment for stress and childhood trauma.

CONCLUSIONS

The current study provides substantial evidence that migraine is associated with the later development of MDEs, but does not provide strong causal evidence of an association in the other direction. Environmental factors such as childhood trauma and stress may shape the expression of this bidirectional relationship; however, the precise underlying mechanisms are not yet known.

Childhood abuse and migraine: epidemiology, sex differences, and potential mechanisms

Migraine and maltreatment are both common conditions that are more prevalent in women. Epidemiological evidence supports an association between childhood abuse and headache, as well as pain in general, although some controversy exists based on methodological concerns of studying the influence of remote, traumatic, stigmatizing events in an often depressed population. There is a growing scientific body of knowledge regarding the neurobiological effects of abuse on brain function and structure that suggest a possible role of early life stress in the pathogenesis of migraine, and a differential impact based on sex. Advances in our understanding of the basic mechanisms by which an adverse environment interacts with and changes the genome, may suggest new treatment strategies.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.

Migraine and psychiatric comorbidity: a review of clinical findings

Migraine is an extremely common disorder. The underlying mechanisms of this chronic illness interspersed with acute symptoms appear to be increasingly complex. An important aspect of migraine heterogeneity is comorbidity with other neurological diseases, cardiovascular disorders, and psychiatric illnesses. Depressive disorders are among the leading causes of disability worldwide according to WHO estimation. In this review, we have mainly considered the findings from general population studies and studies on clinical samples, in adults and children, focusing on the association between migraine and psychiatric disorders (axis I of the DSM), carried over after the first classification of IHS (1988). Though not easily comparable due to differences in methodology to reach diagnosis, general population studies generally indicate an increased risk of affective and anxiety disorders in patients with migraine, compared to non-migrainous subjects. There would also be a trend towards an association of migraine with bipolar disorder, but not with substance abuse/dependence. With respect to migraine subtypes, comorbidity mainly involves migraine with aura. Patients suffering from migraine, however, show a decreased risk of developing affective and anxiety disorders compared to patients with daily chronic headache. It would also appear that psychiatric disorders prevail in patients with chronic headache and substance use than in patients with simple migraine. The mechanisms underlying migraine psychiatric comorbidity are presently poorly understood, but this topic remains a priority for future research. Psychiatric comorbidity indeed affects migraine evolution, may lead to chronic substance use, and may change treatment strategies, eventually modifying the outcome of this important disorder.

Association between intimate partner violence, migraine and probable migraine

OBJECTIVE

Intimate partner violence (IPV) among women is a global public health problem. The association between childhood maltreatment and migraine is well established, but not the association between IPV and migraine. The aim of this cross-sectional study was to evaluate the relationship between type and severity of IPV and migraine in a large cohort of Peruvian women.

METHODS

Women who delivered singleton infants (n = 2066) at the Instituto Nacional Materno Perinatal, Lima, Peru were interviewed during their postpartum hospital stay. Participants were queried about their lifetime experiences with headaches and migraine, and with physical and sexual violence. The International Classification of Headache Disorders (ICHD-2) diagnostic criteria were used to classify participants according to their migraine status. Questions on physical and sexual violence were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module and the World Health Organization (WHO) Multi-Country Study on Violence against Women. Depressive symptoms were assessed using a modified version of the Patient Health Questionnaire-9. Logistic regression was used to estimate multivariate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS

Compared with women without a history of violence, women with experiences of lifetime physical or sexual violence (aOR = 1.44, 95% CI 1.19-1.75), physical violence only (aOR = 1.36, 95% CI 1.10-1.68), sexual violence only (aOR = 1.76, 95% CI 0.97-3.21), and both physical and sexual violence (aOR = 1.61, 95% CI 1.12-2.31) had increased odds of any migraine after adjusting for maternal age, parity, and access to basic foods. There was no gradient of increased odds of any migraine with severity of physical violence. The relationship between IPV and any migraine was strongest among women with moderate to severe levels of depressive symptoms. The odds of any migraine was increased 2.25-fold (95% CI 1.75-2.28) among abused women who also had moderate to severe levels of depressive symptomology compared with women who were not abused and had none or mild levels of depressive symptomology. Associations from sensitivity analyze that segregated women according to probable migraine (ICHD-2 category 1.6.1) and migraine (ICHD-2 category 1.1) diagnoses were of similar magnitudes as those reported here for women with any migraine diagnoses. IPV, particularly sexual violence, appears to be a risk factor for migraine.

