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Keywords:

  • migraine;
  • posttraumatic stress disorder;
  • abuse;
  • physical abuse;
  • sexual abuse;
  • chronic daily headache

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

Objective.— To evaluate the relative frequency of posttraumatic stress disorder (PTSD) in episodic migraine (EM) and chronic daily headache (CDH) sufferers and the impact on headache-related disability.

Background.— Approximately 8% of the population is estimated to have PTSD. Recent studies suggest a higher frequency of PTSD in headache disorders. The association of PTSD and headache-related disability has not been examined.

Methods.— A prospective study was conducted at 6 headache centers. PTSD was assessed using the life events checklist and PTSD checklist, civilian version (PCL-C). We compared data from EM to CDH, and migraine with PTSD to migraine without PTSD. The PHQ-9 was used to assess depression, and headache impact test (HIT-6) to assess disability.

Results.— Of 767 participants, 593 fulfilled criteria for EM or CDH and were used in this analysis. The mean age was 42.2 years and 92% were women. The frequency of PTSD was greater in CDH than in EM (30.3% vs 22.4%, P = .043), but not after adjusting for demographics and depression (P = .87). However, participants with major depression and PTSD were more likely to have CDH than EM (24.6% vs 15.79%, P < .002). Disability was greater in migraineurs with PTSD, even after adjustments (65.2 vs 61.7, P = .002).

Conclusion.— The frequency of PTSD in migraineurs, whether episodic or chronic, is higher than the historically reported prevalence of PTSD in the general population. In addition, in the subset of migraineurs with depression, PTSD frequency is greater in CDH sufferers than in episodic migraineurs. Finally, the presence of PTSD is independently associated with greater headache-related disability in migraineurs.

Migraine and abuse occur more often in women than in men, and abuse has been identified as possible risk factor for migraine chronification.1,2 While the National Violence Against Women Survey has reported that 1 in 6 women (or 16.67% of women) in the United States has experienced an attempted or completed rape, 30-31% of chronic daily headache (CDH) sufferers have reported a history of sexual abuse.1-3 Similarly, while the World Report on Violence and Health notes that 22% of women in the United States report ever being physically assaulted, physical abuse has been reported in 26-29% of CDH sufferers.1,2,4 Both physical abuse and sexual abuse are major traumatic life events (TLEs). In addition, there are many other traumatic events that women and men may be exposed to in their lifetime including motor-vehicle accidents, life-threatening illnesses, natural disasters, unexpected death, and combat.

Approximately 90% of individuals in the general population are exposed to TLEs of some type.5 However, a subpopulation of those exposed to extreme TLE develop posttraumatic stress disorder (PTSD), an often debilitating disorder.6,7 The lifetime prevalence of PTSD is approximately 8%, and it is twice as common in women as men.8,9-12 Individuals who develop it characteristically exhibit emotional and physical symptoms of reexperiencing the event, marked avoidance of stimuli that are associated with the event, and/or symptoms of hyperarousal, such as fragmented sleep and irritability.13 Furthermore, PTSD has been shown to worsen chronicity and disability of chronic pain patients, while treatment of PTSD has been shown to lessen both pain and disability.6-15

Two previous studies have evaluated PTSD in headache patients.16,17 The first study suggested that headache sufferers may have an increased risk of PTSD as compared with the general population. However, the applicability to migraine patients was limited by the inclusion of both tension-type headache sufferers and migraineurs, together as one group, which was compared with masticatory muscle pain subjects.16 In addition, headache frequency was not evaluated and thus a comparison between episodic and chronic headache sufferers could not be done.16 The second study suggested that PTSD may be a risk factor for the chronification of migraine.17 However, the study was limited by the small sample size and by use of self-report to assess depression, a condition comorbid with migraine.17

Given that PTSD and migraine occur in 2-3 times as many women as men, along with the data suggesting that abuse and PTSD may be risk factors for migraine chronification, our current study was designed to: (1) evaluate the relative frequency of PTSD in a large population of episodic and CDH sufferers; and (2) to evaluate the impact of PTSD in headache sufferers in regards to headache-related disability.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

This was a multicenter cross-sectional survey study of headache clinic patients from 6 centers belonging to the research consortium of the American Headache Society Women's Issues Section. The study was conducted after approval was obtained from the Institutional Review Boards of each center. Recruitment was between September 2006 and December 2007. All participants of this study were examined by a physician in a specialty headache clinic. Participation was offered to consecutive patients using the following inclusion criteria: 18-65 years of age with headache, and willingness to complete a self-administered written survey; exclusion criteria included not being physically well enough to complete the survey or not being literate in English.

