Post-traumatic Headache Research Articles

Cutaneous heat and light-induced pain thresholds in post-traumatic headache attributed to mild traumatic brain injury.

The purpose of this study was to characterize cutaneous heat and light-induced pain thresholds in people with post-traumatic headache (PTH) compared with healthy controls (HCs). Photophobia and allodynia are common in PTH, and there is emerging evidence to support multimodal sensory dysfunction. In this age- and sex-matched cohort study, individuals with PTH (n=20) and HCs (n=20), aged 18-65 years, were recruited from an institutional database of research volunteers, from the concussion clinic, and via the use of approved flyers posted on the Mayo Clinic Campus in Scottsdale, Arizona. Participants were assessed using the Allodynia Symptom Checklist (ASC-12), Photosensitivity Assessment Questionnaire (PAQ), State Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI). Quantitative sensory testing quantified heat pain thresholds. A light stimulation device quantified light-induced pain thresholds. Subsequently, heat pain thresholds were obtained immediately, 10, and 40min after a bright light stressor. The mean photophobia symptom severity score, based on the PAQ, was higher in participants with PTH compared with HCs, mean 0.62 (SD=0.25) versus mean 0.24 (SD=0.24), p<0.001. Light-induced pain thresholds were lower in participants with PTH (median=90.5lux and quartiles=17.8 to 378.5) compared with HCs (median=863.5lux and quartiles=519.9 to 4906.5) and were independent from BDI and STAI (p<0.001). Allodynia scores did not differ between participants with PTH and HCs after adjusting for BDI and STAI scores. Baseline forehead heat pain thresholds were not different, participants with PTH mean 41.9°C (SD=0.89) versus HCs mean 44.3°C (SD=0.89), p=0.061; however, forearm heat pain thresholds were lower in participants with PTH compared with HCs, mean 40.8°C (SD=0.80) versus mean 44.4°C (SD=0.80), p=0.002. The forehead heat pain threshold change from baseline post bright light stressor in participants with PTH versus HCs was different immediately (mean -1.2 (SD=0.53), p=0.025), 10min (mean -1.8 (SD=0.74), p=0.015), and 40min (mean -1.8 (SD=0.88), p=0.047). The forearm heat pain threshold change immediately post bright light stressor in participants with PTH versus HCs was different, mean -1.9°C (SD=0.58), p=0.001, however, not different at 10 and 40min. Photophobia is higher and light-induced pain thresholds are lower in participants with PTH. Exposure to a light stressor reduced heat pain thresholds in participants with PTH immediately post bright light stressor, but not in HCs. This study provides evidence for multimodal sensory dysfunction in people with PTH.

Identifying Migraine Phenotype Post Traumatic Headache (MPTH) to Guide Overall Recovery From Traumatic Brain Injury.

Objective: The primary aim of this study is to develop an easy way to identify migraine phenotype posttraumatic headache (MPTH) in children with traumatic brain injury, to treat headache in traumatic brain injury effectively, and to promote faster recovery from traumatic brain injury symptoms overall. Methods: We evaluated youth aged 7-20 years in a pediatric neurology traumatic brain injury (TBI) clinic, assigning a migraine phenotype for post-traumatic headache (MPTH) at the initial visit with the 3-item ID Migraine Screener. We stratified the sample by early (≤6 weeks) and late (>6 weeks) presenters, using days to recovery from concussion symptoms as the primary outcome variable. Results: 397 youth were assessed; 54% were female. Median age was 15.1 years (range 7.0-20.4 years), and 34% of the sample had sports-related injuries. Migraine phenotype for posttraumatic headache (MPTH) was assigned to 56.1% of those seen within 6 weeks of traumatic brain injury and 50.7% of those seen after the 6-week mark. Irrespective of whether they were early or late presenters to our clinic, patients with migraine phenotype (MPTH) took longer to recover from traumatic brain injury than those with posttraumatic headache (PTH) alone. Log rank test indicated that the survival (ie, recovery) distributions between those with migraine phenotype posttraumatic headache (MPTH) and those with posttraumatic headache (PTH) were statistically different, χ2(3) = 50.186 (P < .001). Conclusions: Early identification of migraine phenotype posttraumatic headache (MPTH) following concussion can help guide more effective treatment of headache in traumatic brain injury and provide a road map for the trajectory of recovery from traumatic brain injury symptoms. It will also help us understand better the mechanisms that underlie conversion to persistent posttraumatic headache and chronic migraine after traumatic brain injury.

