PainRelief.com: What should readers take away from your report?
Response: We uncovered three main findings from this trial, which was the first to formally study a non-pharmacological intervention for PTH in a U.S. military veteran population as follows:
- We produced the first evidence supporting the efficacy of a non-pharmacological intervention for PTH. Participants randomly assigned to the CBTH arm of the trial demonstrated significant improvement in headache-related disability (an important metric that assesses the extent to which someone can engage in meaningful life activities despite their pain) compared to the PTSD intervention or usual care (which included medication, interventional pain medicine, physical rehabilitation and complimentary and integrative health). Most notably, this improvement in disability was sustained for at least 6 months without any further intervention.
- We found that, for some veterans, the CBTH headache intervention also led to a significant improvement in PTSD symptom severity that was comparable to outcomes from gold-standard PTSD treatment in the VA. This finding was remarkable because CBTH did not address PTSD directly and was significantly less intensive than the PTSD treatment we studied. Thus, some veterans with PTH and comorbid PTSD symptoms may only need a brief headache intervention to address both conditions. It is important to note, however, that some veterans will need more than CBTH to meaningfully address their PTSD. Interestingly, although the PTSD intervention resulted in significant and sustained improvement in PTSD symptom severity, it did not contribute to significant improvement in headaches.
- We tracked treatment adherence throughout the study and found that participants were significantly more likely to attend CBTH treatment compared to the PTSD intervention. This was remarkable because non-pharmacological treatment outcomes are often dose-dependent, so more frequent use of the treatment is likely to lead to better outcomes. We also noted that training providers in CBTH was very low-burden, amounting to about two hours of orientation to PTH and the treatment manual. This is much briefer than training for many other non-pharmacological treatments, making CBTH likely easier to implement.
PainRelief.com: What recommendations do you have for future research as a result of this work?
Response: There are several recommendations for meaningfully expanding the value of this research.
First, with COVID-19, care was shifted into virtual environments with little evidence available to guide expectations for changes in treatment that would be needed to maintain full efficacy in virtual treatment. So future research (which we have already started) should test virtual CBTH compared to in-person care to determine if virtual treatment is non-inferior.
Second, the treatment needs to be tested in other populations and locales to ensure that the outcomes of our study are not over-fit to our specific sample. We recently began a multisite replication of CBTH for posttraumatic headache in 7 VA and military treatment facilities to formally test the robustness of CBTH across different samples, medical systems, and geographical locations.
Finally, the CBTH treatment is surprisingly simple, so it may be well-suited for children and adolescents with posttraumatic headache after a traumatic brain injury. We are increasingly aware of mTBI in adolescents due to falls, sports injuries, and motor vehicle accidents, and there is documented evidence that posttraumatic headache is a significant problem in this population. CBTH offers a safe treatment option for these adolescents with a reasonable likelihood of efficacy and should be tested in adolescent head injury patients with headache.
No further disclosures that are not already stated in our JAMA Neurology manuscript.
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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