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Cognitive Behavioral, Processing Therapies Show Favorable Results in Comorbid Posttraumatic Headache, PTSD Symptoms

Those randomly assigned to cognitive behavioral therapy reported significantly lower aggregate posttreatment mean HIT-6 scores compared with standard care, but the posttreatment effect for cognitive processing therapy vs treatment per usual was modest.

Data from a single-site study (NCT02419131) of post-9/11 US combat veterans with comorbid posttraumatic headache and posttraumatic stress disorder (PTSD) symptoms showed that cognitive behavioral therapy (CBT) was superior to usual care in improving headache-related disability. Cognitive processing therapy (CPT), the third arm in the study, was efficacious for PTSD symptoms but not for headache disability.1

A total of 193 veterans were assigned to either 8 sessions of CBT for headache (n = 65), 12 sessions of cognitive processing for PTSD (n = 64), or treatment per usual for headache (n = 64). Using the 6-Item Headache Impact Test (HIT-6) to assess headache-related disability, those who received CBT for headache reported –3.4 points (95% CI, –5.4 to –1.4; P <.01) lower, while patients receiving cognitive processing therapy reported –1.4 points (95% CI, –3.7 to 0.8; P = .21) lower.

"The present study provided evidence supporting treatment of [posttraumatic headache] disability using a manualized headache intervention, with outcomes superior to multimodal usual care,” the study investigators concluded. "Notably, the headache intervention also showed promise in addressing PTSD symptoms, but further research is needed to explore how this treatment influences PTH and PTSD, explore dissemination, and examine if integrated CBTH and CPT can improve outcomes."

Lead investigator Donald D. McGeary, PhD, Department of Psychiatry, UT Health San Antonio, and colleagues conducted a 3-parallel group, randomized clinical trial with outcomes assessed at posttreatment, 3-month follow-up, and 6-month follow-up. Treatment engagement was better for CBT and treatment per usual (TPU) compared with CPT with 60% (39 of 65) of patients completing 6 or more CBT sessions, 42% (27 of 64) completing 9 or more CPT sessions, and 83% (53 of 64) completing TPU.

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Veterans entered the study approximately 2 years after initial headache onset, most with intermittent headaches (78%) occurring a mean of 3.8 times per week (standard deviation [SD], 3.1), with a mean duration of 4.2 hours (SD, 3.9) and a mean intensity of 6.9 out of 10 (SD, 2.0). Participants frequently reported medical (75%) and mental health (79%) comorbidities and most reported taking medication for headache (78%) at enrollment.

Aggregate posttreatment HIT-6 estimates were stable throughout posttreatment measurements with the posttreatment contrast between CBT and TPU decreasing –0.5 units (95% CI, –2.9 to 1.9) at 3 months and –1.7 units (95% CI, –4.1 to 0.7) at 6 months whereas the posttreatment contrast between CPT and TPU increased 1.2 units (95% CI, –1.4 to 3.8) at 3 months and decreased –0.7 units (95% CI, –3.4 to 2.0) at 6 months. Participants randomly assigned to CPT demonstrated a mean HIT-6 score decrease of –2.5 units (SD, 0.9) from baseline to posttreatment, which rose to –0.9 units (SD, 1.0) at 3-month follow-up but decreased again at 6-month follow-up to –2.6 units (SD, 0.9).

PTSD symptom severity was assessed using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (PCL-5). Compared with standard care, those in the CBT group reported lower mean aggregate posttreatment PCL-5 scores that did not reach statistical significance (–6.5; 95% CI, –12.7 to –0.3; P = .04), but the difference between participants randomly assigned to CPT vs TPU was statistically significant (–8.9; 95% CI, –15.9 to –1.9; P = .01). The posttreatment difference between CPT and TPU decreased –0.7 points (95% CI, –6.8 to 5.3) from posttreatment to 3 months with an increase of 4.5 points (95% CI, –1.7 to 10.8) at 6 months.

Secondary outcomes, which included headache intensity, headache frequency, depression, anxiety, and insomnia, were not statistically significant between the treatment arms. Compared with TPU, those in the CBT and CPT groups reported an aggregate posttreatment difference in headache intensity of less than 1 point and a difference in headache frequency of –2.9 headache days per month (95% CI, –6.0 to 0.1; P = .07) for CBT and –2.1 (95% CI, –5.6 to 1.4; P = .26) for CPT.

1. McGeary D, Resick PA, Penzien DB, et al. Cognitive behavioral therapy for veterans with comorbid posttraumatic headache and posttraumatic stress disorder symptoms: a randomized clinical trial. JAMA Neurol. Published online June 27, 2022. doi:10.1001/jamaneurol.2022.1567