Posttraumatic Headache in Military Personnel and Veterans of the Iraq and Afghanistan Conflicts

Abstract

Headaches, particularly migraine, are common in US servicemembers (SMs) who are deployed to or have returned from theaters of combat operations in Iraq and Afghanistan. Concussions and exposure to explosive blasts may be a significant contributor to the increased prevalence of headaches in military veterans. Concussions, usually due to blast exposure, occur in approximately 20% of deployed SMs, and headaches are a common symptom after a deployment-related concussion. Posttraumatic headaches (PTHAs) in US SMs usually resemble migraines, and posttraumatic stress disorder (PTSD) and depression are common comorbidities. Treatment of PTHAs in SMs is based upon the treatment setting, whether the headaches are acute or chronic, the headache phenotype, and associated comorbidities. No randomized, controlled clinical trials evaluating the efficacy of therapies for PTHAs have been completed. Pharmacologic and nonpharmacologic management strategies should be selected on an individual basis. Acute therapy with NSAIDs or triptans and prophylactic therapy in acute and chronic settings using valproate, nortriptyline, amitriptyline, propranolol, topiramate, or botulinum toxin are discussed. Triptans and topiramate may be particularly effective in SMs with PTHA. Management of PTHA and other features of the posttraumatic syndrome should be multidisciplinary whenever possible.

Deficient Pain Modulatory Systems in Patients with Mild Traumatic Brain and Chronic Post-Traumatic Headache: Implications for its Mechanism

“…4,5 CPTHA is the most prevalent type of pain after mild TBI, with a prevalence rate of 47-95%, compared with *20-38% in moderatesevere TBI. 1,2,6,7 Two recent studies examined the rate of headache longitudinally among a large cohort during the 1st year after the TBI. 8,9 The incidence at baseline was 54-44%, and the cumulative incidence of headache over 1 year was 71-91%.…”

Post-Traumatic Headache

“…On average, these soldiers were exposed to five or more blasts occurring within 60 feet. 64 Of soldiers with chronic PTH, 77% had blast-induced TBI. 31 Similar to findings in civilian studies, PTH occurring in military cohorts may not meet ICHD criteria for onset within 1 week of injury.…”

“…98,99 In military settings, the Defense and Brain Injury Center (DVBIC) has provided PTH treatment recommendations for deployed and non-deployed members based on Class IV study evidence. 64,100,101 In one retrospective analysis of active duty service members with mTBI and PTH, triptans were effective as acute agents treating a predominantly migraine phenotype. Topiramate was an effective prophylactic agent, associated with a significant reduction in headache frequency, but overall the number of patients using different medications was small, which prevented treatment recommendations.…”

Triptans: over the migraine

“…No randomized, controlled clinical trials evaluating the efficacy of therapies for post-traumatic headaches have been completed. A recent study [13] shows that, among symptomatic therapies, triptans may be particularly effective in posttraumatic headaches in US service members who are deployed to or have returned from theaters of combat operations in Iraq and Afghanistan.…”