Headache is a common disorder in women and chronic daily headache is also more common in women. Childhood sexual abuse has been found to be frequent among women who have disabling headache. We wished to determine the frequency of sexual abuse as well as other forms of abuse in a headache clinic in Utah. Methods: Patients filled out a questionnaire using a personal digital assistant (PDA). Patients also completed depression and somatic symptom severity measures. Results: Two-hundred twenty-two women completed the study. The majority of the women had migraine, over half had chronic daily headache. Sexual abuse in childhood was reported in 34% of women; physical abuse was reported in 32% of women, and emotional abuse in 26%. Of those reporting sexual abuse, 41% of women reported occurrences before they were 12 years and 82% reported occurrences as adolescents less than 20 years. Risk for abuse did not follow socio-economic level, number of headaches, but was more prevalent in women with a lower level of education. Depression was common in over one-half of the patients and women who were abused had an increase in depressive indicators. Multiple somatic symptoms were more common in abused women. Migraine headaches occurred in 85.6% of the patients; 43.7% had daily migraine headaches. Some form of violence was experienced by 63.1% of the women. Conclusion: A reported history of abuse is common among women seen in a headache clinic. Clues to identifying women who have been abused are present when there are increased somatic symptoms and depression. Practitioners should be aware that abuse is common and address this with women with headache.
Headache is a common disorder in women. In fact, almost twenty percent of all women in the population suffer from migraine (Lipton, Stewart, Diamond, Diamond & Reed, 2001). About 4% of the adult population suffers from some sort of chronic daily headache; however, women again share the burden of daily headache twice as often as men (Scher, Stewart, Liberman & Lipton, 1998; Stewart & Lipton, 1993; Silberstein and Lipton, 2000). Sexual abuse in childhood has been estimated to occur in 15-25% of women (Leserman, 2005; Howard, 1995). These women are found to have more chronic complaints (pelvic pain, irritable bowel syndrome), use more health care resources (Walker et al., 1999b; Hilden 2004), have more physical symptoms and have an increase in life-time health problems (Leserman, 2005; Walker et al., 1999a; Roberts, 1996). There is evidence to suggest that a history of childhood sexual abuse may also increase the severity of headache as well as lead to increase in other pain and depression (Felitti, 1991; Domino & Haber, 1997; Emiroglu, Kurul, Akay, Miral & Dirik, 2004). We sought to find the frequency of sexual abuse among women visiting a headache specialty clinic in Utah.
The study was approved by the IRB. All participants were women seen for evaluation and treatment of headache in the University of Utah Headache Clinic. All participants were examined and diagnosed by specialists in headache (KBD, SB). Women patients who met the following criteria were invited to participate: 1) primary headache disorder defined by the International Classification of Headache Disorders (2004) 2) women over 18 years of age; 3) willingness and ability to perform a self-administered questionnaire on a Personal Digital Assistant (PDA). Women were excluded from the study if they were not able to complete the questionnaire on the PDA or if they were unable to read English.
The patient’s diagnosis and the average number of headache days per month over the previous three months were entered by the headache specialist. The electronic questionnaire was designed with Pendragon® Forms 3.2 computer software (Pendragon Software Corporation, Libertyville, IL). Patients responded to questions on the following topics: age, race, household income, highest educational level attained, age of onset of headaches, impact of headaches on daily life, severity of current depression, and somatic symptoms. The questionnaire collected information on physical abuse, sexual abuse, and ‘fear for life’ (emotional abuse) in time periods: childhood years (12 years old), teenage years (13 to 20 years old), adulthood (≥21 years old) and current (within the past year). The participants were asked if they had been the recipient of other abusive behaviors such as: threats, aggression, intimidation, isolation, and coercion. They were also asked if they had stress due to fear of threats or felt they were at risk for future abuse. The participants were asked whether they had witnessed 1) abusive behavior between adults, and 2) drug/alcohol abuse by adults in their childhood home.
The questionnaire also included a disability scale, the Headache Impact Test (HIT-6) (Kosinski et al., 2003) that produces a score ranging from 36 to 78. In this test, there are four levels of disability based on the HIT-6 scores: ‘little or no impact’ for scores less than 49, ‘some impact’ for scores 50-55, ‘substantial impact’ for scores 56-59, ‘very severe impact’ for scores more than 60.
Determination of current (over the prior two weeks) depression was performed using the Personal Health Questionnaire 9 (PHQ-9) (Kroenke, Spitzer & Williams, 2001), that produces a score ranging from 0 to 27. Five levels of depression severity exist based on the PHQ-9 scores: ‘minimal’ for scores 0-4, ‘mild’ for scores 5-9, ‘moderate’ for scores 10-14, ‘moderately severe’ for scores 15-19, and ‘severe’ for scores 20 and above.
