Study design for a randomized clinical trial of cognitive-behavioral therapy for posttraumatic headache

Feasibility of brief behavioral telehealth interventions for sleep and pain in adults with chronic musculoskeletal orofacial pain: An idiographic clinical trial

OBJECTIVE

Brief behavioral interventions targeting pain (Physical Self-Regulation, PSR) or sleep (Brief Behavioral Intervention for Insomnia, BBTI) show promise for interdisciplinary management of chronic pain, though their feasibility with chronic musculoskeletal orofacial pain (MSK-OFP) populations remains underexplored. This pilot study assessed the feasibility of a randomized clinical trial (RCT) of these interventions in a university-affiliated tertiary OFP clinic and explored clinical changes in pain, sleep, and other secondary outcomes.

METHODS

Treatment-seeking participants (N=19) with chronic MSK-OFP and insomnia were randomized to three-session PSR or BBTI. At pre- and post-intervention, participants completed questionnaires (assessing pain intensity, insomnia symptomatology, sleep quality, headache disability, fatigue, jaw-movement limitations, and quality of life), 8 consecutive days of actigraphy and morning/evening diaries. Feasibility outcomes were recruitment, retention, and adherence rates. Clinical outcomes included clinically-meaningful reductions in insomnia symptoms (Insomnia Severity Index [ISI]<15) and pain intensity (>2.5 point on 0-10 Numerical Rating Scale).

RESULTS

Over a 17-month period, of 19 consenting participants (88.9% females, 38.4±12.2y/o, recruitment rate: 1.1/month),12 (92% females, 38.5±11.5y/o) completed the study (retention rate: 63.2%) with high completion rate (questionnaires: 95.8%, daily diaries: 95%, actigraphy: 100%). Despite no significant changes in pain, ISI scores decreased by 6.0 and 4.8-points among BBTI and PSR groups. Improvements in sleep quality, headache disability, fatigue, jaw-movement limitations, and quality of life wereobserved.

CONCLUSION

RCTs of brief behavioral interventions are feasible in tertiary-OFP clinics.

Pilot study evaluating treatment with sumatriptan for moderate to severe post-traumatic headache: A phase 2 open-label study

OBJECTIVE

Our primary outcome was to determine the feasibility of patients with post-traumatic headache (PTH) keeping a daily headache diary and using sumatriptan as directed. Secondary outcomes include determining if sumatriptan is effective in aborting PTH and whether headache resolution is dependent on PTH phenotype.

BACKGROUND

PTH is prevalent and persistent after traumatic brain injury, yet there have been few studies evaluating the effects of pharmacological treatments in individuals with PTH.

METHODS

This is a single-arm, prospective, non-randomized phase 2 clinical trial registered at Clinicaltrials.gov (NCT01854385) and conducted from 2013 to 2017. Data analysis was completed in 2022. Of the 299 participants screened, 40 were enrolled in the study. Participants kept a headache diary documenting headache characteristics and severity. Headache characteristics were used to determine PTH phenotypes of migraine-like, probable migraine-like, or non-migraine-like. Participants reported whether sumatriptan was used for their headache, their response to the medication, if a second dose was taken, and their response to the second dose.

RESULTS

A total of 15 participants out of the 40 enrolled (mean [SD] age, 41.9 [14.2] years, and 53% [21/40] male), met the criteria for the use of sumatriptan, and completed all assessments. Average headache diary compliance rate for the final month of the study was 80% (372/465). While sumatriptan was used for only 19% (122/654) of all reported headaches, 72% (88/122) of those headaches resolved within 2 h of taking the medication. Resolution of headaches with sumatriptan was not significantly different among headache phenotypes (migraine-like: 22/38 [58%], probable migraine-like: 24/29 [83%], non-migraine-like: 6/15 [40%]; p = 0.154).

CONCLUSIONS

A daily headache diary is feasible for tracking headache symptoms. Preliminary results also suggest that sumatriptan, a migraine-specific medication, may be beneficial for the treatment of PTH of different clinical phenotypes. Future studies, such as a phase 3 clinical trial with a larger sample size, are needed to better understand the efficacy of sumatriptan in the treatment of PTH.

Mechanisms of change in posttraumatic headache-related disability: A mediation model

OBJECTIVE

To explore whether the association between change in headache management self-efficacy and posttraumatic headache-related disability is partially mediated by a change in anxiety symptom severity.

BACKGROUND

Many cognitive-behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache-related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches.

METHODS

This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive-behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self-efficacy and headache-related disability, along with partial mediation through change in anxiety symptoms was tested.

RESULTS

The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self-efficacy and headache-related disability (b = -0.45, p < 0.001; 95% confidence interval [CI: -0.58, -0.33]). The total effect of change of headache management self-efficacy scores on change in Headache Impact Test-6 scores was significant with a moderate-to-strong effect (b = -0.57, p = 0.001; 95% CI [-0.73, -0.41]). There was also an indirect effect through anxiety symptom severity change (b = -0.12, p = 0.003; 95% CI [-0.20, -0.04]).

