The first therapy to be developed specifically for post-traumatic headaches has significantly reduced associated disability in veterans following traumatic brain injury (TBI). It also reduced co-occurring symptoms of post-traumatic stress disorder (PTSD) comparable to a standard treatment for PTSD.
Additionally, the innovative treatment, Cognitive Behavioral Therapy for Headache (CBTH), was attractive to patients, showing low dropout rates, and is easy for therapists to learn and deliver, increasing its potential. widespread dissemination and improving the lives of patients. hundreds of thousands of service members and veterans.
These findings were reported today in JAMA Neurology by a team of researchers led by Don McGeary, PhD, of the University of Texas Health Sciences Center at San Antonio (UT Health San Antonio). Their effort was part of the work of the Consortium to Mitigate PTSD, a group jointly funded by the Departments of Defense and Veterans Affairs.
We are excited about this development in the treatment of post-traumatic headache, which, along with TBI, is poorly understood and for which treatment options are so limited. Finding the first major therapeutic success for post-traumatic headache, which is arguably the most debilitating symptom of TBI, and that treatment also significantly reduces comorbid symptoms of PTSD, is a major breakthrough. »
Dr. Don McGeary, associate professor of psychiatry and behavioral sciences at the university’s Joe R. and Teresa Lozano Long School of Medicine
TBI and PTSD are hallmark injuries of post-9/11 military conflict, and the two conditions usually occur together. Post-traumatic headaches, or headaches that develop or worsen following a head or neck injury, become chronic and debilitating in a large percentage of those who experience TBI such as a concussion, inhibiting their ability to engage in activities of daily living. When PTSD is co-occurring, it can make headaches worse and harder to treat.
Effective treatments exist for PTSD, but not for post-traumatic headaches, which scientists are still struggling to understand with TBI. Migraine medications commonly used to relieve headaches do not relieve the associated disability. They also often have unwanted side effects, and overusing them can make headaches worse.
Dr. McGeary explained the current theory that PTSD may be a ‘driver’ of post-traumatic headaches and the disability it causes. The research team therefore wanted to both study the interaction of the conditions and their treatment and find an effective therapy for both.
About the study
Dr. McGeary and his colleagues developed CBTH by modifying a psychotherapy for migraines. In this study, they assessed its effectiveness with concurrent post-traumatic headaches and PTSD symptoms.
The study was conducted at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System. Participants had clinically significant PTSD symptoms and persistent headaches more than three months after TBI. They were randomly assigned to receive either CBTH, a leading treatment for PTSD called Cognitive Processing Therapy (CPT), or usual care provided at the VA Polytrauma Center.
CBTH, which uses cognitive behavioral therapy concepts to reduce headache-related disability and improve mood, includes key elements such as relaxation, goal setting for activities patients wish to resume and planning for these situations.
CPT is a leading psychotherapy for PTSD that teaches patients how to assess and change upsetting and maladaptive thoughts related to their trauma, with the idea that by changing your thoughts, you can change the way you feel.
The usual treatment at the VA Polytrauma Center is a high standard of care which may include injections, physical and occupational therapies, pain medication, acupuncture and massage, as well as long-term medical care.
What the researchers found at the end of treatment was that, compared to usual care, people receiving CBTH reported significant reductions in disability and negative impact on function and quality of daily life. They also showed improvement in PTSD symptoms comparable to the group that received CPT. All of these treatment gains were maintained six months after treatment ended.
CPT, on the other hand, resulted in significant and lasting improvements in PTSD symptoms, but alone did not improve headache-related disability. “It was a surprise,” said Dr. McGeary. “If the theories about PTSD leading to post-traumatic headaches are correct, you would expect CPT to help both PTSD and headaches. Our results call this into question.”
Interestingly, CBTH did not reduce headache intensity or frequency compared to usual care. Dr McGeary said his dramatic reductions in negative life impact are likely due to patients’ confidence that they can control or manage their headaches, a concept known as ‘self-efficacy’ . This sense of control was key to helping patients “get their lives back,” he said.
“If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said. “That’s because, when faced with long-term disabling pain, people decide whether they’re going to actively engage in any type of activity, especially if the activity exacerbates the pain. They make these decisions based on their perceptions of their ability to manage their pain.”
Dr. McGeary believes that the planning component of CBTH is key to improving these perceptions. He said: “There’s a big difference between saying ‘I have to go to this party. What am I going to do?’ and ‘OK, I have a plan for this. I’ll bring my sunglasses to block out bright light. I’ll bring a cold compress. I’ll walk away if the noise gets too loud. Making plans helps individuals to feel that they have improved their self-efficacy when it comes to managing their headaches.”
When it comes to PTSD symptom relief, Dr. McGeary said it’s surprising that CBTH and CPT are comparable. He thinks CBTH was more appealing to patients, so fewer gave up and more received a full dose of treatment. CBTH requires fewer and shorter therapy sessions; usually eight sessions of 30 to 45 minutes each. CPT is a more difficult therapy and usually involves 12 sessions lasting 60-90 minutes each.
Another advantage of CBTH is that it only takes two hours to train clinicians to deliver the therapy, compared to CPT, a complex treatment that requires significant training and learned skills. This would make it relatively easy to increase the number of therapists available to treat veterans with post-traumatic headaches and ease the workload at clinics.
Following this success with San Antonio veterans, Dr. McGeary and his colleagues are looking to replicate their findings in a more diverse sample. As part of a new study affiliated with the STRONG STAR Consortium, they will test the robustness of CBTH in a larger trial at multiple military and VA sites in the United States.
Dr McGeary explained: “We need more women, more racial and ethnic diversity, veterans as well as serving military from different branches, with varying co-morbidities, in different geographic regions attached to different hospitals and medical systems because we are comparing to usual care.”
University of Texas Health Sciences Center at San Antonio
McGeary, DD, et al. (2022) Cognitive-behavioral therapy for veterans with comorbid posttraumatic headaches and symptoms of posttraumatic stress disorder. JAMA Neurology. doi.org/10.1001/jamaneurol.2022.1567.