0642 Characterizing Actigraphy-Measured Sleep Disturbance in Veterans and Service Members with Post-traumatic Headache following Mild Traumatic Brain Injury

Abstract Introduction Post-traumatic headache (PTH) frequently occur following traumatic brain injury (TBI) is particularly prevalent in Veterans with deployment-related TBI. PTH is associated with a range of physical and mental health symptoms, including post-traumatic stress disorder (PTSD), depression, anxiety, post-concussive symptoms, and subjective sleep complaints. Subjective sleep disturbance is associated with greater pain severity, and headaches (HA) are associated with poorer sleep. Poor sleep may be a mechanism by which PTH exerts both direct and indirect effects on health outcomes Despite the high prevalence of sleep problems in individuals with PTH, we know little about sleep disturbance in Veterans and military personnel with PTH. This study sought to characterize the relationship between objective sleep disturbance and HA in Veterans and military personnel with chronic PTH following mild TBI. Methods Veterans and active-duty service members (N=39, Mage= 49.4, 89.7% male) were included from a larger study evaluating prazosin as prophylactic treatment for persistent PTH. Participants completed baseline measures of PTSD symptoms, insomnia, sleep quality, HA frequency and impairment, as well as 7-day actigraphy, sleep diary, and HA logs. Actigraphy-derived sleep parameters include sleep onset latency (SOL), total sleep time (TST), sleep efficiency (SE), and wake after sleep onset (WASO). Daily HA logs were used to assess HA severity and duration. Analyses were conducted in SPSS 26.0 using multilevel modeling, controlling for the effects of time. Results Preliminary results suggest number of HA days at baseline was significantly associated with self-reported sleep quality (r=-.398, p= .016), but not with subjective SOL, TST, or WASO. Number of HA days was significantly correlated with actigraphy-measured WASO (r=.178, p=.003). Actigraphy-measured SOL, SE, WASO, and TST were not significantly associated with same-day HA severity and duration. Conclusion This preliminary data suggest examination of sleep fragmentation may be important in enhancing our understanding of PTH and related impairment. Findings support the importance of using both subjective and objective measures in the assessment of sleep in Veterans and service members with PTH. Support (If Any) This project was supported by a VA Career Development Award 5IK2RX001136 from the United States Department of Veterans Affairs Rehabilitation Research and Development Service. The contents of this work do not represent the views of the Department of Veterans Affairs or the United States government.

Integrated Features for Optimizing Machine Learning Classifiers of Pediatric and Young Adults With a Post-Traumatic Headache From Healthy Controls.

Post-traumatic headache (PTH) is a challenging clinical condition to identify and treat as it integrates multiple subjectively defined symptoms with underlying physiological processes. The precise mechanisms underlying PTH are unclear, and it remains to be understood how to integrate the patient experience with underlying biology when attempting to classify persons with PTH, particularly in the pediatric setting where patient self-report may be highly variable. The objective of this investigation was to evaluate the use of different machine learning (ML) classifiers to differentiate pediatric and young adult subjects with PTH from healthy controls using behavioral data from self-report questionnaires that reflect concussion symptoms, mental health, pain experience of the participants, and structural brain imaging from cortical and sub-cortical locations. Behavioral data, alongside brain imaging, survived data reduction methods and both contributed toward final models. Behavioral data that contributed towards the final model included both the child and parent perspective of the pain-experience. Brain imaging features produced two unique clusters that reflect regions that were previously found in mild traumatic brain injury (mTBI) and PTH. Affinity-based propagation analysis demonstrated that behavioral data remained independent relative to neuroimaging data that suggest there is a role for both behavioral and brain imaging data when attempting to classify children with PTH.

