Relationship Between Headache Characteristics and a Remote History of TBI in Veterans

Abstract

Objective:To examine the association between deployment-related Traumatic Brain Injury (TBI) severity, frequency, and other injury characteristics on headache outcomes in veterans evaluated at a Veterans Administration (VA) polytrauma support clinic.Methods:We conducted a retrospective chart review of 594 comprehensive TBI evaluations between 2011-2021. Diagnostic criteria were based upon the Department of Defense/VA Consensus-Based Classification of Closed TBI. Adjusted Odds Ratios and 95% Confidence Intervals were estimated for headache prevalence (logistic), severity (ordinal), and prevalence of migraine-like features (logistic) using multiple regression analysis. Regression models were adjusted for age, sex, race/ethnicity, time since injury, and mental health diagnoses.Results:TBI severity groups were classified as sub-concussive exposure (n= 189), mild (n= 377), moderate (n = 28), and severe TBI (n = 0). Increased headache severity was reported in veterans with mild TBI (AOR = 1.72 [1.15, 2.57] and moderate TBI (AOR=3.89 [1.64, 9.15]) as compared to those with sub-concussive exposure. A history of multiple mild TBI was associated with more severe headache (AOR = 2.47 [1.34, 4.59]) and migraine-like features (AOR = 5.95 [2.55, 13.77]). No differences were observed between blast and non-blast injuries; however, greater headache severity was reported in veterans with both primary and tertiary blast effects (AOR = 2.56 [1.47, 4.49]). Alterations of consciousness (AOC) and post-traumatic amnesia (PTA) longer than 30 minutes were associated with more severe headache (AORs = 3.37 [1.26, 9.17] and 5.40 [2.21, 13.42], respectively). The length of years between the onset of last TBI and the TBI evaluation was associated with headache severity (AOR = 1.09 [ 1.02, 1.17]) and prevalence of migraine-like features (AOR = 1.27[1.15, 1.40]). Lastly, helmet use is associated with less severe headache (AOR = 0.42 [ 0.23, 0.75]) and lower odds of migraine-like features (AOR = 0.45 [ 0.21, 0.98]).Discussion:Our data support the notion for a dose-response relationship between TBI severity and headache outcomes. A history of multiple mild TBI and longer duration of AOC and PTA are unique risk factors for poor headache outcomes in veterans. Furthermore, this study sheds light on the poor headache outcomes associated with sub-concussive exposure. Past TBI characteristics should be considered when developing headache management plans for veterans.

Risk of Migraine after Traumatic Brain Injury and Effects of Injury Management Levels and Treatment Modalities: A Nationwide Population-Based Cohort Study in Taiwan

“…First, various criteria have been used to define the severity of TBI. These include the duration of loss of conscious [ 44 ], Glasgow Coma Scale score [ 5 , 36 , 45 ], and duration of post-traumatic amnesia (PTA). A recent study even identified more than 50 definitions for mild TBI [ 46 ].…”

“…For example, one study revealed that patients who continued to experience headaches three months after TBI were more likely to exhibit slow continued recovery, particularly after a year of persistent headaches and particularly if their TBI was moderate or severe [ 17 ]. Another study revealed that patients with a history of moderate TBI had higher odds of reporting severe headaches (adjusted odds ratio: 3.89) and migraine-like features (adjusted odds ratio: 15.34) than those with subconcussive exposure, which was limited to mild TBI [ 44 ]. Furthermore, a study revealed that moderate and severe TBI can disrupt the blood–brain barrier and thus allow the migration of neutrophils from leaky blood vessels, resulting in neuroinflammation, which plays a key role in the pathophysiology of post-traumatic headache [ 39 ].…”

Author Response: Reationship Between Headache Characteristics and a Remote History of TBI in Veterans: A 10-Year Retrospective Chart Review

“…We appreciate Dr. Gupta's comments on our article, 1 but respectfully disagree. Our findings indicate clinicians may achieve a more precise prognosis of traumatic brain injury (TBI)–related headaches by eliciting a detailed history of TBI frequency and severity (subconcussive, mild, or moderate), loss of consciousness duration, alterations of consciousness, and posttraumatic amnesia as semicontinuous variables rather than categorical criteria.…”

Reader Response: Relationship Between Headache Characteristics and a Remote History of TBI in Veterans: A 10-Year Retrospective Chart Review

“…Androulakis et al advance the classification of traumatic brain injury (TBI)-associated migraine-like headache in army veterans and focus on remote retrospective multidimensional and cumulative effect. 1 Paradoxically, their data suggest mild/multiple TBI, moderate TBI, and a longer duration as being statistically more contributory toward headache than other factors, besides alteration of consciousness. Conversely, alterations of consciousness and post-traumatic amnesia for longer than 30 minutes are associated with more severe headache.…”

“…Conversely, alterations of consciousness and post-traumatic amnesia for longer than 30 minutes are associated with more severe headache. 1 None of the TBI phenotypes offer any clue to pronociceptive ophthalmic trigeminal (V1) neural activations or their link with the eye. 2 The investigators do not comment on the role of cortical spreading depression (CSD) in migraine.…”