Letters to the Editor

Childhood Sexual Abuse and Chronic Daily Headaches

TO THE EDITOR: I would like to comment on the article¹ by Dr. Maizels in the December 15, 2004, issue of American Family Physician titled “The Patient with Daily Headaches.” I appreciated the thoroughness of discussion, but was dismayed that there was virtually no mention of one of the most common features of patients with chronic daily headaches: a history of childhood sexual abuse. A colleague of mine who was doing a fellowship in chronic pain first brought this association to my attention in the mid-1980s. He indicated that nearly 100 percent of the patients they were seeing in the chronic pain center for daily headache had such a history. Since that revelation, I have heard more than 1,000 stories of abuse from my patients. The patterns have become very clear. There is an extremely high correlation between adverse childhood experiences (most commonly, sexual abuse) and many of the chronic pain syndromes. There are several articles^2,3 in the medical literature supporting this observation, and many more in the social sciences literature. Dr. Vince Felitti, a clinical researcher with Kaiser Permanente in San Diego, writes: “One hundred thirty-one patients who gave a history of childhood sexual abuse were seen in a general medical practice decades after the event and were compared with a control group. The subject patients were found to be distinct for chronic depression; morbid obesity; marital instability; high utilization of medical care; and certain psychosomatic symptoms, particularly chronic gastrointestinal distress and recurrent headaches. It is clear that these remote events can underlie difficult chronic medical problems. Questions about childhood sexual abuse must become part of the practitioner's review of systems in these difficult cases, if not routinely.”²

The book Treating the Lifetime Health Effects of Childhood Victimization³ details much of the literature regarding these phenomena. The literature has become robust in supporting the linkages of childhood victimization and multiple long-term health consequences. It seems, therefore, that the time has come to talk more freely in health care about a seemingly taboo subject. Our patients deserve an understanding physician who is willing to explore difficult areas of their pasts. It is our responsibility to search for the true causes of our patients’ maladies. If a history of abuse is a contributing factor, then we are ethically bound, as professionals, to inquire about such issues. Leaving that discussion out of this article on chronic daily headaches perpetuates the unwillingness to explore violence and abuse as factors contributing to many of the illnesses that we see every day.

david g. mccollum, m.d.

Chair, AMA National Advisory Council on Violence and Abuse

2048 Timberwood Drive

Chanhassen, MN 55317

REFERENCES

in reply: Domestic violence, including childhood physical and sexual abuse, is tragically prevalent, if not endemic, in our society. Persons who suffer neglect or serious family dysfunction as children are more likely to be depressed, to experience psychiatric illness, to have physical symptoms, and to engage in more health-risk behaviors than their nonabused counterparts.¹ However, the relationship of these childhood events to the development of headaches has not been established.

A review² of five general population studies found a weighted mean odds ratio (OR: 1.7) linking sexual assault and headache, controlling for age and education. Persons who were sexually assaulted in childhood consistently had greater odds of headache than those first assaulted in adulthood. However, in a gynecologic study,³ women with headache had no higher prevalence of sexual abuse than did women who were pain-free (and less than women with pelvic pain).

The most carefully documented study of factors associated with migraine transformation found OR’s of 1.7 for female gender, 1.3 for obesity, 3.3 for those without a high school education, and 1.45 for those who were previously married.⁴ Psychiatric diagnoses and a history of abuse were not evaluated in this study. If there is a relationship between childhood sexual abuse and headache, it may well be mediated by any of these factors.

Should we screen patients with headaches for a history of childhood abuse? One study⁵ reviewed the criteria for screening programs in medical practice: (1) the condition is a public health problem; (2) a population at risk for the disease must be defined; (3) the disease must have a recognizable latent phase or early symptomatic stage; (4) effective treatment for the disease must be available and cost effective; (5) an effective screening test must be available; (6) the test must be acceptable to patients and health care professionals; (7) resources must be available for developing, validating, and distributing the test; and (8) the screening and treatment program must be cost effective. Based on these criteria, there are significant challenges to the recommendation to screen for childhood sexual abuse.

