Cognitive Behavioral Therapy Efficacious for Veterans With PTSD and Headache

Cognitive behavioral therapy (CBT) helped treat veterans with comorbid posttraumatic headache and posttraumatic stress disorder (PTSD), according to study findings published in JAMA Neurology.

Veterans are more likely to have experienced head injury and posttraumatic headache within 3 months of injury compared with civilians. Treatment for posttraumatic headache from mild traumatic brain injury is lacking in efficacy. This is the first randomized clinical trial in veterans for a posttraumatic headache intervention.

In the current study, researchers compared CBT for headache and cognitive processing therapy (CPT). CPT has improved PTSD and related headache symptoms, and CBT for headache uses CBT concepts that have indicated impact on headache disability and related mood in primary headaches.

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The researchers recruited participants through a Veterans Affairs hospital, military facilities, and the community. Participants were eligible for pay for participating. Patients (N=193, post-9/11 combat veterans; aged mean 39.7 years; 87% men; 57% White, 42% Hispanic, and 17.6% Black) were randomly assigned to receive 8 sessions of CBT for headache that focused on headache and stress, CPT for 12-hour sessions over 6 weeks focused exclusively on PTSD; or treatment per usual. Treatment per usual involved pharmacotherapies, interventional pain management, physical therapy, and complementary and integrative health treatments.

At baseline, participants’ mean reported Headache Impact Test (HIT-6) scores and PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) scores were 65.8 and 48.4, respectively.

Patients who received CBT for headache had HIT-6 scores that were 3.4 points lower compared with treatment per usual (95% CI, −5.4 to −1.4; P<.01). CPT participants did not have statistically significantly lower posttreatment scores compared with treatment per usual −1.4 (95% CI, −3.7 to 0.8; P =.21) points lower.

CBT and CPT participants both had better PCL-5 outcomes compared with treatment per usual [CBT, −6.5 (95% CI, −12.7 to −0.3; P =.04) and −8.9 (95% CI, −15.9 to −1.9; P =.01) points lower].

Individuals in the CBT for headache and CPT groups had fewer headache days per month compared with the treatment per usual group. Treatment adherence was more than 89% in the CBT for headache and CPT groups. Treatment engagement was higher among CBT for headache and treatment per usual groups compared with CPT.

Adverse events (n=160) were not study related, the researchers said. Two individuals said their PTSD symptoms were temporarily exacerbated due to trial participation in CPT.

Study limitations included selection of HIT-6 as primary outcome, bias involved in blinding a behavioral trial, and high dropout.

“US military combat veterans with [posttraumatic headache] attributable to [mild traumatic brain injury] and comorbid PTSD symptoms showed significant improvement in headache-related disability and PTSD symptom severity in response to nonpharmacological interventions for headache and PTSD,” the researchers noted.

In particular, the CBT for headache intervention helped with headache and provided an unexpected improvement in PTSD symptoms. Meanwhile, CPT only helped with PTSD symptom severity.

Disclosure: This research was supported by the US Department of Defense and the US Department of Veterans Affairs. Please see the original reference for a full list of disclosures


McGeary DD, Resick PA, Penzien DB, et al. Cognitive behavioral therapy for veterans with comorbid posttraumatic headache and posttraumatic stress disorder symptoms: a randomized clinical trial. JAMA Neurol. Published online June 27, 2022. doi: 10.1001/jamaneurol.2022.1567

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