A Whole-Health Approach to Caring for Veterans with Headache Disorders: A Conversation with Jason Sico

By Freda Kreier | November 21, 2023 | Posted in

“I think the best approach to treating headache disease in veterans is to recognize that it is hugely important to look at the entire individual and not ignore the concurrent medical and mental health comorbidities. Also, it’s really important to craft treatment plans that deeply resonate with someone’s values and preferences, even if that may not be the treatment plan we ourselves would want.”
– Jason Sico

Jason Sico, MD, is an associate professor of neurology and internal medicine at Yale School of Medicine in New Haven, US. Since 2018, he’s also headed the Headache Centers of Excellence program established by the Veterans Health Administration, which aims to bring better quality headache care to veterans around the US.

Sico grew up in a family of veterans, many of whom suffered from neurological conditions, including headache disorders. He recently spoke via Zoom with Freda Kreier, a freelance science journalist, about what drew him to work with veterans and the special considerations needed to treat the approximately two million veterans who have suffered from headache disorders. [Also see previous MSC coverage of Sico’s work here.]

I’d like to go back to the beginning. How did you start to work with veterans?

A lot of my early experiences with healthcare had to do with my grandpa Sico and grandpa Exeter. They were both veterans of the Korean War.

When I was old enough to drive, I would take my grandpa Sico to some of his appointments at our local VA medical center back in Pennsylvania. It was clear that he had headaches and they were really debilitating. We would be in his house, and he would be upstairs lying down, and my dad would say: “Grandpa has a really bad headache, and we just need to be quiet and take care of him.”

This was the middle to late 1990s, and at appointments the doctors would say, “Well, there’s not much we can do for you.” In hindsight, his headaches began after a traumatic brain injury [TBI]. The way he put it was that he was blown off the side of a mountain. He was in a coma for several days and has had headaches ever since. Now, being the seasoned headache neurologist that I am and caring for veterans, it’s clear he had post-traumatic headache from his TBI and also post-traumatic stress disorder [PTSD].

Jason Sico

Jason Sico

What I took away from those early experiences is that there has to be more that we can do for people like my grandpa who served our country. In my mid-20s, I tried to get into the military and found out I had some mild hearing loss in my left ear, so that disqualified me. So I figured being a doctor within the VA is the next best thing.

Now I’m providing direct clinical care for veterans, doing research, and running and expanding the national network of Headache Centers of Excellence intended to improve quality of care for people just like my grandpa.

Veterans have high rates of headache disorders. Is that because of brain injuries like the one your grandfather sustained?

We know that between October 2007 and the end of June 2023, almost two million veterans had gotten care for headache within the Veterans Health Administration. That’s about 16% of veterans. Definitely part of it is from military exposures and specifically TBI.

There’s a specific type of headache called post-traumatic headache that begins with a head injury. The types of head injury that active military personnel sometimes have are different from what we see in the civilian arena of even sports-related concussions. The most common thing I hear is, “I got blown up.” So, they’re in a caravan, they roll over an improvised explosive device, and they feel the blast wave of energy from a bomb rip through their body, and they’re thrown within the Humvee from side to side. Just the amount of energy that goes through their body when they’re in close proximity to a bomb is much more than we see with sports concussions.

Another common story is the stress let-down response. In civilian life, this happens when people are going-going-going through the work week and then their stress hormone levels go down on the weekend, which can lead to a headache. That drop is called a stress let-down response – and I have a hard time coming up with a bigger stress let-down response than being in a war zone and then coming back home.

I think those are both likely associated with higher rates of headache among active military personnel and veterans.

Given these differences, do you treat migraine in veterans using the same approach you use for civilians?

For disclosure, I have not treated people living with headache or migraine disease in the civilian population for about 10 years. But one of the differences I see is that there tends to be a greater degree of comorbidities in the veteran population that could contribute to headache. So, a lot of veterans I see for migraine have PTSD and insomnia. Often that means working with a mental health provider to get their PTSD under better control because without that, the more headache-specific treatments won’t be as effective.

