Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study

Abstract

Background Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion. Method A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury. Result 127 participants (66%; 95% CI: 59–72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; p ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt; p = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for DSM-5 = 1.3, 95% CI = −27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = −6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = −2.7, 15.6). Conclusions Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months. ClinicalTrials.gov Identifier NCT02419131

Post-traumatic headache due to mild traumatic brain injury: Current knowledge and future directions

“…In the ICHD-3 criteria, the only evidence for causality between the underlying injury and PTH is the time interval between the injury and headache onset. The ICHD-3 classification committee chose to keep this interval relatively short, to maximize the specificity of the criteria and since data suggest that the majority of PTH does indeed begin within 7 days of injury (5)(6)(7). However, it is recognized that some PTH might begin after the first 7 days (6,8,9).…”

“…The ICHD-3 classification committee chose to keep this interval relatively short, to maximize the specificity of the criteria and since data suggest that the majority of PTH does indeed begin within 7 days of injury (5)(6)(7). However, it is recognized that some PTH might begin after the first 7 days (6,8,9). Thus, the ICHD-3 Appendix includes diagnostic criteria for "delayed onset" PTH, which allow for the headache to begin up to 3 months following the inciting injury.…”

PTSD symptoms and tinnitus severity: An analysis of veterans with posttraumatic headaches.

“…Participants ( N = 112) were a subsample of veterans with reported tinnitus enrolled in a larger randomized controlled trial (McGeary et al, 2021) comparing cognitive-behavioral therapy (CBT) for headache, individual cognitive processing therapy (CPT; Resick et al, 2017) for PTSD, and treatment as usual (TAU). As seen in Table 1, participants were predominantly White (64.5%) men (87.3%) who served in the U.S. Army (78.4%) in support of Operations Enduring Freedom, Iraqi Freedom, or New Dawn and were confirmed to have a diagnosis of PTH through a consensus process (McGeary et al, 2020). PTH is defined as chronic headaches for more than 3 months for individuals who sustained a TBI and reported (a) onset of headaches posttraumatic brain injury (TBI) or (b) exacerbation of intensity, frequency, or duration of headaches, within 3 months post-TBI (International Headache Society, Headache Classification Committee, 2018).…”

“…PTH is defined by the International Classification of Headache Disorders [ICHD-3, (IHS, 2018)] as the development or worsening of headache within 7 days of head injury or recovery from loss of consciousness. However, McGeary et al (2020) established that PTH onset of 7 days after head injury is not significantly different than onset of PTH of up to 3 months in terms of headache severity and comorbidity. Additionally, onset latency did not differ between the two groups based on sex, headache phenotype, and mechanism of head injury.…”

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter

“…Persistent headaches are headaches that have not resolved within 3 months. According to the ICHD‐3β 5.2.2, PTH onset must be within 7 days, but this criterion was deemed as too exclusive, and our research group previously published a manuscript showing no phenotypic difference between persistent PTH meeting ICHD‐3 5.2.2 and A5.2.2.1 29 . Therefore, we included participants with headache onset up to 3 months after the head injury.…”