Trusted source? The Conversation tells migraine sufferers that child abuse may be at the root of their problems

Patients and family members face a challenge obtaining credible, evidence-based information about health conditions from the web.

Migraine sufferers have a particularly acute need because their condition is often inadequately self-managed without access to best available treatment approaches. Demoralized by the failure of past efforts to get relief, some sufferers may give up consulting professionals and desperately seek solutions on Internet.

A lot of both naïve and exploitative quackery that awaits them.

Even well-educated patients cannot always distinguish the credible from the ridiculous.

One search strategy is to rely on websites that have proven themselves as trusted sources.

The Conversation has promoted itself as such a trusted source, but its brand is tarnished by recent nonsense we will review concerning the role of child abuse in migraines.

Despite some excellent material that has appeared in other articles in The Conversation, I’m issuing a reader’s advisory:

exclamation pointThe Conversation cannot be trusted because this article shamelessly misinforms migraine sufferers that child abuse could be at the root of their problems.

The Conversation article concludes with a non sequitur that shifts sufferers and their primary care physicians away from getting consultation with the medical specialists who are most able to improve management of a complex condition.

 

The Conversation article tells us:

Within a migraine clinic population, clinicians should pay special attention to those who have been subjected to maltreatment in childhood, as they are at increased risk of being victims of domestic abuse and intimate partner violence as adults.

That’s why clinicians should screen migraine patients, and particularly women, for current abuse.

This blog post identifies clickbait, manipulation, misapplied buzz terms, and  misinformation – in the The Conversation article.

Perhaps the larger message of this blog post is that persons with complex medical conditions and those who provide formal and informal care for them should not rely solely on what they find on the Internet. This exercise specifically focusing on The Conversation article serves to demonstrate this.

Hopefully, The Conversation will issue a correction, as they promise to do at the website when errors are found.

We are committed to responsible and ethical journalism, with a strict Editorial Charter and codes of conduct. Errors are corrected promptly.

The Conversation article –

Why emotional abuse in childhood may lead to migraines in adulthood

clickbaitA clickbait title offered a seductive  integration of a trending emotionally laden social issue – child abuse – with a serious medical condition – migraines – for which management is often not optimal. A widely circulating estimate is that 60% of migraine sufferers do not get appropriate medical attention in large part because they do not understand the treatment options available and may actually stop consulting physicians.

Some quick background about migraine from another, more credible source:

Migraines are different from other headaches. People who suffer migraines other debilitating symptoms.

  • visual disturbances (flashing lights, blind spots in the vision, zig zag patterns etc).
  • nausea and / or vomiting.
  • sensitivity to light (photophobia).
  • sensitivity to noise (phonophobia).
  • sensitivity to smells (osmophobia).
  • tingling / pins and needles / weakness / numbness in the limbs.

Persons with migraines differ greatly among themselves in terms of the frequency, intensity, and chronicity of their symptoms, as well as their triggers for attacks.

Migraine is triggered by an enormous variety of factors – not just cheese, chocolate and red wine! For most people there is not just one trigger but a combination of factors which individually can be tolerated. When these triggers occur altogether, a threshold is passed and a migraine is triggered. The best way to find your triggers is to keep a migraine diary. Download your free diary now!

Into The Conversation article: What is the link between emotional abuse and migraines?

Without immediately providing a clicklink so that  readers can check sources themselves, The Conversation authors say they are drawing on “previous research, including our own…” to declare there is indeed an association between past abuse and migraines.

Previous research, including our own, has found a link between experiencing migraine headaches in adulthood and experiencing emotional abuse in childhood. So how strong is the link? What is it about childhood emotional abuse that could lead to a physical problem, like migraines, in adulthood?

In invoking the horror of childhood emotional abuse, the authors imply that they are talking about something infrequent – outside the realm of most people’s experience.  If “childhood emotional abuse” is commonplace, how could  it be horrible and devastating?

In their pursuit of click bait sensationalism, the authors have only succeeded in trivializing a serious issue.

A minority of people endorsing items concerning past childhood emotional abuse actually currently meet criteria for a diagnosis of posttraumatic stress disorder. Their needs are not met by throwing them into a larger pool of people who do not meet these criteria and making recommendations based on evidence derived from the combined group.

Spiky_Puffer_Fish_Royalty_Free_Clipart_Picture_090530-025255-184042The Conversation authors employ a manipulative puffer fish strategy [1 and  2 ] They take what is a presumably infrequent condition and  attach horror to it. But they then wildly increase the presumed prevalence by switching to a definition that arises in a very different context:

Any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.