Subjects completed a semi-standardized questionnaire constructed for this study. The questionnaire ascertained demographic information (including age, gender, race, marital status, education, self-reported height and weight, headache characteristics, and headache-related disability utilizing the headache impact test [HIT-6]).18

Headache diagnoses were classified according to the Second Edition of the International Classification of Headache Disorders (ICHD-2).19 Only those with CDH, fulfilling ICHD-2 criteria for probable medication overuse headaches (MOH) or chronic migraine (CM), and episodic migraine (EM), fulfilling ICHD-2 criteria of migraine with or without aura, were included in the study.19

Depression was assessed with the Patient Healthcare Questionnaire (PHQ-9). Subjects completed the life events checklist (LEC) and the PTSD checklist, civilian version (PCL-C), as previously described.17,20

MEASURES DERIVED FROM THE QUESTIONNAIRE

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

Body Mass Index (BMI).— BMI was calculated for all participants using the following formula: wt(pounds)/ht(inches)2 × 703. Six categories were defined as follows: underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9), obesity grade I (30-34.9), obesity grade II (35-39.9), and obesity grade III (≥40).

Headache Impact Test (HIT-6).— The HIT-6 is a validated, brief questionnaire that demonstrates good reliability and validity across various levels of headache impact. The scale consists of 6 items that cover various areas reflected in health-related quality of life: pain, social functioning, role functioning, vitality, cognitive functioning, and psychological distress. Each of the 6 questions is responded to using 1 of 5 response categories: “never,”“rarely,”“sometimes,”“very often,” or “always.” For each item, 6, 8, 10, 11, or 13 points, respectively, are assigned to the response provided. These points are summed to produce a total score that ranges from 36 to 78. Higher scores indicate a greater impact of headaches on the daily life. Scores will be interpreted using 4 groupings, with scores of 49 points or less reflecting “little or no impact,” scores of 50-55 points reflecting “some impact,” scores of 56-59 reflecting “substantial impact,” and scores of 60 or more points reflecting “severe impact.”18,21

Patient Healthcare Questionnaire (PHQ-9).— All participants were evaluated for major depression using the PHQ-9. The PHQ-9 is a self-reported diagnostic measure for current depression that utilizes the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. It was derived from the PHQ of the PRIME-MD (Pfizer Inc., New York, NY, USA) and shown to have superior validity criterion for the diagnosis of major depressive disorder as compared with other established depression scores.22 A score of ≥15 on the PHQ-9 is associated with a 68% sensitivity and 95% specificity in diagnosing “major depressive disorder” using the DSM-IV criteria.22 Thus, major depression was defined as a score ≥15 on the PHQ-9 in participants.

Life Event Checklist (LEC).— The LEC is a checklist used to screen for events that would meet PTSD criteria for DSM-IV criterion A.13 It includes 17 questions regarding potentially difficult or stressful life events. Participants were asked to report if the event or events happened to them personally, they witnessed it, learned about it, were not sure or it did not apply. The events included natural disasters, fire or explosion, serious accidents at work, home, or during recreational activity, physical assault, assault with a weapon, sexual assault, combat, captivity, life-threatening illness or injury, severe human suffering, sudden violent death, unexpected death of someone close to participant, serious injury, and harm or death the participant caused to someone else.

Physical and Sexual Abuse.— Physical abuse was defined as those who answered affirmatively to either of the following two questions on the LEC: 1) Physical assault (for example, being attacked, hit, slapped, kicked, beaten up or 2) Assault with a weapon (for example, being shot, stabbed, threatened with a knife or gun. Sexual abuse was defined as those who answered affirmatively to either of the following two questions on the LEC: 1) Sexual assault (including rape, attempted rape, made to perform any type of sexual act through force or threat of harm or 2) Other unwanted or uncomfortable sexual experience.

