Current Treatment Options in Neurology

, Volume 14, Issue 1, pp 36–49 | Cite as

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

Headache (JR Couch, Section Editor)

Opinion statement

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.


Headache disorders Military personnel Traumatic brain injury Concussion Treatment Management Assessment Headaches Migraine Posttraumatic headache NSAIDs Triptans Topiramate Prophylaxis 

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9–160.Google Scholar
  2. 2.
    Haas DC. Chronic post-traumatic headaches classified and compared with natural headaches. Cephalalgia. 1996;16(7):486–93.PubMedCrossRefGoogle Scholar
  3. 3.
    Evans RW. Expert opinion: post-traumatic headaches among United States soldiers injured in Afghanistan and Iraq. Headache. 2008;48:1216–25.PubMedCrossRefGoogle Scholar
  4. 4.
    Couch JR, Lipton R, Stewart WF. Is post-traumatic headache classifiable and does it exist? Eur J Neurol. 2009;16:12–3.PubMedCrossRefGoogle Scholar
  5. 5.
    Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury: a systematic review. JAMA. 2008;300:711–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Yamaguchi M. Incidence of headache and severity of head injury. Headache. 1992;32(9):427–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Couch JR, Bearss C. Chronic daily headache in the posttraumatic syndrome: relation to extent of head injury. Headache. 2001;41(6):559–64.PubMedCrossRefGoogle Scholar
  8. 8.
    Packard RC. Epidemiology and pathogenesis of posttraumatic headache. J Head Trauma Rehabil. 1999;14(1):9–21.PubMedCrossRefGoogle Scholar
  9. 9.
    Solomon S. Chronic post-traumatic neck and head pain. Headache. 2005;45(1):53–67.PubMedCrossRefGoogle Scholar
  10. 10.
    Faux S, Sheedy J. A prospective controlled study in the prevalence of posttraumatic headache following mild traumatic brain injury. Pain Med. 2008;9(8):1001–11.PubMedCrossRefGoogle Scholar
  11. 11.
    Stovner LJ, Schrader H, Mickeviciene D, et al. Headache after concussion. Eur J Neurol. 2009;16(1):112–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Packard RC, Ham LP. Posttraumatic headache: determining chronicity. Headache. 1993;33(3):133–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury increases the risk of chronic daily headache: a population-based study. Neurology. 2007;69:1169–77.PubMedCrossRefGoogle Scholar
  14. 14.
    Baandrup L, Jensen R. Chronic post-traumatic headache: a clinical analysis in relation to the International Headache Classification 2nd edition. Cephalalgia. 2005;25(2):132–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Jensen OK, Nielsen FF. The influence of sex and pre-traumatic headache on the incidence and severity of headache after head injury. Cephalalgia. 1990;10(6):285–93.PubMedCrossRefGoogle Scholar
  16. 16.
    Duckro PN, Chibnall JT, Tomazic TJ. Anger, depression, and disability: a path analysis of relationships in a sample of chronic posttraumatic headache patients. Headache. 1995;35(1):7–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Branca B. Neuropsychologic aspects of post-traumatic headache and chronic daily headache. Curr Pain Headache Rep. 2006;10(1):54–66.PubMedCrossRefGoogle Scholar
  18. 18.
    TTatrow K, Blanchard EB, Hickling EJ, Silverman DJ. Posttraumatic headache: biopsychosocial comparisons with multiple control groups. Headache. 2003;43(7):755–66.PubMedCrossRefGoogle Scholar
  19. 19.
    Gfeller JD, Chibnall JT, Duckro PN. Postconcussion symptoms and cognitive functioning in posttraumatic headache patients. Headache. 1994;34(9):503–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Helseth EK, Erickson JC. The prevalence and impact of migraine on US military officer trainees. Headache. 2008;48:883–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Theeler BJ, Mercer R, Erickson JC. Prevalence and impact of migraine among U.S. Army soldiers deployed in support of Operation Iraqi Freedom. Headache. 2008;48:876–82.PubMedCrossRefGoogle Scholar
