Mild Head Injuries Pose Risk for Posttraumatic Headaches in Combat Veterans

STOWE, VT—US soldiers who have sustained a mild head injury have an increased risk for chronic posttraumatic headaches, which typically involve moderate to severe migraine-like pain and functional impairment, according to Jay Erickson, MD, PhD. Soldiers with posttraumatic headache are also likely to have a high burden of psychiatric comorbidity and sleep disturbance, he reported at the Headache Cooperative of New England’s 19th Annual Headache Symposium.

Among 5,000 soldiers who returned from deployment to Fort Lewis, Washington, in the summer of 2008, Dr. Erickson and colleagues found that 19% had had a concussion, and more than 90% of this group reported having headaches during the previous three months. About a third of the soldiers had headache onset within one week of head trauma, which meets the definition of a posttraumatic headache per the International Classification of Headache Disorders, Second Edition (ICHD-2).

“A mild head injury is a concussion,” noted Dr. Erickson, Lieutenant Colonel, US Army Medical Corps, and Director of the Neurology Residency Program at Madigan Army Medical Center (MAMC) in Tacoma, Washington. “To have a concussion, you don’t necessarily need to have a loss of consciousness.”

Evaluating and Treating Posttraumatic Headache
Dr. Erickson and colleagues conducted an observational, longitudinal study of 189 soldiers with chronic posttraumatic headaches secondary to mild head injury. The soldiers underwent a standardized clinical evaluation at baseline and were followed up three months later. The examination included a headache questionnaire and use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT)-6, Posttraumatic Syndrome Checklist, and Patient Health Questionnaire (PHQ)-9.

The patients (96% male; mean age, 27) had had a mild head injury while deployed—80% had a mild head injury related to a blast exposure, while others had blunt trauma, a motor vehicle accident, a fall, injury due to fighting, and other accidents. Two-thirds had a concussion with loss of consciousness. About 52% had multiple concussions, and the average number of concussions per soldier was 2.2. The average time from headache onset until the soldiers were evaluated by Dr. Erickson’s group was 16.9 months, and half had had headaches for more than a year. “For many of them, this has been a very chronic process,” said Dr. Erickson.

Two-thirds of participants had moderate pain accompanying their headache, and 24% had severe headaches. Per the ICHD-2 criteria, 96% of these headaches would be classified as migraine-type headaches. In contrast, Lew et al found that 28% of posttraumatic headaches in civilians were migraine-like.

On average, the soldiers had a mean of 16 headache days per month, and half had 15 or more headache days per month during the previous three months. About 72% of the soldiers had severe disability from their headache, per MIDAS scores. Participants had used their acute medications, on average, 12 days per month.

“One-third used acute analgesics for 15 or more days per month and therefore had possible medication-overuse headache,” said Dr. Erickson. Two-thirds of the soldiers had inadequate headache relief with their acute medication, defined as complete or nearly complete relief of head pain within two hours of taking the medication and enabling the individual to return to normal activities.

Psychiatric Comorbidity
According to the PTSD Symptom Checklist, 41% of soldiers screened positive for PTSD, and an additional 21% were in the indeterminate range for PTSD. One-third screened positive for depression on the PHQ-9 scale, and 82% reported moderate or severe difficulty sleeping. Most (71%) reported regular nightmares. “We definitely try to address and treat these comorbid sleep conditions as well as the comorbid psychiatric conditions,” said Dr. Erickson. A number also reported cognitive symptoms, such as decreased concentration, memory impairment, and slowed thinking. “In my experience, the cognitive symptoms are  mostly related to sleep deprivation, anxiety, depression, medications, and alcohol,” noted Dr. Erickson. “Little of this is actually due to the traumatic injury to their brain.”

Treatment Recommendations
Thus far, no randomized controlled trials have been conducted regarding treatment for posttraumatic headache. However, the Defense and Veterans Brain Injury Coalition has developed treatment guidelines, and the Department of Defense has mandated screening for traumatic brain injury in all soldiers returning from deployment. For prophylactic agents in individuals with posttraumatic headache, the coalition recommends amitriptyline, propranolol, topiramate, or gabapentin. For acute therapies, it recommends NSAIDs, triptans, and then cautious use of combination analgesics, as well as trying to avoid narcotics.

Dr. Erickson and colleagues have prescribed triptans to three-quarters of soldiers and NSAIDs to 18% as acute headache medication. As for prophylactic therapies, the researchers have prescribed a tricyclic antidepressant to about half of soldiers, followed by topiramate, propranolol, and valproate. Nonpharmacologic treatment approaches, such as behavioral health, headache education class, and biofeedback therapy, have also been recommended by Dr. Erickson’s group.