CONCLUSION

Our findings suggest the potential importance of considering a history of violence among migraineurs.

Relationship between childhood physical maltreatment and migraine in adolescents

OBJECTIVE

To study the relationship between childhood physical abuse and migraine in adolescents.

BACKGROUND

Childhood maltreatment might lead to an increased probability of migraine among adults. Nevertheless, the relationship between migraine and childhood abuse is unknown in adolescents.

METHODS

We enrolled 3955 students, ages 13-15, from 3 middle schools. Each participant completed a validated headache questionnaire for headache diagnosis and the Adolescent Depression Inventory (ADI). A classification of physical maltreatment was given to students who reported they had been beaten by parents or elder family members.

RESULTS

A total of 926 (23.4%) students were diagnosed with migraine or probable migraine occurring within the 3 months prior to the survey. Physical maltreatment was reported by 945 (23.9%) students, including a frequency of "rarely" in 762 (19.3%) students and "sometimes or often" in 183 (4.6%). The students reporting physical maltreatment were more likely to suffer migraine or probable migraine compared with those who reported no physical maltreatment (30.3% vs 21.3%, odds ratios = 1.6, 95%, CI: 1.4-1.9, P < .001). A higher frequency of physical maltreatment was associated with a higher likelihood of migraine diagnosis (21.3% vs 28.3%, vs 38.3%, "never" vs "rarely" vs "sometimes or often maltreated," respectively, P < .001). In addition, among the students diagnosed with migraine, those reporting physical maltreatment had higher mean ADI scores, a higher frequency of headaches, and a greater proportion of severe headaches.

CONCLUSIONS

The results suggest that physical maltreatment is associated with migraine in adolescents and that physical maltreatment may be related to an increase in the frequency and intensity of headaches in adolescents with migraines. A history of physical maltreatment may be helpful in the treatment of adolescents suffering from migraine.

Investigating the association between childhood physical abuse and migraine

BACKGROUND

Recent clinical and population-based studies suggest that adults who were physically abused as children are more likely to experience migraine than those who were not abused.

OBJECTIVES

To investigate the relationship between childhood physical abuse and migraine while controlling for age, race, and gender, in addition to the following potential confounders: adverse childhood conditions; adult socioeconomic indicators; current health behaviors; current stressors; history of physical health conditions, and history of mood and/or anxiety disorders.

METHODS

Secondary analysis of the 2005 Canadian Community Health Survey was undertaken using a regional sample of 13,089 men and women from Manitoba and Saskatchewan (response rate = 83.3% and 84.1%, respectively) of which 7.4% (n = 1025) of respondents reported childhood physical abuse. A series of logistic regression models were used to determine the association between abuse and self-report of a health professional diagnosis of migraine.

RESULTS

Prevalence of a migraine was almost twice as high for those who reported childhood physical abuse in comparison with those who did not (17.9% vs 8.8%). The crude odds ratio was 2.27 (99% CI = 1.80, 2.86). The odds ratio of migraine was 1.77 (99% CI = 1.39, 2.25) for those who reported childhood physical abuse in comparison with those who did not when only age, gender, and race were adjusted for. When all 6 clusters of potential confounders were included in a final model the odds ratio declined but remained significant at 1.36 (99% CI = 1.04, 1.79).

