The human body is made up of 1 trillion cells, give or take; and 1 hundred million are cradled in the bony cranium, comprising the brain. Within the brain, there lies a vital and delicate network (not yet visualized nor measured) that is crucial to the essence of who we fundamentally are. We call this invisible organ the mind.
The brain preserves memories to predict the future, which is why we perceive the world as a linear progression from past to future. This perception has practical advantages for species survival. Hunters remember where antelopes roam so they can stalk them in the future. Mothers remembers childrens’ facial features to find them in a crowd. We learn the path of a baseball hurtling toward us to accurately predict where to put our glove to catch it. In nature, scientists tell us, there is no such past-future linearity. Time is simply an artificial, albeit valuable, construct of the human mind.
But what happens when memories made and stored are not only not useful, but traumatic? How do we act on them, where are they stored, and what future do they predict? Unfortunately, we have learned that trauma, particularly in childhood, forever changes the brain, alters the mind, and portends a grim future of increased psychopathology and physical ache, including migraine, often bundled together with other seemingly disparate, painful conditions.
Trauma and Pain
In his book, The Body Keeps the Score: Brain, Mind and Body in Healing Trauma,1 Boston University psychiatrist and trauma specialist Bessel Van Der Kolk, M.D describes how, in individuals with prior psychologic trauma, suppressed memories and emotions often play out brutally on the body, causing a host of somatic pains. Published research supports this, showing that neglect and trauma—physical, emotional, or sexual—are risk factors for migraine and conversion of episodic to chronic migraine.2-4 Other chronic pains are also associated with prior trauma, as are anxiety, depression. and substance abuse.5,6
Does this mean then, that chronic pain disorders including migraine, are psychologic? That may be the wrong question. The line separating physical vs psychologic continues to blur, particularly with novel imaging techniques such as functional MRI and PET scanning. We have a mind, within our brain, that processes memories to predict the future. Sadly, this may include horrific ones—memories too awful to keep on the surface of consciousness, which are thus buried or hidden. Imaging studies show these deep recesses of the mind, activated when we recall traumatic memories, do not have connections to language centers in the brain, which could explain why painful posttraumatic memories can manifest in the body as corporal pain. An emerging physiologic tie-in seems to be found in epigenetics. In the brain this means that although we cannot change our genetics, trauma can alter gene splicing, producing different proteins than would have been produced otherwise. Through such epigenetic effects, an individual subjected to trauma can actually become a different person than they would have been absent the trauma—a person who processes pain differently.7 For Kimmie, the patient described in the Case Study, this was the source of her Hateful Eight.
Treating Trauma-Related Pain
Self-awareness is a key to treating trauma-associated pain. Making the connection between mind and memory, body and pain, past and the future is therapeutic. There is good data supporting use of cognitive behavioral therapy (CBT) for chronic trauma-related pain. Yet trauma often hides beyond the reach of cognition, dwelling in the cave of the reptilian ancestors of the brain. To access this dark place, noncognitive techniques, such as eye movement desensitization and reprogramming (EMDR), may be useful. In EMDR, a person is asked to recall a painful memory that may be fragmentary initially, while at the same time following the therapist’s fingers as they repeatedly sweep from left to right and back again.8 Although EMDR is not without controversy, it is listed by the American Psychological Association as evidence-based treatment for posttraumatic stress disorder (PTSD), anxiety, and substance abuse disorders.9 A 2013 Cochrane Review found EMDR equally effective compared to trauma-focused CBT and more effective than several other psychotherapy methods.10
Trauma and Migraine
We need to recognize trauma as a risk factor for migraine and other pain disorders. Our Case Study patient Kimmie did not have 8 separate maladies. Her pains were all yoked to the horror of unspeakable trauma. Migraine is a biopsychosocial disorder, and trauma alters biology. No treatment was likely to be effective until this vital information was unearthed and processed. The key to helping people with trauma-related pain is asking the right questions, delicately, and having a plan when terrible truths present themselves.11
1. Van der Kolk B. The Body Keeps the Score: Brain, Mind and Body in Healing Trauma. Penguin Books, 2014.
2. Tietjen GE, Karmer M, Amiaulchuk AA. Emotional abuse history and migraine among young adults: a retrospective cross-sectional analysis of the add health dataset. Headache. 2017;57(1):45-49.
3. Brennenstuhl S, Fuller-Thompson E. The painful legacy of childhood violence: migraine headaches among adult survivors of adverse childhood experiences. Headache. 2015;55(7):973-983.
4. Mansuri F, Crozier-Nash M, Bakour C, Kip K. Adverse childhood experiences (ACEs) and headaches among children: a cross-sectional analysis. Headache. 2020;60(4):735-744.
5. Morasco BJ, Lovejoy TI, Lu M, Turk DC, Lewis L, Dobscha SK. The relationship between PTSD and chronic pain: Mediating role of coping strategies and depression. Pain. 2013;154(4):609-616.
6. Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron. 2016;89(5):892-909.
7. Sheerin CM, Lind MJ, Bountress KE, Nugent NR, Amstadter AB. The genetics and epigenetics of PTSD: overview, recent advances, and future directions. Curr Opin Psychol. 2017;14:5-11.
8. Shapiro F. EMDR: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress and Trauma. Basics Books, 2004.
9. Clinical practice guideline for the treatment of posttraumatic stress disorder: eye movement desensitization and reprocessing (EMDR) therapy. American Psychological Association. Published May 2017. Accessed June 7, 2020. https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing
10. Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2013;2013(12):CD003388.
11. Roque AM, Weinberg J, Hohler AD. Evaluating exposure to abuse and violence in neurological patients. Neurologist. 2013;19(1):7-10.