Posttraumatic Stress Disorder Checklist—Civilian Version (PCL-C).— The PCL-C is a 17 question, self-report measure used to assess PTSD criterion B-D from the DSM-IV criteria.13 These questions are subdivided into 3 sections to evaluate specific symptoms related to reexperiencing the event, avoidance of related stimuli, and hyperarousal. For each question, the participant is asked to indicate how much they have been bothered by each symptom on a 5-point Likert scale from 1 (not at all) to 5 (extremely) in regards to their most significant life event stressor. The PCL-C has exhibited test–retest stability, an overall internal consistency (α = 0.94) and provides a valid and reliable assessment of the presence of PTSD, with a sensitivity of 0.944 and specificity of 0.864 as compared with the Clinician-Administered PTSD Scale. A total score of ≥44 is considered clinically significant for PTSD.20

Analysis.— Based on the PTSD results, 3 groups were defined. Group 1 (PTSD1) consisted of those who had at least one TLE on the LEC that happened directly to them personally, in the “happened to me” category along with a score of ≥44 on the PCL-C. (Thus, to fulfill PTSD group 1, those who witnessed or learned about a traumatic event were excluded as candidates who may have PTSD.) Group 2 (PTSD2) had at least one TLE on the LEC in either the “happened to me” or “witnessed it” categories, and with a score of ≥44 on the PCL-C. (Thus, those participants that only reported learning about a traumatic event were excluded from group 2.) Group 3 (PTSD3) had one or more TLE on the LEC from any category including, the “happened to me,”“witnessed it,” or “learned about it” categories, along with a score of ≥44 on the PCL-C. Finally, for the PTSD1 group, analysis of the subsections of the PCL-C for symptoms related to reexperiencing the event, avoidance of related stimuli, and hyperarousal was done. Average scores for the subsections were calculated. Each survey respondent was categorized into a cluster based on their largest average score of the 3 subdivisions. If a tie average score occurred, they were put into a new subdivision indicating which clusters were tied. A few respondents had a tie average score for all 3 subdivisions and were subsequently put in a group called “draw.”

All statistical analyses were performed using Data Desk Version 6 by Data Description. Z-approximation test from one-sample proportion was used to compare the relative frequency of PTSD in headache groups to the prevalence reported in previous general population studies.9-12 Differences in continuous variables were tested using ANOVA. Fisher's exact or chi-square approximation tests were used for categorical variable comparisons where appropriate. Subdivision cluster distributions were compared between EM and CDH sufferers using chi-square. Logistic regression was used for models adjusting for demographics and control variables including age, sex, marital status, mean income, BMI, and depression.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

Demographics.— Of the 767 participants who completed the survey, 174 surveys were not able to be utilized due to missing information or not fulfilling inclusion criteria. The number of surveys contributed and the number of surveys able to be utilized from each institution are as follows: Drexel University College of Medicine, PA (105/145 surveys), University of Medicine and Dentistry of New Jersey, NJ (71/84 surveys), Evanston Northwestern Healthcare, IL (74/98 surveys), Nashville Neuroscience Group, TN (272/343 surveys), University of Toledo-Health Science Campus, OH (54/71 surveys), Maimonides Medical Center, NY (25/25 surveys).

The majority of participants were Caucasian women. There were no significant differences between the CDH and EM participants in respect to age, sex, race, marital status, or BMI (Table 1). However, the mean income was significantly lower in CDH than EM participants (P = .01).

Table 1.—. Demographics and Clinical Characteristics
 Episodic migraineCDHTotal groupP value
  • *

    After adjusting for all demographics and depression,

  • **

    **after adjusting for all demographics and site,

  • ***

    ***after adjusting for demographics, depression, and site,

  • †Fisher's exact or chi-square.

N (%)398 (67.1)195 (32.9)593 (93.7) 
Mean age42.8 ± 12.441.1 ± 12.242.2 ± 12.3.12
Female (%)90.692.892.0.41
Caucasian (%)81.396.487.2.11
Marital status   .49
 Single (%)28.631.429.6 
 Married (%)61.655.759.6 
 Divorced/widowed (%)9.812.910.8 
Income level   .011
 <$20,000 (%)9.817.712.5 
 $20,000-$50,000 (%)24.42925.9 
 $50,000-$100,000 (%)39.629.636.3 
 >$100,000 (%)26.223.725.3 
Mean HIT-6 score62.5 ± 7.065.6 ± 5.663.5 ± 6.8<.0002***
Mean PHQ-9 (% PHQ-9 ≥ 15)5.3 ± 5.6 (7.7)7.7 ± 6.2 (16.6)6.0 ± 5.9 (10.3).001**
Mean BMI26.9 ± 6.928.1 ± 7.027.3 ± 6.9.06***
Site   .77*
 DX (%)16.619.017.4 
 IL (%)13.110.812.3 
 NJ (%)9.317.412.0 
 NY (%)4.32.13.5 
 OH (%)8.310.38.9 
 TN (%)48.540.545.9 

