Persistent Posttraumatic Headaches and Functioning in Veterans

Injury Type Can Matter

Paul S. Nabity PhD; Carlos A. Jaramillo MD, PhD; Patricia A. Resick PhD; Cindy A. McGeary PhD; Blessen C. Eapen MD; Casey L. Straud PsyD; Willie J. Hale PhD; Timothy T. Houle PhD; Brett T. Litz PhD; Jim Mintz PhD; Donald B. Penzien PhD; Stacey Young-McCaughan RN, PhD; Terence M. Keane PhD; Alan L. Peterson PhD; Donald D. McGeary PhD


Headache. 2021;61(9):1334-1341. 

In This Article

Abstract and Introduction

Objective: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning.

Background: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments.

Methods: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively.

Results: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms.

Conclusion: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.


More than 400,000 U.S. military personnel were diagnosed with traumatic brain injury (TBI; the majority with mild TBI) over the past two decades and approximately 1.5–2.5 million TBI-related emergency visits occur each year in the United States.[1,2] About 90% of all TBIs are diagnosed as mild and typically occur from blunt force trauma to the head.[3] However, deployment-related TBIs among military personnel are more likely to be due to blast exposure compared with head injuries that occur in garrison (nondeployed settings), which are more representative of civilian blunt head trauma resulting from falls, vehicle collisions, physical assaults, sport injuries, and partner violence.[4–6] In a random sample of veterans with TBI, approximately one-third reported a blast injury exposure.[7]

Posttraumatic headaches (PTHs) are frequent, painful sequelae of TBIs.[8] PTHs are secondary headaches that begin or worsen within 7 days of a head and/or neck trauma.[9] PTHs are paradoxically more prevalent after a mild TBI compared with more severe TBIs.[10] These headaches may present with symptoms similar to migraine or tension-type headaches, though a migraine-like phenotype is more common in military populations.[11,12] PTHs are considered to be persistent once they have occurred for longer than the initial 3-month (acute) period.[9] Rates of acute PTHs after a TBI vary from 30% to 90%, while persistent PTHs occur in approximately 20% of individuals following a TBI.[8,13–16] The term "chronic" refers to the frequency rather than the persistence of headaches, and is defined as equal to or greater than 15 headache days per month.[9] PTHs are disabling and result in lower quality of life and even more so when headache frequency is chronic.[17]

Blast injuries have the potential to affect multiple organs simultaneously and there is debate about whether blast injuries affect headache outcomes and comorbid psychiatric conditions differently compared with blunt traumas.[18] TBIs are also linked to comorbid depression and posttraumatic stress disorder (PTSD).[19,20] In a retrospective medical record review study of 27,169 U.S. Army Special Operations Command personnel with diagnosed blunt, blast, and blast–blunt combination mild TBIs, the simultaneous combination of blast–blunt injuries was related to greater PTSD symptoms compared with either injury type alone.[21] In the same study, blast head injuries were associated with more severe PTSD symptoms compared with blunt head injuries alone. In particular, re-experiencing symptoms (e.g., nightmares, flashbacks) are associated with TBI after a blast injury.[22]

Compared with civilians, military personnel are at higher risk of experiencing PTHs following a mild TBI, especially if the TBI results from blast exposure.[23] In a sample of active duty military personnel with persistent PTHs, which are those that occur for longer than 3 months, the majority reported a blast exposure, whereas only 15% reported blunt head trauma.[12] Roughly half of the sample of U.S. Army personnel experienced at least one blast exposure and those with subsequent continuous headaches were more likely to be medically discharged.[11] Moreover, blast injuries are linked to greater headache prevalence and greater headache severity.[23,24] Military personnel have a uniquely higher risk of blast exposure or a combination of being exposed to a blast and having a blunt head injury in the process; however, the consequences of this unique exposure to the onset and maintenance of PTHs are not well understood.

A study by Mac Donald and colleagues found no significant correlations between head injury mechanism (blast, blunt, or combination) and severity of headache, depression, or PTSD.[25] However, a more recent review by Greer and colleagues reported inconsistent findings about the relationship between head injury mechanism (blast vs. blunt), PTSD, and headache presentations.[26] Given the conflicting findings for the relationship of head injury type to headache phenotype, psychological symptoms (specifically PTSD and depression), and psychosocial functioning, the first aim of this study was to describe these relationships by analyzing baseline data from a large clinical trial comparing two behavioral treatments for PTH to usual care in U.S. military veterans. Second, the relationships among demographics, headache presentations, and head injury types were explored. Because of the unique exposure of military personnel to blast head injury, comparisons between PTH resulting from a blast injury alone, blunt injury alone, or combined (blast+blunt) injury were conducted.

The aim of this study was to evaluate the prevalence and nature of head injury mechanism, headache presentation, head injury history, psychological symptoms, and psychosocial functioning. We hypothesized, a priori, that persistent PTH from combined blast+blunt head injury would be significantly associated with (1) higher levels of baseline headache severity and duration in comparison with either head injury type alone; (2) greater headache-related disability compared with either head injury type alone; and (3) greater psychological symptom severity (i.e., depression, PTSD) and lower psychosocial functioning.