Longitudinal study of headache trajectories after mild traumatic brain injury: relation to posttraumatic stress disorder symptoms

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Longitudinal study of headache trajectories after mild traumatic brain injury: relation to posttraumatic stress disorder symptoms
Key Take-Away: 
  • Headache is common in the year after mild traumatic brain injury (MTBI) with younger people, persons who previously had headaches and persons with posttraumatic stress disorder (PTSD) are more likely to report chronic or worsening headache.
  • Future studies are needed to examine whether PTSD treatment reduces headache pain after MTBI.

Although postconcussive symptoms often resolve within 1 to 2 weeks after mild traumatic brain injury (MTBI), symptoms may persist beyond this window. Typical symptoms after MTBI include fatigue, insomnia, light sensitivity, irritability or mood changes, cognitive difficulties, and headaches. In some individuals, these symptoms persist beyond first 3 months after injury and can cause significant distress or interfere with daily activities. 

ABSTRACT: 
Background: 

Although postconcussive symptoms often resolve within 1 to 2 weeks after mild traumatic brain injury (MTBI), symptoms may persist beyond this window. Typical symptoms after MTBI include fatigue, insomnia, light sensitivity, irritability or mood changes, cognitive difficulties, and headaches. In some individuals, these symptoms persist beyond first 3 months after injury and can cause significant distress or interfere with daily activities.

Headache is one of the most common persistent symptoms after MTBI. One prospective study found that although 30.47% of people reported headaches at 1 month after MTBI, only 15.35% of the sample still reported headaches at 3 months after MTBI. Likewise, another study found 18% to 33% of people reporting headaches 1 year after MTBI. Posttraumatic stress disorder (PTSD) is one factor associated with persistent postconcussive symptoms after MTBI. When examining headaches specifically, there is also some evidence that PTSD is associated with increased likelihood and greater persistence of headaches after MTBI.

Rationale behind research

  1. Much of the literature examining MTBI, headache, and PTSD symptoms has focused on active-duty military personnel or military veterans who experienced MTBI during deployment. These results may not generalize to civilians who have experienced MTBI because military personnel are exposed to a unique set of experiences and risk factors not typically encountered by civilians
  1. This study examined a civilian population of persons with MTBI followed prospectively for 1 year post injury.
  • Objective

To examine headache trajectories among persons with mild traumatic brain injury (MTBI) in the year after injury and the relation of headache trajectory to posttraumatic stress disorder (PTSD) at 1 year post injury.

Methods: 

 

NOTE: This was a prospective longitudinal study in which participants completed a baseline interview within 1 week of their MTBI event and underwent follow-up telephone interviews conducted by trained research assistants at 3, 6, and 12 months post injury. These assessments included questions about presence and characteristics of headache since the previous assessment.

Study outcomes

  • Headache pain intensity: Participants were asked to rate the pain of their current headache. The question was rated on a 0 to 10 numerical rating scale, with 0 being no headache at all and 10 being worst pain imaginable.
  • PTSD checklist civilian version: Each item on the PTSD Checklist-Civilian Version (PCL-C) corresponds to one symptom of PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorders. Participants indicate to what extent they have been bothered by each symptom in the last month, from 1 (not at all) to 5 (extremely).
  • Patient Health Questionnaire: The questionnaire lists each of the 9 symptoms of a major depressive episode, and participants indicate how frequently they have experienced that symptom in the last 2 weeks, from 0 (not at all) to 3 (nearly every day).
  • Time-points
  • Headache Pain Intensity: Baseline, 3, 6 and 12 months
  • PTSD Checklist Civilian Version: 12 month post injury
  • Patient Health Questionnaire: Baseline and 12 months post injury
Results: 

 

Outcomes

  • The 4 classes resulting from the latent class growth analysis were labeled resolved, worsening, improving, and chronic. Forty seven percent of the sample fell into the chronic group, characterized by a moderate to severe level of baseline headache pain intensity that remained stable during the year post injury. The next largest group (30%) was labeled as worsening; this group was characterized by low or absent headache pain intensity at baseline, followed by an increase to mild headache pain intensity during the course of the year post injury. The resolved group (12%) had moderate headache pain intensity at baseline and resolution of headaches within 3 months post injury. Finally, the improving group (11%) had moderate headache pain intensity at baseline, improving to mild pain at 6 months post injury, and resolving by 1 year post injury.
  • In the univariate analyses, younger age, self-reported history of additional MTBI events, and pre injury headache were significantly associated with worse headache outcomes

 

Litigation during the 12 months post injury and depressive symptoms at 12 months post injury were not significantly related to headache trajectory. Younger people and persons with pre injury headache had worse outcomes. Of the sample, 3% met criteria for a PTSD diagnosis at 12-months post injury. 

 

Conclusion: 

Headache is common in the year after MTBI, with younger people, persons who previously had headaches, and persons with PTSD more likely to report chronic or worsening headache. Further research is needed to examine whether PTSD symptoms exacerbate headaches or whether problematic headache symptoms exacerbate PTSD.

Consistent with previous research, this study suggests that headaches are a common problem for many adults in the first year after MTBI.

Archives of Physical Medicine and Rehabilitation 2015
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