Equity and Disparities in Diagnosis, Management, and Research of Post-Traumatic Headache.

There are notable health disparities and inequities in individuals with traumatic brain injury (TBI) and concussion by race, ethnicity, gender, socioeconomic status, and geography. This review will evaluate these disparities and inequities and assess the social determinants of health that drive outcomes for post-traumatic headache. Interventions for achieving this are also discussed. Significant disparities and inequities exist in TBI and concussion among people of different races, socioeconomic status, and geographic locations. Migraine is a common symptom post-concussion, for which disparities and social determinants of health are also discussed. Overall, multi-level interventions to reduce these disparities and inequities are reviewed for post-traumatic headache but require further investigation. Interventions are needed to reduce disparities and inequities including public health initiatives, improvements in clinical care, diversity/inclusion training, and research efforts. As literature expands, we can form guidance to identify solutions for eliminating disparities in care of diverse populations.

Preclinical assessment of onabotulinumtoxinA for the treatment of mild traumatic brain injury-related acute and persistent post-traumatic headache.

ObjectiveInvestigation of onabotulinumtoxinA in a murine model of acute and persistent post-traumatic headache.MethodsMild traumatic brain injury was induced with a weight drop method. Periorbital and hindpaw cutaneous allodynia were measured for 14 days. Mice were then exposed to bright light stress and allodynia was reassessed. OnabotulinumtoxinA (0.5 U) was injected subcutaneously over the cranial sutures at different post-injury time points.ResultsAfter milt traumatic brain injury, mice exhibited periorbital and hindpaw allodynia that lasted for approximately 14 days. Allodynia could be reinstated on days 14–67 by exposure to stress only in previously injured mice. OnabotulinumtoxinA administration at 2 h after mild traumatic brain injury fully blocked both transient acute and stress-induced allodynia up to day 67. When administered 72 h post-mild traumatic brain injury, onabotulinumtoxinA reversed acute allodynia, but only partially prevented stress-induced allodynia. OnabotulinumtoxinA administration at day 12, when initial allodynia was largely resolved, produced incomplete and transient prevention of stress-induced allodynia. The degree of acute allodynia correlated positively with subsequent stress-induced allodynia.ConclusionMild traumatic brain injury induced transient headache-like pain followed by long lasting sensitization and persistent vulnerability to a normally innocuous stress stimulus, respectively modeling acute and persistent post-traumatic headache.. Administration of onabotulinumtoxinA following the resolution of acute post-traumatic headache diminished persistent post-traumatic headache but the effects were transient, suggesting that underlying persistent mild traumatic brain injury-induced maladaptations were not reversed. In contrast, early onabotulinumtoxinA administration fully blocked both acute post-traumatic headache as well as the transition to persistent post-traumatic headache suggesting prevention of neural adaptations that promote vulnerability to headache-like pain. Additionally, the degree of acute post-traumatic headache was predictive of risk of persistent post-traumatic headache.

Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion.

BackgroundThere is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury.MethodsAdults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI).ResultsA total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness.ConclusionsThis study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.

Post-traumatic headaches and vision: A review.

Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.

Effects of acupuncture treatment on posttraumatic headache after traumatic brain injury in patients: A protocol for systematic review.

