“Migraine & PTSD”
Although Migraine disease affects about 12% of the general population, a shockingly disproportionate percentage of Veterans suffer moderate-to-severe head pain including ‘acute attacks’ that characterize Migraine disease. Research by the US Department of Veterans Affairs (VA) has found that as many as one in three (36%) Veterans of the war in Iraq suffer from Migraine attacks. This is even more statistically significant when we observe that a far lesser frequency is seen in the general male population: 6%. What causes Migraine disease to be nearly six times more common in Veterans? This author and fellow sufferer thinks it’s a matter of PTSD ‘tipping the scales’.
Let’s look at Migraine disease in childhood: Approximately 10% of all children experience Migraine attacks, and the prevalence is nearly equal in girls and boys. In children, Migraine symptoms frequently appear without head pain and the prevailing symptoms are abdominal, such as nausea, vomiting, belly-aches/indigestion, etc. Yet, sometime around puberty, the gender equivalence in Migraine diverges and women become three times as likely to develop acute attacks as men; 18% of adult females suffer from the condition. But here’s where military service throws us a curve-ball: Army Soldiers with Migraine contacted 3 months after returning from Iraq had a mean of 5.3 headache days per month and 36% had a Migraine Disability Assessment Scale (MIDAS) ratings of moderate to severe impairment. (Theeler & Erickson, 2008)
In a 2011 Washington Post article, Army Specialist David Hunt recounted that two years after his deployment, he was facing mandatory medical retirement from the military due to Migraine attacks. Spc. Hunt said that the experience of Migraine is: “headache times 10. It’s really hard to handle that while shooting, moving and communicating.” And the VA agrees. Migraine that appears during service or is exacerbated by it is disability compensated by the VA. Still, the trillion-dollar question remains: What makes acute attacks over three times more prevalent for deployed soldiers in their adulthood than the 10% prevalence seen in childhood?
Researchers know there is a genetic component to Migraine disease and higher numbers of sufferers in a family tree increases a person’s ‘genetic load’. However, on top of baseline genetics, both internal and external factors contribute to development of attacks. When these flare, the central nervous system erupts into a neurological cascade of events (similar to seizures) that is typically characterized by moderate to severe, one-sided head pain.
Increased risks such as chronic stress or illness, or physical injuries might combine with a broad range of common triggers such as changes in body chemistry and lack of sleep, hydration or food to create ideal conditions for an attack. Reactions to chemicals found in food (both naturally and as additives); various intense lighting or sound conditions; offending chemicals in products used for health and beauty, laundry, housecleaning, seasonal allergies and more such as extreme weather changes, can tip the scales and bring on an attack. We all know that extreme instances of many of these conditions are embedded into the military lifestyle.
Way beyond simply a ‘bad headache’, Migraine attacks are a full-body experience with additional symptoms that may start as early as 24-48 hours before the ‘head pain’ hits. Debilitating symptoms such as nausea, vomiting and/or diarrhea harken back to those signature childhood symptoms of Migraine. Lack of balance or dropping things and extreme aversion to light, sound, smells or even movement or touch are common. Mood changes may occur, such as onset of sudden and unexplained depression, irritability or even euphoria. Incredibly frustrating and invasive common symptoms are cognitive challenges like ‘brain fog’, difficulty concentrating, ‘finding words’ or understanding them.
Migraine poses extreme challenges to employment, making it the #3 cause of disability in people under the age of 50 worldwide. It is a condition recognized and protected by the Americans with Disabilities Act (ADA). And — here is where we might find some clues — another disability recognized in both civilian and Military-affiliated Migraine sufferers frequently is PTSD.
Concurrently, a 2017 National Health and Resilience in Veterans Study approximated that 40% of Veterans with combat experience met criteria for the diagnosis of Post-Traumatic Stress Disorder. Coincidentally, among these service members with a PTSD diagnosis, 40% report the comorbid occurrence of headaches. (Afari et al., 2009) It is known that people diagnosed with PTS(D) have a higher-level of inflammation throughout their bodies as a result of stress. Generalized or ‘systemic’ inflammation is also seen evident in a higher baseline in people with Migraine disease.
