Military Sexual Trauma, PTSD, Chronic Pain, and Migraine in Veterans

Please note that this episode contains discussions of PTSD and Military Sexual Trauma. Some listeners may find this content sensitive or triggering. We encourage you to listen at your own pace and prioritize your wellbeing.

Melissa Farmer-Hill:
Welcome to Taking Charge of Headache. This is a space where we talk honestly about headache disorders and migraines, not just as diagnoses, but as lived experience shaped by trauma systems, identity, and access to care. My name is Melissa Farmer-Hill. I am an Army veteran. I live with migraines and I am the founder of the Shero Coffee Club.

Today, we’re talking about an intersection that often goes unnamed: military sexual trauma, PTSD, and headache disorder or migraine. For many veterans, particularly women, these conditions don’t exist in isolation. They interact, compound one another, and are frequently misunderstood or dismissed. We’ll begin with clinical grounding and then move into lived experience and community leadership.

Katy Oakley:
Thanks so much, Melissa. And hi, everyone. My name is Katy Oakley. I’m the CEO and Executive Director of the National Headache Foundation and I am so happy today to have an expert on the call with us. Dr. Duren Michael Ready is board-certified in family medicine and in headache medicine. He has extensive experience working alongside veterans who have been impacted by trauma, PTSD, and complex neurological conditions. His work really focuses on how trauma affects the nervous system with pain processing and long-term health, particularly for communities that have historically been underserved or misunderstood. What’s so great about Dr. Ready is that he brings a trauma-informed and veteran-centered lens to migraine and headache care, which is exactly what we’re here to talk about today. I’d love to kick things off by saying, we see this pattern again and again with women veterans who’ve experienced military sexual trauma or PTSD and also of reoccurring migraine or headache attacks.
Can you share with us why that is? What’s happening in their bodies for this to be the case?

Duren Michael Ready, MD:
Well, there may be kind of a common pathway, but the idea as to why people have migraine is that they have a hypersensitive, hypervigilant nervous system. We see in our studies, people with migraine, they’ll see light before people. They hear sounds. They’ll smell before other people. It’s like the volume is turned all the way up. And so, you’ll have individuals who are born that way. We know four out of five people with migraine have that first-degree family member with migraine. And then when you look in a military setting, the signature injury out of Iraq and Afghanistan was TBI, head trauma, whether direct blow or blast wave. And when you have that happen, you can set up a type of brain that is now sensitive. Say mama or daddy didn’t have migraine, but as a result of the head trauma, my brain has changed to where it is now sensitive. So, you have this fertile ground where individuals can have disabling attacks of headache.

And like I tell people with migraine, you will never hear me tell you that you are stressed out. You may be stressed out. That’s not the issue. The issue is this hypersensitive nervous system that is wired to have a bigger response to a stress. I’ll say your thinking brain sees a cat, but your migraine brain reacts like it’s a tiger. So, you’ve already set up this hypervigilance. And then if you encounter another situation, that will produce the vigilance, and a traumatic exposure can be it. Because I tell people, well, I’ll fall back. I’m a foundational guy. And I found one of the things that’s very helpful is an observation that Marcus Aurelius had, one of the philosopher kings, and that was “everything that happens happens as it should, and if you observe carefully, you will find this to be so.” Now, what I take that to mean is there’s a pattern. Like if this happens, we’re not surprised if this follows. And we know the brain’s number one job is survival, getting you into tomorrow to live another day.

And it’s thought in a great many cases, people will develop what we call post-traumatic stress when there was a traumatizing event, either a single event or low-level threat over time where the brain goes, huh, danger. And you didn’t recognize it. So, my solution, crank your sensitivity up even more, your vigilance even more, so there will be no way that you will miss this. And a consequence of that heightened vigilance is it’s very taxing on the body, disrupting sleep, bringing about more headache attacks.

And then depending on what the trauma was, it can have a greater meaning. Like often, I’ll be the first person to ask someone in a practice, say, when you were younger, did anyone ever hurt you? And they’ll say yes or no. And I’ll say, were you able to tell anyone about it? Then they may say yes or no. And if they say yes, then I’ll ask, were you believed? And I’ll have a few patients say, I told mom, but she didn’t believe me. She chose boyfriend over me. And then I’m going, gosh, I’ve never had an experience like that. But I don’t know what’s the greatest trauma, the assault or the one person in the world who’s supposed to protect you from the world didn’t protect you. Then you go, oh my god, all of my protection is on me. And so, you have that vigilance cranked up even more.

Now, in the presence of migraine, how this can be a particular challenge is that I’ll always ask my patients, why do you have migraine. And I’m wanting to expect back from them I have a sensitive brain that doesn’t tolerate change. And they need to know that because that means I’ve got to keep a regular schedule, go to bed at the same time, get up at the same time, not skip meals, stay hydrated. But that brain can be provoked into a disabling attack of pain with stress. Stress didn’t cause it because everyone has stress, not everyone has migraine. But in that person with that hypervigilant nervous system, if a stress comes, the brain will say, no, I don’t want this. And the brain will choose physical pain over psychological distress.

