The first therapy that was developed specifically for posttraumatic headache significantly reduced related disability in veterans after traumatic brain injury (TBI). It also reduced the concomitant symptoms of post-traumatic stress disorder (PTSD) compared with standard treatment for PTSD.
In addition, the innovative treatment, Cognitive Behavioral Therapy for Headache (CBTH), was attractive to patients, showing low dropout rates and is easy to learn and deliver for therapists, increasing its potential for diffusion. broad and improve 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 in San Antonio (UT Health San Antonio). Their effort was part of the Consortium’s work to alleviate 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 little known and for which treatment options are so limited. Finding the first major treatment success for posttraumatic headache, which is possibly the most debilitating symptom of TBI, and for treatment to also significantly reduce the symptoms of comorbid PTSD, is a breakthrough. “
Dr. Don McGeary, associate professor of psychiatry and behavioral sciences at Joe R. and Teresa Lozano Long School of Medicine at the university.
Both BIT and PTSD are signature wounds from post-9/11 military conflicts, and the two conditions usually occur together. Posttraumatic headaches, or headaches that develop or worsen after an injury to the head or neck, become chronic and debilitating in a large percentage of those who suffer from TBI as a concussion, inhibiting their ability to participate in the activities of daily living. When PTSD occurs together, it can make headaches worse and make them harder to treat.
There are effective treatments for PTSD, but not for any post-traumatic stress disorder, which along with TBI, scientists are still working to understand. Migraine medications that are commonly used to relieve headache pain do not relieve the related disability. They also often have unwanted side effects and their excessive use can make headaches worse.
Dr. McGeary explained the current theory that PTSD can be a “driver” of post-traumatic headache and the disability it causes. So the research team wanted to study the interaction of the conditions and their treatment and find an effective therapy for both.
About the study
Dr. McGeary and colleagues developed CBTH by modifying psychotherapy for migraine. In this study, they evaluated its effectiveness with post-traumatic headache and PTSD symptoms.
The study was conducted at the South Texas Veterans Health Care System Polytrauma Rehabilitation Center. Participants had clinically significant PTSD symptoms and headaches that persisted for more than three months after a TBI. They were randomly assigned to receive CBTH, a leading PTSD treatment called Cognitive Processing Therapy (CPT), or the usual care provided at the VA Polytrauma Center.
CBTH, which uses cognitive-behavioral therapy concepts to reduce headache disability and improve mood, includes key components such as relaxation, goal setting for activities that patients want to resume. and planning for these situations.
CPT is a leading PTSD psychotherapy that teaches patients how to assess and change the annoying 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 level of care that may include injections, physical and occupational therapies, painkillers, acupuncture and massage, and long-term medical care.
Research results
What the researchers found at the end of treatment was that, compared with usual care, those who received CBTH reported significant reductions in disability and the negative impact on function and quality of daily life. They also showed an improvement in PTSD symptoms comparable to the group that received CPT. All of these treatment gains were maintained for six months after the end of treatment.
CPT, on the other hand, resulted in significant and lasting improvements in PTSD symptoms, but alone did not improve the disability of the headache. “That was a surprise,” Dr. McGeary said. “If the theories about PTSD leading to post-traumatic headache are correct, expect CPT to help both PTSD and headache. Our findings call this into question.”
Interpretation of results
Interestingly, CBTH did not reduce the intensity or frequency of the headache compared to regular care. Dr. McGeary said his dramatic reductions in the negative impact of life are likely due to his confidence in patients who can control or manage their headaches, a concept known as “self-efficacy.” This sense of control was key to helping patients “recover their lives,” he said.
“If you can improve a person’s belief that they can control their headache, they work better,” Dr. McGeary said. “This is because when it comes to a long-term disabling pain condition, people make decisions about whether to actively participate in any type of activity, especially if the activity aggravates the pain condition. They take these decisions based on their perceptions of their ability to manage their pain. “
Dr. McGeary believes the CBTH planning component 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 “Okay, I have a plan for this. I’ll wear my sunglasses to block out the bright light. I’ll wear a cold compress. I’ll walk away if the noise gets too much.” Making plans helps people feel that they have improved their self-efficacy in managing their headaches. ”
As for the relief of PTSD symptoms, Dr. McGeary said it is surprising that CBTH and CPT were comparable. He believes CBTH was more appealing to patients, so fewer dropped out and more received a full dose of treatment. CBTH requires fewer therapy sessions and shorter ones; usually eight sessions of 30-45 minutes each. CPT is a more difficult therapy and usually includes 12 sessions of 60-90 minutes each.
Another advantage of CBTH is that it only takes two hours to train doctors to offer therapy, compared to CPT, a complex treatment that requires significant training and acquired skills. This would make it relatively easy to increase the number of therapists available to treat veterans with post-traumatic headaches and facilitate the loading of cases in clinics.
Next steps
Following this success with veterans in San Antonio, Dr. McGeary and 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 the CBTH in a larger trial at several U.S. military and VA locations.
Dr McGeary explained: “We need more women, more racial and ethnic diversity, active veterans and military from different branches, with different comorbidities, in different geographical regions linked to different hospitals and medical systems because we are comparing with regular care. “
Source:
University of Texas Health Sciences Center in San Antonio
Magazine reference:
McGeary, DD, et al. (2022) Cognitive behavioral therapy for veterans with comorbid posttraumatic headache and posttraumatic stress disorder symptoms. JAMA Neurology. doi.org/10.1001/jamaneurol.2022.1567.