1. Among US military veterans with posttraumatic headache and comorbid posttraumatic stress disorder symptoms, nonpharmacological interventions significantly improved headache-related disability and posttraumatic stress disorder symptom severity.

2. Cognitive behavioral therapy improved both headache and posttraumatic stress disorder symptoms, whereas cognitive processing therapy only successfully addressed posttraumatic stress disorder symptom severity.

Evidence Rating Level: 1 (Excellent)

Study Rundown: There is currently minimal evidence on established treatments for comorbid posttraumatic stress disorder (PTSD) symptoms and posttraumatic headache (PTH). This randomized trial examined 2 nonpharmacological interventions for PTH in military veterans with persistent headache related to comorbid mild traumatic brain injury (mTBI) and clinical PTSD symptoms. Key outcomes included headache-related disability on the Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual (PCL-5) assessed up to 6 months posttreatment. Among 193 combat veterans with PTH and PTSD symptoms, headache disability significantly improved with cognitive behavioral therapy (CBT) compared to usual treatment. Additionally, PTSD symptom severity significantly improved in patients receiving cognitive processing therapy compared to usual treatment, however, there was no significant effect of cognitive processing therapy on headache disability. A limitation of this study was the high dropout rate among combat veteran subjects resulting in increased effects of potential outliers.

Click to read the study in JAMA Neurology

Relevant Reading: A systematic review of dropout from psychotherapy for posttraumatic stress disorder among Iraq and Afghanistan combat veterans

In-Depth [randomized clinical trial]: This single center randomized trial included 193 post-9/11 US combat veterans (mean [SD] age, 39.7 [8.4] years; 167 [87%] male) with comorbid PTSD headache and symptoms from 2015-2019, with follow-up posttreatment at 3 and 6 months. Patients were randomized to 1 of 3 parallel groups: 1) CBT, 2) cognitive processing therapy or 3) treatment per usual for headache. Overall, the cohort reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For headache-related disability assessed on HIT-6, patients receiving CBT and cognitive processing therapy reported −3.4 (95%CI, −5.4 to −1.4; P < .01) and −1.4 (95%CI, −3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements vs usual care. For PTSD symptom severity assessed on PCL-5, patients receiving CBT and cognitive processing therapy reported −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 vs usual care.

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