Depression.— Criteria for major depression based on the PHQ-9 were fulfilled in 10.3% of the total participants. In addition, depression was significantly greater in subjects with CDH (16.6%) than EM subjects (7.69%, P = .003) (Table 1).

LEC.— The most commonly reported TLEs in any of the 3 categories (“happened to me,”“witnessed,” or “learned about”), by any participant, with or without PTSD, were: sudden violent death (29.6%), natural disaster (26.1%), transportation accident (22.8%), fire or explosion (22.8%), and combat (22.6%). Of those in the entire group who reported an event as “happened to me,” whether fulfilling PTSD or not, the most commonly reported TLEs were: transportation accidents (53.3%), sudden unexpected death (35.0%), physical assault (24%), and sexual assault (24.1%).

Of the total participants who fulfilled PTSD criteria, the most commonly reported TLEs reported in any of the categories (“happened to me,”“witnessed,” or “learned about”) were: natural disaster (33.8%), sudden violent death (33.8%), combat (26.8%), and transportation accident (25.5%). Of the total participants who fulfilled PTSD criteria and reported an event as “happened to me,” the most commonly reported were transportation accident (59.2%), sudden unexpected death (45.2%), physical assault (41.4%), and sexual assault (27.4%).

Physical and Sexual Abuse.— Physical abuse was reported by 27.7% of all participants (30.8% of those with CDH; 26.1% of those with EM); sexual abuse was reported by 28.8% of all participants, (27.7% of CDH sufferers, 29.4% of those with EM,). When evaluated together, physical or sexual abuse was reported by 42.2% of all participants, (43.1% of CDH sufferers, 41.7% of those with EM).

In addition of those participants with PTSD, 47.3% reported physical abuse (52.5% of CDH sufferers; 43.8% of those with EM); and 45.3% reported sexual abuse (47.5% of CDH sufferers, 43.8% of those with EM). When physical or sexual abuse were evaluated together, a total of 64.9% of those with PTSD reported physical or sexual abuse (72.9% of CDH sufferers, 59.6% of those with EM).

There was no significant difference in the percentage of episodic migraineurs reporting at least one significant TLE as “happened to me,”“witnessed it,” or “learned about it” individually or when the groups were combined. Overall, 81.5% of the participants reported at least one significant TLE that happened to them. And of EM, 81.9% reported at least one significant TLE that happened to them, as did 80.5% of CM participants (NS) (Table 2). There was also no significant difference in the mean number of reported life event that EM as compared with CDH participants reported as “happened to me,”“witnessed it,” or “learned about it” individually or when the groups were combined (Table 2).

Table 2.—. Frequency and Mean Traumatic Life Events on the Life Event Checklist
Life event (LE) reportedEM (n = 398)CDH (n = 195)
≥1 LEMean TLE≥1 LEMean TLE
  1. There were no significant differences between EM and CDH in frequency or mean number of TLE in any of the 5 categories.

“Happened To Me”81.9%2.60 ± 2.2380.5%2.75 ± 2.34
“Witnessed It”64.1%1.52 ± 1.8062.6%1.69 ± 2.13
“Learned About It”70.1%3.03 ± 3.4668.2%2.77 ± 3.25
“Happened To Me” or “Witnessed It”91.5%4.12 ± 3.2790.8%4.44 ± 3.67
“Happened To Me,”“Witnessed It,” or “Learned About It”95.2%7.14 ± 5.1993.8%7.21 ± 5.50

Finally, sequential examination of the potential association with increasing number of traumatic events reported between EM and CDH participants was evaluated. When unadjusted for demographics and depression the CDH/EM index was increasingly significant with increases in the number of TLEs, up to 4 life events. However, after adjustment for depression significance could not be shown (Table 3).