When a person with Migraine becomes ‘over-loaded’ due to changing environmental conditions and exacerbating triggers, the ‘scales tip’ and their entire central nervous system is pulled into the impending attack. A neurological storm-like activity in the brain called ‘cortical spreading depression’ (CSD) culminates in a relative silencing of the neuronal system while the body’s systemic inflammation increases even further.
Notably, ‘cortical spreading depression’ involves many of the same brain structures, nerve pathways and hormones that are known to activate the ‘fight, flight, or freeze’ response that becomes active in people who suffer PTSD. This similarity between the physical features of PTSD and Migraine disease might self perpetuate the frequent co-occurrence (comorbidity) of the two disorders. Furthermore, it could be that the body’s response to anxiety, panic or trauma that may indeed be the one of the key triggers that induce the neurological storm of an acute Migraine attack!
Hopefully, this discussion of the physiology of PTSD and Migraine might serve to indicate to service members that neither of these disorders are signs of weakness or ‘character defect’. All of these conditions are physiological responses to triggering conditions. Genetically, hypersensitive individuals may be hard-wired to be humanity’s early-warning-system — and perhaps, like service members, Migraine warriors might be thanked, too, for indicating societal health risks similar to the ‘canary in the coal mine’.
Goodness knows that families, jobs and lives are lost to Migraine disease. Nearly 1 in 4 households in the US includes someone with Migraine. Acute attacks most commonly occur in people between the ages of 25 and 55, prime years of their employment. (“Migraine Facts,” n.d.) Just like PTSD, Migraine is frequently accompanied by major depression, a leading cause of suicide across all demographics.
Even more upsetting is the lack of research funding — the National Institutes of Health is granted about 53-cents of research funding for every one of the 39 million sufferers in the US. Now add another huge gap in care: There are fewer than 530 board-certified Headache Specialists in the entire nation — that’s roughly one specialist for every 75,000 patients. Clearly, most patients will never lay eyes on a Headache Specialist. Treatment defaults to general practitioners, whose education includes approximately two hours of instruction on all types of headache combined. Sounds dismal doesn’t it?
However, breaking through the darkness are rays of light. New antibody drugs are emerging that reduce systemic inflammation. Some study results are far exceeding their target levels of effectiveness in reduction of the frequency and severity of Migraine attacks. Here’s the upshot: These immunotherapies, while causing a reduction in the body’s levels of inflammation, do not arrest the neurological phenomenon of cortical spreading depression (CSD).
Possibly the most promising new frontier in Migraine research — and indeed research for depression, PTSD and other anxiety related disorders is the emergence of new forms of non-invasive treatment being explored through alternative medicine interventions. For example, one such area of exploration utilizes magnets to provide slight alteration in the nervous system through mild energetic stimulation. Another that I am becoming increasing familiar with is neuromodulation.
This 21st century breakthrough is showing promise for interrupting cortical spreading depression (CSD). Neuromodulation techniques are non-pharmaceutical, which scores high marks in the face of the current opioid crisis. Indeed, the medicines currently used off-label to treat Migraine are notorious for side-effects that are frequently as troubling as the disease itself.
Neuromodulation devices that are currently in clinical usage or research for Migraine preventives are targeting the specific neurological phenomenon of cortical spreading depression. However, these modalities still do not address any of the psychological underpinnings that frequent this mercurial disease. As described earlier, PTSD, whose co-occurrence with Migraine is supported by a substantial body of research, has far more obvious causes than chronic depression or general anxiety.
I posit that the correlation of the hyperarousal of the brain observed in both CSD and the ‘fight, fight, or freeze’ autonomic state sustained in patients with PTSD is noteworthy. I am not alone in the perspective that treating PTSD effectively will likely have a significant positive and enduring effect on the frequency and severity of comorbid Migraine. I am intrigued with a non-pharmaceutical, binaural sound-based protocol called RESET Therapy. This intervention is based on the ‘reconsolidation’ of stored memories that contribute to the development of Post-Traumatic Stress.