The type and severity of current somatic symptoms (over the prior 4 weeks) was assessed using Personal Health Questionnaire 15 (PHQ-15) (Kroenke, Spitzer & Williams, 2002). The symptoms include: joint or limb pain, dizziness, headaches, back pain, abdominal pain, chest pain, breathing trouble, fainting, gas or indigestion, sleeping trouble, palpitations, menstrual problems, diarrhea (constipation), and sexual pain/problems. In this test, 15 symptoms were graded by the patient as ‘not bothered at all’ (scored as 0), ‘bothered a little’ (scored as 1), or ‘bothered a lot’ (scored as 2). The PHQ-15 reveals four levels of somatic symptom severity: ‘minimal’ for 0-4, ‘low’ for 5-9, ‘medium’ for 10-14, and ‘high’ for 15-30.
Patients took about 15 minutes to answer the questions. A security code was entered at the end of the survey, uploaded data to a central database using the PDA, and synchronized to a central database through a Pendragen SyncServe computer software. The database was kept at the University of Toledo, Ohio which was the primary site for the study.
Data for Utah were transferred to SPSS for analysis. Chi-square test, t-test, and regression were used for analysis. This study was part of a multi-centered study. Only the data from Utah are presented here. Previous publications of the aggregate data include Tietjen et al. (2007).
There were 222 women who participated in this study. The ages were 18-72 with a mean age of 40.8. The majority of the women were Caucasian. The vast majority, 97%, had attained high school graduation and many, 44%, had attained a baccalaureate degree or higher. Sixty percent of the women had household incomes more than $50,000 and only 10% had incomes less than $20,000. The number of people in a household ranged from 1-12; the average household size was 3.2. See Table 1 for demographic data and its comparison to the demographic
information of women from the State of Utah. The headache clinic population and the female Utah population were found not to significantly differ on race and average number of household members. But the cohort did differ on age (t=16.351, p<0.001), education (Ȥ2=8.309, p<0.01), and income (Ȥ2=66.611, p<0.001). It was found that, on average, the headache clinic sample was significantly older, more educated, and had higher income levels than the female Utah population. Some statistics representing only women were unavailable. For these demographic variables (i.e. income and average household number), information from the general Utah population was used for comparison.
The primary headache type was most frequently migraine (190/222, 85.6%), and less frequently: tension-type (5/222, 2.3%), post-traumatic (12/222, 5.4%), and other (15/222, 6.6%). Headaches occurred less than 15 days per month in 101/222 (45.5%) patients and more than 15 days per month in 121/222 (54.5%) patients. Severe headaches were found in 170/222 (76.6%) patients as defined by the HIT-6 test score of over 60. The average HIT-6 score was 63 and the range of scores was 48-76. See figure 1.
The women reported their headaches to begin between the ages of 1 and 61 years with a mean of 21.5 years. Headaches beginning before the age of 20 were experienced by 105 (47.3%) women.
Moderate to severe depression, as determined by the PHQ-9 score of 15 or greater, occurred in 84 (37.8%) women. Minimal or no depression, indicated by a PHQ-9 score of 0-4, occurred in 76 (34.2%) women. See figure 2.
Somatic symptoms were highly prevalent in this group; 161 (72.5%) women had somatic symptoms that the PHQ-15 determined were of medium or high severity. See figure 3.
Thirty-four (15.3%) women currently or in the past abused drugs or alcohol; 13/34 (38.2%) of these women recalled alcohol or drug abuse to be present in their childhood homes. Some type of violent behavior was reported by 140 (63.1%) women—this includes physical, sexual, and emotional abuse, other abusive behaviors, or had witnessed violent behaviors. Fifty-four (54.3%) of these women reported a personal previous history of sexual abuse (76/140).
Physical abuse (as defined as being hit, punched, slapped, kicked, bitten, grabbed choked, by a family member, current or former spouse, or significant other) occurred in 71 (32%) women. These 71 women indicated that they had been physically abused at different ages, so there was a total of 106 reports of abuse. The physical abuse occurred at 12 years of age or younger (29.2%), 13-20 years of age (38.7%), 21 years of age or older (13.5%). Only 3.8% reported current physical abuse. See figure 4.
