Migraine is second only to stroke as the leading contributor to disability-adjusted life-years globally. Studies suggest greater odds of migraine in presumably cisgender lesbian women, cisgender gay men, and bisexual people of any gender. However, little is known about migraine prevalence and severity in transgender and gender non-binary individuals. Dr. Anna Pace, along with Dr. Grethen Tietjen, Distinguished University Professor Emerita of Neurology at the University of Toledo, Ohio, discussed the purpose of this study and the outcomes of the research.
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Hello, I'm dr Gretchen T gin. I'm a professor emeritus at the University of Toledo and um we are going to be speaking today on an article and I'm going to have my colleague anna Pace introduced the article and summarize it for you. Hi everyone. My name is Dr Anna Pace. I'm assistant professor of neurology and the headache medicine fellowship director at the Icahn School of Medicine at Mount Sinai in new york. Today. We're going to be talking about a really interesting article that I was super excited to see was published in the journal um called migraine migraine disability, trauma and discrimination and sexual and gender minority individuals. So, um as I mentioned, I think this was a really great study and I was actually very excited to see that this was published because there's such a significant um dearth of literature on sexual and gender minority individuals. So this was really refreshing to see that someone finally was looking at um my migraine and disability in sexual and gender minority individuals. So the study by Rosendale and colleagues really sought to determine the frequency and severity of what they termed migrants headache um in sexual and gender, minority adults and also examine the relationship between um history of trauma and or discrimination and how it relates to migraine associated disability. Um one of the things I did want to discuss really quickly before we go kind of delve into the summary is actually what sexual and gender minority individuals, what that term actually means. Um and as an inclusive term. Really used to describe individuals whose sexual orientation or and or gender identity don't align with societal expectations based on their sex assigned at birth. So it's including but not limited to people who identify as part of the L. G. B. T. Q. Plus community. So for the time being we'll just use the term S. G. M. To mean sexual and gender minority individuals. So we already know insists gender women as well as adolescents that there seems to be a link between a history of trauma um and a greater prevalence or increased severity of migraine. But we don't have this data in S. G. M. Individuals who we know have a higher likelihood of history of trauma or discrimination. Things like into personal violence, sexual assault, physical assault discrimination and stigma. So one of the things that this study really looks at is trying to determine for those who identify as part of the L. G. B. T. Q. Plus community. If they have a history of trauma or discrimination, do they also have headaches? Do they meet criteria for migraine? And if so what is their disability related to their migraine headaches? So the study was a cross sectional study. They created a 68 question survey and then sent it to um individuals in the Pride study and the Pride study basically as a national online prospective longitudinal cohort of um S. G. M. Adults and they're looking at basically the physical mental and societal health. Um So it's the largest database that exists currently. And the survey was offered basically to anyone who had a self reported history of headache. And they determined that by a you know general screen screen question and then individuals were identified as having a migrant this type of headache using the I. D. Migraine screening tool. They also then included the midas scale to help quantify migraine related disability. And then they asked questions about whether or not the individual had a history of trauma or discrimination in the past. And they kind of grouped those as kind of three variables either trauma only discrimination only or a history of both trauma and discrimination. And basically what they found was actually of the population um That they were looking at. 52% of those actually screened positive for migrants headache based on the I. D. Migraine criteria. 40% were identified themselves as transgender gender queer or another gender identity and 98.6% reported a non heterosexual sexual orientation. So it was a pretty good um sample of S. G. M. Individuals They found that the gender minority respondents were more likely to have migraine headache. Um and those with Migraine also reported a history of trauma and or discrimination. About 93% of them actually and 72% of them had both those with migraine also were more likely to report a lifetime history of depression, current depression anxiety and PTSD. And this will kind of come up a little bit later when we talk about some of the variables in the relationship with disability related to their headaches, there didn't seem to be a difference in the number of migraine headache days that were reported and those who had a history of trauma and discrimination and those without, but they did find that those who had a history of both trauma and discrimination um had a higher likelihood of having moderate severe disability related to their headaches and that persisted even after adjusting for socio demographic and clinical factors, but not for psychiatric comorbidities. Um, so that kind of raises a number of questions that will hopefully talk about in a minute. Um and the more it seemed that the more the number, the greater number of types of trauma and discrimination was associated with an increased migraine disability even after adjusting for the psychiatric comorbidities. Okay, well, you know, I'm not gonna add anything to that because I thought, you know, you really summarized it beautifully. Um my area of interest and research probably for 20 years. Um one of the things that I've been interested in is trauma, particularly