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.
I met Kimmie the day before her 40th birthday, when she came to my clinic seeking treatment of “nonstop” headaches. Kimmie worked part-time directing a local nonprofit, when not chasing after her 2 daughters. Her husband, like many professionals in her affluent community, was a “finance guy”, who took the train to the city and came home late. While obtaining her history, I asked Kimmie if headache was the only pain she experienced. Her response was succinct and well-rehearsed.
“No, I have 8 separate pain disorders: chronic migraine, TMJ disorder, costochondritis, irritable bowel syndrome, interstitial cystitis, vulvodynia, plantar fasciitis, and fibromyalgia. I’ve begun calling them The Hateful Eight, like that Quentin Tarantino movie—I’m a huge Quentin fan. I need help with the blinding headaches. I have other doctors for the other pains. And just so you know, I’ve tried all the pain meds out there—nothing works—they all seem to just bounce off me.”
Further History
I set my laptop aside and asked a series of delicate questions. Kimmie’s initially halting answers coupled with tears were, sadly, so common in my practice that any other response would have surprised me. Thus, began her treatment in earnest.
Kimmie told me that her childhood, which appeared idyllic to an outsider, was chaotic. Her father was a verbally abusive and unpredictable alcoholic; her mother was cold and distant. From age 9 to 12 she was repeatedly sexually assaulted by her 2 older brothers. In college she was again sexually assaulted, on a first date and told no one. Finally, while Kimmie was away in grad school, her younger sister, who was suffering from untreated depression, committed suicide. Through all of this, Kimmie forged on, excelling academically and in sports (she was a champion fencer in college), landing a lucrative, high-stress job, marrying “the perfect guy,” and giving birth to 2 beautiful children. But the pain, everything always came back to the pain. Since early childhood a myriad of uninvited agonies arrived 1 by 1, until there were 8 controlling her life. Eventually, she could scarcely remember a day without these constant companions—The Hateful Eight.
Kimmie had unexplained belly pain throughout elementary and middle school. She remembers her pediatrician telling her she had “spastic colon” and recommending increased fiber in her diet. She missed countless school days due to widespread somatic pains and was even diagnosed with seronegative juvenile rheumatoid arthritis for a while.
Kimmie’s headaches began, as her mother’s had, just before menarche. Throbbing waves of pounding pain accompanied a queasy stomach, waking her many nights a month, dragging her to the bathroom she shared with her brothers. She was accused of faking her symptoms to get out of school. Before she turned 15, she was averaging 15 or more headache days a month. She always had an over-the-counter combination of acetaminophen and caffeine with her and took it many times per week. Other pains and other diagnoses, made by various specialists, accumulated over the years.
Diagnosis and Initial Treatment
Kimmie’s headache diagnosis, by International Committee on Headache Diagnosis 3rd edition criteria, was straightforward: chronic migraine, (CM) with the modifier of medication-overuse headache (MOH). In a vacuum, the treatment was equally straightforward, consisting of education about MOH, discontinuation of the overused medications, a migraine preventive treatment with high quality evidence for CM, and optimization of acute therapy.
Despite the relatively straightforward treatment for CM described, we didn’t start there. Instead, I told Kimmie that her Hateful Eight was actually a Hateful One—a widespread centrally sensitized pain syndrome manifesting, quite literally, from head to toe because of her prior trauma. I relayed to her the fable of blindfolded physicians, each feeling a different part of the elephant, and reporting their findings in isolation. Likewise, I said, all the neurologists, rheumatologists, gastroenterologists, urologists and other specialists with whom she had consulted over the years were only reporting on “their” body part, in isolation, without taking a step back (or removing the blindfold, as it were) to put the pieces together. It took a while, but Kimmie seemed to grasp what I was saying. An action-oriented person, her first question was, “Okay, assuming what you’re telling me is true, what’s our next step?” “It’s a difficult process”, I told her, “And we still don’t have it all sorted out, but we have to begin.”
I connected Kimmie with a local psychologist experienced in trauma for CBT and EMDR. In addition, she agreed, grudgingly, to a trial of duloxetine, buying into it after I told her it was approved for the treatment of several physical pains as well and psychologic conditions. We discussed diet, hydration, exercise, and stress management. Only then, did I provide MOH education, and we worked on a plan to reduce use of over-the-counter headache treatments. Kimmie agreed to try prazosin, an alpha-1 blocker, to help with sleep. I sent her on her way with an 8-week follow-up appointment.
Follow-Up
When she arrived to see me 2 months later the difference in Kimmie was palpable. She seemed more relaxed and happier, with a delightful smile adorning her visage like a red jewel. She admitted that it had been tough going—particularly the EMDR sessions. She had cried a great deal over the last months, but the dark, faceless feelings had all but stopped, and she had learned how to focus on her breathing and turn her attention inward, without fear, to areas of her mind she had not dare to explore previously.
“And your physical pains?” I asked. “The Hateful Eight?” “Some are better, and few are gone”, she replied. “I’d say The Hateful Eight has been replaced by The Unpleasant Three. My jaw is still tight, my neck sore, and the migraines—I kept track of those. I’m down to about 8 a month. Mostly around my period, just like my mom, but other scattered ones as well.”
Moving Toward Peace
By the time Kimmie returned, having been through psychotherapy, detoxification from over-the-counter migraine treatments, and 2 months into pharmacotherapy, she was finally ready to address the condition for which she sought treatment in the first place. Her past sorted, she was ready to embrace a better future. Her mind, that unseen lattice, was learning to be at peace, allowing us to focus on her brain, her primary headache disorder, and the quieting of trigemino-cervical sensory afferents. With the difficult part out of the way, treating her migraines would be a piece of cake.
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
