A Retrospective, Comparative Study on the Frequency of Abuse in Migraine and Chronic Daily Headache

B. Lee Peterlin, DO; Thomas Ward, MD; Jeffrey Lidicker, MSc; Morris Levin, MD

Headache. 2007;47(3):397-401. 

Abstract and Introduction

Objective: To assess and contrast the relative frequency of a past history of physical and/or sexual abuse in patients with chronic daily headache (CDH) versus migraine.
Background: A number of risk factors have been identified as risk factors for chronification of headache disorders. Limited data exist regarding the influence of physical and/or sexual abuse on primary headache disorders.
Methods: This was a retrospective chart review of 183 consecutive new headache patients seen from December 2004 through August 2005 at an outpatient tertiary-care center. Patients were included in the study if they had chronic daily headache (with criteria for medication over-use headache or chronic migraine), or migraine with or without aura. A history of physical and/or sexual abuse was systematically asked of all headache patients at their first visit in the clinic. This information was then transferred to a semi-standardized form and the relative frequency of abuse in both groups contrasted.
Results: Of the 161 patients included in the study, 90.1% were female with a mean age of 36.4 ± 12.0. A total of 59.0% of the patients were diagnosed with CDH and 41.0% were diagnosed with migraine. Overall, 34.8% of all patients, 40.0% of CDH patients, and 27.3% of migraine patients had a history of physical and/or sexual abuse. The relative frequency of a history of physical and/or sexual abuse was higher in the CDH group as compared to the migraine group (P = .048).
Conclusion: The relative frequency of abuse is higher in CDH sufferers than migraineurs, suggesting that physical and sexual abuse may be risk factors for chronification.

A variety of risk factors have been identified for chronification of headaches. These factors include female gender, Caucasian race, lower educational level, obesity, caffeine ingestion, hypothyroidism, and a history of having been previously married.[1,2]

Although population studies suggest that physical and sexual abuse are not uncommon in the population, limited data exist in regards to the influence of abuse in the primary headache disorders. Most of the available data are limited by lack of uniformity in the headache diagnosis and/or a small sample size. One notable exception is a preliminary study by Tietjen et al, which suggests a higher prevalence of abuse in patients reporting headache.[3-7]

Our study was designed to evaluate the relative frequency of physical and/or sexual abuse, self-reported by patients during a routine history and physical intake, with a primary diagnosis of CDH or migraine. We hypothesized that CDH patients would report a past history of abuse more frequently than migraine patients.

Materials and Methods

This is a retrospective study, conducted from December 2004 to August 2005 at an out-patient headache clinic. The charts of 183 new headache patients from our facility were retrospectively reviewed.

During the entire duration of the study, all patients seen in the clinic were interviewed, examined, and diagnosed by one of us (BLP) and reviewed with one of the co-authors (TNW or ML). Information was then abstracted from the charts into semi-standardized forms developed for this study.

Subjects were classified according to the Second Edition of the International Classification of Headache Disorders (ICHD-2). According to their diagnosis, patients were divided into 2 groups. Group 1 consisted of CDH patients having an ICHD-2 code of probable medication overuse headaches (MOH) or chronic migraine (CM) and group 2 consisted of migraineurs with an ICHD-2 code of migraine with (MWA) or without aura (MWoA).[8]

Charts were then reviewed for a patient self-reported history of physical and/or sexual abuse at any time in their life. Patients were simply and systematically asked "Do you have any history of physical abuse at any time in your life?" and "Do you have any history of sexual abuse at any time in your life?" following the intake of their past medical history. No definitions of physical or sexual abuse were provided. No attempt was made to verify the patient's report of abuse or at what age the abuse began or ended.

Fisher exact test was used for comparisons of categorical, demographic variables. A 2-tailed T-test was used for comparison of continuous demographic variables. As a preliminary study has shown that abuse was more prevalent in CDH than in migraine,[7] hypothesis tests associating CDH and migraine frequencies to abuse are assumed to be one-sided. Data was summarized using summary tables. Proportions were compared using a standard 1-sided 2-sample proportions test. The study was IRB approved.

Results

Of the 183 patients, 22 patients were excluded; 21 of these patients had headache diagnoses other than those pertaining to the study. One was eliminated due to lack of information on abuse.

Of the 161 patients included in the study, 145 (90.1%) were female and 16 (9.9%) were male. The mean age was 36.4 SD ±12.0. Information on race was unavailable on 2 charts; marital status was unavailable from 3 charts; and information on a history of a previous marriage was unavailable on 8 charts. Overall, 156 (98.1%) of 159 patients were Caucasian. Of the 158 patients whose marital status was available, 83 (52.5%) were married and 75 (47.5%) were single. Overall, 30 (19.6%) of 153 patients had a history of a previous marriage ( ).

  Summary of Demographics and Group Characteristics

  Overall CDH Migraine
% n N % n N % n N
Female* 90.1 145 161 86.3 82 95 95.5 63 66
Race (Caucasian)** 98.1 156 159 98.9 93 94 96.9 63 65
Married (not single)*** 52.5 83 158 48.4 46 95 58.7 38 63
Previouse marriage**** 19.6 30 153 22.2 20 90 15.9 10 63
Mean SD N Mean SD N Mean SD N
Age***** 36.4 12 161 36.2 11.7 95 36.7 12.4 66

AllPvalues are comparisons between CDH and migraine groups.
*P = .065, **P = .40, ***P = .25,***P = .41, *****P = .79.