Sexual abuse was reported to occur in 76 (34.2%) of women. These 76 women indicated that they had been sexually abused at different ages, so there was a total of 107 reports of abuse. The sexual abuse occurred at 12 years of age or younger (41.1%), 13-20 years of age (39.3%), 21 years of age or older (15.9%); rarely was there current sexual abuse (1.9%). See figure 4.
Emotional Abuse/Fear for life (as defined by being hurt or frightened so badly by a family member that they feared for their life) occurred in 57 (25.7%) women. These 57 women indicated that they had been emotionally abused at different ages, so there was a total of 73 reports of abuse. The emotional abuse occurred at 12 years of age or younger (21.9%), 13-20 years of age (34.2%), 21 years of age or older (38.4%); current emotional abuse occurred in 5.5% of the 57 women. See figure 4.
One hundred and one (45.5%) women reported no sexual, physical or emotional abuse.
While patients with a history of physical or sexual abuse showed no statistical increase in headache frequency when compared to patients with no history of physical abuse and sexual abuse, patients with a history of emotional abuse showed an increase in headache frequency when compared to patients with no history of emotional abuse (Ȥ2=13.553, p<0.001).
Women with a history of physical, sexual, or emotional abuse usually reported more than one type of abuse. Of the women who had physical, sexual, and/or emotional abuse 55/121 (45.5%) had witnessed abusive behavior between adults in their childhood home, whereas 18/10 (18.0%) who had never had abuse, had witnessed abusive behavior in their childhood home. See figure 5.
Other abusive behaviors (independent of physical, sexual, or emotional abuse) were reported by 107 women. In response to questions about these other abusive behaviors, women reported they had been: threatened (51; 45.5%), shown aggression (44; 19.8%); harassed (42; 18.9%); intimidated (71; 31.98%), isolated (53; 23.9%), and controlled/coerced (52; 23.4%).
Table 2 compares the samples of women with no history of physical, sexual, or emotional abuse (N=101) and the sample of women with a history of physical, sexual, and/or emotional abuse (N=121). The two groups did not differ significantly in age, race, income, number of household members, and headache frequency. The sub-sample of women with a history of physical, sexual and/or emotional abuse had significantly different education levels when compared to those who did not experience any abuse (Ȥ2=10.732, p=0.013).
Table 3 shows the results of linear regression models to fit the somatic symptom severity score (PHQ-15), the depression score (PHQ-9), and the headache-related disability score (HIT-6).
The PHQ-15 score (somatic symptoms) is significantly associated to sexual abuse, emotional abuse, income level and headache frequency. Higher PHQ-15 scores are observed for participants who have had a history of sexual and/or emotional abuse and also for those who experience more than 15 headaches a month. The PHQ-15 score seems to be negatively related to income level (i.e., higher income level relates to lower PHQ-15 score) after controlling for all other factors.
The PHQ-9 score (depression) is significantly associated to emotional abuse, income level, and headache frequency. The presence of emotional abuse, increasing income levels, and increasing headache frequency result in higher PHQ-9 scores; this is quantified by the parameter estimates shown in Table 4. Although sexual abuse was not found to be significantly associated with PHQ-9 at the 0.05 level (p=0.056), it was very close to the significance value and we have chosen to leave this factor in. Again, as with the PHQ-15, the PHQ-9 is negatively associated with income level.
The HIT-6 score was found to be significantly associated only with age and headache frequency. Age was negatively related to the HIT-6 score (i.e., older women show lower HIT-6 scores). The headache frequency seemed to be the major predictor of the HIT-6 score.
This study shows that a large number of women in a sub-specialty headache clinic in Utah have had sexual, physical and/or emotional abuse. Sexual abuse was the most frequent at 34%. Most of the sexual abuse occurred before the age of 20. The estimated rate of sexual abuse in the general population is 15-25% (Scher, Stewart, Liberman & Lipton, 1998). In chronic headache patients at a specialty clinic, Utah appears to be above this average. Sexual abuse is known to be associated with a poor health status (Leserman, 2005; Walker et al., 1999 as well as more physical symptoms (Tietjen et al., 2007), and a higher utilization of health resources and increased cost to society (Walker et al., 1999). In addition, sexual abuse has been found to be associated with other forms of abuse (physical and emotional) (Dong et al., 2004). In our cohort of 140 patients with some type of abuse, it was common to have other forms as well. We found that almost 21% of the abused women reported all three forms of abuse (sexual, physical and emotional).
As noted in other studies, sexual abuse can occur in any socioeconomic group and education (Swahnberg et al., 2004). In our population, women were from a higher socioeconomic status and had more high school or college experience than our general Utah population.
