Adolescent survivors of terrorist attacks appear to have a substantially increased risk for persistent weekly or daily migraine and tension-type headache, new research suggests.
The results may also apply to individuals who have experienced other violence or continual stress, and healthcare professionals should be aware of the connection, the authors note.
The research involved questioning survivors of the 2011 Norwegian terror attack, when a gunman opened fire on a summer camp for teenagers on the island of Utøya, killing 69 people.
Results showed that survivors of the attack were four times more likely to experience regular headaches than controls, after adjustment for many other factors, including post-traumatic stress.
“Individuals who had headaches before the attack had more frequent headaches after, and those who didn’t have regular headaches before were more likely to develop them after compared with matched controls,” lead author, Synne Stensland, MD, Oslo University Hospital, Norway, told Medscape Medical News.
“While some of the headaches could be related to post-traumatic stress, which was six times higher in this population than in a regular population, when we adjusted for this we still we saw a strong relationship between previous trauma and headaches. So we don’t think this is just a result of depression and anxiety.”
The study was published online December 13 in Neurology.
Pain Threshold Lowered
The researchers believe the mechanism may be due to the brain becoming hypersensitive to other stimuli after trauma.
“Violence and other gruesome experiences appear to gear the brain up so it becomes more sensitive to various triggers and the threshold for migraine and other pain is lowered,” said Dr Stensland.
“The reason we wanted to look at this is that headaches may go under the radar in this sort of population. These individuals often have so many other problems they may not report headache,” she added.
For the study, the researchers invited the 358 survivors (aged 13 to 20 years) of the Norwegian attack to participate in the Utøya interview study. Among the 213 (59%) respondents, half were male, the mean age was 17.7 years, and 13 (6%) were severely injured.
For each survivor, 8 matched controls were drawn from a population-based study. Interviews took place 4 to 5 months after the mass shooting, and for the current analysis the main outcome was migraine and tension-type headache over the past 3 months measured with a validated headache questionnaire.
After exposure to terror, the odds ratio for migraine was 4.27 (95% confidence interval [CI], 2.54 – 7.17) and for tension type headache it was 3.39 (95% CI, 2.22 – 5.18), as estimated in multivariable logistic regression models adjusted for injury, sex, age, family structure and economy, prior exposure to physical or sexual violence, and psychological distress.
The observed increased risk for headache in survivors was related largely to an increase in weekly and daily headaches.
These results suggest that physiologic and somatic problems can continue for many months after the trauma, Dr Stensland noted.
“We need to work on improved integration of physiological and physical care for patients after trauma. While most healthcare professionals will be on the lookout for psychological problems in this situation, they may not be aware that physical problems, such as headaches, can also be increased,” she said.
“Also we need to understand that the occurrence of an increased frequency of headaches in adolescents could be the result of a previous trauma. In the current study the trauma was well known but there will be people who have suffered a trauma and not told anyone or their doctor will be unaware of it. These patients may benefit from more than just the usual headache medication. They may also need psychological help,” she added.
Long-term Impact
In an accompanying editorial, Geoffrey L. Heyer, MD, Nationwide Children’s Hospital and The Ohio State University, Columbus, and Kenneth J. Mack, MD, Mayo Clinic, Rochester, Minnesota, suggest that chronic daily stressors may also cause increases in headaches.
They explain that the brain responds to potential and actual stressful events by modifying behaviors and by activating hormonal and neural mediators, including increased sympathetic output and increased cortisol production, leading to increased arousal and potential changes to the dopamine serotonin and β-endorphin systems.
“While the response to each day-to-day stressor may be subtle, changes over time can accumulate, leading to new steady states that may be adaptive or maladaptive. Long-term forms of stress can alter hormone function, activate an inflammatory response, and even cause epigenetic changes.”
The study, they note, shows that a single exposure to a horrific event can have long-term effects.
“The specific physiologic changes that lower headache threshold after trauma are not yet known. With follow-up, this group of survivors may help us understand how the stress of terror affects headaches and other somatic symptoms long-term.
“Given the unfortunate frequency of these events in our modern world, further research is needed to characterize the harmful effects of trauma and to find ways to mitigate them,” they write.
The study was funded by the Norwegian Directorate of Health and theNorwegian Research Council. The authors and editorialists have disclosed no relevant financial relationships.
Neurology. Published online December 13, 2017. Abstract, Editorial
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