Now, that’s not a conscious choice, but the brain will say, I’ve got to take their mind off of this stress, whether it was something that reminded them of it, around an anniversary date, something similar that they read about. The brain will go I can’t let you go there, and the only way I know to draw your attention is to give you something that you were wired to reflexively pay attention to more than that. Because when your head’s killing you, you don’t care about the stuff that’s bothering you. And we know that stress can do this because if you take 100 people with migraine, 100 people with low back pain, 100 people with irritable bowel symptoms, and you stress them, the people with migraine get more migraine attacks, the people with low back pain get more low back pain, people with IBS get more IBS symptoms. So, it is established that stress will bring about physical pain.

Melissa Farmer-Hill:
Wow. Dr. Ready, thank you. Thank you for that. Especially when we talk about just stress, the nervous system, and just being hypersensitive. Now, are those considered triggers? And if they are, because that could remind someone of their trauma, how can a person change the way they feel about their body when these things start to happen?

Duren Michael Ready, MD:
Well, I think the most important thing, it’s finding out what’s going to work for someone. But a big driver I believe of the hypervigilance is your brain does not know that it’s safe. You may be safe. You may have the biggest dog in the world. And you may have the sufficient warning systems, but your brain doesn’t know that. So, we have to find ways of sending it safety signals. And also recognize, in a sense, don’t beat yourself up. The only way to get it to not run this program is to write a new one. But that has to be built on, I am safe. If there is a threat that comes up, I can accept that and respond to it. But I also have to recognize I cannot guarantee safety in every circumstance. So, in a great many things, we do have to be willing to accept some risk, but I know that for the most part that’s not a threat.

Katy Oakley:
That’s so interesting. I’d love to dig deeper into the PTSD symptom side of it. Things like hypervigilance, poor sleep, flashbacks, how do those things end up affecting someone who is having migraine attacks? And how does it impact the attacks?

Duren Michael Ready, MD:
Well, when it looks at migraine, I’ve never been a big fan of, say, trigger chasing per se, because I think triggers declare themselves. I do this, I get a headache. Well, don’t do that. I like to think of it more along the lines of vulnerability. What makes you more vulnerable for a provocation or a trigger like a weather change or a menstrual cycle or an anniversary date to bring on an attack. And I look at this as sleep is really our foundation, because if you can get blood to a part of the body and if you can sleep, you’re going to heal almost anything. And that’s what we really want to do. But where both migraine and post-traumatic stress worsen sleep are through the heightened vigilance. Like the best way that we understand sleep, it’s known as a two-process model of sleep, a Process S and a Process C. Process S is your sleep drive. That’s the longer you’re awake, the more sleepy you are because our receptors, adenosine binds to them, and the longer we’re awake the more adenosine, you go to sleep or take a nap, the adenosine falls off.

But getting to sleep is not just having enough sleep drive. The Process C, stands for circadian rhythm, is how awake or alert the brain is at any one particular point in time, also kind of low first thing in the morning, then builds peaks around mid-afternoon, and then starts to drop off. And when you have the greatest delta or difference between your drive and alertness is when we say the sleep gate opens and we’re able to fall asleep. And then the sleep drive falls off, the alertness kind of hits a trough until it repeats again. So, people can be very, very tired, have a high sleep drive, but because of that heightened vigilance, you don’t have enough of that delta to get to sleep. Or even if you do fall asleep, you burn off your sleep drive so rapidly, you can’t get back to sleep.

So, the post-traumatic stress, your brain is going, what are you doing? Wait, I can’t let you go to sleep. Wait, if you go to sleep, we’re not on guard. This is a dangerous world out there. I got to keep us safe. I can’t let you go to sleep. And so, you’re lying in bed and then that happens enough and you start to lose the association of bed, sleep, bed, sleep. Now, similarly with migraine, with that heightened alertness, oh, if I’m aware of that, I must need to pay attention to it. So, the alertness kind of naturally goes up.
And then you see if there are nightmares, my gosh, who’s going to want to let go if you know what’s waiting for you. So, you have that kicking back into the vigilance. And then you have this platform of poor sleep to where you start having more migraine headache attacks because of the poor sleep.

Melissa Farmer-Hill:
I’d like to get into like the cost of dismissal. So, like when someone is told that their migraine is, oh, it’s just anxiety. Oh, you know, it’s just PTSD. They kind of blow it off. What kind of impact does that have physically and emotionally?

Duren Michael Ready, MD:
Well, it’s interesting. And I try to redirect patients if I can, because I’ll tell them I’m in the believing business. Because I can scan your head. It’s not going to show me why you’re having migraine. So, I can either accept that you’re having disabling attacks of pain, or say, gosh, we can’t find anything wrong with you. It must be in your head. Well, of course it’s in your head. Everything’s in your head. Your brain controls everything, your breathing, your heart rate, your perspiration. That’s like saying water’s wet.