  22. 22.
    Migraines and other headaches, active components, U.S. Armed Forces, 2001–2007. MSMR Med Surveill Mon Rep. 2008;15(4):6–10.Google Scholar
  23. 23.
    Theeler BJ, Kenney K, Prokhorenko OA, Fideli US, Campbell W, Erickson JC. Headache triggers in the US Military. Headache. 2010;50:790–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Afari N, Harder LH, Madra NJ, et al. PTSD, combat injury, and headache in veterans returning from Iraq/Afghanistan. Headache. 2009;49:1267–76.PubMedCrossRefGoogle Scholar
  25. 25.
    Theeler BJ, Erickson JC. Mild head trauma and chronic headaches in returning US soldiers. Headache. 2009;49:529–34.PubMedCrossRefGoogle Scholar
  26. 26.
    Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. soldier returning from Iraq. N Engl J Med. 2008;358:453–63.PubMedCrossRefGoogle Scholar
  27. 27.
    Schwab KA, Ivins B, Cramer G, et al. Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: Initial investigation of the usefulness of a short screening tool for traumatic brain injury. J Head Trauma Rehabil. 2007;22:377–89.PubMedCrossRefGoogle Scholar
  28. 28.
    Terrio H, Brenner LA, Ivins BJ, Cho JM, Helmick K, Schwab K, Scally K, Bretthauer R, Warden D. Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team. J Head Trauma Rehabil. 2009;24(1):14–23.PubMedCrossRefGoogle Scholar
  29. 29.
    Deriving case counts from medical encounter data: considerations when interpreting health surveillance reports. MSMR Med Surveill Mon Rep. 2009;16(12):2–8.Google Scholar
  30. 30.•
    Cernak I. The importance of systemic response in the pathobiology of blast-induced neurotrauma. Front Neurol. 2010;1:151.PubMedGoogle Scholar
  31. 31.
    Ling G, Bandak F, Armonda R, Grant G, Ecklund J. Explosive blast neurotrauma. J Neurotrauma. 2009;26(6):815–25.PubMedCrossRefGoogle Scholar
  32. 32.••
    Theeler BJ, Flynn FG, Erickson JC. Headaches after concussion in US soldiers returning from Iraq or Afghanistan. Headache. 2010;50(8):1262–72.PubMedCrossRefGoogle Scholar
  33. 33.•
    Risk factors for migraine after OEF/OIF deployment, active component, U.S. Armed Forces. MSMR Med Surveill Mon Rep. 2009;16(12):10–13. This study used the military-wide electronic medical record to determine risk factors associated with migraine after return from deployment to Iraq or Afghanistan.Google Scholar
  34. 34.
    Ruff RL, Ruff SS, Wang XF. Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. J Rehabil Res Dev. 2008;45:941–52.PubMedCrossRefGoogle Scholar
  35. 35.
    Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932–44.PubMedCrossRefGoogle Scholar
  36. 36.
    Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85:619–27.PubMedCrossRefGoogle Scholar
  37. 37.
    Lucas S, Hoffman JM, Bell K, Dikmen S. Natural history of headache in the first year after traumatic brain injury. Neurology. 2011; 76(9) supplement 4:A161.Google Scholar
  38. 38.
    Kozminski M. Combat-related posttraumatic headache: diagnosis, mechanisms of injury, and challenges to treatment. J Am Osteopath Assoc. 2010;110(9):514–9.PubMedGoogle Scholar
  39. 39.
    Peterlin BL, Tietjen G, Meng S, Lidicker J, Bigal M. Post-traumatic stress disorder in episodic and chronic migraine. Headache. 2008;48(4):517–22.PubMedCrossRefGoogle Scholar
  40. 40.
    de Leeuw R, Schmidt JE, Carlson CR. Traumatic stressors and post-traumatic stress disorder symptoms in headache patients. Headache. 2005;45(10):1365–74.PubMedCrossRefGoogle Scholar