Also, historically, if you look across the military, most veterans are men. So, the percentage of men we see with migraine among veterans is so much more than you would see in any community practice. There are some specific considerations when caring for men with headache disorders. Even the diagnostic criteria for migraine were all developed and assembled largely on a sample made up of women. And sometimes we find that medications seem to work better for women than for men. So that’s one of the realities of treating veterans living with migraine disease.

Speaking of those realities, what are the biggest challenges in treating veterans with migraine?

Two million veterans treated for headache is an impressive number. But it’s an underestimate. There are a lot of veterans living and suffering with migraine and other headache diseases who are not being treated. It’s not uncommon for us to hear that people think, “The headache is all in my head, and I need to suck it up and deal with it.”

Some of that comes from military culture. I’ve treated a number of veterans who tell me that their headache started when they were on active duty, and they purposely did not get treatment because they wanted to be there for their band of brothers and sisters. They knew there was a chance they could be put on medical leave and they might be taken off the front line.

Even my grandpa Sico didn’t want to talk about his headache. I was like, “Grandpa, you have headaches. Let’s see what the doctors can do for you.”

The important message is to know that if you’re a veteran with a headache, you’re not alone. There are treatments, and you don’t have to suffer in silence.

You treat migraine, but you also study it. What does your research focus on?

We use big data to understand care and delivery, and see if there are differences between men and women with headache in terms of medical comorbidities or the healthcare they’re receiving. For example, I could tell you that within the VA, men were much less likely to see a neurologist for their headache.

We’ve also made a map of the US to show where veterans with different types of headache disease are throughout the country, and we have a standing engagement with about 80 veterans to understand some of the experiences they’ve had and how we could do a better job.

What findings from your research have contributed to treating veterans more effectively?

We compared veterans who have had a TBI and developed headache to a similar group without post-traumatic headache. We found there is a much higher rate of suicide-related behavior among those with post-traumatic headache. The post-traumatic group also had higher rates of depression, PTSD, anxiety, and insomnia compared to those who didn’t have post-traumatic headache and don’t have another type of headache.

So, one of the things that we’re doing now is capitalizing on the suicide screening initiative that the VA has had in place for a long time, making sure that veterans get plugged into mental health services if they’re not already.

What is the number one thing you’d like clinicians or researchers to know about treating veterans with headache conditions?

My message for clinicians would be that, yes, there’s a lot that the VA can offer in terms of treatment options. But I think the best approach to treating headache disease in veterans is to recognize that it is hugely important to look at the entire individual and not ignore the concurrent medical and mental health comorbidities. Also, it’s really important to craft treatment plans that deeply resonate with someone’s values and preferences, even if that may not be the treatment plan we ourselves would want.

I have veterans who exclusively use non-pharmacologic treatment options. For clinicians, we’re so used to going for pharmacologic therapies that we could come up with the best treatment plan possible that’s all medication. But if someone just isn’t interested in taking medication, then you know that’s not the treatment plan. As clinicians, we have so many things in our toolbox. We need to be cognizant of the person in front of us in our clinic or at the telehealth meeting in terms of who they are as a person, what their values and preferences are, and come up with a plan that incorporates the whole-health approach.

For researchers, I want them to know that the VA is an exceptionally good place to do research. We’ve built a dataset that has complete capture of every veteran who has been diagnosed with any headache disease since 2008. It’s also an excellent place to do research on men living with migraine and with headache disease, especially since men have been an underrepresented group when it comes to migraine clinical trials as well as migraine research.

Is there anything else you’d like to say?

To serve veterans living with migraine and other headache diseases has been the biggest professional blessing of my life, and the most personally satisfying coming from a family of veterans. The healthcare I deliver and the research that we do – educational initiatives and growing a national program to improve headache care quality and delivery – is sorely needed.

We’ve just scratched the surface in terms of meeting the needs of veterans living with migraine and headache disease. I really appreciate any initiatives to increase awareness of this very important population.

Freda Kreier is a freelance science journalist based out of Washington, DC.

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