“In this population at baseline, 20% were using an acute medication that provided adequate relief,” said Dr. Erickson. “With our treatments, we got that up to 64%.” About 79% of soldiers who were given a triptan reported having adequate two-hour headache relief, compared with 29% who were taking a nontriptan. “This provides evidence that triptans are effective in this population,” he added. “It also helps support the idea that in many of these [cases], the headache itself is a migraine or something very similar to a migraine.”

The response to prophylactic therapies for posttraumatic headache has been “disappointing,” however, said Dr. Erickson. “We don’t seem to have a robust response in terms of headache frequency in the short term,” he commented. “In comparison, if you look at patients with nontraumatic migraine in our clinic, we get a pretty robust response with the initial prophylactic agent. Likewise, patients with nontraumatic migraine who have PTSD also seem to have a pretty good response to prophylactic therapy. So traumatic migraine doesn’t seem to respond the same as nontraumatic migraine. Disability scores do decrease between baseline and follow-up, and I think this is largely related to the effectiveness of acute medications. The triptan is effective, so [soldiers] are less disabled from their headache attacks. If we were able to reduce headache frequency, then I would expect their disability to drop even further.

“Trying to treat their headache in isolation is not going to be as successful as trying to identify all of the problems that are contributing to it,” he continued. “It is important to follow these patients maybe a little bit more closely than you would a typical migraine patient, knowing that the response to prophylactic therapies is not quite as robust. I believe that these patients are going to need more adjustments of their treatment. Finally, I think patient education and expectations for recovery are key in this population.”

STOWE, VT—US soldiers who have sustained a mild head injury have an increased risk for chronic posttraumatic headaches, which typically involve moderate to severe migraine-like pain and functional impairment, according to Jay Erickson, MD, PhD. Soldiers with posttraumatic headache are also likely to have a high burden of psychiatric comorbidity and sleep disturbance, he reported at the Headache Cooperative of New England’s 19th Annual Headache Symposium.

Among 5,000 soldiers who returned from deployment to Fort Lewis, Washington, in the summer of 2008, Dr. Erickson and colleagues found that 19% had had a concussion, and more than 90% of this group reported having headaches during the previous three months. About a third of the soldiers had headache onset within one week of head trauma, which meets the definition of a posttraumatic headache per the International Classification of Headache Disorders, Second Edition (ICHD-2).

“A mild head injury is a concussion,” noted Dr. Erickson, Lieutenant Colonel, US Army Medical Corps, and Director of the Neurology Residency Program at Madigan Army Medical Center (MAMC) in Tacoma, Washington. “To have a concussion, you don’t necessarily need to have a loss of consciousness.”

Evaluating and Treating Posttraumatic Headache
Dr. Erickson and colleagues conducted an observational, longitudinal study of 189 soldiers with chronic posttraumatic headaches secondary to mild head injury. The soldiers underwent a standardized clinical evaluation at baseline and were followed up three months later. The examination included a headache questionnaire and use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT)-6, Posttraumatic Syndrome Checklist, and Patient Health Questionnaire (PHQ)-9.

The patients (96% male; mean age, 27) had had a mild head injury while deployed—80% had a mild head injury related to a blast exposure, while others had blunt trauma, a motor vehicle accident, a fall, injury due to fighting, and other accidents. Two-thirds had a concussion with loss of consciousness. About 52% had multiple concussions, and the average number of concussions per soldier was 2.2. The average time from headache onset until the soldiers were evaluated by Dr. Erickson’s group was 16.9 months, and half had had headaches for more than a year. “For many of them, this has been a very chronic process,” said Dr. Erickson.

Two-thirds of participants had moderate pain accompanying their headache, and 24% had severe headaches. Per the ICHD-2 criteria, 96% of these headaches would be classified as migraine-type headaches. In contrast, Lew et al found that 28% of posttraumatic headaches in civilians were migraine-like.

On average, the soldiers had a mean of 16 headache days per month, and half had 15 or more headache days per month during the previous three months. About 72% of the soldiers had severe disability from their headache, per MIDAS scores. Participants had used their acute medications, on average, 12 days per month.

“One-third used acute analgesics for 15 or more days per month and therefore had possible medication-overuse headache,” said Dr. Erickson. Two-thirds of the soldiers had inadequate headache relief with their acute medication, defined as complete or nearly complete relief of head pain within two hours of taking the medication and enabling the individual to return to normal activities.