Table 3.—. The CM/EM Index of Increasing Numbers of Traumatic Life Events Reported as “Happened To Me” in Participants Fulfilling PTSD Criteria on the PCL
 Total group (n = 593)CDH (n = 195)EM (n = 398)CDH/EM indexP valueP value*P value**
  • *

    Corrected for sex, age, race, marital status, BMI, and income,

  • **

    **corrected for sex, age, race, marital status, BMI, income, and depression,

  • †uncorrected for depression or other confounders.

PTSD and ≥1 traumatic LE as “Happened To Me”25.0%30.3%22.4%1.35.0433.092.78
PTSD and ≥2 traumatic LE as “Happened To Me”21.8%27.7%18.8%1.47.020.018.27
PTSD and ≥3 traumatic LE as “Happened To Me”17.7%22.6%15.3%1.48.039.058.33
PTSD and ≥4 traumatic LE as “Happened To Me”13.0%17.4%10.8%1.61.027.054.27
PTSD and ≥6 traumatic LE as “Happened To Me”5.9%7.7%5.0%1.54.20.20.77

PTSD.— The relative frequency of PTSD found in the total group of all headache participants (25%) (as well as in the EM and CDH groups individually), was significantly greater than that reported in previous general population studies (8%, P < .001).9-12 In the most stringently defined PTSD group, PTSD1, the relative frequency of PTSD was significantly greater in CDH participants than in EM, with 22.4% of EM and 30.3% of the CDH participants fulfilling PTSD criteria (P = .04); however, after adjusting for age, sex, marital status, income, BMI, and depression, this did not remain significant (P = .78, Table 4). While a total of 23.4% of EM participants and 30.3% of CDH sufferers fulfilled PTSD2, and 23.6% of EM and 30.8% of CDH sufferers fulfilled PTSD3, there was no significance between EM and CDH participants in either group.

Table 4.—. The Effect of PTSD on Depression (PHQ-9) and Headache Related Disability (HIT-6) in Migraineurs
 NOverall(−) PTSD(+) PTSDP value*P value**
PHQ-9PHQ-9PHQ-9
Major depression      
 All participants (CDH + migraine)5066.0 ± 5.94.6 ± 4.910.4 ± 6.3<.0001<.0001
 CDH1517.7 ± 6.25.7 ± 5.112.7 ± 6.0<.0001.0019
 Migraine3515.3 ± 5.64.1 ± 4.89.2 ± 6.2§<.0001<.0001
 NOverall(−) PTSD(+) PTSDP value*P value***
HIT-6HIT-6HIT-6
  • *

    ANOVA test,

  • **

    **corrected for demographics and site,

  • ***

    ***corrected for demographics, depression, and site,

  • the difference between CDH and migraine is P = .0012 after adjusting for all demographics and site,

  • the difference between CDH and migraine is P = .053 after adjusting for all demographics and site,

  • §

    the difference between CDH and migraine is P = .0095 after adjusting for all demographics and site.

Headache-related disability      
 All participants (CDH + migraine)58763.5 ± 6.862.6 ± 6.865.8 ± 5.9<.0001.0025
 CDH19365.6 ± 5.664.9 ± 5.966.9 ± 5.3.0944.91
 Migraine39062.5 ± 7.061.7 ± 6.865.2 ± 6.1.0005.0018

A total of 24.6% of participants with PTSD1 fulfilled criteria for major depression on the PHQ-9. The mean PHQ-9 scores of CDH sufferers fulfilling PTSD1 (12.7 ± 6.0) were significantly greater as compared with CDH sufferers without PTSD1 (5.7 ± 5.1) (P < .0001). Similarly, of EM fulfilling PTSD1, mean PHQ-9 scores were significantly greater in those with PTSD (9.2 ± 6.2) as compared with EM sufferers without PTSD (4.1 ± 4.8) (P < .0001). Finally, of all PTSD1 participants, the mean PHQ-9 score was significantly greater in CDH sufferers (12.7 ± 6.0) as compared with EM sufferers (9.2 ± 6.2) (P = .0095, Table 5).

Table 5.—. Evaluation of the Effect of PTSD Presence (+) or Absence (−) in EM and CDH Participants With Major Depression (PHQ-9 ≥ 15)
 NEMCDHP value*
  • *

    Fisher's exact test.