CONCLUSIONS

In this study, most of the improvements in headache-related disability were related to increased headache management self-efficacy with mediation occurring through change in anxiety. This indicates that headache management self-efficacy is a likely mechanism of change of posttraumatic headache-related disability with decreases in anxiety explaining part of the improvement in headache-related disability.

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

Question

Do cognitive behavioral therapies for posttraumatic headache and posttraumatic stress disorder (PTSD) symptoms improve headache-related disability in veterans compared with treatment per usual?

Findings

A randomized clinical trial of 193 post-9/11 combat veterans with posttraumatic headache and PTSD symptoms found headache disability was significantly improved with cognitive behavioral therapy for headaches compared with treatment per usual. Though participants randomly assigned to cognitive processing therapy reported significantly greater improvement in PTSD symptom severity compared with treatment per usual, there was no significant effect of cognitive processing therapy on headache disability.

Meaning

Cognitive behavioral therapies are efficacious treatments for veterans with comorbid posttraumatic headache and PTSD symptoms.

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

PTSD symptoms and tinnitus severity: An analysis of veterans with posttraumatic headaches

OBJECTIVE

Tinnitus and posttraumatic stress disorder (PTSD) are among the top service-connected disabilities within the Veterans Health Administration. Extant research shows that there is considerable overlap between tinnitus-related distress and PTSD, including sleep difficulty, irritability, hyperarousal, and concentration problems. However, no studies have prospectively examined the relationship between the two disorders. The purpose of this study was to examine that relationship.

METHOD

Participants (N = 112) with posttraumatic headache completed measures of tinnitus and PTSD. Correlational analyses and analyses of variance were conducted to examine the associations with PTSD symptom clusters and factors of tinnitus-related distress.

RESULTS

Approximately, half of participants with tinnitus demonstrated severe impairment. Correlational analyses indicated that reexperiencing, avoidance, negative emotions and cognitions, and hyperarousal PTSD symptoms were significantly related to many factors of tinnitus-related distress, including intrusiveness of tinnitus, perceived loudness, awareness, and annoyance. Participants with severe tinnitus demonstrated significantly greater reexperiencing, negative mood/cognitions, hyperarousal, and PTSD total severity compared to those with mild or moderate tinnitus.

CONCLUSIONS

Trauma therapists should assess for the presence of tinnitus in order to more fully conceptualize key health problems of help-seeking patients. Heightened psychological symptoms seemingly related to PTSD may be a function of tinnitus-related distress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Two-Step Resilience-Oriented Intervention for Veterans with Traumatic Brain Injury: A Pilot Randomized Controlled Trial

OBJECTIVE

The present randomized parallel two-arm pilot study aimed to compare the efficacy of two-step resilience-oriented intervention with treatment as usual in veterans with mild to moderate traumatic brain injury.

METHOD

Two-step Resilience-Oriented Intervention (TROI) is a brief psychological intervention that targets cognitive (step 1) and emotional (step 2) factors of resilience and consists of six 1-hour sessions. Overall, 70 Ukrainian veterans serviced in Anti-Terrorist Operation / Joint Forces Operation were randomly assigned to an intervention group (TROI group) or a control group that underwent treatment as usual (TAU group). For pre- (T1) and post-treatment (T2) assessment the Connor-Davidson Resilience Scale (CD-RISC), Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment Scale (MoCA), Neurobehavioral Symptom Inventory (NSI), Posttraumatic Stress Disorder Checklist 5 (PCL-5), Chaban Quality of Life Scale (CQLS), Positive and Negative Affect Scale (PANAS) were used.

RESULTS

Multivariable linear regression with the treatment group, gender, baseline cognitive performance level and TBI severity as the independent variables revealed statistically significant improvements in the TROI group in resilience (CD-RISC), cognitive performance (MoCA), postconcussive symptoms (NSI), posttraumatic symptoms (PCL-5), positive affect (PANAS) and quality of life (CQLS) comparing to such in TAU group. We found no statistically significant differences between groups in depression, anxiety (HADS) and negative affect (PANAS) outcomes. Additionally, Wilcoxon signed-rank test revealed that participants who completed two-step resilience-oriented intervention had significantly improved scores for all outcomes compared to the baseline (p < 0.05).

CONCLUSIONS

In summary, we can tentatively conclude that adding TROI to the standard treatment measures may improve the resilience and sustainable symptoms in veterans with TBI when compared with standard treatment. Targeting cognitive and emotional factors like problem-solving, decision-making, positive thinking can promote resilience in veterans with TBI and be useful in facilitating recovery from injury. Results of this pilot study are promising, but the intervention needs to be studied in a larger trial.

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter

OBJECTIVE

To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning.

BACKGROUND

Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments.

METHODS

This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively.

RESULTS

Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms.

CONCLUSION

The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.