CBT May Improve Comorbid Posttraumatic Headache, PTSD

Megan Brooks

July 01, 2022

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder (PTSD), new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, Department of Rehabilitation Medicine, the University of Texas Health Science Center at San Antonio, noted the improvements shown in headache disability after CBT were likely due to its building of patients' confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients "get their lives back. If you can improve a person's belief that they can control their headache, they function better," McGeary said in a news release.

The findings were published online June 27 in JAMA Neurology.

Signature Wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators note. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo eight sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood ― and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large VA multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The co-primary outcomes were headache-related disability on the six-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).

Significant Improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, -3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, -6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

"This was a surprise," McGeary said. "If theories about PTSD driving posttraumatic headache are correct, you'd expect CPT to help both PTSD and headache. Our findings call that into question."

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

"We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we're comparing to usual care," McGeary said.

A Step Forward

Commenting for Medscape Medical News, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center in Washington, DC, said she was "pleased" to see that this study was conducted and that she was pleased with the results.

"It's been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work," said Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is "good and is a step forward. The more alternatives we have, the better," she concluded.

The study was supported in part by the US Department of Defense and the US Department of Veterans Affairs. McGeary and Ritchie have reported no relevant financial relationships.

JAMA Neurol. Published June 27, 2022. Full article

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