It is my supposition that the resulting constant of the ‘on the edge’ state forthcoming from trauma exposure primes the body for Migraine attacks. Further, it is my hypothesis that since RESET Therapy has shown significant efficacy in the remediation of PTSD symptoms, (Lindenfeld, 2015) it may potentially contribute to the diminishment or control of Migraine attacks.
Dr. Lindenfeld’s pilot RESET study of six Veterans did not include observation of possible comorbid Migraine symptoms. However, the participants’ Clinician-Administered PTS Scale for DSM-5 (CAPS-5) are so promising that I believe that there is substantial support for further research to explore this potential non-invasive alternative approach.
As a Migraine sufferer and Military Family advocate, I am committed to finding non-invasive solutions. It would be wonderful if we were able to mitigate some of the causation factors related to Migraine attacks as a result of RESET Therapy. Independent of the ultimate findings in efficacy for Migraine disease, I find myself envisioning the use of RESET Therapy in many acute trauma situations such as downrange combat scenarios and on-site implementation for first responders, victims of violence, terror and interpersonal abuse. While trauma is nearly unavoidable in the human experience, my sincere hope and wish is that we can find a rapid and permanent solution to counter its tragic and destructive effects by expediting the healing process.
Nicci Eisenhauer is the Executive Director and CoFounder of American Initiatives for Military Support (AIMS) and Director of Strategic Partnerships for the medically-reviewed resource MigraineDisease.com. Studies at the Rochester Institute of Technology (RIT), University of Rochester Medical School and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury are the foundations for her continued independent study of PTSD, TBI and Migraine Disease.
References:
Afari, N., Harder, L. H., Madra, N. J., Heppner, P. S., Moeller-Bertram, T., King, C., & Baker, D. G. (2009). PTSD, combat injury, and headache in Veterans Returning from Iraq/Afghanistan. Headache, 49(9), 1267–1276. https://doi.org/10.1111/j.1526-4610.2009.01517.x
Global Burden of Disease Report 2015: migraine is the third cause of disability in under 50s
Timothy J. Steiner, Lars J. Stovner, Theo Vos, Journal Headache Pain. (2016). 17(1): 104. Published online 2016 Nov 14. doi: 10.1186/s10194-016-0699-5 PMCID: PMC5108738
Lindenfeld, G.L., & Bruursema, L. R. (2015). Resetting the Fear Switch in PTSD: A Novel Treatment Using Acoustical Neuromodulation to Modify Memory Reconsolidation. http://www.academia.edu/12683048/ Resetting_the_Fear_Switch_in_PTSD_A_Novel_Treatment_Using_Acoustical_Neuromodulation_to_Modify_Memory_Reconsolidation
Migraine Facts. (n.d.). http://migraineresearchfoundation.org/about-migraine/migraine-facts/
pmhdev. (n.d.). Migraine - National Library of Medicine. https://www.ncbi.nlm.nih.gov/ pubmedhealth/PMHT0024778/
Theeler, B. J., & Erickson, J. C. (2012). Posttraumatic headache in military personnel and veterans of the iraq and afghanistan conflicts. Current Treatment Options in Neurology, 14(1), 36–49. https://doi.org/10.1007/s11940-011-0157-2
Theeler, B. J., Mercer, R. and Erickson, J. C. (2008), Prevalence and Impact of Migraine Among US Army Soldiers Deployed in Support of Operation Iraqi Freedom. Headache: The Journal of Head and Face Pain, 48: 876–882. doi:10.1111/j.1526-4610.2008.01159.x
Theory Behind Migraine Emerges. (n.d.). http://www.dana.org/Publications/ Brainwork/Details.aspx?id=43724
Torres, C. (11 November 2011). Migraine and headaches prompt new research focused on military personnel Link: https://www.washingtonpost.com/national/health-science/migraine-and-headaches-prompt-new-research-focused-on-military-personnel/2011/10/24/gIQAlS0RvM_story.html?utm_ term=.ac40e2dbb0f6
