July 7, 2015
The first time it shook me out of what should be the soothing soupy whir of teen dreams into bewildered chaos. It wasn’t unlike the surprise of a violent assault; confusion, horror, all your senses going into a tortured hyperdrive and not knowing why or how. The thundering, splitting pain radiating across and through your skull and neck, all the way deep into your guts, shaking them into agonal spasms. Crying at the toilet bowl as each heave made the pain echo louder, as you kept spitting up even when there was nothing to spit up except bile. Your mom stroked your hair as you sat weeping on the cold tile floor in the night’s wee hours. The nausea was actually worse than the pain. It was your first migraine. Soon you had day ones too, worse in that you were awake to see the evil “prodrome,” the flashing Kandinsky-esque zigzag patterns that made you go blind in one eye, and struck deep terror in your soul at the horrors to come.
Migraines remain extremely common, affecting more than 36 million people in the United States alone, and nearly three times as more women than men. It ranks as one of the top 20 most disabling medical illnesses in the world. Earlier this year, news reports covered a January 2015 study published in Neurology by Gretchen Tietjen M.D., et al., that found a correlation between adverse childhood experiences (ACE) and migraine, even moreso than with regular tension-type headaches. Rates of ACEs were about 24.5% in people with emotional neglect who got migraines (vs. 21.5 percent with regular headaches), 22.5 percent for emotional abuse (vs. 16.7 percent), and 17.7 percent for sexual abuse (vs. 13.3 percent). The odds of migraine reportedly went up when more than one form of ACE occurred in a person. Given that there remains an epidemic of abuse and trauma, particularly with women as recipients, it’s interesting that the rates of migraine are also so much higher in women.
Another Canadian study by Sarah Brennenstuhl Ph.D. and Esme Fuller-Thomson Ph.D. published in Headache just came out this month with similar results, showing that exposure to parental domestic violence during childhood increased risk of migraine. Other studies have indicated similar trends, with an April 2014 study in the Journal of Psychosomatic Research by Suat Kucukgoncu, et al., also showing higher rates of childhood emotional abuse in patients with migraine (and also patients with regular tension-type headaches in this study). More physical abuse histories correlated with increased duration and chronicity of headache in these patients. Other past studies like Dawn Buse’s in the November 2012 Journal of Neurology have also shown some correlation between PTSD (post-traumatic stress disorder) and migraine.
It was extremely tough for me during my teen years and twenties to find anything to relieve the severe violence of a migraine attack. Sometimes Tylenol or Advil helped a touch, but not really. The new “breakthrough” Imitrex (sumatriptan) turned out to be a big disappointment. The pain magically disappeared for a time, but then the zigzag would return out of the blue a few hours later. It was almost worse than letting it happen to begin with. Other variations of Imitrex didn’t help much more. Ultimately only an older generic medication called Midrin helped some (and somehow because it wasn’t a patented drug company profitmaker like the triptans, it was taken off the market later on). I would also sometimes try taking a Xanax to just sleep through an episode, even if it didn’t help the pain much. I felt that in theory, a benzodiazepine might calm down a brain that felt like it was ablaze with neural lightning, a kind of neurovascular seizure attack.
The worst couple episodes I still remember like bad historical events; where the pain and nausea would take a life of its own and escalate instead of just passing through. Nightmare episode one was during college, and one of my roommates had to walk me in tears to the student infirmary. I got a shot of Compazine which came over me like the sweetest relief, smoothing the knots out of my tumultuous stomach, even if the headache was still pounding. I went home after taking Fioricet and slept insensibly, and was practically giddy the next day out of gratitude for not being utterly miserable. Mind-blowing episode two happened when I was in medical school, and again I had to go to the clinic and get a Compazine shot. It worked also, and I debated afterwards whether to try a preventative medication like a beta-blocker or anticonvulsant, but decided against it out of worries about other side effects. I just continued to live in quiet terror of a future episode, even starting to do little tics out of anxiety like cracking my jaw and blinking my eyes and pinching my face, hoping it would magically ward off any unusual spots in my vision or muscle tension that could blow up into the next evil monster. I also took daily Tylenols out of fear. (I stopped after I realized I had finished a jumbo-sized bottle in a few months, and realized I could be giving myself rebound headaches and liver damage to boot.) Even hearing Imitrex commercials on TV or talking about the word “migraine” would make me feel panicked. I was lucky in that they became less intense and less frequent as I got older, but I still cowered in fear from them.