Background:Posttraumatic headache (PTH) after traumatic brain injury (TBI) is a common clinical symptom, which refers to a headache that occurs after TBI. Acupuncture is often used for the treatment of such patients in China, and significant clinical effects have been achieved. However, to date, its efficacy has not been methodically evaluated. The purpose of this systematic review is to provide evidence to prove the effectiveness of acupuncture in the treatment of PTH in patients with TBI.Methods:This systematic review will be conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols. The following electronic databases will be searched from their inception to February 2022: PubMed, Web of Science, Embase, PsycINFO, the Cochrane Library, and Chinese databases such as Chinese Biomedical Literature (CBM), Chinese Medical Current Content (CMCC), Chinese Scientific Journal Database (VIP), WanFang Database, and China National Knowledge Infrastructure (CNKI). No language restrictions will be applied to the search strategy. Randomized controlled trials and cohort and case-control studies that met the inclusion and exclusion criteria will be included in this study. The meta-analysis will be performed using RevMan 5.3 software. Each session of this systematic review will be conducted independently by 2 members.Results:This review evaluates the efficacy of acupuncture in the treatment of PTH after TBI.Conclusion:This review provides substantial evidence for the clinical application of acupuncture in PTH treatment after TBI.Ethics and dissemination:Since the data in this study will be retrieved from published trials, therefore the Patient Consent Statement and Ethical Approval are not required. We will disseminate our results by publishing the research in a peer-reviewed journal.Trail registration number:The protocol was registered in INPLASY (INPLASY 202220073).

Expert Consensus on the Benefits and Limitations of the Diagnostic Criteria for Post-Traumatic Headache as Defined by the International Classification of Headache Disorders-3rd Edition: A Qualitative Study (P8-2.003)

Expert Consensus on the Benefits and Limitations of the Diagnostic Criteria for Post-Traumatic Headache as Defined by the International Classification of Headache Disorders-3rd Edition: A Qualitative Study (P8-2.003)

The Pathophysiology of Long COVID throughout the Renin-Angiotensin System.

COVID-19 has expanded across the world since its discovery in Wuhan (China) and has had a significant impact on people’s lives and health. Long COVID is a term coined by the World Health Organization (WHO) to describe a variety of persistent symptoms after acute SARS-CoV-2 infection. Long COVID has been demonstrated to affect various SARS-CoV-2-infected persons, independently of the acute disease severity. The symptoms of long COVID, like acute COVID-19, consist in the set of damage to various organs and systems such as the respiratory, cardiovascular, neurological, endocrine, urinary, and immune systems. Fatigue, dyspnea, cardiac abnormalities, cognitive and attention impairments, sleep disturbances, post-traumatic stress disorder, muscle pain, concentration problems, and headache were all reported as symptoms of long COVID. At the molecular level, the renin-angiotensin system (RAS) is heavily involved in the pathogenesis of this illness, much as it is in the acute phase of the viral infection. In this review, we summarize the impact of long COVID on several organs and tissues, with a special focus on the significance of the RAS in the disease pathogenesis. Long COVID risk factors and potential therapy approaches are also explored.

The impact of pre‐morbid headaches on headache features and long‐term health outcomes following traumatic brain injury: Insights from the American Registry for Migraine Research

To investigate the impact of having headaches prior to traumatic brain injury (TBI) on headache features and long-term patient health outcomes. This was an exploratory analysis of patients with TBI who were enrolled in the American Registry for Migraine Research (ARMR), a multicenter, prospective, longitudinal patient registry composed of patients with International Classification of Headache Disorders, 3rd edition (ICHD-3)-defined headache diagnoses. The ARMR study enrolled 2,707 patients between February 1, 2016 and May 6, 2020, 565 of whom qualified for this analysis. Those with headaches prior to their TBI were compared to those without headaches prior to their TBI for ICHD-3 diagnoses, headache frequency and intensity, headache-related disability (Migraine Disability Assessment score), symptoms of anxiety (General Anxiety Disorder [GAD-7]), depression (two items from Patient Health Questionnaire-9), post-traumatic stress disorder (PTSD), cutaneous allodynia (12-item Allodynia Symptom Checklist [ASC-12]), cognitive dysfunction (Migraine Attacks Subjective Cognitive Impairments Scale [Mig-SCog]), pain interference (Patient-Reported Outcomes Measurement Information System-Pain Interference), and work productivity (Work Productivity and Activity Impairment). Among 565 participants with TBI, 350had headaches prior to their TBI. Those with pre-TBI headaches were less likely to receive a diagnosis of post-traumatic headache (PTH; 14/350 [4.0%] vs. 21/215 [9.8%], p=0.006), even though 25.7% reported new or worsening headaches within 7 days of their TBI. Those with pre-TBI headaches had higher ASC-12scores (2.4±3.5 vs. 1.8±3.4, p=0.030), Mig-SCog scores (9.3±4.7 vs. 8±4.9, p=0.004), and GAD-7scores (6.9±5.1 vs. 6.2±5.4, p=0.039), and were more likely to have a migraine diagnosis (335/350 [95.7%] vs. 192/215 [89.3%], p=0.003). Those with headaches prior to TBI are less likely to receive a diagnosis of PTH. They have more severe symptoms of cutaneous allodynia, cognitive impairment, and generalized anxiety. This analysis suggests that pre-TBI headaches might impact post-TBI headache diagnoses and associated features.

