Cognitive behavioral therapy improved symptoms of headache, PTSD in US veterans

Headache-related disability and PTSD symptom severity improved with cognitive behavioral therapy compared with usual care in United States military veterans with posttraumatic headache and PTSD, according to a study in JAMA Neurology.

“Veterans are more likely than civilians to develop [posttraumatic headache (PTH)] after [mild traumatic brain injury], and mechanisms of PTH are poorly understood,” Donald D. McGeary, PhD, of the department of psychiatry and behavioral sciences at the University of Texas Health Science Center at San Antonio, and colleagues wrote. “Manualized cognitive behavioral therapies offer safe, broad-spectrum treatment for PTH, but limited evidence supports their use.”

McGeary and fellow researchers sought to compare CBTs for headache and PTSD with treatment per usual for posttraumatic headache attributed to mild TBI.

They conducted a randomized clinical trial at a large Veterans Administration multiple-trauma rehabilitation center between May 2015 and May 2019 and enrolled 193 combat veterans (87% men; mean age, 39.7 years) who had at least one post-9/11 deployment and were diagnosed with comorbid posttraumatic headache and PTSD symptoms.

Researchers randomized patients on a 1:1:1 basis to receive eight, 1-hour sessions of weekly or biweekly CBT for headache; 12-hour sessions of cognitive processing therapy (CPT) for PTSD over 6 weeks; or usual care for headache, which included pharmacotherapies, physical therapy and complementary and integrative health treatments.

Primary outcomes included headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (PCL-5), which were measured at posttreatment and 3- and 6-month posttreatment follow-ups. At baseline, all participants had severe headache-related disability (mean HIT-6 score, 65.8) and severe PTSD symptoms (mean PCL-5 score, 48.4).

Compared with usual care, patients receiving CBT for headache reported 3.4 points lower (95% CI, 5.4 to 1.4) on HIT-6, and patients receiving CPT reported 1.4 points lower (95% CI, 3.7 to 0.8) across aggregated posttreatment measurements, according to study results.

For PCL-5, patients receiving CBT for headache reported 6.5 points lower (95% CI, 12.7 to 0.3), and patients receiving cognitive processing therapy reported 8.9 points lower (95% CI, 15.9 to 1.9) across aggregated posttreatment measurements, compared with usual care.

“The CBTH intervention successfully addressed headache with unexpected improvement in PTSD symptoms, whereas CPT only successfully addressed PTSD symptom severity,” McGeary and colleagues wrote. “The present study provided evidence supporting treatment of PTH disability using a manualized headache intervention, with outcomes superior to multimodal usual care.”