early life stress, childhood trauma, but childhood trauma, in addition to that adult trauma and how that relates in general populations. Um and including the subset of migraine. And I had looked at that in like the ace study as well as in the migraine, a MPP study, american migraine prevalence of prevention study and in the add health study, which was adolescence uh populations and just sort of having reviewed that literature. I thought for people that you know before you sort of say like, okay, so what does this add to the literature? It's nice to just have a little summary of what the literature is. So I thought I just uh talk to that a little bit, you know, um up to 14% of the population is thought to have migraine and you know, the prevalence is in their thirties. And this population, the mean age was, you know, in the mid thirties area. And so I'm not sure that the 33% of the population that we found in this group is that different. But it's not really compared to a group. So we can't really say too much about that in general. I think what really did strike me, what is the percentage of people in that, you know, group migraine that actually had trauma? I mean, you know, 93% or something that's huge. You know, in there was an interesting study that came out in 2018 that was a systematic review when they looked at Club Med and Covid and UNICEF Data Bank UK database. Uh h W the W H O over a 17 year period and there they found that uh 20 to 40% of women depending on the type, had experienced some abuse and mails it was like slower but 13 to 24. So you could say about 2025% of the population report, some history of abuse and uh, you know, trauma has in many studies been associated with trauma and abuse have been associated with migraine and particularly chronic migraine and the high disability. And you had alluded to some of those studies in adolescents and women. Um and the more types of trauma, almost all of them have shown that dose response relationship, the more trauma you have stronger the association. So, uh, you know, that I think was an important finding if they hadn't found that I would have been very surprised. So, uh and within the migrant population, which, you know, most of the studies that have been looked at, you know, they're mostly women. Um you know, it maybe it looks like it's a little higher and the odds ratios are usually in the 1.6 to 2 range for, you know, if you in a migraine group for if you have a type of abuse and it's stronger in certain abuse. The types, like a couple of studies that I looked at, it was really the emotional abuse, which is probably more insidious and more const over time that some of the other abuse types might be. Um and that migraine as, you know, we sort of saw in this study as well is associated with depression, anxiety and PTSD. So that was something that was interesting, but um I think the other thing was is that there have been some studies that I just wanted to mention here when we talk a little bit more that have suggested that it is, you know, I had my studies just looked at abuse and migraine is a relationship. We looked at one with mediation through neuroticism, you know, because that neurotic personality types more common and those that work you stand in my brain to see if it mediated. And I played a small role and most of the studies have controlled for depression and anxiety like this one does. But you don't see uh as many studies on PTSD and migraine, I had done one, it was mostly men migrant workers uh you know that had the association uh to PTSD. But um two studies, one I can think by uh author last name of Raphael, that I think was published in about 2005, was obtained uh investigator and then Todd Smitherman, who's a psychologist that works a lot in migraine. Both of them had reported in different types of studies, but that um they thought that the main association was with PTSD and pain or PTSD and migrate and not in the trauma itself. So, you know, since all people with PTSD have had preceding trauma, that's why it's PTSD. Um but if they looked at those that had trauma but did not have a history of PTSD, they didn't find that there was an association with my greater with pain and that's a little problematic and there's not been many studies that have looked at that. So I think that kind of comes into play when we talk a little bit more about this one. But you know to me with the paper added and I'm certainly not um um an expert in the S. G. M. Populations but um it seemed like it was the first study, at least I know that I had looked at and you can correct me if I'm wrong. But that looked with such detail into all the different groups of both sexual orientation identification and gender identification and really kind of separated them out at least for when they were stratified by migraine uh non migraine headache and no headache. And looking at some of the overall statistics of prevalence in the groups. Um And I thought that also looking at you know the whole thing of trauma and migraine disability and and adding that discrimination thing or actually I think they're discrimination variable was discrimination and harassment. But given that this group, you know probably experience discrimination on a very regular basis. Um I thought that it was you know interesting and really I'd like to know more about that since they didn't find discrimination by itself to be a variable that was associated with migraine disability. So I sort of took away the main findings being that migraines really common amongst adults and that the experiences with trauma and discrimination together is associated with increased migraine disability and that that dose response relationship is there and that the number of trauma experiences and their discrimination really strengthen the association and of trauma and discrimination with the migraine disability even when they adjusted for the psychiatric comorbidities. And that you know certainly in this population that looked like psychiatric comorbidities play a really significant role. But I think that that's true of most things. And until you compared a group like this to uh you know a control group which of