Introduction to Topical Issue on mHealth for Brain Injury Rehabilitation.

Introduction to Topical Issue on mHealth for Brain Injury Rehabilitation.

P 17 Posttraumatic Headache – Pain Related Evoked Potentials (PREP) and Conditioned Pain Modulation (CPM) as possible biomarkers for identification of risk patients

Introduction : Posttraumatic headache (PTH) is one of the most common complications following traumatic brain injury (TBI)[1], though its underlying pathomechanisms have not been fully understood yet. An altered descending pain modulation seems to contribute to its development and persistence[2]. The aim of our study was to examine the pain processing in PTH-patients using pain-related evoked potentials after electrical stimulation (PREP) and conditioned pain modulation (CPM), based on their N1P1-amplitude as an objective readout. We chose a longitudinal design to analyse if PREP and CPM can be used as biomarkers for persisting PTH. Methods : We plan to recruit 30 patients with PTH and 20 healthy control subjects. Currently (October 2021) we have recruited 21 PTH-patients and 19 healthy control subjects. The patients were invited for follow-up sessions at 3 and 6 months after inclusion. The painful stimuli were applied at the dorsum of the right hand and above the right eyebrow with a concentric surface electrode while PREP were recorded over Cz and evoked pain was assessed on the numerical rating scale (NRS), as previously described [3]. For CPM we used the same electrode for painful cutaneous electric stimulation on the right hand as the test stimulus and the immersion of the left hand in a 10°C cold water bath as the conditioning stimulus. With the assessed data we calculated early and late CPM-effects for the subjective pain ratings and the objective N1-P1-amplitudes in the EEG, as recently reported[4]. Results : PTH-patients were on average 41.3 (± 10.7) years old, had a mean headache duration of 103 (± 265) weeks and a mean headache intensity of 5.9 (± 1.9) on the NRS (0-10). We currently present data at baseline. PREP parameters in both regions did not differ between PTH-patients and age-matched controls. The early CPM-effect based on PREP-amplitudes and the late CPM effect based on pain-rating were significantly less pronounced in patients than in controls. The early and late CPM effect for pain and amplitudes correlated significantly in both groups, but no significant correlation comparing CPM effects based on pain with the CPM effects based on amplitudes could be detected. Conclusions : Our preliminary results display a deficient endogenous pain modulation in PTH-patients also based on PREP-amplitude as an objective readout. The missing correlation between CPM-effects based on subjective pain ratings and PREP-amplitudes indicate different pathways involved in nociception and subjective pain perception. Further analysis of subgroups is planned after complete recruitment.

P 45 Satisfaction with and safety of repetitive neuromuscular magnetic stimulation in children with headache disorders

