Headache Significant Cause of Attrition in Deployed Soldiers

Pauline Anderson

October 20, 2011

October 20, 2011 — Headaches represent a significant burden to American soldiers deployed to combat zones, with only about a third of those evacuated with a primary diagnosis of headache returning to duty, according to a new study.

"The overall [return-to-duty] rate of 33.6% is one of the lowest among all injury types, and to some degree reflects the observation that a large percentage of headaches were incurred during combat operations," the authors conclude. "Although the ability of interventions to return this subset of individuals back to their unit will likely be limited, better guidelines for the management of headache are needed in theatre and postevacuation."

The study, led by Steven P. Cohen, MD, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, Baltimore, Maryland, and a colonel in the US Army Reserves, was published online October 12 in Cephalalgia, the journal of the International Headache Society.

In a statement from Johns Hopkins, Dr. Cohen points out that postconcussion headaches and migraines were the most common headache types, and that physical trauma led to almost half of the debilitating headaches.

A significant number of headaches were the result of damage to or pressure on the occipital nerve, Dr. Cohen noted in the release, the result, for many, of long hours spent wearing heavy Kevlar helmets.

"Everyone who goes on patrol wears a Kevlar helmet," Dr. Cohen said. "They are heavy. They are hard to wear. But if you get a headache from your helmet, you still must wear it. If you can't tolerate your helmet, you can't do your job. It would be too dangerous. So these folks end up being evacuated and not returning to duty."

Deployed Medical Management Center Database

The aims of the study were to estimate the prevalence of the various subcategories of headache during war, provide an overview of treatment, and determine which demographic and clinical variables affect outcome.

Researchers used the Deployed Warrior Medical Management Center database, which contains information on more than 98% of medically evacuated service members. The database keeps information on age, sex, rank, service component, date of evacuation, and whether the injury was battle related or non–battle related.

The researchers also accessed electronic medical records for data on variables related to the nature of the headache and treatment.

The analysis included 985 participants (mean age, 29.6 years; 87.5% men) who were medically evacuated from Iraq and Afghanistan between 2004 and 2009 with a primary diagnosis of headache.

The most common diagnoses were postconcussive (34.1%), migraine (30.0%), and tension-type (11.4%) headaches. Just more than half (51.9%) of the headaches were episodic. The most frequent inciting event by far was physical trauma (47.6%).

More than 95% of the participants received multiple pharmacological treatments, with nonsteroidal anti-inflammatory drugs prescribed most often.

During the study, 33.6% of the participants returned to duty. The highest return-to-duty rate was associated with tension headache (49.6%), whereas the lowest rates were for postconcussion (18.7%) and occipital neuralgia (23.1%) headache, both of which are associated with trauma.

Participants who returned to duty were significantly older and more likely to be women and to be officers, rather than enlisted service members. Patients not receiving treatment were most likely to return to duty, whereas the use of opioids, beta blockers, and multiple modalities were associated with the lowest return-to-duty rates.

This work was supported in part by a Congressional Grant from the John P. Murtha Neuroscience and Pain Institute, the US Army, and the Army Regional Anesthesia and Pain Medicine Initiative.

Cephalalgia. Published online October 12, 2011. Full text

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