A total of 95 (59.0%) patients were diagnosed with CDH (either MOH or CM) and 66 (41.0%) patients were diagnosed with migraine or probable migraine with and/or without aura. Among the 95 patients with CDH, 72 (75.8%) were diagnosed with probable MOH and 23 (24.2%) had CM; and among the 66 migraineurs, 42 (63.6%) had only migraine without aura and 24 (36.4%) had MWA with or without MWoA.

Overall, 34.8 ± 3.8% of all patient's included in this study reported a history of physical and/or sexual abuse ( ). A total of 14.9 ± 2.8% reported a history of both physical and sexual abuse, 26.7 ± 3.5% reported sexual abuse (either isolated or in association with physical abuse), and 23.0 ± 3.3% reported physical abuse (either in isolation or in association with sexual abuse). Sexual abuse alone was reported by 11.8 ± 2.5% and physical abuse alone was reported by 8.1 ± 2.1%.

  Summary of Demographics and Group Characteristics

  Overall CDH Migraine
% n N % n N % n N
Female* 90.1 145 161 86.3 82 95 95.5 63 66
Race (Caucasian)** 98.1 156 159 98.9 93 94 96.9 63 65
Married (not single)*** 52.5 83 158 48.4 46 95 58.7 38 63
Previouse marriage**** 19.6 30 153 22.2 20 90 15.9 10 63
Mean SD N Mean SD N Mean SD N
Age***** 36.4 12 161 36.2 11.7 95 36.7 12.4 66

AllPvalues are comparisons between CDH and migraine groups.
*P = .065, **P = .40, ***P = .25,***P = .41, *****P = .79.

In the CDH group, 40.0 ± 5.0% reported physical and/or sexual abuse. A total of 16.8 ± 3.8% reported a history of both physical and sexual abuse, 30.5 ± 4.7% reported a history of sexual abuse (either isolated or in association with physical abuse), and 26.3 ± 4.5% reported a history of physical abuse (either isolated or in association with sexual abuse). Sexual abuse alone was reported by 13.7 ± 3.5% and physical abuse alone was reported by 9.4 ± 3.0% in the CDH group.

Of patients with migraine, 27.3 ± 5.5% reported physical and/or sexual abuse. A total of 12.1 ± 4.0% reported a history of both physical and sexual abuse; 21.2 ± 5.0% reported a history of sexual abuse (either isolated or in association with physical abuse), and 18.2 ± 4.7% reported a history of physical abuse (either isolated or in association with sexual abuse). Sexual abuse alone was reported by 9.1 ± 3.5% and physical abuse alone was reported by 6.1 ± 2.9% in the migraine group (Fig. 1).

Percent of overall, CDH, and migraine patients reporting abuse histories. The relative frequency of physical and/or sexual abuse is significantly higher in CDH patients as compared to migraineurs (P = .048).

Contrasting the relative frequency of abuse in the CDH group to the migraine group showed a significant difference between patients reporting physical and/or sexual abuse (P = .048). There was no significant difference for any other subgroup including both physical and sexual abuse (P = .20), sexual abuse, (isolated or in association with physical abuse, P = .094), physical abuse (isolated or in association with physical abuse, P = .11), sexual abuse alone (P = .19), or physical abuse alone (P = .22).

Comments

The prevalence of physical and sexual abuse in the general population is difficult to determine. Several limitations exist, including the patient's hesitancy to report physical and sexual abuse as well as inconsistent definitions and measurements of abuse in the studies that do exist.[3-6,9]

However, according to the World Report on Violence and Health, 22% of women in the United States report ever being physically assaulted by an intimate partner at some point in their lives.[10] The National Violence Against Women Survey reported 1 in 6 women (16.67%) in the United States has experienced an attempted or completed rape at some time in their lives. They also report 26% of women and 8% of men are victimized by intimate partners in the form of physical assault, rape, or stalking during the course of a lifetime.[11]

In the present study we have shown that the proportion of patients reporting a history of physical and/or sexual abuse is most significant for the subset of patients who are diagnosed with CDH. In this subset, it was reported in 40% of our patients compared to 27% of migraineurs.

Furthermore, the relative frequency of physical and sexual abuse in CDH patients versus episodic migraineurs in our study is comparable to what Tietjen et al found. In Tietjen's study, 30% of women with CDH had a history of sexual abuse compared to 31% in our study; and 29% of women with CDH had a history of physical abuse as compared to 26% in our study.[7]

Although our data indicate a higher frequency of abuse among CDH patients than migraineurs, cautions are required when interpreting our results. First, although subjects were systematically asked about a past history of abuse, this information was not further investigated, specifically in regards to the temporal relationship between the onset and end of the reported abuse and the onset of headaches.

Second, we did not obtain information in regards to socioeconomics or psychiatric disorders, including post-traumatic stress disorder (PTSD). This may be particularly important as a recent study by de Leeuw et al found that more than 16% of headache patients reported current symptoms consistent with a diagnosis of PTSD. (This was compared to a rate of about 10% in the general population.) Furthermore, the headache patients in de Leeuw's study included both tension-type headache patients and migraine patients.[12] This raises the possibility that the prevalence of PTSD may be even higher if CDH patients were studied.

Third, our study lacked a general population control. Thus, no comparison can be made in regards to abuse frequency in migraineurs and CDH patients compared to the general population.

Lastly, although significant, our results are not robust due to our restricted sample size. Despite its limitations, however, our study shows a higher frequency of abuse in CDH patients than in episodic migraine patients. This underscores the potential import of abuse in relation to headache chronification and presents a strong argument that a larger scale study is warranted to further characterize and delineate this association.


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