CBT Improved Headache Disability in Veterans With Mild TBI

Post-9/11 U.S. combat veterans with mild traumatic brain injury (TBI) reported improvements in both headache disability and post-traumatic stress disorder (PTSD) symptom severity after cognitive behavioral therapy (CBT) for headache, a single-site clinical trial found.

Donald McGeary, PhD, of the University of Texas Health Science Center at San Antonio, and co-authors randomized veterans with post-traumatic headache to eight sessions of CBT for headache, 12 sessions of cognitive processing therapy (CPT) for PTSD, or treatment as usual.

Across aggregated post-treatment measurements over 6 months, veterans reported significantly lower headache disability scores with CBT for headache (−3.4 points, 95% CI −5.4 to −1.4, P<0.001) compared with usual care, the researchers reported in JAMA Neurology.

Veterans receiving CBT for headache reported lower PTSD symptom severity scores (−6.5 points, 95% CI −12.7 to −0.3, P=0.04), compared with usual care. Veterans receiving CPT also reported lower PTSD symptom severity scores (–8.9 points, 95% CI −15.9 to −1.9, P=0.01), but the difference between CPT and CBT was not significant.

"To find the first major treatment success for post-traumatic headache, which is arguably the most debilitating symptom of TBI—and that the treatment also significantly reduces comorbid PTSD symptoms—is a major breakthrough," McGeary said in a statement.

"If you can improve a person’s belief that they can control their headache, they function better," he pointed out.

"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," McGeary continued. "They make those decisions based on their perceptions of their ability to handle their pain."

Military conflicts after 9/11 have led to both TBI and PTSD in veterans; the two conditions commonly occur together. Post-traumatic headaches become chronic and debilitating in a large percentage of veterans with TBI. When PTSD co-occurs, it can worsen headaches and make them more difficult to treat.

Veterans are more likely than civilians to develop post-traumatic headache after mild TBI, and mechanisms of post-traumatic headache are poorly understood. "There are no confirmed frontline treatments for post-traumatic headache attributable to mild TBI," McGeary and colleagues wrote.

"A previous treatment study concluded that nonpharmacological interventions (i.e., CBT) may not work for individuals with post-traumatic headache," they noted. "However, the present trial offers the first evidence showing that a nonpharmacological intervention (CBT for headache) can significantly improve headache-related disability in post-traumatic headache attributable to mild traumatic brain injury for up to 6 months compared with usual care."

CBT for headache uses cognitive behavioral therapy concepts to reduce headache disability and improve mood. CPT teaches patients how to evaluate and change thoughts related to trauma; it has been shown to improve health-related symptoms.

"CBT for headache and CPT were both developed using a CBT framework," the researchers explained. "The CBT for headache intervention focused exclusively on headache and stress, relying heavily on behavioral interventions and stress management with some cognitive therapy. CPT focused exclusively on PTSD, emphasizing cognitive therapy."

McGeary and co-authors enrolled post-911 combat veterans between May 2015 and June 2019, following them through October 2019. They randomized 193 participants to eight sessions of CBT for headache (n=65), 12 sessions of CPT for PTSD (n=64), or treatment as usual (n=64).

The cohort had a mean age of 39.7 and 87% were men. All met criteria for persistent or delayed-onset headache attributable to mild traumatic brain injury. The study defined post-traumatic headache as beginning within 3 months of injury rather than the typical definition of within 7 days, the researchers noted.

Participants reported frequent medical (75%) and mental health (79%) comorbidities; 78% were taking a medication specifically for headache.

The 6-Item Headache Impact Test (HIT-6) was used to measure headache disability. PTSD symptom severity was assessed using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PCL-5). Baseline headache- and PTSD-related disability were severe, with mean HIT-6 and PCL-5 scores of 65.8 and 48.4, respectively.

At baseline, headaches were mostly intermittent (78%) with mean duration of 4.2 hours occurring a mean of 3.8 times per week with mean intensity of 6.9 of 10. Headaches were unremitting in 8%.

Treatment initiation rates for the CBT, CPT, and usual treatment groups were 85%, 75%, and 89%, respectively. Overall, 61.7% of the cohort provided at least one post-treatment outcome assessment; the intention-to-treat population was 193 and the per-protocol population was 105.

Secondary analyses did not find a significant improvement in headache frequency or intensity despite improvements in HIT-6 headache disability scores. This was "surprising because headache frequency and intensity are strong predictors of disability in studies of migraine and tension-type headache," the researchers wrote.

"Behavioral interventions like CBT for headache are better suited to address disability than headache frequency or intensity, especially when headaches are chronic and pain cognitions/behaviors (the primary targets of CBT treatment) may be more related to function than pain experience," they added.

On the HIT-6, veterans receiving CPT reported an insignificant change compared with usual treatment (−1.4 points, 95% CI −3.7 to 0.8, P=0.21). Overall, adverse events were minimal across treatment groups.

Limitations include a threshold for detection of change in HIT-6 scores based on studies in other headache populations with less severe headaches. "Therefore, the chosen threshold of clinically significant change may not apply," McGeary and colleagues wrote.

The researchers also acknowledged that dropout and missing data from the trial were high, "though consistent with dropout risk in this population."

This research was supported in part by Consortium to Alleviate Posttraumatic Stress Disorder from the U.S. Department of Defense, Defense Health Program, and Psychological Health and Traumatic Brain Injury Research Program, and from the U.S. Department of Veterans Affairs, Office of Research & Development, Clinical Science Research & Development Service.

McGeary had no disclosures.

McGeary DD, et al "Cognitive behavioral therapy for veterans with comorbid posttraumatic headache and posttraumatic stress disorder symptoms: A randomized clinical trial" JAMA Neurol 2022; DOI: 10.1001/jamaneurol.2022.1567.