CONCLUSIONS

This study found a stable association between childhood physical abuse and migraine that persisted when 6 clusters of potentially confounding factors were adjusted for. Future research should investigate possible mechanisms which explain the abuse-migraine association.

The approach to the difficult patient

Specific patient and physician characteristics may contribute to a perception that a particular headache patient is "difficult." Headache patients with psychiatric pathology, multiple unexplained symptoms, substance abuse problems, or refractory headaches are commonly perceived as challenging to manage. Physicians who are younger, under more stress, and who do not use collaborative treatment models are more likely to find patients difficult. General principles that may be helpful in coping with headache patients perceived as difficult include: (1) evaluation for possible psychiatric or substance abuse problems with institution of specific treatment if found; (2) a shift in treatment philosophy away from a goal of cure toward a goal of management; (3) the use of written agreements that outline conditions of treatment, including medication amounts; and (4) an integrated, multimodality treatment approach including behavioral and non-pharmacological treatment.

Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications

Migraine is often comorbid with psychiatric disorders such as major depression, bipolar disorder, and anxiety disorders. Although most of the research on psychiatric comorbidities and migraine is of an epidemiologic nature, a growing body of literature has investigated possible mechanisms underlying this relationship, such as medication overuse, serotonergic dysfunction, ovarian hormone fluctuations, and central sensitization. The present article overviews this growing literature and notes strategies for the clinical management of migraine patients with psychiatric comorbidities.

Childhood maltreatment and migraine (part III). Association with comorbid pain conditions

OBJECTIVE

To evaluate in a headache clinic population the relationship of childhood maltreatment on the prevalence of pain conditions comorbid with migraine.

BACKGROUND

Childhood maltreatment is highly prevalent and has been frequently associated with recurrent headache. The relationship of maltreatment and pain has, however, been a subject of some debate.

METHODS

Cross-sectional data on self-reported physician-diagnosed pain conditions were electronically collected from persons with migraine (diagnosed according to International Classification of Headache Disorders-2), seeking treatment in headache clinics at 11 centers across the US and Canada. These included irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), fibromyalgia (FM), interstitial cystitis (IC), arthritis, endometriosis, and uterine fibroids. Other information included demographics, migraine characteristics (frequency, headache-related disability), remote and current depression (The Patient Health Questionnaire-9), and remote and current anxiety (The Beck Anxiety Inventory). Patients also completed the Childhood Trauma Questionnaire regarding sexual, emotional, and physical abuse, and emotional and physical neglect under the age of 18 years old. Statistical analyses accounted for the survey design and appropriate procedures in SAS such as surveymeans, surveyfreq, and surveylogistic were applied to the weighted data.

RESULTS

A total of 1348 migraineurs (88% women) were included in this study (mean age 41 years). Based on physician diagnosis or validated criteria, 31% had IBS, 16% had CFS, and 10% had FM. Diagnosis of IC was reported by 6.5%, arthritis by 25%, and in women, endometriosis was reported by 15% and uterine fibroids by 14%. At least 1 comorbid pain condition was reported by 61%, 2 conditions by 18%, and 3 or more by 13%. Childhood maltreatment was reported by 58% of the patients. Emotional abuse was associated with increased prevalence of IBS, CFS, arthritis, and physical neglect with arthritis. In women, physical abuse was associated with endometriosis and physical neglect with uterine fibroids. Emotional abuse, and physical abuse and neglect (P < .0001 for all) were also associated with increased total number of comorbid conditions. In ordinal logistic regression models, adjusted for sociodemographics and current depression (prevalence 28%) and anxiety (prevalence 56%), emotional abuse (odds ratios [OR] = 1.69, 95% confidence intervals [CI]: 1.224-2.33) and physical neglect (OR = 1.73, 95% CI: 1.22-2.46) were independently associated with an increased number of pain conditions. The cohort of women, similarly, had associations of emotional abuse (OR = 1.94, 95% CI: 1.40-2.72) and physical neglect (OR = 1.90, 95% CI: 1.34-2.68) with an increased number of pain comorbidities.

