Contribution of Psychological Health Comorbidity to Personalized Treatment for Headache Attributable to mTBI

Traumatic brain injury, including mild TBI or concussion, is a signature wound of post-9/11 military conflicts, affecting hundreds of thousands of military service members and veterans. For many, the injury results in chronic headaches that can become not only bothersome but debilitating. Despite significant growth in research over the past decade on headaches resulting from mTBI, called posttraumatic headache (PTH), surprisingly little is known about how to treat them effectively.

PTH is uniquely challenging to assess and treat for a variety of reasons: the clinical symptoms that accompany them are diverse; they often co-occur with other trauma-related conditions that can impact treatment response; and mTBI-caused changes in the central nervous system result in headache mechanisms that differ from other types of headaches and therefore do not respond to most frontline headache interventions. The result is extraordinary variety in provider treatment recommendations and patients’ response to those treatments.

It is no wonder, then, that PTH is associated with high rates of treatment failure and why experts predict that current efforts to develop new treatments are likely to fail most PTH patients.

Multi-project effort aims to provide comprehensive guidance, personalized treatment

This focused program award funded by the U.S. Department of Defense and led by Don McGeary, PhD, of The University of Texas Health Science Center at San Antonio takes a multi-faceted research approach with the aim of delivering the first comprehensive, patient-centered treatment guidance for service members and veterans suffering from PTH. Investigators believe this will provide the best hope of improving treatment outcomes, alleviating suffering and reducing disability in this population.

The project involves four independent but complementary studies that leverage ongoing research combined with novel qualitative, retrospective, and prospective studies. In a synergistic way, these projects aim to identify patient-centered targets and outcomes for PTH treatment as well as factors that predict patient response to treatments that target those outcomes. With this knowledge, investigators also plan to introduce a clinical tool that can help patients forecast when a headache attack will occur and recommend the most effective intervention in real time.

Project 1 is led by Cindy McGeary, PhD, of The University of Texas Health Science Center at San Antonio and will utilize focus groups of both patients and providers from a completed clinical trial. The focus groups will help researchers identify (1) which headache symptoms are the most bothersome to patients and the highest priority to target in treatment and (2) which treatment outcomes are most meaningful to patients (e.g., reduced headache severity, headache frequency, or headache-related disability). Focus group participants also will provide qualitative feedback to investigators on Projects 2 – 4 as they are happening.

Project 2 is led by Paul Nabity, PhD, of The University of Texas Health Science Center at San Antonio and will involve secondary analyses with existing research data along with information derived from the focus groups in Project 1. In this investigation, he and the study team will assess the influence of psychological health, demographics, and other factors on patient outcomes with cognitive-behavioral therapy for PTH. This will help the team identify predictors of whether and how well a patient will respond to non-medication treatments for PTH (e.g., relaxation, stress management, psychotherapy).

Project 3 is led by Mary Jo Pugh, PhD, RN, of the University of Utah and will utilize completed and ongoing observational research as well as focus group information from Project 1. Through this effort, researchers aim to identify variable factors (e.g., demographics, headache severity/duration/frequency, sleep, psychological health, medication side effects and patient preference, health system factors) that affect medication use over time and that can be used to predict patient response to pharmacotherapy for PTH.

Project 4 is led by Timothy Houle, PhD, of Harvard Medical School and Massachusetts General Hospital. This project aims to create an interactive headache diary that uses information provided by the patient to predict when a headache attack will occur and to provide treatment recommendations tailored to that individual patient. In this effort, Dr. Houle and the study team will use knowledge gained from Projects 1 – 3 to update an existing forecasting model he previously developed for migraine headaches. The new diary will be designed to assess the most bothersome symptoms of PTH attributable to mTBI and variables found to be associated with them. The group will then pilot test the PTH headache diary with 50 service members and veterans to evaluate its ability to predict when a headache attack is likely to occur and to recommend treatments that are most likely to help at that time.

If successful, this research effort would be a major leap forward in the field, offering the first ever comprehensive guidance on PTH treatment and a personalized, more effective treatment approach that reduces disability and greatly improves the quality of life for affected service members and veterans.