Military Post-Traumatic Headache: A Hidden Injury of War
Alan Finkel, MD
Key Points
- Mild Traumatic Brain Injury (TBI) is a very common injury of the Global War on Terrorism
- Because of improvements in protective gear, more soldiers are surviving blasts; they are developing symptoms including headache which are just beginning to be understood. Military agencies are continuing to develop guidelines to try to reduce more injuries.
- Headaches result from concussions to the head from both direct impact and blasts; treating the headaches as if they were primary headaches such as migraine is the current standard of care.
- Post-Traumatic Stress Disorder (PTSD) and mild TBI have many symptoms in common including sleep, mood, cognitive and balance problems.
- The long term goals of all efforts should be to return injured warriors to an active and productive life.
Mild TBI and Post-traumatic Headache: What, where, when, how and why
They were horse soldiers and foot soldiers and soldiers blown up and shot down. They were jumping from planes and breaching buildings. They were driving their cars or fighting in bars. They were men and women in the prime of life.
His first war related injury was in Iraq, February 2007. He was walking outside of his vehicle when a 40 lb land mine exploded. It ripped off his helmet cover, breaking off a piece. He didn’t remember anything after the “flash”. He awoke in the helicopter with dizziness, headache, and gagging. He was hospitalized for 3 days and went back to the fighting 10 days later. For a month he had terrible headaches. In March he sustained 3 injuries in 36 hours. In the first an IED exploded beneath the Humvee he was driving. He lurched forward, smashing his helmeted head on the steering wheel. During the blast he first experienced a “vacuum” feeling and then a “crisp smack” in the face, chest and stomach followed by “energy passing through” like a “ghost inside”. Some others were mortally wounded. One hour later his vehicle was hit with mortar and his headache and left ear ringing worsened. The following day an antitank mine went off below his Humvee which was thrown and rolled. He immediately had sharp, shooting neck pain, dizziness, vomiting and dramatic worsening of the headache from the day before. May 2007 another Humvee and another IED flipped the truck on its side. June and July brought 2 more blasts and with the last he was medically evacuated to his American base. His headaches, initially extreme and continuous, eventually became exactly like a left sided cluster headache. He took Topamax and triptans and improved, and eventually was medically discharged.
Traumatic brain injury (TBI) in civilians accounts for over 1.3 million emergency room visits, 275,000 hospitalizations and 52,000 deaths per year. Most of these are car wrecks or falls and accidents. Post-traumatic Stress Disorder (PTSD) in civilians is most often after assault, rape or accident.
In the military at war, other things happen. Bullets happen. Massive explosions sending people, and shrapnel and multi-ton vehicles flying into the air happen. These were the daily norms in the early to middle days of the Global Wars on Terrorism in Iraq and Afghanistan. Advances in armor helped to deflect blasts away from vehicles; scientifically designed helmets absorbed more and more of the forces that otherwise would have killed. Concussions without something hard smacking the head became another daily norm. And still our soldiers survived. They returned with invisible injuries. They were not understood by their pals or their families. And their doctors and other medical personnel often didn’t know what was wrong or how to fix it.
The Defense and Veterans Brain Injury Centers (DVBIC) estimates that in the wars of the last 10 years, there have been more than 178 thousand mild traumatic brain injuries. To date, the Veteran’s Administration has screened over 426,000 soldiers where one in five claim some concussion and 7.5% had confirmed TBI. According to Defense data, in 2009 there were 22,684 active duty soldiers with mild TBI. Compared to the 3,690 moderate to severe injuries, soldiers with invisible injuries made up 75-80% of all TBI. In response to these statistics, agencies inside the military have been increasingly aggressive to make sure that command decisions do not put soldiers at greater risk. The most recent guideline for concussion forces the soldier to rest for 24 hours after first concussion. A second concussion in the next 12 months results in limited duty. This includes the avoidance of contact sports until one week after symptom resolution and medical clearance. A third concussion will mandate a comprehensive evaluation and clearance by a neurologist or certified practitioner prior to return to full duty or contact sports. Sadly, the guidelines for how headache is assessed are vague; DVBIC and DOD require evidence, and for headache that evidence is just becoming available.