course wasn't a control study in that respect. It was all everybody was S. G. M. That was in the study. It would be really interesting to see you know what the differences might be compared to you know cis gendered uh individuals. Um people with a heterosexual orientation completely agree. I think you know one of the things that I found um really great about this study is that it did look at a number of different people who identify across the spectrum of gender identity and sexual orientation which we really don't have in neurology data or headache data at this point. Um And the you know as you mentioned the the predominant population that was studied in the study where um S. Gm. Individuals I think there was only one person who identified as heterosexual or cis gender. Um So the population really is uniquely S. G. M. Which is you know again I imagine many of us are seeing a lot of these patients and don't know um that they may identify in the L. G. B. T. Q. Community. And so one of the other things I wonder is you know for some of these studies that have been done in the past for patients who have a history of trauma PTSD depression, anxiety and high disability with their migraine. How many of them actually. Now if we were to actually ask the question um identify as an S. G. M. Individual. Um And if so how does that how does that change our interpretation of some of these studies? Um You know I think one of the limitations to the study is you kind of already alluded to us. Obviously the complex relationship between migraine and psychiatric conditions and you know the study didn't really look specifically at the incidence of PTSD related to trauma and how that may mediate migraine related disability. I think one of the other things that we do need to acknowledge is that they use the I. D. Migraine screening tool which um from my recollection has a sensitivity of roughly around 80 85% and may have missed patients who have migraine with aura. Um Or for people who you know the question they asked was whether or not headache is limiting their ability to do their day to day routine if that self selected for people who already have a higher likelihood of disability related to their headaches. Um And you know selection bias is another thing to think about here especially because the study was um you know I guess advertised to the pride study participants as one specifically looking at an experience of headache and how it's influenced by a history of trauma. So perhaps the people who were answering had a higher likelihood of history of trauma. Right. Right. I do think though that the fact that you know they were sort of self selecting for with that question for people that had probably higher migraine associated disability. Because if you didn't answer that question you know I mean they only you had to have only two out of three questions. So maybe that was one you didn't have. But on the other hand since you're advertising it like that it probably does self select for people with disability but then they're taking the disability and looking at it associated with trauma which wasn't I don't think in the main question of what they asked. No I think they originally screened for headache first and then if the patient tested positive I guess for the I. D. Migraine then some of the other. So I think they probably you know it was a biased population and as they mentioned in their limitations to do this kind of a study in a similar population but maybe a larger population where that's a subset and you really sort of have a control and you could generalize the findings of a little bit more with it. So I you know, I think that it's a great start but you know you have to start with something like you know with a population. I know that we did one where we were looking at migraine and abuse and wanted to see if there was an association. Well we started with you know, a population of migraine and just looked at types of abuse, how common it was, how frequently the headaches were chronic, how many comorbidities they had. We could do all those things. But what we couldn't say was that migraine was associated with abuse. You know what I mean? Because you didn't have that control group and this is kind of the same thing. You can't say S. Gm is necessarily associated with trauma because you don't have a non S. G. M. Population to other than historical controls to compare to. But you know that the questions they asked I thought was valid questions to answer with the database. It's just that there's more definitely we'd like to see. And one of the other things that I had thought about and uh you know when it came to the whole uh maybe it being a mediator and you know you'd think that if you control for it and you still have some uh you know elevated odds ratio that you'd say well it's partially mediating the relationship between disability and trauma and if it totally disappears. Um as it seemed to in this one, when they looked at disability, migrant disability and trauma, then you'd say, well it does look like it could be a mediator of the relationship, but but you know, there are other kinds of ways to get at that whole mediation thing, which I didn't think that they did recently, there was a study published in a Canadian study, published prospective study published in Children and looking at it uh with abuse and migraine. And one of the things that they did was uh kind of a structural equation modeling, where, you know, they found there was a direct relationship between abuse in migraine and that it wasn't mediated through depression and anxiety for actual abuse types, where if they took, like, just sort of household chaos and dysfunction, they looked at that earlier and they found that that did seem to be mediated by depression and anxiety. And I was interested in that because I had done a study a couple of years ago that we presented the and where we did it in the at health population, um which they were adults at the time, but they had been followed since they were Children. And there we found in the structural structural equation model that um the variable of different abuse types all associated directly with depression