Combined Nonpharmacological Therapies for MTBI-Related Headaches
Abstract
Headache (HA) is one of the most debilitating conditions in either active or retired military personnel with mild traumatic brain injury (MTBI). This high prevalence of chronic HA is often associated with neuropsychological dysfunction in mood, anxiety, and attention, which casts a profound negative impact on patients quality of life. Unfortunately, medications frequently prescribed for MTBI-related headache (MTBI-HA) has not been shown to be effective and drugs such as narcotics contain many long-term untoward psychosomatic and abusive side effects. This calls for an urgent need in developing alternate HA prevention, treatment, and rehabilitation strategies for this rapidly increasing patient population. Transcranial Magnetic Stimulation (TMS) is currently a U.S. Food and Drug Administration-approved non-invasive treatment for major depression and preventing migraine HA. When TMS is given repeatedly, it is called repetitive TMS (rTMS). Recent expert review of existing randomized and controlled studies indicates rTMS can alleviate various chronic pain conditions including headaches when applied at brain regions called the motor cortex or left dorsolateral prefrontal cortices. In addition, recently an international TMS expert review panel deemed rTMS as definitively effective for alleviating MTBI-HA and recommended clinical implementation. Our group was the first in the U.S. Department of Veterans Affairs (VA) system to adopt brain imaging based neuronavigation guided rTMS as a treatment option for chronic pain including MTBI-HA since 2010. Evidence from a randomized controlled study indicate rTMS at the left dorsolateral prefrontal cortex (LDLPFC) can significantly reduce the intensity and exacerbation pattern of MTBI-HA, and comorbid depressive symptoms. In addition, our clinical longitudinal case series for over 200 patients treated at the VA San Diego Center for TMS demonstrated a combination of induction and maintenance rTMS sessions is effective in long-term headache management for as long as 10 years for over 70% of the treated patients. In assessing the efficacy of psychological interventions of chronic headaches, several credible studies indicate therapies such as online telehealth Cognitive Behavioral Therapy (OT-CBT) can significantly reduce chronic migraine/tension headache, depressive and anxiety symptoms, and minimize pain medication requirement. CBT is currently considered as one of the most “effective psychological treatments” for chronic pain by the VA, which has implemented national initiatives to disseminate evidence-based psychotherapies for various mental and behavioral health conditions, such as depression, post-traumatic stress disorder, insomnia, chronic pain, substance use disorders, and serious mental illness. As part of this effort, VA has implemented successful national, competency-based training programs in each of these therapies. Recently, a therapist manual was developed to support the VA Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) Training Program that has been disseminated throughout the Veterans Health Administration (VHA). Despite the enhanced clinical availability of both treatments in managing MTBI-HA, the potential augmenting effect of combining OT-CBT with other non-invasive physical treatment modalities such as rTMS in reducing MTBI-HA and improving associated neuropsychological dysfunction in Veterans and active military personnel has not been fully assessed. Thus building upon the existing outcome evidence and to further augment the existing treatment options for MTBI-HA and comorbid conditions, here we propose a highly translational and clinically disseminable four-arm study comparing the effect of combining OT-CBT with rTMS in reducing the symptoms of MTBI-HA and comorbid depressive symptoms in both active and retired military personnel with MTBI to sham rTMS and Online Telehealth Headache Education Control (OT-HEC). Both rTMS and OT-CBT are non-invasive non-pharmacolo
Document Details
- Document Type
- DoD Grant Award
- Publication Date
- Dec 05, 2021
- Source ID
- W81XWH2110831
Entities
People
- Albert Leung
Organizations
- United States Army
- Veterans Medical Research Foundation of San Diego