CONCLUSION

The association of childhood maltreatment and pain was stronger in those reporting multiple pain conditions and multiple maltreatment types. This finding suggests that in migraineurs childhood maltreatment may be a risk factor for development of comorbid pain disorders.

Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification

OBJECTIVES

To assess in a headache clinic population the relationship of childhood abuse and neglect with migraine characteristics, including type, frequency, disability, allodynia, and age of migraine onset.

BACKGROUND

Childhood maltreatment is highly prevalent and has been associated with recurrent headache. Maltreatment is associated with many of the same risk factors for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity.

METHODS

Electronic surveys were completed by patients seeking treatment in headache clinics at 11 centers across the United States and Canada. Physician-determined data for all participants included the primary headache diagnoses based on the International Classification of Headache Disorders-2 criteria, average monthly headache frequency, whether headaches transformed from episodic to chronic, and if headaches were continuous. Analysis includes all persons with migraine with aura, and migraine without aura. Questionnaire collected information on demographics, social history, age at onset of headaches, migraine-associated allodynic symptoms, headache-related disability (The Headache Impact Test-6), current depression (The Patient Health Questionnaire-9), and current anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire.

RESULTS

A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (>or=15 days/month) was reported by 34%. Transformation from episodic to chronic was reported by 26%. Prevalence of current depression was 28% and anxiety was 56%. Childhood maltreatment was reported as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. In univariate analyses, physical abuse and emotional abuse and neglect were significantly associated with chronic migraine and transformed migraine. Emotional abuse was also associated with continuous daily headache, severe headache-related disability, and migraine-associated allodynia. After adjusting for sociodemographic factors and current depression and anxiety, there remained an association between emotional abuse in childhood and both chronic (odds ratio [OR] = 1.77, 95% confidence intervals [CI]: 1.19-2.62) and transformed migraine (OR = 1.89, 95% CI: 1.25-2.85). Childhood emotional abuse was also associated with younger median age of headache onset (16 years vs 19 years, P = .0002).

CONCLUSION

Our findings suggest that physical abuse, emotional abuse, and emotional neglect may be risk factors for development of chronic headache, including transformed migraine. The association of maltreatment and headache frequency appears to be independent of depression and anxiety, which are related to both childhood abuse and chronic daily headache. The finding that emotional abuse was associated with an earlier age of migraine onset may have implications for the role of stress responses in migraine pathophysiology.

The associations between migraine, unipolar psychiatric comorbidities, and stress-related disorders and the role of estrogen

Migraine is a common and often disabling neurovascular disorder. It has been linked with several psychiatric disorders, such as depression and anxiety, and to stress-related disorders, such as abuse and posttraumatic stress disorder (PTSD). Epidemiological data have consistently shown a higher prevalence of migraine, depression, anxiety, abuse, and PTSD in women as compared with men. The increased vulnerability of women to migraine and psychiatric disorders often occurs during periods of marked hormonal fluctuations of ovarian hormones. One consequence of these associations is the hypothesis that estrogens have a role in the pathophysiology of both disorders. This article offers an in-depth review of several studies linking psychiatric disorders and stress-related disorders with migraine. We also discuss the role of estrogen in the pathophysiologic overlap between these disorders. Finally, we briefly touch on where future research may be headed, in light of these data.

A twin study of depression and migraine: evidence for a shared genetic vulnerability

OBJECTIVE

To determine if shared genetic or environmental vulnerabilities could underlie depression and migraine.

BACKGROUND

Depression and migraine headaches frequently coexist and their comorbidity may be due to shared etiologies.

METHODS

Female twins in the University of Washington Twin Registry responded to a mailed survey regarding their health history. Depression and migraine were determined by self-report of a physician's diagnosis. We used bivariate structural equation modeling to test for shared genetic, common environmental, and unique environmental components, and to estimate the magnitude of any shared component.

