New therapy reduces headache disability after brain injury

The first therapy developed for post-traumatic headache significantly reduced related disability in veterans following a traumatic brain injury and decreased co-occurring symptoms of post-traumatic stress disorder.

The treatment, called Cognitive Behavioral Therapy for Headache, was appealing to patients, showing low drop-out rates. In addition, it is easy for therapists to learn and deliver. The findings were reported in JAMA Neurology.illustration of a brain with electric bolts extending behind it.

“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,” said Don McGeary, PhD, associate professor of psychiatry and behavioral sciences in the Joe R. and Teresa Lozano Long School of Medicine. “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 other PTSD symptoms, is a major breakthrough.”

Both TBI and PTSD are signature wounds of post-9/11 military conflicts, and the two conditions commonly occur together. Post-traumatic headaches, or headaches that develop or worsen following a head or neck injury, become chronic and debilitating in a large percentage of those who experience a TBI, such as a concussion, inhibiting their ability to engage in the activities of daily life. When PTSD occurs with other symptoms, it can worsen the headaches and make them more difficult to treat.

Although effective treatments exist for PTSD, they do not for post-traumatic headache. Migraine medications alleviate the headache pain but do not relieve related disability. They also often have unwanted side effects, and their overuse can worsen headaches.

McGeary and his colleagues developed Cognitive Behavioral Therapy for Headache by modifying a psychotherapy for migraine headaches. It includes key components such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

Cognitive Behavioral Therapy for Headache requires eight sessions of 30-45 minutes each. This is shorter than Cognitive Processing Theory, a leading psychotherapy for PTSD that typically requires 12 sessions lasting 60-90 minutes each. The new therapy teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma.

Those receiving Cognitive Behavioral Therapy for Headache reported significant reductions in disability and in negative impact on function and quality of daily life. They also showed improvement in PTSD symptoms. All of these treatment gains were maintained six months after treatment completion. However, the therapy did not reduce headache intensity or frequency compared to usual care, which can include injections, physical and occupational therapies, pain medications, acupuncture and massage, and long-term medical care.

McGeary said the therapy’s reductions on negative life impact are likely due to its building patients’ confidence that they could control or manage their headaches, a concept known as “self-efficacy.” That sense of control was key to helping patients “get their lives back,” he said.

“If you can improve a person’s belief that they can control their headache, they function better,” McGeary said. “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.”

McGeary believes the planning component of the therapy is key to improving those perceptions.Another benefit of the therapy is that it requires only two hours to train clinicians to provide the care. That would make it relatively easy to increase the number of therapists available to treat veterans with post-traumatic headache and ease caseloads at clinics.

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