Question To assess the safety of and satisfaction with a repetitive neuromuscular magnet stimulation (NMS) intervention targeting to the upper trapezius muscles (UTM) in pediatric patients with headache disorders. Methods Retrospective chart review including 33 patients with migraine, tension-type headache, or post-traumatic headache, who had received at least one test rNMS session targeting to UTM. In patients choosing to undergo rNMS intervention, adherence rate was calculated based on the number of completed rNMS sessions. For patients undergoing the rNMS intervention, safety of and satisfaction with the intervention were assessed by customized questionnaires. Results 33 patients (13.94 ± 2.51 years; 61% females) received at least a test rNMS session to become acquainted with the stimulation setting, resulting in 182 rNMS sessions. In 142 sessions (78%) no adverse events were reported. 43 adverse events were documented for 40 sessions (22%). Related side effects during stimulation included tingling (32.6%), shoulder pain (9.3%), back pain (9.3%), feeling of heaviness (4.7%), trembling (2.3%), and unpleasant tension (2.3%). Related side effects in-between interventions included muscle sore (25.5%), headache (4.7%), and a short-lasting muscle cramp in the upper arm (2.3%). Adverse events categorized unlikely related to the intervention were described in 3 sessions by 2 patients and included shoulder pain (4.7%) and an electrifying feeling radiating to the right hip (2.3%). In these 33 patients, 6 patients (18%) did not continue after the test rNMS session and 4 patients (12%) who started the intervention did not complete the full treatment. 23 patients (70%) completed 28 rNMS interventions with at least 5 of 6 sessions. At follow-up (FU) of 24 interventions, patients completed the customized satisfaction questionnaire. After 13 interventions (54.2%), the treatment was rated as “the therapy helped very well”, after 5 interventions (20.8%) as “the therapy helped well”, after 1 intervention (4.2%) as “indecisive”, after 3 interventions as “the therapy rather did not help”, and after 2 interventions as “the therapy did not help”. At FU of 25 interventions, patients completed the customized questionnaire regarding repetition of the treatment. After 23 interventions (88.5%), patients would repeat the treatment. At FU of 19 interventions, patients completed the questionnaire regarding recommendation of treatment. After 18 interventions (96.2%), patients would recommend rNMS to other affected patients. Conclusion Stimulation by rNMS was found to be a feasible, safe, and well-accepted treatment option for children and adolescents with headache disorders. Thus, rNMS of the UTM may become a valuable non-invasive, non-pharmacological treatment option for pediatric headache disorders.

P 46 Effects of repetitive neuromuscular magnetic stimulation targeting to the upper trapezius muscles in children with headache disorders

Question To assess clinical and muscular effects of a repetitive neuromuscular magnetic stimulation (rNMS) intervention targeting to the upper trapezius muscles (UTM) in pediatric patients with headache disorders. Methods A retrospective chart review resulted in 23 patients with migraine, migraine + tension-type headache (TTH), or post-traumatic headache (PTH), who received 28 rNMS interventions in a pediatric headache center. During 6 sessions, rNMS was delivered to UTM bilaterally (duration: 15min/side, frequency: 20 Hz, 7s ON-time, 10s OFF-time). Headache frequency, duration, and intensity 3 months before and after treatment were recorded using a customized standardized questionnaire prior to the first treatment and at follow-up (FU). We categorized patients into responder classes based on the relative reduction in headache frequency (≥25%, ≥50%, ≥75%). Effects on the muscular level were assessed by pressure pain thresholds (PPTs) above the UTM before, during rNMS treatment, and at FU after 4 to 20 weeks. Results Data from 20 patients were analyzed (14.10 ± 2.69 years; 60% females) as 2 patients were lost to FU and data of 1 patient was classified as outlier based on a late FU (3 SDs above mean FU time) and excluded from analysis. Compared to baseline, headache frequency (p=.017) and minimum and maximum headache intensities (p=.017; p=.023) were significantly reduced at FU. 11 patients (44%) were classified as ≥25% responders, with 7 patients (28%) experiencing a ≥75% reduction of monthly headache days. PPTs above the UTM significantly increased from baseline (left lateral: 2.00 ± 1.37, left medial: 1.96 ± 1.27, right medial: 1.83 ± 1.26, right lateral: 1.94 ± 1.37) to the last treatment session (left lateral: 3.28 ± 2.21, left medial: 3.17 ± 1.99, right medial: 3.17 ± 2.06, right lateral: 3.24 ± 2.25) (left lateral: p=.002, left medial: p=.002, right medial: p=.001, right lateral: p=.003). This increase from baseline sustains until FU (left lateral: 2.87 ± 2.11, left medial: 2.95 ± 2.11, right medial: 2.95 ± 2.11, right lateral: 2.81 ± 2.04) (left lateral: p=.047, left medial: p=.012, right medial: p=.002, right lateral: p=.028). After 14 rNMS interventions in the primary headache group, 6 patients (43%) were classified as ≥25% responders, with 2 patients (14%) experiencing a ≥75% reduction of monthly headache days. After 11 rNMS interventions in the PTH group, 5 patients (46%) were classified as ≥25% responders, with 5 patients (46%) experiencing a ≥75% reduction of monthly headache days. Conclusion Beneficial effects regarding headache characteristics and muscular PPTs were documented in pediatric patients with headache disorders. The latter having a sustained effect up to weeks to months. Based on the concept of the trigemino-cervical complex, rNMS of the UTM may act via neuromodulation of nociceptive processing at the central level.

