A new prospective study documents a direct relationship between ACEs and migraine, independent of depression or anxiety.
It’s well established that adverse childhood experiences (ACEs) can have a detrimental effect on many aspects of health later in life, including the risk of headache. However, previous studies documenting a link between ACEs and headache have methodological limitations that complicate their interpretation. New research now overcomes some of those shortcomings, and in doing so provides convincing evidence for a direct ACE-migraine connection in adolescents.
Using a longitudinal, prospective cohort study design, Serena Orr, University of Calgary, Canada, and colleagues report an increased risk of migraine in adolescents who experienced one or more ACEs. The study, which relies on Canada’s National Longitudinal Survey of Children and Youth (NLSCY) data set, also finds that this association was direct, rather than mediated by depression or anxiety in late childhood. No association between ACEs and non-migraine frequent headache was observed.
Melanie Noel, a pediatric pain scientist and psychologist who studies ACEs and pain at the University of Calgary but was not involved with the new work, said the research is the first longitudinal study to show that ACEs confer a higher risk of migraine in adolescents.
“One of the problems in ACEs research is that we don’t follow kids over time – most studies are retrospective,” she said. “These researchers had access to this longitudinal data and were able to follow these kids over time, finding that when children had ACEs at six, seven, or eight years of age, it predicted the onset of migraine in the adolescent years. So many studies that look at ACEs can’t answer that basic chicken-and-egg question: What came first? But with this data, we can say the trauma came first because they didn’t develop migraine at six, seven, or eight years old,” according to Noel.
In an accompanying guest editorial, Gretchen Tietjen, University of Toledo College of Medicine & Life Sciences, US, echoed that feeling, calling the study a “rare find.”
“Despite the striking differences in methodology and limitations between prospective and retrospective studies, this cohort study corroborates the ACE-migraine link found in cross-sectional studies,” she wrote.
“Another important contribution of this prospective study is the finding that the relationship of ACEs and migraine was direct, and not mediated by depression and anxiety, thus strengthening the case for causality,” Tietjen also wrote.
The study and guest editorial appeared in the March 2022 issue of Headache.
The need for a prospective study
Study after study has shown that adversity in childhood has a lasting impact on a person’s physical and mental health. When the first Centers for Disease Control and Prevention (CDC)-Kaiser Adverse Childhood Experiences studies were published in the late 1990s, the research community saw evidence of what many physicians had long suspected: Childhood trauma, including physical abuse, emotional abuse, sexual abuse, neglect, and/or exposure to imprisoned, addicted, or mentally ill family members, was strongly associated with a wide variety of health issues in adulthood.
Notably, such experiences are linked not only to emotional or psychological conditions. ACEs are also associated with chronic physical health problems like obesity, cardiovascular disease, chronic obstructive pulmonary disease (COPD) – and headache.
But scour the literature on ACEs and headache, and readers will see that while a link between the two has been established for some time, existing studies have been retrospective investigations, which cannot address whether the link is a causal one. Previous studies also have other important limitations that make them difficult to interpret.
“Most of the studies published before ours involved samples of adults with migraine and asking them about what kind of ACEs they may have experienced in childhood. There were also a few pediatric studies that asked retrospectively about ACEs,” Orr said.
“But as someone who is interested in the environmental risk factors for migraine – because those are things we can act on to help prevent or treat migraine – it was obvious to me we needed a longitudinal study that actually collected data prospectively to understand what role ACEs might play, without the problems of recall bias and other methodological issues,” Orr continued.
The relationship between ACEs and headache
Orr, first author Nicole Hammond, and co-author Ian Colman looked to a unique pediatric data set, the NLSCY, to perform their research. The NLSCY study followed non-institutionalized Canadians from their first year of life through adolescence. Every two years, the study asked the children and the person most knowledgeable about them (PMK), usually the mother, to answer questions about the child’s mental and physical health, and about environmental stressors they were experiencing. This included standardized measures of depression and anxiety, as well as PMK-reported health professional diagnoses of migraine (the primary outcome of the current study) and self-report of non-migraine frequent headache (the secondary outcome).
“We were excited that the cohort had measures of anxiety and depression so we could look at those factors, too,” said Hammond. “We initially hypothesized that there would be a relationship between ACEs and migraine, but it would be driven through anxiety and depression, as we had found that those types of symptoms mediated migraine in adolescents who had experienced chronic family stress during childhood, in a previous study.”
The current study included 2,058 people for the migraine analysis, 71 of whom had migraine, and 1,730 for the frequent headache analysis, 204 of whom had frequent headache. After adjusting for sex, parental migraine, and economic deprivation, the team estimated both direct and indirect effects of ACEs on headache.
The researchers found direct associations between experiencing one, or two or more ACEs and migraine. Specifically, those experiencing one ACE had 1.7 times the odds of having migraine in adolescence, compared to those not exposed to ACEs, while those with two or more ACEs had 2.3 times the odds.
But there was no association between ACEs and non-migraine frequent headache. Also, contrary to their initial hypothesis, the investigators found that depression and anxiety did not play a role in the relationship between ACEs and migraine.
“We don’t know what might be driving this relationship,” said Orr. “I would hypothesize it has something to do with the toxic stress and how it might skew brain development at sensitive ages. But it could also be inflammation, stress hormones, or some kind of epigenetic effect. It speaks to the need for more research and to not just assume the relationship is mediated by psychiatric comorbidity.”
For her part, Noel said she would also like to see future studies further tease apart which specific ACEs are most related to later development of migraine.
“There’s reason to think there may be differences between maltreatment, which is abuse and neglect, and household dysfunction, like if you live in a house where someone was incarcerated,” said Noel. “Not all ACEs are the same. The limitation here is that the study asked about abuse but didn’t specify the type of abuse or ask about neglect. There may be some interesting connections between the type of ACE and the later development of migraine that can help us better characterize this relationship.”
Orr, Hammond, and Colman plan to continue to investigate the nature of the relationship between ACEs and migraine in future studies. But in the meantime, Orr said there is enough evidence for policy makers to take notice.
“I think studies like these just drive home the bigger picture for politicians and people who make decisions about social programming,” she said. “We really need to be investing in our communities to not only try to prevent ACEs, but to look at developing positive environmental factors within neighborhoods to provide more support and resilience to these families. We assume that individuals have to be resilient. But we can also look at resilience from a larger social perspective and social policy level to help support a more preventative landscape for everyone.”
Noel added that the study also reveals the need for trauma-informed care, a healthcare approach that recognizes trauma symptoms and acknowledges their potential role in different health conditions, for patients who live with migraine or any other chronic condition. She stressed that recovery and resilience are very possible in the face of the most devastating kinds of childhood trauma – but only if clinicians are trained to deal with people who have a past history of ACEs.
“Most clinicians treating migraine or pain likely don’t even ask about ACEs,” Noel said. “There are already recommended trauma-based care models and trainings out there that we can draw from. This kind of care helps clinicians understand what trauma is and what effect it can have on individuals and their families. And in taking the time to listen to these stories, we can put the right supports in place and be more effective providers.”
Kayt Sukel is a freelance writer based outside Houston, Texas.
Adverse childhood experiences and onset of migraine in Canadian adolescents: A cohort study. Hammond et al. Headache. 2022 Mar;62(3):319-28.
The relationship of childhood adversity and migraine and the value of prospective studies. Tietjen, GE. Headache. 2022 Mar;62(3):223-4.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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