Post-Traumatic Headaches in Veterans:

TBI or PTSD?

Kavita Manchikanti, PGY-2May 23, 2013

Traumatic Brain Injury

“disruption of brain function as a result of an external force marked by LOC, PTA, alteration in mental state, neurologic deficits, or intracranial lesion” (VA/DoD Clinical Practice Guidelines for Management of Concussion/mTBI 2009)Mild TBI Moderate TBI Severe

TBI

Initial GCS 13-15 9-12 <9

LOC 0-30 mins >30 mins, <24 hours

>24 hours

Alteration of consciousness

A moment up to 24 hours

>24 hours >24 hours

PTA 0-1 day >1 and <7 days >7 days

.Prevalence and treatment of headaches in veterans with mild traumatic brain injury.Patil VK, St Andre JR, Crisan E, Smith BM, Evans CT, Steiner ML, Pape TL.Headache. 2011 Jul-Aug;51(7):1112-21. doi: 10.1111/j.1526-4610.2011.01946.x.

Traumatic Brain Injury (TBI)

Post-Traumatic Headache (PTH)

Onset within 7 days of head trauma or regaining consciousness

Secondary headache

No defining clinical features

Chronic >3 months

Inverse relationship with TBI severity

Characteristics and treatment of headache after traumatic brain injury: a focused review.Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WCAm J Phys Med Rehabil. 2006 Jul;85(7):619-27. Review.

Treatment of PTHPhysical and Psychological

Evaluation

Peripheral mechanism

Physical therapy or simple analgesics

Central mechanism

Migraine-like headache

Acute: analgesics, NSAID,

ergotamines, triptans

Prophylaxis: Ca Channel blockers, anticonvulsants, antidepressants,

beta blockers

Tension-type-like headache

Acute: Analgesics, NSAIDs

Prophylaxis: antidepressants, muscle relaxants

Psychological and behavioral

therapies usually necessary

PTSD and TBI

Relationships between mild traumatic brain injury sustained in combat and post-traumatic stress disorder.Ruff RL, Riechers RG, Ruff SS.F1000 Med Rep. 2010 Aug 19;2:64. doi: 10.3410/M2-64.

Research PlanPost Traumatic Headaches: A Description and

Comparison of Headache Patterns in Traumatic Brain Injury and Post-Traumatic Stress Disorder

Objective

Describe and compare headache patterns in veterans with TBI versus those with PTSD.

Aim 1: Describe headache characteristics (onset, frequency, duration, location, severity, triggers, quality, associated symptoms, response to treatment) in groups of veterans exposed to blasts who have been diagnosed with either TBI or PTSD.

Aim 2: Compare headache characteristics between groups of veterans diagnosed with TBI or PTSD to determine if a significant difference exists.

DesignOEF/OIF Veterans with blast exposure

Positive TBI ScreenNeuropsych Testing

TBI ProfileHeadache Profile

PTSD Profile

Mixed TBI/PTSD

Neither

Negative TBI ScreenMental Health Clinic

PTSDHeadache Profile

Hypothesis

Traumatic Event

PTSDHeadaches

TBI