Headache Diary Mobile Application for Monitoring and Characterizing Posttraumatic Headaches.

This study analyzed the data collected using a headache diary mobile application to characterize posttraumatic headaches (PTHs) in a sample of US veterans. Specifically, we measured patient engagement with the mobile application and compared our findings with previous literature regarding PTHs. A Headache Center of Excellence (HCoE) in a Veterans Health Administration facility. Forty-nine veterans currently being treated for ongoing PTH-related complaints with English fluency, reliable access to the internet, and a mobile phone. Observational study of PTH characteristics using the mobile application over the course of 1 year. Main outcome measures were collected via a headache diary mobile application developed for patients to track headache-associated symptoms, headache location, triggers, type, intensity, and duration. Patients also completed a baseline Headache Impact Test (HIT-6) survey. In total, 1569 entries were completed during the first year of application deployment. On average, patients completed 2.5 entries per week and used the application for 70 days. They frequently reported associated PTH symptoms of photophobia (56.7%) and headaches triggered by emotional stress (35.1%). Network analyses revealed patterns of co-occurrence in triggers of headache pain, associated symptoms, and headache pain location. Headache pain severity and impact ratings from the headache diary demonstrated convergent validity with the established HIT-6 measure. Headache diary mobile applications are a promising tool for monitoring and characterizing PTHs in veterans. Present results mirror past studies of PTH characteristics. Mobile application headache diaries may be used in both clinical and research settings to monitor headache symptoms and communicate the functional impact of headaches in real time.

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

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. 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. 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. 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).

Post-traumatic headache after mild traumatic brain injury in a one-year follow up study \u2013 risk factors and return to work

BackgroundPost-traumatic headache (PTH) is a common symptom following mild traumatic brain injury (mTBI). Patients at risk to develop acute PTH (aPTH) and further persistent PTH (pPTH) need to be recognized.MethodsThis is a one-year follow-up of 127 patients with mTBI, aged 18 to 68, referred to outpatient clinic in the Helsinki University Hospital. Symptoms were assessed at the emergency department (ED), with structured interview at outpatient clinic visit and with Rivermead post-concussion symptom questionnaire at one, three, and 12 months after injury. Psychiatric disorders were assessed with Structured Clinical Interview for DSM-IV Axis I disorders at 3-4 months and return to work (RTW) from patient records.ResultsAt one month, 77/127 patients (61%) had aPTH. According to multiple logistic regression analysis, risk factors for aPTH were headache at the emergency department (ED) (OR 5.43), other pain (OR 3.19), insomnia (OR 3.23), and vertigo (OR 5.98). At three months, 17 patients (22% of aPTH patients) had developed pPTH, and at one year, 4 patients (24% of pPTH patients) still presented with pPTH. Risk factors for pPTH at three months were older age (OR 1.06) and current insomnia (OR 12.3). The frequency of psychiatric disorders did not differ between the groups. pPTH patients performed worse on their RTW.ConclusionsRisk factors for aPTH were insomnia, headache at ED, other pain, and vertigo and for pPTH, insomnia and older age. RTW rate was lower among pPTH patients.

Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms.

Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI. Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.