Psychiatric Comorbidity
According to the PTSD Symptom Checklist, 41% of soldiers screened positive for PTSD, and an additional 21% were in the indeterminate range for PTSD. One-third screened positive for depression on the PHQ-9 scale, and 82% reported moderate or severe difficulty sleeping. Most (71%) reported regular nightmares. “We definitely try to address and treat these comorbid sleep conditions as well as the comorbid psychiatric conditions,” said Dr. Erickson. A number also reported cognitive symptoms, such as decreased concentration, memory impairment, and slowed thinking. “In my experience, the cognitive symptoms are  mostly related to sleep deprivation, anxiety, depression, medications, and alcohol,” noted Dr. Erickson. “Little of this is actually due to the traumatic injury to their brain.”

Treatment Recommendations
Thus far, no randomized controlled trials have been conducted regarding treatment for posttraumatic headache. However, the Defense and Veterans Brain Injury Coalition has developed treatment guidelines, and the Department of Defense has mandated screening for traumatic brain injury in all soldiers returning from deployment. For prophylactic agents in individuals with posttraumatic headache, the coalition recommends amitriptyline, propranolol, topiramate, or gabapentin. For acute therapies, it recommends NSAIDs, triptans, and then cautious use of combination analgesics, as well as trying to avoid narcotics.

Dr. Erickson and colleagues have prescribed triptans to three-quarters of soldiers and NSAIDs to 18% as acute headache medication. As for prophylactic therapies, the researchers have prescribed a tricyclic antidepressant to about half of soldiers, followed by topiramate, propranolol, and valproate. Nonpharmacologic treatment approaches, such as behavioral health, headache education class, and biofeedback therapy, have also been recommended by Dr. Erickson’s group.

“In this population at baseline, 20% were using an acute medication that provided adequate relief,” said Dr. Erickson. “With our treatments, we got that up to 64%.” About 79% of soldiers who were given a triptan reported having adequate two-hour headache relief, compared with 29% who were taking a nontriptan. “This provides evidence that triptans are effective in this population,” he added. “It also helps support the idea that in many of these [cases], the headache itself is a migraine or something very similar to a migraine.”

The response to prophylactic therapies for posttraumatic headache has been “disappointing,” however, said Dr. Erickson. “We don’t seem to have a robust response in terms of headache frequency in the short term,” he commented. “In comparison, if you look at patients with nontraumatic migraine in our clinic, we get a pretty robust response with the initial prophylactic agent. Likewise, patients with nontraumatic migraine who have PTSD also seem to have a pretty good response to prophylactic therapy. So traumatic migraine doesn’t seem to respond the same as nontraumatic migraine. Disability scores do decrease between baseline and follow-up, and I think this is largely related to the effectiveness of acute medications. The triptan is effective, so [soldiers] are less disabled from their headache attacks. If we were able to reduce headache frequency, then I would expect their disability to drop even further.

“Trying to treat their headache in isolation is not going to be as successful as trying to identify all of the problems that are contributing to it,” he continued. “It is important to follow these patients maybe a little bit more closely than you would a typical migraine patient, knowing that the response to prophylactic therapies is not quite as robust. I believe that these patients are going to need more adjustments of their treatment. Finally, I think patient education and expectations for recovery are key in this population.”

STOWE, VT—US soldiers who have sustained a mild head injury have an increased risk for chronic posttraumatic headaches, which typically involve moderate to severe migraine-like pain and functional impairment, according to Jay Erickson, MD, PhD. Soldiers with posttraumatic headache are also likely to have a high burden of psychiatric comorbidity and sleep disturbance, he reported at the Headache Cooperative of New England’s 19th Annual Headache Symposium.

Among 5,000 soldiers who returned from deployment to Fort Lewis, Washington, in the summer of 2008, Dr. Erickson and colleagues found that 19% had had a concussion, and more than 90% of this group reported having headaches during the previous three months. About a third of the soldiers had headache onset within one week of head trauma, which meets the definition of a posttraumatic headache per the International Classification of Headache Disorders, Second Edition (ICHD-2).

“A mild head injury is a concussion,” noted Dr. Erickson, Lieutenant Colonel, US Army Medical Corps, and Director of the Neurology Residency Program at Madigan Army Medical Center (MAMC) in Tacoma, Washington. “To have a concussion, you don’t necessarily need to have a loss of consciousness.”

Evaluating and Treating Posttraumatic Headache
Dr. Erickson and colleagues conducted an observational, longitudinal study of 189 soldiers with chronic posttraumatic headaches secondary to mild head injury. The soldiers underwent a standardized clinical evaluation at baseline and were followed up three months later. The examination included a headache questionnaire and use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT)-6, Posttraumatic Syndrome Checklist, and Patient Health Questionnaire (PHQ)-9.