associated directly with anxiety, directly with migraine, and that my depression and anxiety didn't mediate the relationship. Um And so that's why with this one, and it's, you know, that they found that they of course, they didn't look at migraine per se. They looked at since it wasn't a control group, but they did look at um the migraine, um what is it, disability, and they did find that it, you know, disappeared, which would suggest that it was a mediator. But I'd like to have seen a little bit more on that, because I think that's kind of a really interesting thing because it's sort of one of the things that PTSD was in the past, away from the trauma to the PTSD to migraine as as they applied what if they had done it, where they looked first at anxiety and depression, maybe they would have found it, maybe they wouldn't have. But then looked at PTSD maybe separately, since that's a really kind of novel way to, we don't have a lot of PTSD and a lot of these studies like this on migraine per se. So, I thought that would have been really interesting to me to make sure they were over adjusting by and losing the significance just because it was already in the, you know, the pathway. So, yeah, I mean, I think this is a great start, and especially given the lack of data that we have on SJM individuals and neurology and headache in particular. Um but I think it has opened up a lot of opportunity for future research to really kind of delve as you suggested a little bit further into the complex relationship between some of these psychiatric comorbidities, gender minority stress which has been discussed as possibly related to increased disability in these patients and the you know, the incidence prevalence and severity of migraine. Um you know the I think one of the things that we can kind of take home as part of the study as providers is really thinking about our patients who um you know have a history of trauma, whether they're cis gender or identifying as part of the L. G. B. T. Q. Plus community as well as some of the you know, discrimination events as well as barriers to access to care and how we as providers can really think about these as well as you know, think about how it may affect their perception of their migraine, their disability, their ability to work to go to school um to socialize and those kinds of things. I think it's just a nice reminder of thinking about the whole person and not just migraine itself when we're thinking about treating them. Um and just having this data, I think to start is a really great place for us to kind of you know, really ponder what else could be at play for these patients when you know, they're experiencing migraine frequently or very severely and what we can do as providers to really help address all of the the contributors to or potential contributors to their migraine disability. Yeah I think so and I think that you know a couple of things that I was thinking of that as from a clinician standpoint is um you know since you're right you have to screen for because if you don't know the person uh you know is in in S. G. M. Community then you may not be thinking as much about the right questions to ask. But I think since trauma is so common in particular and you know to assure that people when we see them to ask about it and to make sure that they're living you know that they have a safe living environment, a safe working environment because a lot of people don't ask about that and uh you know I think that that's something where just being asked about it you know you they have to make their own decisions but sometimes there are things that they could potentially alter at least in their home environment. But I think the other thing too I was thinking about is that both discrimination and trauma. I mean those are really stressful experiences and these people it probably uh you know can be a regular occurrence, maybe it's been an occurrence through their whole lives. You know it doesn't really delve into it. Um And so I think that um prescribing therapies besides pretending for migraine of course but also make sure to include therapies for stress management whether it be mindfulness based stress reduction therapy or some other cognitive behavioral therapy which you know, is effective in migraine. But um I thought that that would be something that, you know, would probably be something that might help them from of managing their own stress so that it doesn't have such a bad physiologic effect on them because that affects the health of the rest of your life. And the other thing too is that, you know, it's it's well known that people that have experienced a lot of traumatic events early in life, uh you know, the data shows that their life expectancies are lower and if, you know, if they have like more than six aces uh adverse childhood experiences, they have a 20 year decrease in their life expectancy. Now, some of it's because of the physiologic effects it has on the body and you're more prone to afro sclerosis and hypertension and some of those things. But another, I think big part of it is that people who experience a lot of trauma and uh potentially stressful discrimination is that they have a lot of health behaviors that are very uh you know, unhealthy or you know, their behavior role risks, like smoking is higher substance abuse is higher and populations that have experienced trauma and post behaviors reckless driving, you know, just putting themselves at risk and that, you know, is one of the reasons why a lot of uh you know, there's a higher mortality at a younger age in those populations. So I think that it's really important to probably screen for some of those things as well. Um, and you know, they did mention that depression, anxiety, PTSD maybe are potentially modifiable risk factors um, for, you know, their migraine and migraine disability, you know, we don't even know that in regular popular, you know, general populations, if we, you know, just control there, we do it, but if we just control the depression and control their anxiety better, will that make the actual migraines better? But I think it's something that's a really good question that they