Headache has been reported to be a major symptom seen in patients who have had sexual abuse. In fact, in one large study of abused women, chronic daily headaches were more than twice as common as in women who were not abused (Felitti, 1991). Early childhood sexual abuse is associated with more headache than in those who have sexual abuse in adulthood (Golding 1999). Chronic headache is associated with depression since 38% of our population had moderate to severe depression. In our population, depression was more severe in those who have had sexual or emotional abuse.
Juang, Wang, Fuh, Lu, and Chen (2004) found that physical abuse in childhood tended to increase the likelihood of chronic daily headache in adolescence. Romans, Belaise, Martin, Morris and Raffi (2002) reported that headache and migraine were definitely correlated with adult physical abuse. Krantz and Ostergren (2000) showed that physical abuse was associated with headache and that women who had physical abuse in childhood or adulthood had an increased likelihood of multiple somatic symptoms In our study, physical abuse was neither associated with headache nor multiple somatic symptoms.
Depression is strongly associated with migraine in patients without abuse. In fact, the prevalence of depression among patients with migraine is 14.7/100,000 vs those who do not have migraine (7/100,000) (Hamelsky & Lipton, 2006). Merikangas, Angst, and Isler (1990) and Breslau et al. (2000) and Breslau et al. (2003) found that those with migraine had three times the incidence of depression than those without migraine. Shared genetic and neuro-biologic factors may link migraine and depression (Silberstein, 2001). Walling et al. (1994a) and Walling et al. (1994b) found that early childhood physical abuse predicted depression, anxiety and somatization. Other studies have also found that women experiencing violence have a significantly higher rate of depression (Nicolaidis, Curry, McFarland & Gerrity, 2004). Depression associated with abuse has also been found to be associated with morbid obesity (Felitti, 1991). Depression was found in 38% of our patients. Depression was increased in our patients with sexual and emotional abuse.
An increase in multiple somatic complaints is similar to other studies of women with all forms of abuse (Tietjen et al., 2007; Krantz & Ostergren, 2000). In our study, 96 (80%) of 120 abused women had a ‘medium’ or ‘high’ level multiple somatic complaints. This finding suggests that women with multiple somatic complaints should also be queried about forms of abuse.
Our headache clinic population is similar in several demographics to the state of Utah. The clinic and general population were not significantly different in race and average number of household members. The clinic patients were significantly more educated (Ȥ2=41.611, p<0.001) and had significantly higher incomes (Ȥ2=30.02, p<0.001) than the general population of the state of Utah. Nevertheless, our study shows that headaches and abuse affects a wide range of individuals even those who are more educated and of higher economic fortune.
We would make the following recommendations for practitioners who see women who have chronic headache. First, the practitioner should ask about abuse in childhood. Recently two questions were found to predict sexual abuse: (a) “When I was growing up, people in my family hit me so hard that it left me with bruises or marks” and (b) “When I was growing up, someone tried to touch me in a sexual way or tried to make me touch them.” (Thombs, Bernstein, Ziegelstein, Bennett & Walker, 2007) These questions had sensitivity 85% and specificity of 88% in predicting sexual abuse. Further, women with multiple chronic health symptoms should also be queried about abuse. Despite many articles about the importance of querying for abuse, only 21% of women with a history of abuse presenting to medical clinics are asked about it (Pearse, 1994).
Treatment for women with headache who have been abused has not been extensively studied. Cognitive behavioral approaches are most frequently used and have the most evidence for success (Leserman, 2005). Behavioral and cognitive therapy are more efficacious in some cases than medications (Payne & Colletti, 1991). Psychotherapy (Martsolf & Draucker, 2005), group therapy (Kessler, White & Nelson, 2003; Talbot et al., 1999), and even inpatient treatment (Stalker, Palmer, Wright & Gebotys, 2005) have been used. No single therapy has been found to be superior, however. In general, finding a single medication that completely stops headache is almost impossible. However, every attempt to reduce the migraine headache with standard preventive medications such as beta blockers, calcium channel blockers, and anti-convulsants should be attempted (Goadsby, Lipton & Ferrari, 2002).
The reason for emotional abuse causing increased rates of headache is not clear. Clearly more work is needed to understand the pathophysiology of increased headache in women with all forms of abuse and to determine the best treatment of these disabling headaches.
There are limitations to our study. We do not address any type of abuse in men. We are using a highly specialized population (those going to a headache clinic) so our findings may not be generalizable to all headache patients. The study also relied on the woman’s recollection of abuse. Nevertheless, this study gives us insight into some women visiting a chronic headache clinic in Utah.
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