The patients (96% male; mean age, 27) had had a mild head injury while deployed—80% had a mild head injury related to a blast exposure, while others had blunt trauma, a motor vehicle accident, a fall, injury due to fighting, and other accidents. Two-thirds had a concussion with loss of consciousness. About 52% had multiple concussions, and the average number of concussions per soldier was 2.2. The average time from headache onset until the soldiers were evaluated by Dr. Erickson’s group was 16.9 months, and half had had headaches for more than a year. “For many of them, this has been a very chronic process,” said Dr. Erickson.

Two-thirds of participants had moderate pain accompanying their headache, and 24% had severe headaches. Per the ICHD-2 criteria, 96% of these headaches would be classified as migraine-type headaches. In contrast, Lew et al found that 28% of posttraumatic headaches in civilians were migraine-like.

On average, the soldiers had a mean of 16 headache days per month, and half had 15 or more headache days per month during the previous three months. About 72% of the soldiers had severe disability from their headache, per MIDAS scores. Participants had used their acute medications, on average, 12 days per month.

“One-third used acute analgesics for 15 or more days per month and therefore had possible medication-overuse headache,” said Dr. Erickson. Two-thirds of the soldiers had inadequate headache relief with their acute medication, defined as complete or nearly complete relief of head pain within two hours of taking the medication and enabling the individual to return to normal activities.

Psychiatric Comorbidity
According to the PTSD Symptom Checklist, 41% of soldiers screened positive for PTSD, and an additional 21% were in the indeterminate range for PTSD. One-third screened positive for depression on the PHQ-9 scale, and 82% reported moderate or severe difficulty sleeping. Most (71%) reported regular nightmares. “We definitely try to address and treat these comorbid sleep conditions as well as the comorbid psychiatric conditions,” said Dr. Erickson. A number also reported cognitive symptoms, such as decreased concentration, memory impairment, and slowed thinking. “In my experience, the cognitive symptoms are  mostly related to sleep deprivation, anxiety, depression, medications, and alcohol,” noted Dr. Erickson. “Little of this is actually due to the traumatic injury to their brain.”

Treatment Recommendations
Thus far, no randomized controlled trials have been conducted regarding treatment for posttraumatic headache. However, the Defense and Veterans Brain Injury Coalition has developed treatment guidelines, and the Department of Defense has mandated screening for traumatic brain injury in all soldiers returning from deployment. For prophylactic agents in individuals with posttraumatic headache, the coalition recommends amitriptyline, propranolol, topiramate, or gabapentin. For acute therapies, it recommends NSAIDs, triptans, and then cautious use of combination analgesics, as well as trying to avoid narcotics.

Dr. Erickson and colleagues have prescribed triptans to three-quarters of soldiers and NSAIDs to 18% as acute headache medication. As for prophylactic therapies, the researchers have prescribed a tricyclic antidepressant to about half of soldiers, followed by topiramate, propranolol, and valproate. Nonpharmacologic treatment approaches, such as behavioral health, headache education class, and biofeedback therapy, have also been recommended by Dr. Erickson’s group.

“In this population at baseline, 20% were using an acute medication that provided adequate relief,” said Dr. Erickson. “With our treatments, we got that up to 64%.” About 79% of soldiers who were given a triptan reported having adequate two-hour headache relief, compared with 29% who were taking a nontriptan. “This provides evidence that triptans are effective in this population,” he added. “It also helps support the idea that in many of these [cases], the headache itself is a migraine or something very similar to a migraine.”

The response to prophylactic therapies for posttraumatic headache has been “disappointing,” however, said Dr. Erickson. “We don’t seem to have a robust response in terms of headache frequency in the short term,” he commented. “In comparison, if you look at patients with nontraumatic migraine in our clinic, we get a pretty robust response with the initial prophylactic agent. Likewise, patients with nontraumatic migraine who have PTSD also seem to have a pretty good response to prophylactic therapy. So traumatic migraine doesn’t seem to respond the same as nontraumatic migraine. Disability scores do decrease between baseline and follow-up, and I think this is largely related to the effectiveness of acute medications. The triptan is effective, so [soldiers] are less disabled from their headache attacks. If we were able to reduce headache frequency, then I would expect their disability to drop even further.

“Trying to treat their headache in isolation is not going to be as successful as trying to identify all of the problems that are contributing to it,” he continued. “It is important to follow these patients maybe a little bit more closely than you would a typical migraine patient, knowing that the response to prophylactic therapies is not quite as robust. I believe that these patients are going to need more adjustments of their treatment. Finally, I think patient education and expectations for recovery are key in this population.”