RESULTS

Among 758 monozygotic and 306 dizygotic female pairs, 23% reported depression and 20% reported migraine headaches. Heritability was estimated to be 58% (95% confidence interval: 48-67%) for depression and 44% (95% confidence interval: 32-56%) for migraine. Bivariate structural equation modeling estimated that 20% of the variability in depression and migraine headaches was due to shared genes and 4% was due to shared unique environmental factors.

CONCLUSIONS

The comorbidity of depression and migraine headache may be due in part to shared genetic risk factors. Research should focus attention on shared pathways, thereby making progress on 2 disease fronts simultaneously and perhaps providing clinicians with unified treatment strategies.

Why cause matters

Recently, some commentators have suggested, for either pragmatic or philosophical reasons, that the cause of mental distress is irrelevant. In this paper it is suggested that downplaying the role of cause leads to ignoring the link between abuse and mental health difficulties which is disempowering for individuals, short-sighted for service provision and fails to challenge the social structures, inequalities, conditions, practices, values and attitudes that allow abuse to happen. Acknowledging the causal link between abuse and mental health difficulties implies that in addition to building recovery focused therapeutic relationships with individuals, as mental health nurses we need to take seriously our role in mental health promotion from infancy onwards and to acknowledge the importance of being politically aware and involved.

Association of headache with childhood adversity and mental disorder: cross-national study

BACKGROUND

Community studies about the association of headache with both childhood family adversities and depression/anxiety disorders are limited.

AIMS

To assess the independent and joint associations of childhood family adversities and early-onset depression and anxiety disorders with risks of adult-onset headache.

METHOD

Data were pooled from cross-sectional community surveys conducted in ten Latin and North American, European and Asian countries (n=18 303) by using standardised instruments. Headache and a range of childhood family adversities were assessed by self-report.

RESULTS

The number of childhood family adversities was associated with adult-onset headache after adjusting for gender, age, country and early-onset depression/anxiety disorder status (for one adversity, hazard ratio (HR)=1.22-1.6; for two adversities, HR=1.19-1.67; for three or more adversities, HR=1.37-1.95). Early and current onset of depression/anxiety disorders were independently associated (HR=1.42-1.89) with adult-onset headache after controlling for number of childhood family adversities.

CONCLUSIONS

The findings call for a broad developmental perspective concerning risk factors for development of headache.

Major Life Changes Before and After the Onset of Chronic Daily Headache: A Population-Based Study

Chronic daily headache (CDH), when defined as ≥ 15 headache days per month, affects 3-5% of the adult population. Major life changes are putative precipitating events for onset of chronic pain, including chronic headache. This study compared the occurrence of specific life events between CDH cases and episodic headache controls in a community sample. CDH cases (180+ headache days per year: n = 206) and episodic headache controls (2-104 headache days per year: n = 507) were identified from a randomly selected adult US population. Subjects were interviewed about the occurrence of certain major life changes or events (change of residence, employment status, marital status, related to their children, deaths of relatives or close friends, and ‘extremely stressful’ ongoing situations) occurring in a defined time period. Events that occurred during the same year or year before frequent headache onset in cases or in an equivalent time period in controls were considered to be antecedent events. Those that occurred after this time were considered subsequent events. Compared with episodic headache controls, CDH cases had more major life changes in the year before or same year as CDH onset. After adjusting for age, gender, headache type and year of event, the odds of CDH increased additionally with each antecedent event [odds ratio (OR) 1.20 (1.1, 1.3), P < 0.001], but not with subsequent events [OR 0.94 (0.8, 1.1), P < 0.4]. In secondary analyses, the association between antecedent events and CDH was significant only for the approximately half of CDH cases who were aged ≥ 40 years [OR 1.33 (1.2, 1.50) vs. OR 1.04 (0.9, 1.2), P < 0.05 for interaction by age]. These results suggest that major life changes are associated with the onset of chronic daily headache, particularly in middle age.