Following a traumatic brain injury, the first treatment designed exclusively for post-traumatic headache considerably decreased related disability in veterans (TBI). Additionally, it lowered co-occurring PTSD symptoms in a manner comparable to a gold-standard PTSD treatment.
Additionally, Cognitive Behavioral Therapy for Headache (CBTH), an innovative treatment, had low drop-out rates, was well-liked by patients, and was simple for therapists to learn and administer, all of which increased its likelihood of being widely disseminated and helping hundreds of thousands of service members and veterans.
A group of researchers from The University of Texas Health Science Center at San Antonio led by Don McGeary, PhD, published their findings in JAMA Neurology today. Their work was part of the Consortium to Alleviate PTSD, which was financed jointly by the Departments of Defense and Veterans Affairs.
Dr. McGeary, an associate professor of psychiatry and behavioral sciences at the university’s Joe R. and Teresa Lozano Long School of Medicine, said, “We are excited by this development in the treatment of post-traumatic headache, which along with TBI is poorly understood and for which treatment options are so limited.”
According to the authors, it is a big breakthrough to discover the first significant therapeutic success for post-traumatic headache, which is undoubtedly the most debilitating symptom of TBI. The treatment also considerably lessens associated PTSD symptoms.
TBI and PTSD are two of the hallmark injuries of post-9/11 military wars, and the two illnesses frequently co-occur. A significant portion of people who sustain a TBI such as a concussion get chronic and incapacitating post-traumatic headaches, or headaches that arise from or get worse after a head or neck injury, making it difficult for them to go about their everyday lives. Co-occurring PTSD can exacerbate headaches and make them more challenging to cure.
Although post-traumatic headache is a condition that researchers are still trying to understand, there are effective medications for PTSD but not for it. Medication for migraines, which is frequently used to treat headache pain, does not treat associated impairment. Additionally, they generally have negative side effects, and overusing them can make headaches worse.
Dr. McGeary described the current notion that PTSD may be a “driver” of post-traumatic headache and the resulting impairment. In order to develop a therapy that was beneficial for both illnesses, the research team also needed to examine how the conditions and their treatments interacted.
About the research
By altering psychotherapy for migraine headaches, Dr. McGeary and his associates created CBTH. They assessed its effectiveness in this trial when PTSD symptoms and post-traumatic headache co-occurred.
The South Texas Veterans Health Care System’s Polytrauma Rehabilitation Center served as the study’s site. Participants had headaches that persisted for more than three months after a TBI and clinically significant PTSD symptoms. They were randomized to receive CBTH, Cognitive Processing Therapy (CPT), a very effective PTSD treatment, or standard care at the VA Polytrauma Center.
Key elements of CBTH include relaxation, goal-setting for activities patients desire to resume, and preparation for such situations. CBTH incorporates cognitive behavioral therapy techniques to reduce headache disability and enhance mood.
CPT is a pioneering PTSD treatment that teaches patients how to examine and change disturbing and maladaptive beliefs about their trauma, with the concept that changing your thinking will improve the way you feel.
Summary of the Findings
Researchers discovered that those undergoing CBTH reported significantly lower levels of disability and adverse effects on function and everyday life at the end of treatment compared to those receiving conventional care. They improved similarly to the group that underwent CPT in terms of their PTSD symptoms. Six months after the end of the treatment, all of these benefits were still present.
Contrarily, CPT resulted in large and long-lasting improvements in PTSD symptoms, but it did not reduce headache disability on its own. Dr. McGeary remarked, “This was a surprise. If theories about PTSD driving post-traumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”
Interpreting results
Interestingly, when compared to standard therapy, CBTH did not lessen headache frequency or intensity. According to Dr. McGeary, the treatment’s strikingly reduced negative effects on patients’ quality of life are probably the result of the patients’ growing sense of “self-efficacy,” or their ability to control or manage their migraines. For patients to “get their lives back,” he said, they needed to feel in control.
According to Dr. McGeary, people perform better if their belief that they can control their headaches is strengthened. “That’s because, when dealing with a long-term, disabling pain condition, people make decisions about whether they’re going to actively engage in any kind of activity, especially if the activity exacerbates the pain condition. They make those decisions based on their perceptions of their ability to handle their pain .”
Dr. McGeary thinks that the planning part of CBTH is the key to changing these views. “There’s a big difference between saying ‘I’ve got to go to this party. What am I going to do?’, versus ‘OK, I have a plan for this. I’m going to bring my sunglasses to block bright light. I’ll bring a cold compress. I’ll step away if the noise becomes too much.’ Forming plans helps individuals feel like they have improved their self-efficacy when it comes to managing their headaches .”
Dr. McGeary expressed surprise that CBTH and CPT had similar effects on PTSD symptom alleviation. He thinks that because CBTH was more enticing to patients, more of them completed their full course of treatment and fewer discontinued it. The normal number of CBTH therapy sessions is eight, lasting 30 to 45 minutes each. The typical number of sessions for CPT is 12, with each session lasting between 60 and 90 minutes.
Another advantage of CBTH is that, unlike CPT, which is a sophisticated treatment that necessitates extensive training and learned competence, CBTH just requires two hours of training for doctors to deliver the therapy. With fewer cases to handle at clinics, it would be quite simple to expand the number of therapists available to treat veterans with posttraumatic headaches.
Next actions
Dr. McGeary and associates want to confirm their findings in a more diverse population in order to build on their success with San Antonio veterans. They will examine the resilience of CBTH in a larger trial at numerous military and VA facilities across the United States as part of a new study affiliated with the STRONG STAR Consortium.
“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches, with varying comorbidities, in different geographic regions attached to different hospitals and medical systems because we’re comparing to usual care,” Dr. McGeary said.
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