Combat-related posttraumatic headache: diagnosis, mechanisms of injury, and challenges to treatment.

CONTEXT Studies have revealed the rates of posttraumatic stress disorder (PTSD) and concussion among US soldiers returning from combat, but only one study has focused on the subpopulation of soldiers with headache. OBJECTIVES To determine the rate of PTSD among US soldiers with comorbid chronic posttraumatic headache attributed to head injury, to identify common mechanisms of head injury, and to identify the common challenges a healthcare provider must face when treating US soldiers with chronic posttraumatic headache attributed to head injury. METHODS Between July 2007 and December 2008, the author examined 42 US Army soldiers with complaint of chronic headache. In March 2009, the author retrospectively reviewed the outpatient records for diagnoses, mechanisms of injury, and challenges to treatment. RESULTS The rate of concussion, defined by the Defense and Veterans Brain Injury Center Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings, was 95%. The rate of PTSD, as determined either with the PTSD Checklist or by confirming a prior diagnosis by another healthcare provider, was 97.9%. Both rates are remarkably higher than rates reported in the literature. The most common mechanisms of injury were proximity to blast (18 [45.2%]) and direct target of blast (15 [35.7%]). The most common treatment challenges were overuse of headache-abortive medications (10 [23.8%]) and poor patient followup (7 [16.7%]). CONCLUSION Physicians should be aware that the rates of PTSD and concussion for US soldiers, most often linked to involvement in or proximity to a blast, are higher for soldiers complaining of chronic headache. Physicians should also be aware of the potential for overuse of medications in this patient population.