were asking for that. One of the things that I thought about, uh, the, when we were talking about, um, some of the other things of what we'd like to see next in the research was, I would have loved to have heard a little bit more, you know, they had a really broad question of just, um, you know, their trauma, but really know, like the different types of trauma play a role in affecting their migraine, the severity of the migraine severity of the disability severity of the depression, anxiety and all that kind of thing. I would have liked to have known more because it really does look like in other population studies, that it does play a role, certain traumas are worse and also the severity the frequency of the trauma. I think they did get that at that a little bit uh, you know, the age at which the traumas occur make a difference. And the perpetrators of the trauma that they have a good support system. You know, maybe trying to do things like building resilience. Are they resilient individuals? Can we, you know, test that and and sort of capitalize on that. Um, and also to know if in these populations do certain treatments work better than others. You know, they do better if you treat their depression anxiety and give them stress reduction techniques than, you know, in addition to their migraine remedies rather than just treating migraine by itself, Do they need more? So, um, I had done a study once where we looked at, we had a group of all migraine and so we looked at and we took all the ones that had depression since it was a large part of the group since it was a headache clinic based studies. So, you know, a lot of patients are depressed. So we took all these patients that had depression and migraine. But I wondered if those that had experienced trauma early in life compared to those that had not if they were different, you know, cause they both had depression and migraine. And it was not not too big a leap to find out that faith that they had the group that had uh the abuse history, they had more severe depression, more hospitalizations for depression. Depression occurred earlier and the same with migraine. More severe migraine. More refractory migraine younger age of onset of migraine. Um And you know anxiety too. And I just think that you know we really sort of start have to start looking at some of these factors combined together and see like are the treatments does it make a difference in treatment? You know, were away a ways away from that there. But I think that that's how we can really probably help people once we identify these things as if we you know, know the answers to some of those questions. Absolutely. I mean clinically when I have patients who identify as transgender who tell me a bit about their trauma history or history of discrimination and stigma. Um I do find clinically that the combination of pharmacologic therapy for their migraine as well as non pharmacologic therapies such as CBT mindfulness based stress reduction. Um And those kinds of things really can be incredible helpful um In terms of improving quality of life reducing migraine related disability. I mean obviously that's just anecdotal but I can imagine that employing a um you know multidisciplinary multimodal treatment plan for these patients would be ideal. Especially you know in light of some of the information that's been presented as part of this study. Um I think really just the biggest thing is that they the investigators looked at the S. G. M. Population it's we need to do better at including these individuals in our trials and in our studies that we can actually get a better assessment of their you know primary headache experiences as well as their non headache experiences. And actually as you suggested compare to this is gender population to really know are they experiencing more trauma? Different trauma. Is that really affecting their headaches more significantly than we realize? I wouldn't be surprised if they were, but I think this is just one big step and really just at the very basic including these individuals in a study so that we can really understand how to help them. It's a it's an important study I think uh you know when they acknowledge that they've got so many other things that they could you know look at and add to. But uh I think it was a great a great start for getting people interested and aware of um you know some of the things affected this particular population and as you said a lot of us see people see people with migrate and we don't really know anything about their uh gender identification or sexual orientation and you know knowing that especially if that looks like that is associated with it, I would think it would be more discrimination in the workplace and in their families even that you know knowing the effect that that has and I think it's probably mostly through you know stress related things but you know there may be some hormonal things as well um in these populations that affect that have affect some things, like having. Absolutely. Did you have anything else that you wanted to add? Um I don't think so, I think we covered quite a bit, I think, you know, it just hopefully will um spark interest in a lot of the people who are reading this article to think about um the STM population and hopefully include them and more studies and trials going forward, as I said, so we can really just better understand their experience of headache and really help them um, you know, and cater their treatment plans based on some of the factors that could be contributing. Um you know, I think there's just a lot of opportunity here that comes out of this study, so hopefully more and more will uh, come about from this and we can um continue to move forward and create more inclusive practices as part of our research. Well, thank you for doing this with me and it was really a pleasure talking with you about this study uh and I learned a lot from you through the course of just doing this. It's nice to get another perspective. I learned a lot from you as well. And so thank you very much for having me and I really enjoyed this conversation. Bye bye.
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