Military Post-Traumatic Headache: What are we doing about it: Government?
Teshamae Monteith, MD
Key Points
- Congressionally Directed Medical Research Programs FY2010 exist for chronic migraine and posttraumatic headache, but still require funding.
- National Defense Authorization Act for 2010 to develop and implement a comprehensive policy on pain management by the Army Pain Management Task Force
- Key components of the National Pain Care Policy Act included in the Patient Protection and Affordable Care Act.
Background
I met a young veteran not too long ago, whose personal stories remains vivid in my mind. He was exposed to an improvised explosive device that resulted in a traumatic blast injury and an early discharge. Now back at home, he is currently taking biology classes to become an army physician and help soldiers with TBI. Unfortunately, he has intrusive flashbacks, cognitive impairments and daily headaches that interfere with his performance. He now takes daily Vicodin, but this only dulls the pain.
Traumatic Brain Injury (TBI) is a serious public health concern afflicting our active duty soldiers and veterans alike. In fact, an estimated 15-20% of soldiers have sustained TBIs in Iraq and Afghanistan, making it the signature injury of our current conflicts. While TBI is the signature wound, headache has become the signature symptom. Posttraumatic headache is a serious problem, especially in military populations, as cultural barriers exist in pain reporting. Inadequately treated pain may cause mental anguish, exacerbate psychological or psychiatric disorders and may contribute to rising rates of suicide. Furthermore, acute pain may progress to chronic headache, medication overuse, and dependency on controlled prescriptions. All these elements may confound the disability associated with TBI and affect the quality of life and functional capacity of afflicted service-members. So we asked what is the government doing about it?
Congressionally Directed Medical Research Programs FY2010
In response to this growing public health problems associated with TBI, the fiscal year 2007 marked a dramatic increase in psychological health and traumatic brain injury research when the Congressionally Directed Medical Research Programs (CDMRP) was allocated an unprecedented $301million(M) to advance the military’s understanding of these disorders. $151M is for research on Posttraumatic Stress Disorder and $150M for research on TBI. Despite the large burden in headache prevalence of those afflicted with TBI, headache disorders have been under-investigated and there are large gaps in our knowledge base of service-connected migraine and posttraumatic headache.
Neurologists, headache specialists, patients, and veteran advocacy groups including members of the Alliance for Headache Disorders Advocacy contacted Congress in concern for returning troops suffering from posttraumatic headache. In response to advocacy initiatives for the health care needs of the Armed Forces, Congress fortunately added chronic migraine and posttraumatic headache to the list of topic areas for the Peer Reviewed Medical Research Programs (PRMRP) for the fiscal year 2010. The programs seek a wide spectrum of disciplines with the vision to identify and fund the best medical research to protect and support our servicemen. These programs currently remain unfunded, but the Office of the CDMRP expects to allot approximately $6.6M of the $50M FY10 PRMRP appropriation to fund approximately 2 clinical trial applications including headache.
Congressional Brain Injury Task Force
The Congressional Brain Injury Task Force or TBI Caucus held a congressional briefing in February 2010 with the American Academy of Neurology Palatucci Advocacy Leadership Forum and representatives from the American Headache Society (AHS), including Past President Fred Sheftell, MD, immediate past co-chair of the AHS Posttraumatic Headache Section Ann Scher, Ph.D, National Director of the Neurology for the Veteran Affairs Health System (VHA), and Peter J. Goadsby, MD, PhD. As a result, the TBI caucus sent out a Dear Colleague Letter in support of the Department of Defense (DoD) appropriations of $10M for migraine and posttraumatic headache research for FY2011. While, the Department of Defense did not support the exact recommendations of the caucus, a greater awareness for the impact of posttraumatic headache in the military population arouse.
National Defense Authorization Act FY2010
Section 711 of the National Defense Authorization Act (NDAA) for fiscal year 2010 tasked the Secretary of Defense to develop and implement a comprehensive policy on pain management by the military health care system, no later than March 31, 2011. Hopefully, the military headache will be addressed along with other pain conditions, as a part of this comprehensive and interdisciplinary pain management approach in compliance with Section 711 of the NDAA.
Army Pain Management Task Force
The Army Surgeon General LTG Eric B. Schoomaker chartered the Army Pain Management Task Force in August 2009 to provide a standardized DoD and VHA vision and approach to pain management to optimize the care for Warriors and their families. The Task Force members included a variety of medical specialist disciplines from the Army, and representatives from Navy, Air Force, TRICARE Management Activity and Veterans Health Administration (VHA). In the May 2010 final report, 109 recommendations emphasized a holistic, multidisciplinary and multimodal approach. The recommendations depend on an education and communication plan that crosses DoD and VHA medical staff. The recommendations may be divided into four areas: to provide tools and infrastructure that support and encourage practice and research advancements, build a set of best practices, focus on the warrior and family, and to promote pain awareness, education, and proactive intervention. The task force emphasizes the need for prevention, prompt and appropriate treatment that relieves acute pain and eliminates progression. Over time, we look forward to see how these initiatives provide the groundwork necessary to reduce the pain and suffering associated with posttraumatic headache.
National Pain Care Policy Act into Law
The National Pain Care Policy Act (NPCPA) resulted from the diligent work of several advocacy groups including the Pain Care Coalition (PCC), the American Pain Foundation and others. The PCC was organized in 1989 by the American Pain Society, American Association of Pain Medicine, and the AHS. These advocacy groups contributed to the inclusion of key components from the 2009 NPCPA into the Patient Protection and Affordable Care Act, the landmark healthcare reform bill. The National Pain Care Policy Act of 2009 requires the Secretary of Health and Human Services seek to enter into an agreement with the Institute of Medicine to convene a Conference on pain, which may be major way forward in the road to providing better care for serviceman with posttraumatic headache. The purpose of the conference is to address key medical and policy issues of pain care. Secondly, training programs will be necessary to improve health care skills of assessing and treating pain. Lastly, Sections in the NPCPA also requires that the Director of the National Institutes of Health (NIH) continue to expand research through the NIH Pain Consortium. The Consortium is lead by directors of the NIH Centers for Complementary and Alternative Medicine, and Institutes of Nursing Research, Neurological Disorders and Stroke, Dental and Craniofacial Research and Drug Abuse. Through collaboration the NIH Pain Consortium could help us understand more about both the basic mechanisms and clinical challenges of posttraumatic headache. The Consortium is responsible for submitting recommendations to the Director of NIH with the goals of expanding the pain research agenda.
Summary:
TBI and the sequelae of posttraumatic headache can be a disabling condition that interferes with assimilation and adjustment of our military servicemen back into society. In order to best manage posttraumatic headache, research efforts in the basic, translational and clinical sciences is greatly necessary to both fill gaps in knowledge and provide the best medicines. Thanks to our government, pain management efforts across the DoD and VHA are underway to address these issues. In order to adequately address headache and prevent widespread disability, more work needs to be done in the interest of military headache sufferers. As secretary of the Posttraumatic Section of the American Headache Society, rest assured that we are committed to improving the quality of lives of our servicemen. You may then ask how can I help? Patient advocacy is a powerful way to move the government and ensure the best is being done for our brave soldier and veterans. You may help by writing to your representatives and ask them to support increased NIH funding for headache and pain research.
For more reading and ways to support:
Defense and Veterans Brain Injury Center
Alliance for Headache Disorders Advocacy
American Migraine Foundation
Teshamae Monteith, MD, Headache Group, Department of Neurology, University of California, San Francisco, San Francisco, CA