  41. 41.
    Rosenthal J, Erickson JC. Post-traumatic stress disorder in US soldiers with migraine and post-traumatic headache. Headache. 2011;51(S1):3–4.Google Scholar
  42. 42.
    Hoge CW, Goldberg HM, Castro CA. Care of war veterans with mild traumatic brain injury–flawed perspectives. N Engl J Med. 2009;360(16):1588–91.PubMedCrossRefGoogle Scholar
  43. 43.
    Ruff RL, Riechers RG, Ruff SS. Relationships between mild traumatic brain injury sustained in combat and post-traumatic stress disorder. F1000 Med Rep. 2010;2:64.PubMedGoogle Scholar
  44. 44.
    VA/DoD Evidence Based Guideline: Evaluation and Management of Concussion/mTBI - Subacute/Chronic (CONUS). Accessed November 2011.
  45. 45.
    Clinical Guidance for Evaluation and Management of Concussion/mTBI - Acute/Subacute (CONUS). Accessed November 2011.
  46. 46.
    Clinical Guidance for Evaluation and Management of Concussion/mTBI - Acute/Subacute. Deployed Setting Version.
  47. 47.
    Kosinski M, Bayliss MS, Bjorner JB, et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res. 2003;12(8):963–74.PubMedCrossRefGoogle Scholar
  48. 48.
    Packard RC. Treatment of chronic daily posttraumatic headache with divalproex sodium. Headache. 2000;40(9):736–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Weiss HD, Stern BJ, Goldberg J. Post-traumatic migraine: chronic migraine precipitated by minor head or neck trauma. Headache. 1991;31(7):451–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Tyler GS, McNeely HE, Dick ML. Treatment of post traumatic headache with amitriptyline. Headache. 1980;20(4):213–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Ruff RL, Ruff SS, Wang XF. Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. J Rehabil Res Dev. 2009;46:1071–84.PubMedCrossRefGoogle Scholar
  52. 52.
    Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49(10):1521–33.PubMedCrossRefGoogle Scholar
  53. 53.
    Hecht JS. Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. J Head Trauma Rehabil. 2004;19(1):58–71.PubMedCrossRefGoogle Scholar
  54. 54.
    Freitag FG, Diamond S, Diamond M, Urban G. Botulinum toxin type A in the treatment of chronic migraine without medication overuse. Headache. 2008;48(2):201–9.PubMedGoogle Scholar
  55. 55.
    Mathew N, Kailasam J, Meadors L. Predictors of response to botulinum toxin type A (BoNTA) in chronic daily headache. Headache. 2007;48(2):194–200.PubMedGoogle Scholar
  56. 56.
    Matthew NT, Jaffri SF. A double-blind comparison of onabotulinum toxin A (BOTOX) and topiramate (TOPAMAX) for the prophylactic treatment of chronic migraine. Headache. 2009;49(10):1466–78.CrossRefGoogle Scholar
  57. 57.
    Whyte C, Tepper SJ, Evans RW. Expert Opinion: Rescue me: rescue medication for migraine. Headache. 2010;50:307–13.PubMedCrossRefGoogle Scholar
  58. 58.
    Levy D, Jakubowski M, Burstein R. Disruption of communication between peripheral and central trigeminovascular neurons mediates the antimigraine action of 5HT 1B/1D receptor agonists. Proc Natl Acad Sci U S A. 2004;101:4274–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Gurr B, Coetzer BR. The effectiveness of cognitive-behavioral therapy for post-traumatic headaches. Brain Inj. 2005;19(7):481–91.PubMedCrossRefGoogle Scholar
  60. 60.
    Tatrow K, Blanchard EB, Silverman DJ. Post-traumatic headache: an exploratory treatment study. Appl Psychophysiol Biofeedback. 2003;28(4):2670–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Medical Corps, United States ArmyFort Sam HoustonUSA
  2. 2.187th Medical Battalion, AMEDD Student DetachmentFort Sam HoustonUSA
  3. 3.Department of Medicine, Neurology ServiceMadigan Army Medical CenterFort LewisUSA

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