Project MARCH: Multisite Advancement of Research on Chronic Posttraumatic Headache

Jul 24, 2023

Nearly 3 million U.S. service members have deployed since 9/11, with up to 690,000 estimated to have suffered a traumatic brain injury (TBI). Posttraumatic headache (PTH), or headache onset or worsening after a head or neck injury, is the most common and disabling symptom from TBI. Other co-occurring conditions, such as posttraumatic stress disorder (PTSD), also can compound or even cause headaches. A national study showed chronic PTH (lasting more than 3 months) among 60%-65% of veterans with service-related TBI. Other studies have shown high unemployment rates and decreased activity levels in this population even 10 years after injury.

Non-medication treatments are needed
However, military PTH is poorly understood, with little guidance from research on how to manage it effectively. Due to its similarity to migraines, PTH is typically treated with the same types of medications. However, medication does not cure PTH, and overuse can worsen it, while side effects cause many to avoid or discontinue their use. And since medications do not address contributing factors like PTSD, there is great need for non-medication treatments for co-occurring psychological problems.

A promising non-medication intervention
In the first large, randomized clinical trial for military-related headache, a group of investigators successfully treated manualized, multi-component, cognitive-behavioral therapy for migraine headache adapted specifically for military PTH. The research team led by Donald McGeary, PhD, of the University of Texas Health Science Center at San Antonio, used a treatment called Combined Cognitive-Behavioral Therapy for PTH. It led to significant, lasting improvement in PTH and related disability in veterans who had PTH and PTSD symptoms and was as effective as a top PTSD therapy in reducing PTSD symptoms. By comparison, veterans receiving treatment as usual at a U.S. Department of Veterans Affairs (VA) polytrauma center showed no significant improvement in disability.

Building on success of previous trial
Dr. McGeary’s group has designed a STRONG STAR-affiliated study to build on that success. The group will enroll 525 participants from clinics at seven VA and U.S. Department of Defense sites nationwide. Military personnel and veterans who have chronic PTH with or without PTSD will be assigned randomly to one of three treatment arms: Combined Cognitive-Behavioral Therapy (CCBT), Telemedicine-Based Combined Cognitive-Behavioral Therapy (TCBT), or treatment as usual. That will allow investigators to compare CCBT and TCBT to treatment as usual among patients with diverse demographics, trauma and headache histories, and comorbidities and when delivered in different military and VA settings. It also will provide evidence about the therapy’s efficacy when delivered via telehealth, compared to in-person in a clinic. The research group will include Co-Principal Investigator Blessen Eapen, MD, chief of Physical Medicine & Rehabilitation at the Greater Los Angeles Veterans Health Care System, who has extensive experience in military trauma research.

Potential relief for thousands
If successful, this study will provide a needed evidence-based, non-medication treatment for reducing PTH and PTSD symptoms and disability that can be widely disseminated in military and VA facilities to a diversity of patients. Validation of the treatment via telehealth would further expand access at smaller or more remote locations. CCBT and TCBT potentially could improve the lives of hundreds of thousands of service members and veterans, boost military readiness, and reduce military and VA disability costs. With the high prevalence of PTH in civilians, the treatment also could benefit the general public.

Project Remission: Maximizing Outcomes with Intensive Treatments for Combat-Related PTSD

Dec 22, 2017

This study by the Consortium to Alleviate PTSD aims to maximize improvements and, if possible, treat patients with combat-related PTSD into remission so they can return to full fitness for military duty or successfully integrate into civilian life.

The need for tailored, intensive treatment programs

Effective treatment of combat-related PTSD requires tailored and enhanced approaches that work quickly in getting PTSD into remission. The leading exposure therapies, in which patients confront traumatic memories and environmental triggers rather than avoid them, show 80 percent success rates with civilian victims of assault, accidents, and similar traumas. But the rate of remission with service members and veterans has been lower and often is less than 50 percent of those studied.

Reasons for the lower success rate with combat PTSD include the fact that service members in combat zones are more likely to experience multiple types of trauma and repeated exposure to trauma. That may require extra time and attention to address multiple, varied traumatic memories and more trauma-related issues. Also, military culture may increase concerns about the stigma of mental health care, perhaps making service members reluctant to seek treatment in the first place, while work schedules may interfere with patients’ ability to complete treatment.

How the CAP IOP study works

With those challenges in mind, Alan Peterson, PhD, of The University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System leads a study for the Consortium to Alleviate PTSD to evaluate two versions of intensive outpatient treatment programs for military service members and veterans with PTSD. Patients involved in this study will participate in a three-week, fulltime treatment program at a designated treatment center. The aim with this approach is to both maximize improvements and streamline the treatment length.

The study will compare two intensive, enhanced forms of Prolonged Exposure (PE), the PTSD treatment with the most scientific support for efficacy with civilians.

Rather than the traditional PE treatment of 10 therapy sessions delivered over a period of three to four months, participants will receive more sessions in a shorter time period, three weeks. They will be randomly placed into one of two treatment arms with different levels of therapy enhancement:

Massed-PE format, with 15 daily sessions over three weeks, or
Intensive Outpatient PE (IOP-PE) format, also with 15 daily sessions over three weeks, but with additional enhancements to better tailor the treatment to those with combat-related PTSD or otherwise help improve treatment outcomes.

The researchers hypothesize that both formats will result in improved outcomes over standard PE delivery and that IOP-PE will provide maximum benefit. Participants in this randomized clinical trial will include 100 active duty military service members recruited worldwide and 100 veterans, treated at military and Department of Veterans Affairs sites in South and Central Texas.

Potential benefits

If the intensive outpatient format is found to be highly effective at reducing PTSD symptoms, it will offer the military and VA a valuable option that would increase access to care, boost patient retention, and improve treatment outcomes. It also could enable creation of specialized PTSD treatment centers to which service members could travel from around the world for short-term, state-of-the-art care. This would make it possible for more service members to stay on active duty and for veterans to reintegrate more quickly into civilian life, potentially saving the nation millions of dollars in long-term disability payments to veterans.