So we are now talking about ‘Any act or series of acts? ‘.. That results in ‘harm, potential for harm or threat’? The authors then assert that yes, whatever they are talking about is indeed that common. But the clicklink to support for this claim takes the reader behind a pay wall where a consumer can’t venture without access to a university library account.

Most readers are left with the authors’ assertion as an authority they can’t check. I have access to a med school library and I checked. The link is  to a secondary source. It is not a systematic review of the full range of available evidence. Instead, it is a  selective search for evidence favoring particular speculations. Disconfirming evidence is mostly ignored. Yet, this article actually contradicts other assertions of The Conversation authors. For instance, the paywalled article says that there is actually little evidence that cognitive behavior therapy is effective for people whose need for therapy is only because they  reported abuse in early childhood.

Even if you can’t check The Conversation authors’ claims, know that adults’ retrospective of childhood adversity are not particularly reliable or valid, especially studies relying on checklist responses of adults to broad categories, as this research dos.

When we are dealing with claims that depend on adult retrospective reports of childhood adversity, we are dealing with a literature with seriously deficiencies. This literature grossly overinterprets common endorsement of particular childhood experiences as strong evidence of exposure to horrific conditions. This literature has a strong confirmation bias. Positive findings are highlighted. Negative findings do not get cited much. Serious limitations in methodology and inconsistency and findings generally ignored.

[This condemnation is worthy of a blog post or two itself. But ahead I will provide some documentation.]

The Conversation authors explain the discrepancy between estimates based on administrative data of one in eight children suffering abuse or neglect before age 18 versus much higher estimates from retrospective adult reports on the basis of so much abuse going unreported.

The discrepancy may be because so many cases of childhood abuse, particularly cases of emotional or psychological abuse, are unreported. This specific type of abuse may occur within a family over the course of years without recognition or detection.

This could certainly be true, but let’s see the evidence. A lack of reporting could also indicate a lack of many experiences reaching a threshold prompting reporting. I’m willing to be convinced otherwise, but let’s see the evidence.

The link between emotional abuse and migraines

The Conversation authors provide links only to their own research for their claim:

While all forms of childhood maltreatment have been shown to be linked to migraines, the strongest and most significant link is with emotional abuse. Two studies using nationally representative samples of older Americans (the mean ages were 50 and 56 years old, respectively) have found a link.

The first link is to an article that is paywalled except for its abstract. The abstract shows  the study does not involve a nationally representative sample of adults. The study compared patients with tension headaches to patients with migraines, without a no-headache control group. There is thus no opportunity to examine whether persons with migraines recall more emotional abuse than persons who do not suffer headaches.  Any significant associations in a huge sample disappeared after controlling for self-reported depression and anxiety.

My interpretation: There is nothing robust here. Results could be due to crude measurement, confounding of retrospective self-report by current self-report anxious or depressive symptoms. We can’t say much without a no-headache control group.

The second of the authors’ studies is also paywalled, but we can see from the abstract:

We used data from the Adverse Childhood Experiences (ACE) study, which included 17,337 adult members of the Kaiser Health Plan in San Diego, CA who were undergoing a comprehensive preventive medical evaluation. The study assessed 8 ACEs including abuse (emotional, physical, sexual), witnessing domestic violence, growing up with mentally ill, substance abusing, or criminal household members, and parental separation or divorce. Our measure of headaches came from the medical review of systems using the question: “Are you troubled by frequent headaches?” We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a “dose–response” relationship of the ACE score to the prevalence and risk of frequent headaches.

Results — Each of the ACEs was associated with an increased prevalence and risk of frequent headaches. As the ACE score increased the prevalence and risk of frequent headaches increased in a “dose–response” fashion. The risk of frequent headaches increased more than 2-fold (odds ratio 2.1, 95% confidence interval 1.8-2.4) in persons with an ACE score ≥5, compared to persons with and ACE score of 0. The dose–response relationship of the ACE score to frequent headaches was seen for both men and women.

The Conversation authors misrepresent this study. It is about self-reported headaches, not the subgroup of these patients reporting migraines. But in the first of their own studies they just cited, the authors contrast tension headaches with migraine headaches, with no controls.

So the data did not allow examination of the association between adult retrospective reports of childhood emotional abuse and migraines. There is no mention of self-reported depression and anxiety, which wiped out any relationship with childhood adversity in headaches in the first study. I would expect that a survey of ACES would include such self-report. And the ACEs equate either parental divorce and separation (the same common situation likely occur together and so are counted twice) with sexual abuse in calculating an overall score.

