Psychiatric and cognitive comorbidities of persistent post- traumatic headache attributed to mild traumatic brain injury

DOI: https://doi.org/10.1186/s10194- 021- 01287- 7

Abstract-Summary A total of 100 patients with persistent PTH attributed to mild TBI and 100 age- and gender-matched healthy controls free of mild TBI were enrolled between July 2018 and June 2019.

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In 100 patients with persistent PTH, 85% reported poor quality sleep, compared

with 42% of healthy controls (P < 0.01).

The relative frequency of probable to high risk of anxiety was 52% in the persis- tent PTH group vs. 8% in healthy controls (P < 0.01), while the relative frequency of probable to high risk of depression was 42% in the persistent PTH group vs. 2% in healthy controls (P < 0.01).

Twenty-seven percent of the patients with persistent PTH had mild cognitive

impairment while 10% had probable PTSD.

Poor quality of sleep as well as symptoms suggestive of anxiety and depression

were more common in patients with persistent PTH than healthy controls.

Extended: In 100 patients with persistent PTH, 85% had poor quality of sleep, 52% had at least probable risk of anxiety, 42% had at least probable risk of depres- sion, 27% had mild cognitive impairment, and 10% had probable PTSD.

Poor quality of sleep is defined as global scores of 5 or higher.

Introduction Few efforts have been made to assess the broader clinical picture of post-traumatic headache (PTH) [37, 162–167].

The diagnosis of PTH is based on clinical criteria provided by the International Classification of Headache Disorders, 3rd edition (ICHD-3), and termed headache attributed to traumatic injury to the head [76].

A key observation from clinic-based studies is that persistent PTH most often resembles a migraine-like headache phenotype, although some patients may report a ‘pure’ tension-type-like headache (TTH-like) phenotype [37, 162, 164].

In this cross-sectional study, we assessed quality of sleep, anxiety, depression,

cognitive impairment, and PTSD as comorbidities of persistent PTH.

We hypothesized that symptoms suggestive of these comorbidities would be

more frequent in patients with persistent PTH, compared with healthy controls.

Methods The diagnosis of persistent PTH attributed to mild TBI was established by a trained locum doctor (AI) using a semi-structured interview and made in accordance with the ICHD-3 criteria for persistent headache attributed to mild traumatic injury to the head [76].

Other inclusion criteria for individuals with persistent PTH were: (1) mild TBI to have occurred at least 12 months prior to study participation and (2) age between 18 and 65 years.

Inclusion criteria for healthy controls were (1) age between 18 and 65 years, (2) no history of known head trauma or whiplash injury, (3) no history of primary head- ache disorder (except infrequent episodic TTH), (4) no first-degree relatives with primary headache disorder, (5) no daily intake of medicine other than oral contra- ceptives, (6) no history of neurological or psychological disorders, (7) no history of structural heart disease.

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As study inclusion was based on a diagnosis of persistent PTH attributed mild TBI, we used terms such as migraine-like and TTH-like to describe assigned head- ache phenotypes.

Results In 100 patients with persistent PTH, 85% had poor quality of sleep, 52% had at least probable risk of anxiety, 42% had at least probable risk of depression, 27% had mild cognitive impairment, and 10% had probable PTSD.

Compared with healthy controls, patients with persistent PTH had a higher rela- tive frequency of poor quality of sleep (85% vs. 42%, P < 0.01), anxiety (52% vs. 8%, P < 0.01), and depression (42% vs. 2%, P < 0.01).

Another observation was that 28% of patients with persistent PTH had poor

quality of sleep, as well as at least probable risk of both anxiety and depression.

HADS anxiety scores correlated with HADS depression scores (r  =  0.56; P  <  0.01), whilst no relationship was observed with monthly headache days (r = −0.02; P = 0.86), monthly migraine days (r = 0.02; P = 0.83), or months with headache attributed to mild TBI (r = −0.13; P = 0.19). Discussion This study presents data on comorbidities in 100 patients with persistent PTH and 100 age- and gender-matched healthy controls.

A meta-analysis has estimated that sleep disturbances are experienced by about 50% of individuals who sustain a TBI [165], Taken together, it is evident that poor quality of sleep is prevalent in patients with persistent PTH attributed to mild TBI.

Besides poor quality of sleep, we found that anxiety and depression are more

frequent in patients with persistent PTH, compared with healthy controls.

A prospective cohort study found that the relative frequency of anxiety and depression was higher in patients with persistent PTH, compared with those who had sustained a mild TBI but did not report headache [166].

An interesting finding from our study is that mild cognitive impairment was

experienced by 27% of patients with persistent PTH.

Conclusions Poor quality of sleep, anxiety, and depression are more common in patients with persistent PTH, compared with healthy controls.

Some patients with persistent PTH have symptoms suggestive of mild cognitive

impairment and PTSD.

Effective management of comorbidities might be useful in improving treatment

outcomes for persistent PTH.

Acknowledgement A machine generated summary based on the work of Ashina, Håkan; Al-Khazali, Haidar Muhsen; Iljazi, Afrim; Ashina, Sait; Amin, Faisal Mohammad; Lipton, Richard B.; Schytz, Henrik Winther 2021 in The Journal of Headache and Pain.

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Interrelations between migraine-like headache and persistent post-traumatic headache attributed to mild traumatic brain injury: a prospective diary study