Why studying persistent post-traumatic headaches in soldiers matter
The Pentagon confirmed that the U.S. forces carried out airstrikes in Iraq at five weapon storage sites run by Iranian-backed militia, in direct retaliation for a rocket attack that killed one British soldier and two Americans. Meanwhile, according to recent reports, the number of U.S. soldiers with traumatic brain injuries from the January Iranian missile strike on American troops in Iraq has risen to at least 110.
While the majority have returned to active duty, some are still undergoing advanced care. Because there is no adequate diagnostic test, the Pentagon reports that the numbers of reported brain injuries will continue to rise. President Donald Trump, however, has minimized the injuries calling them “headaches.” “I can report it is not very serious,” Trump said.
Trump also claimed that “no Americans were harmed.” Unfortunately, he is not alone in his thinking. Sure, migraine attacks are not the same as an amputation. However, according to the World Headache Organization (WHO), acute migraine attacks are comparable to being quadriplegic due to the high levels of disability. People who suffer from migraines often feel as if they have to power through their lives and often carry high levels of stigma.
There are several reasons why headaches are trivialized and not taken seriously.
Yet migraines are the second leading cause of years lived with disability worldwide and are associated with severe social and economic consequences. It has been a long time since the influential headache researcher, Dr. Harold G Wolff, coined the term “migraine personality” in the late 1930s, based on his psychosomatic views of migraine as one associated with obsessive-compulsive traits and perfectionism.
But even though our understanding has evolved and migraine is now considered a complex brain disorder, the stigma remains, in part, because they are more common in women and, ironically, because of how frequently they occur.
Sadly, traumatic brain injuries are the signature wounds of the conflicts in the Middle East, and headaches are the most common symptom, signifying an invisible wound. Often, posttraumatic headaches can be disabling and look identical to migraine attacks. A migraine is characterized by recurrent episodes of severe pain and is often accompanied by nausea, vomiting, and sensitivity to light, sound, and even movements.
Much like a post-concussive syndrome that may linger after a head injury, a migraine may also cause ringing in the ears, balance problems, visual changes, weakness, speech changes, and emotional and cognitive disturbances. A group of neurologists recently found that persistent posttraumatic headache attributed to even mild head injury was most commonly associated with chronic migraine-like headaches. Chronic migraine is one of the most disabling conditions; it can cause high levels of work disability, high direct and indirect costs, and frequent emergency room visits.
As a headache neurologist, I have treated many patients with headaches related to traumatic brain injuries, such as the soldiers in Iraq. I have also briefed Congress on headache disorders in post-deployed veterans as a consequence of war and advocated for Congressionally Directed Medical Research Programs (CDMRP) to include research funding for chronic migraine and posttraumatic headaches. Despite a growing number of novel treatment options for migraine, there is still a great need for much more federal funding from the NIH than the current allotment of about $20 million to develop more effective, safe, and non-addictive interventions.
Back in January, Defense Secretary Mark Esper dismissed the injuries of the U.S. soldiers in Iraq as “mostly outpatient stuff.” Unfortunately, our medical system reflects a similar disregard for headache sufferers. About 47 million people in the United States have migraines, and there are currently only 564 board-certified headache specialists who treat complicated headache disorders like those associated with head injuries.
According to the Alliance for Headache Disorders, that is one-sixth of the number needed. This shortage of headache specialists means those who suffer must endure long wait times to see a doctor. Moreover, there is an imperative need to train the next generation of highly skilled specialists to treat posttraumatic headaches and migraines.
The Opioid Workforce Act, introduced in the House last June, would fund 1,000 new physician training positions. However, the bill should be amended (H.R.3414/S.2892) to ensure specialized fellowship programs in Pain and Headache Medicine specifically. Similar to proposed responses to the Coronavirus, expansion of telehealth services and coverage may also be an ideal way to deal with a shortage of headache specialists.
For all that our veterans have sacrificed for this great country, let’s not downplay these disorders, but instead provide the appropriate attention and response. It is time to recognize the growing burden of traumatic brain injury, which is more than just a headache.
Teshamae Monteith, M.D., is an associate professor of Clinical Neurology at the University of Miami, Miller School of Medicine.