PTSD, Combat Injury, and Headache in Veterans Returning From Iraq/Afghanistan

Headache: The Journal of Head and Face Pain
Volume 49 Issue 9, Pages 1267 - 1276
Published Online: 29 Sep 2009

Copyright © 2009 American Headache Society
Niloofar Afari, PhD; Laura H. Harder, BA; Naju J. Madra, MA; Pia S. Heppner, PhD; Tobias Moeller-Bertram, MD; Clay King, MSW; Dewleen G. Baker, MD
From Department of Psychiatry, University of California, San Diego, San Diego, CA, USA (N. Afari, P. S. Heppner, and D. G. Baker); Veterans Affairs San Diego Healthcare System, San Diego, CA, USA (N. Afari, L. H. Harder, N. J. Madra, P. S. Heppner, T. Moeller-Bertram, C. King, and D. G. Baker); Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA (N. Afari, P. S. Heppner, T. Moeller-Bertram, and D. G. Baker); Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA (T. Moeller-Bertram).Correspondence to N. Afari, Department of Psychiatry, UCSD, 9500 Gilman Drive, Mail Stop 0738, La Jolla, CA 92093, USA.

ABSTRACT
Objective.—To examine the relationship between posttraumatic stress disorder, combat injury, and headache in Operation Iraqi Freedom and Operation Enduring Freedom veterans at the VA San Diego Healthcare System.

Background.—Previous investigations suggest that a relationship between posttraumatic stress disorder and primary headache disorders exists and could be complicated by the contribution of physical injury, especially one that results in loss of consciousness. These associations have not been systematically examined in Operation Iraqi Freedom and Operation Enduring Freedom veterans.

Methods.—In this observational cross-sectional study, a battery of self-report, standardized questionnaires was completed by 308 newly registered veterans between March and October 2006. The Davidson Trauma Scale was used to determine the degree of posttraumatic stress disorder symptoms and combat-related physical injury was assessed by self-report. The presence of headache was based on a symptom checklist measure and self-reported doctor diagnoses. Logistic regression analysis was performed to predict presence of headache and determine odds ratios and 95% confidence intervals associated with demographic, military, in-theatre, and mental health characteristics.

Results.—About 40% of the veterans met the criteria for posttraumatic stress disorder; 40% self-reported current headache, 10% reported a physician diagnosis of migraine, 12% a physician diagnosis of tension-type headache, and 6% reported both types of headache. Results from the logistic regression model indicated that combat-related physical injury (odds ratio: 2.25; 95% confidence interval: 1.17-4.33) and posttraumatic stress disorder (odds ratio: 4.13; 95% confidence interval: 2.44-6.99) were independent predictors of self-reported headache. Additional analyses found that veterans with both tension and migraine headache had higher rates of posttraumatic stress disorder (chi-square [d.f. = 3] = 15.89; P = .001) whereas veterans with migraine headache alone had higher rates of combat-related physical injury (chi-square [d.f. = 9] = 22.00; P = .009).

Conclusion.—Posttraumatic stress disorder and combat-related physical injury were related to higher rates of self-reported headache in newly returning veterans. Our finding that posttraumatic stress disorder and injury during combat are differentially related to migraine and tension-type headache, point to a complex relationship between physical and psychological trauma and headache. These findings have implications for a comprehensive approach to interventions for headache and the physical and psychological sequelae of trauma.