Post-traumatic headache (PTHA) is defined as headache that develops within 7 days of trauma and has no typical presenting characteristics.1 This imprecise definition, published in the International Classification of Headache Disorders, limits the ability of NPs and PAs to evaluate, diagnose and treat veterans with PTHA. As the medical community develops greater understanding of postwar health problems such as PTHA, migraine-like syndrome after concussion, mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD), future definitions and diagnostic criteria should be more useful.
Literature Review
To assess the current clinical picture with regard to PTHA, I performed a review of the literature published after the onset of Operation Enduring Freedom in 2001. I searched CINAHL, Cochrane, MEDLINE, ProQuest and PubMed databases using the key words "migraine," "headache," "post-traumatic headache," "traumatic brain injury" and "veterans." These searches yielded six peer-reviewed studies that served as the basis for this article.
Incidence
The incidence of PTHA in veterans who served in Iraq or Afghanistan is estimated to be in the range of 16% to 38%.2,3 In the civilian population of the United States, approximately 17% of women and 7% of men are diagnosed with migraine headaches.4 Women are three times more likely to experience migraine headaches than men.4 Veterans diagnosed with mTBI are seven times more likely to experience PTHA or migraine-like syndrome after concussion than their civilian counterparts, irrespective of gender.4
Etiology
The most common symptom after a closed or open head trauma is mental status change, initially identified using the Glasgow Coma Scale. Just as important, however, is the mechanism of soft tissue injury to the brain. So-called blast concussions resulting from modern explosive devices are sufficient to alter mental status when the devices are detonated within 25 yards of the patient.
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The modern battlefield is also associated with psychological factors not usually linked with head injuries or migraine headaches in noncombat life. It is common for soldiers to experience a combination of hypervigilance (an acute state of awareness characterized by sensitivity to sudden movement, light and noise) and chronic insomnia. This pairing rarely exists in the modern civilian lifestyle,5 but in a battlefield environment, it may literally save lives. Research has demonstrated that the somatic expression of chronic hypervigilance and insomnia are associated with chronic physical manifestations such as obesity, hypertension and depression. Anecdotally, PTHA may be correlated with acute and chronic stress associated with deployment.6 However, recent research involving veterans diagnosed with mTBI did not demonstrate a clear association between PTHA and anxiety or depression.7
How a soldier encounters and reacts to the multiple stressors present during deployment is unique. If three deployed service members are within the blast radius of an improvised explosive device when it is detonated, one may develop mTBI with migraine-like syndrome, another may develop mTBI with no long-term consequences, and the third may escape developing mTBI but may experience PTSD. Every situation and person is unique, and his or her symptomatology must be viewed as real and concrete in order to select the most effective treatment and return the patient to the highest level of function possible.
Presentation
As mentioned at the start, the presentation of PTHA is imprecise. Unlike the typical migraine presentation in nonveterans (an aura or other prodromal symptoms, unilateral cephalgia consistently presenting on the same side, or pain presentation concurrent with the rise and fall of hormones), PTHA symptoms in veterans vary widely and may include unilateral cephalgia, occipital cephalgia, photophobia, nausea, migraine headache, tension headache or mixed headache.2,5,7
In the six studies that examined the phenomena of headaches in deployed veterans (n = 255), 78% of soldiers were diagnosed with migraine headaches and the remainder were diagnosed with tension or mixed headaches.6 The most common distinguishing characteristic among veterans presenting with headaches was exposure to a blast from an explosive device.
Blast injuries are the most common cause of head and neck injury in returning veterans, and 72% of soldiers across the study populations reported migraine symptoms or worsening symptomology within a week of blast exposure.2,5,7 Therefore, any patient identifying themselves as a veteran of the wars in Afghanistan or Iraq should be questioned about his or her experiences while deployed. An excellent opening is, "Thank you for your service." That simple phrase, delivered with sincerity, can help unlock memories and information the veteran may be reluctant to share.
Diagnostic Process
The history and physical exam for a combat veteran are the same as for any other patient, but it's important to gather details about exposure to explosive blasts (including frequency); past diagnosis with mTBI; allergies to medications; environmental triggers; use of prescribed medications, nicotine or alcohol; and use or abuse of prescribed medications or street drugs.
The diagnosis of PTHA is most commonly made on the basis of the history and physical examination, and the reasonable exclusion of other causes.
Rule out life-threatening conditions with tools such as laboratory testing, a lumbar puncture (if indicated), computerized tomography or magnetic resonance imaging. A patient previously diagnosed with PTHA does not require diagnostic imaging or other invasive procedures, unless indicated by the most recent history and physical exam.
Therapeutic Plan
Medication management decisions should reflect the patient's presentation. Alone or in combination, the use of 5HT1 agonists, ergot alkaloids, NSAIDs or prazosin can successfully manage headache symptoms, frequency and duration in veterans with symptoms of PTHA.1 Recent evidence also supports use of the triptans.8 Short-term use of benzodiazepines may be helpful, particularly if the patient reports periods of chronic insomnia or difficulty sleeping.9 Use caution when prescribing benzodiazepines, however, due to the risk of addiction with long-term use.
In addition to pharmacotherapy strategies, all patients with PTHA should receive a referral to a mental health professional. Cognitive behavioral therapy can decrease headache symptoms over time.9,10 When suggesting cognitive behavioral therapy, strive to remove the stigma of seeing a "shrink." If the patient declines, suggest this therapy again during future patient interactions. Although it might be difficult to manage due to medical privacy laws, it can be helpful to involve the patient's spouse in convincing the veteran to see a mental health professional.
Follow-Up
A recently discharged veteran may experience an altered sense of self and identity after leaving the service. Many federal, state and county resources are available to assist veterans, but they may need encouragement or guidance. Handouts and pamphlets explaining the agencies available to assist the veteran are useful.
If possible, an open-door policy should be available to the veteran with PTHA in order to address questions and concerns and to abate new symptomatology associated with the headaches. A combination of medications may be needed. Educate the veteran that the first medication class selected may not be effective for him or her, and that multiple visits and medication changes may be needed to identify the right combination.
If the patient has never been tested for allergies, a referral to an allergist may be helpful to determine whether an underlying food or environmental allergy is contributing to the headache or symptom profile.
References
1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24(Suppl 1):9-160.
2. Theeler BJ, et al. Prevalence and impact of migraine among U.S. Army soldiers deployed in support of Operation Iraqi Freedom. Headache. 2008;48(6):876-882.
3. Walker WC, et al. Headache after moderate and severe traumatic brain injury: A longitudinal analysis. Arch Phys Med Rehab. 2005;86(9):1793-1800.
4. Neely ET, et al. Clinical review and epidemiology of headache disorders in US service members: with emphasis on post-traumatic headache. Headache. 2009;49(7):1089-1096.
5. Gironda RJ, et al. Traumatic brain injury, polytrauma, and pain: challenges and treatment strategies for the polytrauma rehabilitation. Rehab Psychol. 2009;54(3):247-258.
6. Ruff RL, et al. Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. J Rehabil Res Devel. 2008;45(7):941-952.
7. Hoge CW, et al. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.
8. Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932-944.
9. Ruff RL, et al. Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. J Rehabil Res Devel. 2009;46(9):1071-1084.
10. Blanchard MS, et al. Chronic multisymptom illness complex in Gulf War I veterans 10 years later. Am J Epidemiol. 2006;163(1):66-75.
Robert S. Barrett is a student in the family nurse practitioner program at the University of North Florida in Jacksonville. He has been a registered nurse since 1996 and is a veteran of Operation Iraqi Freedom and Operation Enduring Freedom.