Post-Traumatic Headache in the Military

Heads Up: A Word from our Guest Editor Gen(R) Peter W. Chiarelli

Dear Spotlight On Readers,General Peter Chiarelli_medium

As we join together to honor those who have served our nation, let’s be sure we remember those who are still struggling with the after-effects of war. Thousands of brave men and women who served their country in Iraq and Afghanistan are dealing with an invisible enemy that stalks them wherever they go, inflicting pain and disability on them and their families, and in too many cases, leading to despair.

As you’ll see in this issue of Spotlight On, the invisible enemy is brain injury and the many conditions related to it:

  • Traumatic brain injury (TBI) from exposure to blasts from enemy and friendly explosives.
  • Post-traumatic stress from exposure to psychologically devastating events that are all too common in wartime.

A long list of health problems can develop after a TBI, from sleep disorders to seizures to mood swings and cognitive changes. Our focus in this Spotlight On—painful and disabling post-traumatic headache (PTH)—is nearly universal among those who have experienced a TBI.

Most people understand that our military personnel, particularly those injured in the line of duty, deserve the best medical treatment our country can offer. Unfortunately, the reality is that we are significantly behind the times when it comes to caring for those with brain injury and disease.

That’s why our organization, One Mind (www.onemind.org), is working for change. We are pleased to join with the American Migraine Foundation to:

  • Benefit all affected by brain illness and injury.
  • Foster fundamental changes that radically accelerate the development and implementation of improved diagnostics, treatments, and cures.
  • Eliminate the stigma that comes with brain disease.

Our mission is fueled by our belief in open science principles and creating global public-private partnerships among governmental, corporate, scientific, and philanthropic communities. These beliefs align nicely with the mission of the American Migraine Foundation—to support innovative research and education that will lead to improvement in the lives of those who suffer from migraine and other disabling headaches.

It’s been my pleasure to collaborate on this edition of Spotlight On, as it helps to call attention to some of the most important research regarding TBI and PTH in our military veterans. We look forward to future cooperation between our organizations and hope you will continue to support our combined efforts.

Gen(R) Peter W. Chiarelli

TBI: The “Signature Injury”

Soldier Returning Home And Greeted By SonExposure to combat-related explosions is the leading cause of injury to US service personnel in Iraq and Afghanistan—earning traumatic brain injury (TBI) the notorious title of “signature injury” of the Middle Eastern conflicts. Even in the relative safety of their homeland, many veterans’ lives are disrupted by long-lasting effects of TBI, including:

  • Post-traumatic headache (PTH)
  • Post-traumatic stress
  • Depression
  • Sleep disorders
  • Motor and cognitive impairments

These persistent symptoms can make re-entry into civilian life even more challenging than it already is for many service men and women. After surviving combat overseas, many veterans now face this more personal battle here at home.

A Larger, More Serious Problem

Military-related TBI is a larger, more serious problem than many people realize. To date, more than 330,000 military personnel have sustained a TBI—that’s more than the entire population of St. Louis, Missouri! While most TBIs in military personnel are classified as mild—which might make some people think the problem is not that serious—the milder form of TBI is actually the type most often associated with the pain and disability of PTH.

After a TBI, the headaches and disabilities don’t always start right away. In some veterans, they show up weeks or months after the injury. Since experts diagnose PTH by looking for headaches occurring within seven days of an injury, these slow-developing cases have led some to reconsider how PTH is defined.

Headache Isn’t the End of the Story

The most common PTH symptoms can feel like migraine attacks or cluster headaches, although some patients have symptoms that are more like tension-type headaches. Whatever the individual experience, all PTH patients have head pain—sometimes severe. Many also get an upset stomach and become sensitive to bright lights and loud noises.

Headache isn’t the end of the story. Some patients with PTH also have sleep disorders, poor concentration, dizziness, fatigue, nervousness, and depression. More than 80% have episodes of post-traumatic stress—a severe anxiety reaction in which they relive the traumatic event and avoid stimuli associated with it.

For those who suffer and for those who live with or care for the injured, the headaches are more than just a pain of the head. They make life hard. They make the promise of duty to comrades more difficult to keep. They add to the struggle to find a place to rest or work or love.
– Alan Finkel, MD, FAHS

Treatment

For the majority of patients with PTH, physicians use the same drugs they use for migraine and cluster headache—headache types that are similar to PTH.1 For those showing signs of post-traumatic stress, some of the most helpful treatments may not involve medication.