Undiagnosed patients who present to physicians with migraine are correctly diagnosed only one half of the time. One of the common misdiagnoses is “stress” or “depression.” Patients with migraine often are stigmatized by society and physicians, and have been made to feel that migraine is a psychologic disorder. To some extent, they have been made to feel “at blame” for their disorder. An emphasis on remote childhood events may further stigmatize the patient with headache. Unless there are clearly resources available to the patient for coping with such histories, suggesting a connection between the trauma and headache may cause more harm than good. Evaluating risks for current domestic violence, however, may be useful.

Migraine is a biopsychosocial disorder. A wealth of literature⁶ documents the preventive benefit of behavioral interventions, including relaxation therapies, biofeedback, and cognitive behavior therapy. Patients with significant psychiatric comorbidity and lifestyle stressors often will benefit from referral to a psychologist skilled in applying behavioral principles to headache.

Morris Maizels, M.D.

Department of Family Practice

Woodland Hills Headache Clinic

Kaiser Permanente

Woodland Hills, CA 91365

REFERENCES

Reconsideration of the Smallpox Vaccination Administration Site

to the editor: Following the terrorist attacks of September 11, 2001, concerns of smallpox being used as a biologic weapon increased, prompting the federal government to immunize 500,000 public health care workers and all deployable U.S. military forces. The smallpox vaccine available in the United States is a live-virus preparation of vaccinia virus, which contains the antibiotics polymyxin B, streptomycin, tetracycline, and neomycin, with glycerin and phenol as a preservative. Using a bifurcated needle, the dermis in the region of the deltoid of the non-dominant arm is injected multiple times with the vaccine, with the intention of limiting the territory to a 5-mm circle. Although many of the adverse sequelae following vaccine administration have been well documented, the poor aesthetic outcomes and painful scarring following vaccination in the shoulder region have been neglected (Figures 1a and 1b).¹ For the reconstructive surgeon, treatment of a post-vaccination hypertrophic scar or keloid in the deltoid region often gives disappointing results, despite different treatment modalities including: irradiation, corticosteroid injection, excision, dermabrasion, laser therapy, silicone gel sheeting, or a combination of these methods.² The shoulder region, the chest, and the earlobes have long been known to be areas associated with an increased incidence of hypertrophic scarring and keloid formation, especially in patients with darker complexions. An initial recommendation was made to avoid the problem of upper shoulder scarring by lowering the location of vaccine administration to well below the tip of the shoulder³; however, because routine vaccination was no longer deemed necessary at that time, dealing with problems related to optimal methods of vaccine administration was no longer important.⁴

Figure 1a. Young girl with keloid scar after smallpox vaccination as a young child and subsequent re-vaccination in the same region.

Figure 1b. Young girl with hypertrophic scar after smallpox vaccination in deltoid region.

The inner aspect of the forearm, outer aspect of the thigh, and abdominal wall have been used as sites for vaccination in the past, yielding an improvement in scar aesthetics as well as the ability to conceal a scar when present. The deltoid region, however, continues to be favored as the site for smallpox vaccination, as was seen during the most recent smallpox alarm.

A plea is made for shifting the location of smallpox vaccine administration away from the shoulder region, because many persons today are troubled by this minor, yet occasionally discomforting and distressing disfigurement that could so easily be circumvented. This contention is particularly valuable in individuals with a history of hypertrophic scarring or keloid formation or in individuals prone to increased scarring because of a genetic predisposition.

christopher j. salgado, m.d.

Division of Plastic Surgery, Department of Surgery

Cooper University Hospital

The University of Medicine and Dentistry of New Jersey

Robert Wood Johnson Medical School

Three Cooper Plaza, Suite 411

Camden, N.J. 08103

samir mardini, m.d.

hung-chi chen, m.d.

Department of Plastic Surgery

E-Da Hospital/I-Shou University

1, E-Da Rd., Jiau-shu Tsuen, Yan-chau Shiang,

Kaohsiung County, Taiwan, 824, R.O.C.

REFERENCES

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.

Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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