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Am Fam Physician. 2005;72(3):online-only-

to the editor: 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 articles2,3 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.

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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