Deborah Brauser

July 04, 2017

BOSTON — Intense headaches can persist up to 11 years following traumatic brain injury (TBI), new research suggests.

A case-control study of more than 170 veterans, all of whom had been deployed to the wars in Afghanistan or Iraq 2 to 11 years previously, showed that 75.6% of those who had suffered a TBI on duty had severe or disabling headaches vs 25.7% of their counterparts without TBI.

In addition, subgroup analyses showed similarly significant between-group differences whether the TBI occurred earlier or later.

"We divided them by 2 to 7 years and 8 to 11 years after TBI to see if they were getting any better over time, and the answer is no," lead author James R. Couch, MD, professor of neurology at the Oklahoma University Health Sciences Center in Oklahoma City, told Medscape Medical News.

Dr Couch presented the findings here at the American Headache Society Annual Scientific Meeting (AHS) 2017.

During a pre-meeting webcast, AHS scientific program chair Peter Goadsby, MD, PhD, professor of neurology at King's College London, UK, and the University of California, San Francisco, noted that the study shows "just how troublesome the problem of TBI is" in this population.

"It was three times as common in those with TBI to have troublesome headaches years later," said Dr Goadsby. "It's not right that we don't understand this well enough, it's not right that there's not more research done on it, and it's not right that there aren't [better] treatments for it."

'Very Little Data'

Dr Couch noted that there have been several short-term studies on headache in veterans of recent wars.

At the 2016 AHS annual meeting, a study was presented showing that headaches in a civilian population can persist for at least 5 years after a TBI, as reported by Medscape Medical News.

However, the current investigators write that there are "very little data" on levels of headache severity post-TBI, especially over the long term.

The researchers recruited 86 veterans with and 86 without (matched controls) deployment-related TBI. All were part of the Veterans Affairs (VA) program known as Operation New Dawn, which screens for TBI and refers those with the condition to specialized TBI clinics.

The patient population was interviewed by phone and administered four questionnaires. Headache severity was divided between the following three levels:

  • Disabling: 100% decrease in activity and bedridden

  • Severe: 50% to 90% decrease in activity

  • Mild/moderate: At least 50% of usual activity could still be done

As shown in the table below, significantly more veterans who experienced a TBI had a disabling or severe headache compared with those who never had a TBI, while significantly fewer had headaches considered to be mild/moderate.

Table 1. Distribution of Headache Severity by Group

Severity With TBIs (%) Controls (%) P Value
Disabling 44.2 7.9 < .0001
Severe 31.4 21.1 < .0001
Mild/moderate 24.4 74.3 < .0001


The distribution among the severity levels was similar whether the interviews occurred 2 to 7 years or 8 to 11 years after occurrence for those with TBI or after deployment for the control group.

Table 2. Group Distribution of Headache Severity by Time

Severity With TBIs (%) Controls (%) P Value
2–7 years after TBI/deployment      
Disabling 40.0 11.4 < .0001
Severe 33.3 8.6 < .0001
Mild/moderate 26.7 71.1 < .0001
8–11 years after TBI/deployment      
Disabling 52.6 11.4 < .0001
Severe 26.3 8.6 < .0001
Mild/moderate 21.1 80.0 < .0001


In addition, the TBI group had significantly greater headache frequency than the control group, with 29.4% vs 9.4%, respectively, averaging 10 to 14 headache days per month and 45.9% vs 7.1% having chronic daily headaches, defined as more than 15 headache days per month (both comparisons, P < .0001).

Severity of TBI did not significantly affect headache frequency.

Finally, the odds ratios (ORs) for the most painful levels of headache were significantly higher for those who had a TBI.  

Table 3. ORs of Disabling and Severe Headaches (With vs Without TBI)

Group OR (95% CI)
Full group 12.0 (5.8 – 24.8)
2–7 years post-TBI 8.5 (3.3 – 21.9)
8–11 years post-TBI 18.9 (6.0 – 59.3)


"The occurrence of headaches of this severity can impact employment, marriage, and quality of life significantly," write the investigators. The reason for the wide between-group differences found "is not known but will require further investigation," they add.

In other words, "this needs more work to figure out why these things are so persistent and, secondly, what we can do to help" in regards to interventions, said Dr Couch.

'A Real Plague'

In a press release, Dr Goadsby called the study results "striking" and said they fill an important gap in understanding TBI and its impact on headache severity. 

"We don't know exactly how TBI causes these severe headaches, but their long-term persistence suggests that processes related to TBI remain active or produce permanent changes in the brain, allowing the headaches to continue," he said.

"These and other findings indicate that headaches following TBI will unfortunately continue to be a major problem for many veterans," said Dr Goadsby. 

Dr Goadsby told Medscape Medical News that severe headache "is a real plague for many with brain injuries after they get back from serving their country. And this needs to be taken seriously." 

The study was funded by the Veterans Administration. Dr Couch and Dr Goadsby have disclosed no relevant financial relationships. 

American Headache Society Annual Scientific Meeting (AHS) 2017. Abstract PS59. Presented June 10, 2017.

Follow Deborah Brauser on Twitter: @MedscapeDeb. For more Medscape Neurology news, join us on Facebook and Twitter.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.