The authors make a big deal of the “dose-response” they found. But this dose-response could just represent uncontrolled confounding  – the more ACEs indicates the more confounding, greater likelihood that respondents faced other social, person, economic, and neighborhood deprivations.  The higher the ACE score, the greater likelihood that other background characteristic s are coming into play.

The only other evidence the authors cite is again another one of their papers, available only as a conference abstract. But the abstract states:

Results: About 14.2% (n = 2,061) of the sample reported a migraine diagnosis. Childhood abuse was recalled by 60.5% (n =1,246) of the migraine sample and 49% (n = 6,088) of the non-migraine sample. Childhood abuse increased the chances of a migraine diagnosis by 55% (OR: 1.55; 95% CI 1.35 – 1.77). Of the three types of abuse, emotional abuse had a stronger effect on migraine (OR: 1.52; 95% CI 1.34 – 1.73) when compared to physical and sexual abuse. When controlled for depression and anxiety, the effect of childhood abuse on migraine (OR: 1.32; 95% CI 1.15 – 1.51) attenuated but remained significant. Similarly, the effect of emotional abuse on migraine decreased but remained significant (OR: 1.33; 95% CI 1.16 – 1.52), when controlled for depression and anxiety.

The rates of childhood abuse seem curiously high for both the migraine and non-migraine samples. If you dig a bit on the web for details of the National Longitudinal Study of Adolescent Health, you can find how crude the measurement is.  The broad question assessing emotional abuse covers the full range of normal to abnormal situations without distinguishing among them.

How often did a parent or other adult caregiver say things that really hurt your feelings or made you feel like you were not wanted or loved? How old were you the first time this happened? (Emotional abuse).

An odds ratio of 1.33 is not going to attract much attention from an epidemiologist, particularly when it is obtained from such messy data.

I conclude that the authors have made only a weak case for the following statement: While all forms of childhood maltreatment have been shown to be linked to migraines, the strongest and most significant link is with emotional abuse.

Oddly, if we jump ahead to the closing section of The Conversation article, the authors concede:

Childhood maltreatment probably contributes to only a small portion of the number of people with migraine.

But, as we will  see, they make recommendations that assume a strong link has been established.

Why would emotional abuse in childhood lead to migraines in adulthood?

This section throws out a number of trending buzz terms, strings them together in a way that should impress and intimidate consumers, rather than allow them independent evaluation of what is being said.

got everything

The section also comes below a stock blue picture of the brain.  In web searches, the picture  is associated with social media where the brain is superficially brought into  in discussions where neuroscience is  not relevant.

An Australian neuroscientist commented on Facebook:

Deborah on blowing brains

The section starts out:

The fact that the risk goes up in response to increased exposure is what indicates that abuse may cause biological changes that can lead to migraine later in life. While the exact mechanism between migraine and childhood maltreatment is not yet established, research has deepened our understanding of what might be going on in the body and brain.

We could lost in a quagmire trying to figuring out the evidence for the loose associations that are packed into a five paragraph section.  Instead,  I’ll make some observations that can be followed up by interested readers.

The authors acknowledge that no mechanism has been established linking migraines and child maltreatment. The link for this statement takes the reader to the authors own pay walled article that is explicitly labeled “Opinion Statement ”.

The authors ignore a huge literature that acknowledges great heterogeneity among sufferers of migraines, but points to some rather strong evidence for treatments based on particular mechanisms identified among carefully selected patients. For instance, a paper published in The New England Journal of Medicine with well over 1500 citations:

Goadsby PJ, Lipton RB, Ferrari MD. Migraine—current understanding and treatment. New England Journal of Medicine. 2002 Jan 24;346(4):257-70.

Speculations concerning the connections between childhood adversity, migraines and the HPA axis are loose. The Conversation authors their obviousness needs to be better document with evidence.

For instance, if we try to link “childhood adversity” to the HPA axis, we need to consider the lack of specificity of” childhood adversity’ as defined by retrospective endorsement of Adverse Childhood Experiences (ACEs). Suppose we rely on individual checklist items or cumulative scores based on number of endorsements. We can’t be sure that we are dealing with actual rather than assumed exposure to traumatic events or that there be any consistent correlates in current measures derived from the HPA axis.

Any non-biological factor defined so vaguely is not going to be a candidate for mapping into causal processes or biological measurements.