Overall PHQ-9 ≥ 153517.7%16.6%.0039
PHQ-9 ≥ 15 and (+) PTSD8315.7%24.6%.002
PHQ-9 ≥ 15 and (−) PTSD2685.2%6.5%.62

Analysis of the symptom subsections of the PCL for group 1 showed that there were no significant differences between CDH sufferers and episodic migraineurs in regards to those who reported symptoms related to reexperiencing the event or for avoidance symptoms. Although the mean score for hyperarousal symptoms was greater in CDH sufferers (2.26 ± SD 1.17) than in episodic migraineurs (1.94 ± SD 1.01, P = .009), prior to controlling for demographics and depression, a strong correlation between hyperarousal symptoms and depression was found (P < 1.001); and after controlling for depression, no significant correlation was found (P = .33, Table 6). Similarly, comparison of PCL-C symptom subdivisions by cluster analysis was not significant after controlling for demographics and depression (Table 7).

Table 6.—. Summary Results of PCL-C Subdivisions Average Scores
PCL-C subdivisionEpisodic migraineCDHTotal groupP value
  • *

    ANOVA test between episodic migraine (EM) and chronic daily headache (CDH) participants,

  • **

    **corrected for demographics and site,

  • ***

    ***corrected for demographics, site, and depression.

Reexperience2.2 ± 1.02.3 ± 1.12.2 ± 1.1.22*
Avoidance1.9 ± 0.92.0 ± 1.01.9 ± 0.9.085*
Hyperarousal1.9 ± 1.02.3 ± 1.22.0 ± 1.1.0009* .0065** .33***
Table 7.—. Cluster Analysis of PCL-C Symptom Subdivisions
PCL-C symptom subdivisionEM (%)CDH (%)Total (%)
  1. Comparison of PCL subdivision cluster distributions between EM and CDH participants was significant prior to adjustments (P = .024), but not after being adjusted for demographics and site (P = .23) or depression (P = .53).

Avoidance7.5110.68.5
Draw (3-way tie between symptom clusters of reexperience, avoidance, and hyperarousal)7.777.227.6
Hyperarousal and reexperience tie3.758.335.2
Hyperarousal21.226.723.0
Reexperience59.847.255.7
Total100100100

Of participants who fulfilled criteria for major depression on the PHQ-9 (PHQ-9 ≥15), but not PTSD1, there was NS difference in the relative frequency of CDH (6.5%) and EM (5.22%) (Table 4). However, of those participants who fulfilled criteria for major depression on the PHQ-9 and PTSD1, a significantly greater relative frequency were CDH sufferers (24.6%) as compared with EM sufferers (15.7%) (P = .002).

Disability.— The headache-related disability, as determined utilizing the HIT-6, was significantly greater in all headache participants with PTSD (65.8 ± 5.9) as compared with those without PTSD (62.6 ± 6.8) (P < .0001) and remained so even after adjusting for demographics, BMI, and depression (P = .0025, Table 5). Similarly, the headache-related disability in EM participants with PTSD (65.2 ± 6.1) was significantly greater as compared with those EM without PTSD (61.7 ± 6.8) even after adjusting for demographics and depression (P = .0018). However, no significant difference was able to be shown in headache-related disability in CDH sufferers with PTSD alone as compared with those CDH sufferers without PTSD, most likely secondary to the smaller sample size, in conjunction with the already higher baseline disability score of the CDH sufferers.

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

Approximately 25-30% of victims of traumatic events develop symptoms of PTSD.5,8 In our current study almost 82% of participants reported a TLE as having happened directly to them, while 95% reported having a TLE happen to them, learned about or witnessed. This is consistent with the prevalence we reported in our pilot study of 78% and 93%, respectively, and is comparable to the results from the 1996 Detroit Area survey, which found approximately a 90% lifetime prevalence of exposure to at least one traumatic event.9,17

Identification of PTSD in patients, especially migraineurs, may be particularly important for several reasons. First, treatment of PTSD alone has been shown to positively influence both pain and disability in chronic pain patients.6-15 Second, patients with PTSD have been shown to utilize health care resources more often than patients without PTSD.10 Thus, identification and treatment of PTSD in migraineurs has potential implications for both the individual sufferer and society.