After I went into psychiatry, I always paid careful attention when patients mentioned a history of migraine, or even other pain syndromes, out of sympathy for the misery involved. In fact, the only good thing about my own migraine history was that it made me a better doctor when it came to treating pain issues and sympathizing with that state of utter, helpless suffering that physical illness could cause. I did tend to notice some anecdotal patterns in terms of which people tended to get migraines more often: people, both male and female but more often women, who seemed more anxious, high-strung, perfectionistic, sort of a self-punitive archetype, and sometimes with histories of trauma or harsher upbringings. It was hard to say what was the “chicken or egg”: were anxiety issues correlated with migraines on a genetic or biophysiological level? Was there something else environmental going on?
The possible causes of this correlation remain unclear, although some interesting theories connect back to the same neurochemical systems that regulate depression and anxiety conditions. Early traumatic experiences have been associated with abnormalities in the HPA (hypothalamic-pituitary-adrenal) axis, the body’s system of regulation for its fight-or-flight fear response. In this system, the brain perceives a threat which triggers and signals the release of stress hormones (like cortisol) that in turn activate one’s adrenal glands and other body systems to raise one’s blood pressure and heartrate, etc. to prepare the body for “battle.” In a healthy system, there are negative feedback mechanisms that help deactivate this fear response once a threat has passed, and return the system to a calm state. But in people who have been exposed to consistent trauma or danger (as in war or repeated abuse), the system of checks and balances in the body change; the signaling mechanisms become alternately dulled in some regions and hyperreactive in others, leading to persistent anxiety and stress in the afflicted individual. Other people may also just be born with an unusual or hyperreactive HPA axis system and may be prone to anxiety or similar conditions without trauma as well, or may be even more sensitive to changes if they are indeed exposed to danger. Systems are also more malleable and sensitive to change during childhood. There is a complex spectrum of both genetic and environmental factors that can cause an individual to develop HPA axis dysregulation and corresponding anxiety and mood disorders.
Migraines may also have some correlation with these fight-or-flight responses and anxiety disorders. Migraines often involve a cascade of autonomic system dysregulation (the nerves that trigger fight-or-flight responses are the autonomic system) and have been termed as a “hyperexcitable” state by some neurologists. Elevated heart rate, nausea and stomach upset, vasospasm (constriction and expansion of blood vessels), hypersensitivity to light and sound and smells all are part of the syndrome of sympathetic activation involved. Serotonin is theorized to play a role in triggering migraines as well, which is a chemical well-known to regulate depression and anxiety and gut functions (and medications like imitrex work on a different serotonin receptor pathway). Beta-blockers, which counteract sympathetic responses, are known to help prevent migraines.
There is also definitely some correlation with hormone regulation in people (as migraines tend to be worse during puberty, and also during periods in some women). It may even be that migraines are more common in women specifically due to issues with estrogen regulation and its effects on the HPA Axis, moreso than societal trends towards female abuse. Higher rates of depression and anxiety also afflict women, which also have some relationship to hormone regulation. But the exact mechanisms remain somewhat hazy and complicated, and more research needs to be done.
As far as possible “psychodynamic” explanations regarding the correlation between migraine and abuse, it may be that there is some component of internalized trauma memory that flares up in these physiological fight-or-flight states, whether subconsciously or otherwise. Stress often triggers migraines in people; it may be that stress system activation in these individuals with their sensitized axes may activate migraines as well as anxiety states. It may unfortunately reinforce the ongoing sense of “punishment” that accompanies traumatic upbringings, as stress leads to pain from headaches and a perpetuating cycle, and an ongoing fragility towards future stressors.
In my life, I too experienced some exposure to childhood trauma and abuse, as well as some depression and anxiety, so I fit the stereotypical picture of a migraineur doomed with a hyperreactive nervous system. But in my fortunate case, I found a cure. After many years of reluctance, I took an SSRI for mild depression and anxiety which helped me significantly in terms of mental health symptoms, but also completely rid me of migraines. I have not had one since, for going on 5 years. I realize SSRIs do not work for everyone this way; I have heard many cases of worsening migraines on SSRIs, and other recommendations for norepinephrine-reuptake medications or mood stabilizers as more effective for treating and preventing migraines. Migraine sufferers ought to customize what works for them in consultation with their neurologist. But for me, that unexpected benefit has been a true blessing and makes sense. The medication has helped my sensitized system go back to normal. And I no longer live in fear of the iron hand of the migraine striking me down again.