And so, I do think if people are coming from an environment where they’re not believed, there can be a tendency to embellish symptoms, like to make them bigger. And I try to point that out. I had an example I used to give when people would come in and say, my pain’s a 15 on a 0 to 10 scale, or it’s a 20. And I’ll ask, okay, what happens when you pour a 20-ounce Coke into a 12-ounce glass? Well, I got 12 ounces of Coke and an 8-ounce mess. So, when you’re telling me your pain is over what it can maximally be, that’s telling me you’re having a big psychological response to the pain. And that’s not blaming. It’s just saying that’s telling us we’ve got to work on this because we will be able to get through this. And I believe you. Now, other people may not, but we can count that in a way as a blessing.

And people with migraine do not have these physical signs. Like if there’s a burn scar or an amputation that, oh yeah, I see migraine in you. And so, I readily accept that there are things I cannot see, but they are there. You can’t see the wind, but it’s there. I can see stuff the wind’s blowing around, but I can’t see the wind. Same way I can’t see electricity, but it’s what’s powering everything we have. So, I try to reassure them that I believe you, but we may not be able to have everyone understand this and that’s okay

Katy Oakley:
I couldn’t agree more i mean it’s an invisible disease that so many people feel very misunderstood. And sometimes they don’t even really understand what’s going on in their own body and what’s causing it. Which is actually a perfect lead into my next question which was for the people who maybe don’t understand what’s happening and don’t understand that this could be a trauma response, it’s not a weakness, it’s not something that they’re causing, how would you respond to that?

Duren Michael Ready, MD:
Well, I definitely tell them it’s not a weakness, but we have to work to try, what can we do to recover?
And I think there is a particular balance where this is very important, especially in victims of sexual trauma, because it’s like, as you mentioned, I’m a family physician by training. I just have a special interest in headache. And I believe almost all successful societies are built around family. And very often those families’ intimate relationships are very important. And many breakdowns of bonds have occurred when people have difficulties engaging in intimacies. And so, if the intimacy brings back the memory of a trauma, it’s very hard to engage in that.

So, this is a goal that kind of has to be worked on, but nothing like this is something that can be forced. But it’s also, it’s like there’s an old saying, if you want a hard life, do easy things. If you want an easy life, do hard things. But the way I look at it is that if you commit to the work, over time, friction between the boulder and the mountain are going to wear both down. So, the only way the work gets easier is that if you commit to the work, and if you don’t do it, then you’re getting harder. It will be harder to start.
And it’s not right, it’s not fair, but it’s saying, how do I heal. And I need to go about healing. Because the world needs you as a person. No one can do what you can do in your life, your family, the connections you have. And so, to get there, I have to be willing to do those hard things. Because I’m going to be the only one who can do them. And I’ll tell people, I’m your coach. I can guide you. I can cheerlead. But you’re the one pushing the boulder.

Katy Oakley:
Yeah. Yeah, absolutely. I’ve got one last question for you. We know healing takes capacity and pain takes a lot of that. So, what does chronic pain do to somebody who is trying to engage in trauma therapy, long-term healing? Can you speak to the chronic pain element that folks, especially veterans, especially women, who are living with migraine attacks, who have had PTSD or MST, and how that impacts their long-term healing?

Duren Michael Ready, MD:
If you’re in therapy, and let’s say like a common therapy technique could be EMDR, eye movement reprocessing, or it can be exposure therapy, depending upon the trauma, and you’re starting to make a breakthrough, the dumb brain may go, oh, hell no. I’m not going to let you get anywhere near there. And so, what tool do I have to keep you from getting near there, from opening the Pandora’s box, the best tool I have, pain. Because I know reflexively the brain is wired to pay attention to pain more than anything else. Because the brain only understands pain as a threat. And when there’s a threat, you better pay attention to it because it’s a threat. So sometimes I will pass on to my patients that when you’re working at healing, you may see an expected increase in pain. And that’s just your brain reflexively saying, I don’t know that you can do this. It’s trying to do it to protect you, but this is where you have to use your conscious mind to guide or I say you use your thinking brain to guide your acting brain to say, no, we’re safe, while we’re also working on sending safety signals to it.

Katy Oakley:
A lot going on all at one time. It’s really great information. I’m so glad that we had you here today to be able to give your expertise because it’s such a complex topic. And I love your analogies. I feel like it really paints a really important picture for listeners out there who may be struggling.

Melissa Farmer-Hill:
And I just want to say thank you, too. It was very informative, but it was inspirational. I love how you put the onus on the individual. It’s up to us to take care of ourselves and do the right thing by ourselves. And just giving us better examples about pain and how we relate to pain and different things like that. So, thank you so much, Dr. Ready.

Duren Michael Ready, MD:
Oh, it’s my pleasure. And I appreciate the work that y’all do at the National Headache Foundation. And I recommend y’all’s videos to my patients all the time.

Katy Oakley:
I’m so glad to hear that. Yeah, we, we care so deeply about migraine and headache patients and especially the veteran community, which is why we’ve created this entire resource in partnership with Shero to be able to help the people who deserve it the most. Thank you so much, Dr. Ready.

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