An excellent recent Mind the Brain article by my colleague blogger Shaili Jain interviews Dr. Rachel Yehuda, who had a key role in researching HPA axis in stress. Dr. Yehuda says endocrinologists would cringe at the kind of misrepresentations that are being made in The Conversation article.

A recent systematic review concludes the evidence for specific links between child treatment and inflammatory markers is of limited and poor quality.

Coelho R, Viola TW, Walss‐Bass C, Brietzke E, Grassi‐Oliveira R. Childhood maltreatment and inflammatory markers: a systematic review. Acta Psychiatrica Scandinavica. 2014 Mar 1;129(3):180-92.

The Conversation article misrepresents gross inconsistencies in the evidence of biological correlates representing biomarkers. There are as yet no biomarkers for migraines in the sense of a biological measurement that reliably distinguishes persons with migraines from other patient populations with whom they may be confused. See an excellent funny blog post by Hilda Bastian.

Notice the rhetorical trick in authors of The Conversation article’s assertion that

Migraine is considered to be a hereditary condition. But, except in a small minority of cases, the genes responsible have not been identified.

Genetic denialists like Oliver James  or Richard Bentall commonly phrased questions in this manner to be a matter of hereditary versus non-hereditary. But complex traits like height, intelligence, or migraines involve combinations of variations in a number of genes, not a single gene or even a few genes.. For an example of the kind of insights that sophisticated genetic studies of migraines are yielding see:

Yang Y, Ligthart L, Terwindt GM, Boomsma DI, Rodriguez-Acevedo AJ, Nyholt DR. Genetic epidemiology of migraine and depression. Cephalalgia. 2016 Mar 9:0333102416638520.

The Conversation article ends with some signature nonsense speculation about epigenetics:

However, stress early in life induces alterations in gene expression without altering the DNA sequence. These are called epigenetic changes, and they are long-lasting and may even be passed on to offspring.

Interested readers can find these claims demolished in Epigenetic Ain’t Magic by PZ Myers, a biologist who attempts to rescue an extremely important development concept from its misuse.

Or Carl Zimmer’s Growing Pains for Field of Epigenetics as Some Call for Overhaul.

What does this mean for doctors treating migraine patients?

The Conversation authors startle readers with an acknowledgment that contradicts what they have been saying earlier in their article:

Childhood maltreatment probably contributes to only a small portion of the number of people with migraine.

It is therefore puzzling when they next say:

But because research indicates that there is a strong link between the two, clinicians may want to bear that in mind when evaluating patients.

Cognitive behavior therapy is misrepresented as an established effective treatment for migraines. A recent systematic review and meta-analysis  had to combine migraines with other chronic headaches and order to get ten studies to consider.

The conclusion of this meta-analysis:

Methodology inadequacies in the evidence base make it difficult to draw any meaningful conclusions or to make any recommendations.

The Conversation article notes that the FDA has approved anti-epileptic drugs such as valproate and topiramate for treatment of migraines. However, the article’s claim that the efficacy of these drugs are due to their effects on epigenetics is quite inconsistent with what is said in the larger literature.

Clinicians specializing and treating fibromyalgia or irritable bowel syndrome would be troubled by the authors’ lumping these conditions with migraines and suggesting that a psychiatric consultation is the most appropriate referral for patients who are having difficulty achieving satisfactory management.

See for instance the links contained in my blog post, No, irritable bowel syndrome is not all in your head.

The Conversation article closes with:

Within a migraine clinic population, clinicians should pay special attention to those who have been subjected to maltreatment in childhood, as they are at increased risk of being victims of domestic abuse and intimate partner violence as adults.

That’s why clinicians should screen migraine patients, and particularly women, for current abuse.

It’s difficult to how this recommendation is relevant to what has preceded it. Routine screening is not evidence-based.

The authors should know that the World Health Organization formerly recommended screening primary care women for intimate abuse but withdrew the recommendation because of a lack of evidence that it improved outcomes for women facing abuse and a lack of evidence that no harm was being done.

I am sharing this blog post with the authors of The Conversation article. I am requesting a correction from The Conversation. Let’s see what they have to say.

Meanwhile, patients seeking health information are advised to avoid The Conversation.

5 thoughts on “Trusted source? The Conversation tells migraine sufferers that child abuse may be at the root of their problems”

  1. Disclaimer: I would like to emphasise that I have not actually carried out research on the correlation between reliable neuroscience and pictures of glowing brains, although I would be willing to give it a go.

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