In our current study we found a relative frequency of PTSD of 30.3% in CDH sufferers and 22.4% in EM sufferers, a relative frequency, which is notably higher than the 7.8% and 8.3% lifetime prevalence reported in general population studies.5,11 In addition we also found an association between PTSD and depression in migraineurs. Previous studies have shown that both migraine and PTSD are comorbid with depression.23 Specifically, women with PTSD are 4.1 times as likely to develop depression as those without PTSD, while men with PTSD are 6.9 times as likely to develop depression as those men without PTSD.8 In our study of those patients with major depression and PTSD, a higher frequency had CDH than EM, whereas no difference in headache chronicity was seen in those with major depression in the absence of PTSD. This suggests that PTSD is the factor responsible for the increased risk of CDH. It also suggests that in those migraineurs who are screened with the PHQ-9, and screen positively, that strong consideration should be given for further evaluation of PTSD.

Several studies have shown that PTSD has a negative impact on the disability of chronic pain patients.6-15 Similarly, our current data suggest that migraine sufferers with PTSD have a significantly greater disability than those without PTSD and in those migraineurs with depression and PTSD, there is greater risk of chronification. Thus, our current findings, taken together with previous study findings showing that treatment of PTSD alone positively influences both pain and disability,15 suggest that identification and treatment of PTSD in migraineurs is important and is a potentially modifiable part of their care.

The main limitation of our current study is the lack of a headache-free control group, which would allow for a direct comparison between migraineurs and the general population. In addition, although not surprising, the majority of our sample was women. Thus, further research evaluating the PTSD-migraine association with controls as well as with specific attention to men is warranted.

The association between migraine and PTSD is complex and probably multifactorial. A potential explanation for the association is the concept of limbically augmented pain syndrome (LAPS). Rome and Rome introduced LAPS as the clinical manifestation of corticolimbic sensitization.24 The normal psychobiological arousal that acute pain produces in the limbic system becomes a pathogenic stress when it persists over time. Because of the loss in the ability to turn off the mind-body's arousal hormones, optimal homeostatsis and adaptation cannot be maintained. As a result, the sensory and affective pain pathways become sensitized, resulting in an augmented response because of previous experiences or memories of a painful stimulus.24,25 It is possible that PTSD could act as one such stimulus resulting in neuroplastic changes in the corticolimbic system and LAPS.

Both PTSD and migraine have also been linked to dysfunction of the autonomic system, hypothalamic-pituitary-adrenal axis, and serotonin modulation. Specifically in PTSD patients, elevated urinary norepinephrine (NE) and epinephrine levels have been shown as compared with patients with other psychiatric disorder.26 However, plasma levels of NE have been shown to be lower in subjects with PTSD.27 Similarly, migraine patients have been shown to have lower levels of plasma and platelet NE.28-31 Further evidence of noradrenergic hypofunction in CM has been shown by Martignoni et al with an inverse correlation between clonidine-induced b-endorphine secretion and pretest pain.32

Cortisol modulation may also play a role in the shared pathophysiology of PTSD and migraine. Raine et al recently reported that although basal levels of cortisol were not significantly different in a subgroup of chronic migraineurs with MOH as compared with controls, following administration of cortisol secreting hormone, CM sufferers showed significantly higher levels of ACTH and cortisol than controls.33 In addition, serotonin is well described as having a significant role in modulating the noradrenergic system; and chronic low levels of serotonin have been implicated in both PTSD and migraine.34-37 Other, as yet unknown, factors may further contribute as well.

CONCLUSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

The frequency of PTSD in both CDH and EM is higher than the historically reported prevalence of PTSD in general population studies. In addition, in the subset of migraineurs with major depression, PTSD is more frequent in those with CDH as compared with those with EM. This suggests that: (1) PTSD occurs more commonly in those with migraine (whether episodic or chronic) than in those without migraine; (2) PTSD is a risk factor for migraine chronification in those migraineurs with depression; (3) the presence of PTSD in migraine sufferers is associated with a significantly greater level of disability as compared with those migraine sufferers without PTSD. Taken together, our findings suggest that identification and treatment of PTSD in migraine sufferers is an important and potentially modifiable part of their care that may reduce migraine-related disability and progression to CDH.

Acknowledgments

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES

Acknowledgments: This study was funded in part by a grant from the Women's Issues Special Interest Section of the American Headache Society. Statistical analysis of data was performed by Jeffrey Lidicker from Berkley, California.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. MEASURES DERIVED FROM THE QUESTIONNAIRE
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgments
  9. REFERENCES
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