We don’t know exactly what happens to the brain when blows to the head occur. More mysterious is the impact that being blasted by explosives has upon the brain, nerves, skin, muscles, and bones of the head. Whereas most think of concussion as the head hitting something or vice versa, blasts add new complications. The wave, called an overpressure, coming off some bombs is travelling at twice the speed of sound, smashing or compressing everything in its wake. Most of the injuries these cause are called mild because no bones are breached or tissue scraped or bloodied.
All the studies of returning soldiers detail how common headache really is. About a third of soldiers returning say they have migraine type pain in the first months after being home. Most of those get better. But, amongst those with significant injuries headaches abound. About 90% of those who were blasted by explosives have headaches lasting more than 3 months after injury. Those who have many injuries are more likely to have more headaches. On the ground they say the headaches are constant and they may rage severe. They may be like migraine with vomiting, or like cluster with unbearable pain. They may want to disappear when the headaches are so severe; they say they want to beat their heads; they fear the pain and how it makes them feel. They say they are always there, or come at times like exercise or making love. They make their lives an unpredictable misery or a constant struggle to feel normal. Combining this with the other symptoms after concussion such as balance and hearing problems it becomes hard to think straight or feel safe and calm. Yet even with that, many choose to go back to duty and keep their families and love their service to country. Then some are not so lucky or able to dedicate themselves, remaining in wounded warrior battalions.
Why do they get headaches? The simple answer is that we don’t exactly know, but there may be subtle brain damage after having your bell rung and head rocked. Damage to the parts of nerves called axons occurs because of twisting and shearing. This is not routinely seen on brain scans. Like a wire stripped of insulation, sparks may fly and “brown outs” of the brain are experienced as problems of memory or pain. Getting annoyed or even violent over usual stress can come from this “just missing”. Headaches may come from waves of “wrong messages” as the brain struggles to get the point of what is going on in life.
In order to understand particular headaches and their treatment, specialists will classify them with such names as migraine, or tension type or cluster. Treatments are made to match this diagnosis or primary headache. This is now most evident in the established fact that triptans are effective in migraine but not necessarily in tension headache. Post-traumatic headaches may “act like” these so called primary headaches, even if the causes may be different. Does this mean that TBI creates migraine or tension or cluster headache? Or are they are a completely new and different type of headache? What is happening to our warriors who have bad parachute landings, or who fall from high places, or who fly inside or outside the MRAP as an IED batters the armor and the persons it was created to protect? What of the death and destruction? Shouldn’t effective drugs or techniques that work for migraine work in headaches that are “migraine-like” even if they occur after being blasted? Sometimes they do. Many times they don’t.
The biggest controversy in the military literature right now is, simply stated, the difference between the emotional versus the physical damage to the brain, alternately called PTSD and TBI. The most prominent author on the subject, Charles Hoge, has published several reports which show that much of what the soldier’s suffer can be ascribed to the events that leave traces of impossible memories and psychological states which are experienced as physical symptoms such as dizziness, balance and sleep problems. These are also the well known symptoms that can follow concussion. Although these studies are not universally accepted, other studies opposing them are few. And, amazingly, for all the work so far, headache has remained the singular symptom which has no adequate explanation, except for concussion and/or TBI.
There is a growing awareness that injured soldiers should be helped to return to service, or to the often chaotic life beyond deployment or discharge. Both of these paths demand all the efforts that one can muster. Government, industry, foundations and individuals are examining everything from armor to personal protection. For those who suffer and for those who live with or care for the injured, the headaches are more than just a pain of the head. They make life hard. They make the promise of duty to comrades more difficult to keep. They add to the struggle to find a place to rest or work or love.
Our hope is that through better understanding, the headaches after war will be knowable and treatable. For now the challenges are great. The American Headache Society and its partners are dedicated to this challenge and we offer this special edition of the NEWSLETTER in hopes that the information and links will help all those involved.
Alan Finkel, MD Carolina Headache Institute, Chapel Hill, NC, TBI Center of Womack Army Medical Center, Fort Bragg, NC and Chair of the Post-Traumatic Headache Section of the American Headache Society
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense.
Brain Injury Information and Deployment Health Links:
Service Branch Programs:
Veteran Services Information:
Vocational and Reemployment Service Information:
Assistive Technology and Accommodations Information: