A cohort study examining headaches among veterans of Iraq and Afghanistan wars: Associations with traumatic brain injury, PTSD, and depression.
To describe the prevalence and persistence of headache and associated conditions in an inception cohort of U.S. veterans of Iraq and Afghanistan wars.
Iraq and Afghanistan war veterans (IAV) suffer from persistent and difficult-to-treat headaches that have been found to co-occur with traumatic brain injury (TBI) and other deployment related comorbidities.
This longitudinal retrospective cohort study used data from the national Veterans Health Administration (VA) data repository for IAV who first received VA care in 2008 (baseline) and also received care each year in 2009, 2010, and 2011. We used ICD-9-CM codes, to identify those treated for headache each year (2008-2011). Individuals with headache diagnosed each year were classified as having persistent headache. We also identified comorbidities that may be associated with baseline headache using algorithms validated for use with ICD-9-CM codes. Comorbidities included TBI, posttraumatic stress disorder (PTSD), depression, and conditions associated with these diagnoses (anxiety, memory/attention/cognition, neck pain, tinnitus/hyperacusis, photosensitivity/photo blurring, insomnia, malaise/fatigue, and vertigo/dizziness). Multivariable logistic regression analysis was used to determine characteristics associated with baseline headache as well as those associated with persistent headache.
Among all IAV, 38,426 received their first year of VA care in 2008 and had care each year 2009-2011: 13.7% of these were diagnosed with headache in 2008. Veterans diagnosed with headache in 2008 were more likely than those without a headache diagnosis to also have a diagnosis of TBI alone (adjusted odds ratios [AOR] 6.75; 95% CI 5.79-7.86), TBI + depression (AOR 7.09; 95% CI 5.23-9.66), TBI + PTSD (AOR 10.16; 95% CI 8.96-11.53), TBI + PTSD + depression (AOR 9.40; 95% CI 8.12-10.09), and neck pain (AOR 2.44; 95% CI 2.14-2.77). Among those with headache diagnosis in 2008, 24.3% had a headache diagnosis each of the subsequent years of care (persistent headache). While diagnoses of TBI, PTSD, and/or depression at baseline were not associated with headache persistence, persistence was more likely for individuals with baseline tinnitus/hyperacusis (AOR 1.21; 95% CI 1.02-1.45), insomnia (AOR 1.19; 95% CI 1.02-1.39), and vertigo/dizziness (AOR 1.83; 95% CI 1.30-2.57).
Our results indicate that TBI alone is a strong predictor of headache in the first year of VA care among IAV and that comorbid psychiatric comorbidities increase the likelihood of headache among individuals with TBI. However, among those with baseline headache, only tinnitus, insomnia, and vertigo were baseline clinical predictors of headache persistence. These results suggest that attention to other symptoms and conditions early in the diagnosis and treatment of headaches may be important for understanding prognosis. These comorbidities offer potential targets for intervention strategies that may help address postdeployment headaches.
Jaramillo CA
，Eapen BC
，McGeary CA
，McGeary DD
，Robinson J
，Amuan M
，Pugh MJ
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Headache diagnoses among Iraq and Afghanistan war veterans enrolled in VA: a gender comparison.
To examine the prevalence and correlates of headache diagnoses, by gender, among Iraq and Afghanistan War Veterans who use Department of Veterans Affairs (VA) health care.
Understanding the health care needs of recent Veterans, and how these needs differ between women and men, is a priority for the VA. The potential for a large burden of headache disorders among Veterans seeking VA services exists but has not been examined in a representative sample.
We conducted a historical cohort study using national VA inpatient and outpatient data from fiscal year 2011. Participants were all (n = 470,215) Iraq and Afghanistan War Veteran VA users in 2011; nearly 13% were women. We identified headache diagnoses using International Classification of Diseases (ICD-9) diagnosis codes assigned during one or more VA inpatient or outpatient encounters. Descriptive analyses included frequencies of patient characteristics, prevalence and types of headache diagnoses, and prevalence of comorbid diagnoses. Prevalence ratios (PR) with 95% confidence intervals (CI) were used to estimate associations between gender and headache diagnoses. Multivariate models adjusted for age and race. Additional models also adjusted for comorbid diagnoses.
In 2011, 56,300 (11.9%) Veterans received a headache-related diagnosis. While controlling for age and race, headache diagnoses were 1.61 times more prevalent (95% CI = 1.58-1.64) among women (18%) than men (11%). Most of this difference was associated with migraine diagnoses, which were 2.66 times more prevalent (95% CI = 2.59-2.73) among women. Cluster and post-traumatic headache diagnoses were less prevalent in women than in men. These patterns remained the same when also controlling for comorbid diagnoses, which were common among both women and men with headache diagnoses. The most prevalent comorbid diagnoses examined were depression (46% of women with headache diagnoses vs 40% of men), post-traumatic stress disorder (38% vs 58%), and back pain (38% vs 46%).
Results of this study have implications for the delivery of post-deployment health services to Iraq and Afghanistan War Veterans. Migraine and other headache diagnoses are common among Veterans, particularly women, and tend to occur in combination with other post-deployment health conditions for which patients are being treated.
Carlson KF
，Taylor BC
，Hagel EM
，Cutting A
，Kerns R
，Sayer NA
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Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions.
To characterize the association between traumatic brain injury (TBI) and chronic pain and pain disability in the context of comorbid conditions, posttraumatic stress disorder (PTSD), and depression to better inform care of combat veterans.
Retrospective cohort study.
Medical centers and community clinics.
Combat veterans (N=116,913) who received Veterans Affairs care between October 1, 2007 and March 31, 2015, completed a Comprehensive Traumatic Brain Injury Evaluation, and received a criterion standard diagnosis of TBI (none, mild, or moderate to severe).
Not applicable.
Chronic pain defined as ≥2 of the same pain diagnoses ≥90 days apart and pain disability defined as self-reported pain causing moderate to very severe interference with daily functioning.
Fifty-seven percent received ≥1 chronic pain diagnosis. Compared to those with no TBI, PTSD, or depression, there was an independent risk for chronic pain in veterans with mild TBI, which was higher in veterans with moderate to severe TBI. The risk of chronic pain was additive and highest when all 3 conditions-TBI, depression, and PTSD-were copresent (adjusted relative risk, 1.53 and 1.62 [95% confidence interval, 1.50-1.66] for mild and moderate or severe TBI, respectively, plus other diagnoses). The relation of pain disability to TBI, PTSD, and depression followed a similar additive pattern.
In combat veterans, chronic pain and pain disability are most commonly associated with TBI in conjunction with PTSD, depression, or both. Integrated models of care that simultaneously address pain in conjunction with TBI, PTSD, and depression will likely be the most clinically effective.
Seal KH
，Bertenthal D
，Barnes DE
，Byers AL
，Strigo I
，Yaffe K
，Chronic Effects of Neurotrauma Consortium Study Group
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