Type of Treatment Overall Approach
Trauma-focused cognitive behavioral therapy Teaches new skills to help process thoughts and feelings related to traumatic life events.
Guided imagery Uses words and music to evoke positive imaginary scenarios and promote a relaxed mental state.
Stress management Introduces healthier ways to cope with stress and reduce its harmful effects.
Eye movement desensitization and reprocessing Combines many therapies to reduce the intensity of traumatic images and the emotional response to disturbing memories.

Where Do We Go From Here?

The good news is that the medical community recognizes military and civilian traumatic brain injury, PTH, and PTS as significant problems, and numerous research projects are completed or underway. It is hoped that additional and better-focused research will help doctors improve diagnoses and reduce the suffering and disability associated with PTH.

Journal Watch: Recent PTH Studies

With so many military-related cases, researchers began to focus on PTH in new ways. Here’s a brief look at what they’ve learned recently.

Deployment, TBI, and Headache

To see how combat deployment and TBI were related to headache, researchers interviewed 92 veterans, half of whom had sustained a iStock_000020338978_SmallTBI and half who had not, about TBI, headache, and depression. They specifically asked the veterans to describe their headache attacks and recorded how often the attacks occurred and how severe they were.
Headache was very common in both groups, but the soldiers with TBI were far more likely to have headaches—everyone in the group with TBIs had them in addition to migraine. Most with TBIs had attacks at least twice a week; most without a TBI had less than one a month. Veterans with TBIs were also five times more likely to have trouble with everyday activities, such as walking and driving, due to their headaches.

Interview Question No TBI (%) TBI (%)
Headache 76 100
Migraine 28 89
Decreased activity (90%) 9 48

TBI, Work, and Marriage

How does TBI affect the work and love lives of military personnel after they get iStock_000002118567_Smallback home?

If work with 134 veterans of the conflicts in Afghanistan or Iraq is any indicator, they’re far less likely to have a job—even more than ten years after they got hurt.
The good news is that TBI patients were about as likely to be married as veterans without a TBI.

Years after injury Employed (%) Married (%)
TBI No TBI TBI No TBI
2-7 64 90 69 74
8-11 50 93 75 79

Treating PTH with Magnets?

Treating PTH can be a challenge. Traditional medications don’t always work, and many non-traditional approaches have never been studied. Scientists recently evaluated one of them.

In this study, no drugs were used. Instead, doctors place an insulated coil on the scalp over the area of the brain involved. The coil generates brief repetitive and painless magnetic pulses, which pass through the skull and into the brain.

This method, sometimes used in the treatment of depression, is technically known as transcranial magnetic stimulation (TMS). Patients in this study were treated three times in a single week, and another group received simulated treatment.

After one week, patients who received the treatment:

  • Were less likely to have constant headache.
  • Had less intense headache pain.
  • The benefits were still noticeable a month after treatment.

Earlier Studies: A Summary

Before the most recent round of research into PTH, several important studies were published. Their main findings included:

  • Headache and concussion are strongly linked.
  • Migraine is very common in patients with concussion and/or PTH.
  • PTH often prevents personnel from returning to duty.
  • Some traditional migraine medications can relieve the symptoms of PTH.

Details about them are summarized below.

Patients Studied Key Findings
2,525 infantry soldiers returning from a 1-year combat deployment in Iraq Headache was the only symptom associated with concussion.
About 1.25 million US military personnel deployed before December 2008 Soldiers with a concussion during deployment were 5 times more likely to see a doctor about migraine than those without concussions.
1,033 US Army soldiers with concussion undergoing a 5-month post-deployment evaluation
  • 98% had headaches
  • 37% had PTH
  • 89% who had PTH also had features of migraine
  • Most (55%) with chronic daily headache had migraine
985 combat veterans evacuated from Operation Iraqi Freedom and Operation Enduring Freedom
  • 34% of soldiers evacuated for headache had PTH
  • PTH had the lowest return-to-duty rate of any headache type (18.7%)
100 consecutive soldiers with chronic PTH patients treated in the US Army headache clinic
  • 77% of patients had blast-related PTH
  • More than 95% met the criteria for migraine
  • Triptans were effective
  • Topiramate was most effective