Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial

Abstract

Importance: Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity.

Objective: To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury.

Design, setting, and participants: This was a single-site, 3-parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022.

Interventions: Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache.

Main outcomes and measures: Co-primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment.

Results: A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and 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 the HIT-6, compared with usual care, patients receiving CBT for headache reported -3.4 (95% CI, -5.4 to -1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported -1.4 (95% CI, -3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported -6.5 (95% CI, -12.7 to -0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported -8.9 (95% CI, -15.9 to -1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups.

Conclusions and relevance: This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability.

Trial registration: ClinicalTrials.gov Identifier: NCT02419131.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Resick reported receiving research and consultation support from the Congressionally Directed Medical Research Programs, the Department of Justice Office of Victims of Crime, and the National Institutes of Health; paid honoraria for lectures and training workshops delivered to the New York City Cognitive Behavioral Therapy Association, the Swedish Red Cross, CBT Reach, University of Urbano and Eurpoean Society of Traumatic Stress Studies, and PsychConsulting; and travel funding through the Anxiety and Depression Association of America. Dr. Houle reported serving on the editorial boards of the American Society of Anesthesiology and the American Headache Society. No other disclosures were reported.

Figures

Figure 1.. Consolidated Standards of Reporting Trials (CONSORT) Flow Diagram

CBTH indicates cognitive behavioral therapy for headache; CPT, cognitive processing therapy; HIT-6, 6-Item Headache Impact Test; ITT, intention to treat; PCL-5, PTSD Checklist for DSM-5; PTSD; posttraumatic stress disorder.

Figure 2.. Change in 6-Item Headache Impact Test (HIT-6) and Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) for the Cognitive Behavioral Therapy for Headache (CBTH), Cognitive Processing Therapy (CPT), and Treatment per Usual (TPU) Study Groups

The contrasts reflect the mean (SE) change in HIT-6 (A) and PCL-5 (B) scores for that group from their baseline values. Plotted values are the observed data based on intention to treat. aStatistically significant difference between CBTH and TPU at that assessment time point. bStatistically significant difference between CPT and TPU at that assessment time point.