Headache Disorders in Veterans: A Big Problem

Two recent studies highlight the impact of headache and migraine in US veterans, with a focus on gender differences and other factors.

The Veterans Health Administration (VHA) is the largest healthcare system in the United States, providing services for roughly nine million veterans per year. Headache disorders are particularly problematic for veterans, considering the injuries and trauma many of them sustain in combat. This highlights the need to advance understanding of headache epidemiology as well as demographic and other important features of this population. Two new companion studies now do exactly that.

First, Jason Sico, VA Connecticut Healthcare System, West Haven, US, and Yale School of Medicine, New Haven, US, and colleagues describe the characteristics of headache in more than 1.5 million veterans who used VHA services over more than a decade, with a particular focus on gender differences. The researchers identified many such differences, including in sociodemographic characteristics, headache diagnoses, and healthcare utilization.

In the second paper, Elizabeth Seng, also from the VA Connecticut Healthcare System as well as Yeshiva University and Albert Einstein College of Medicine, New York City, US, and colleagues devote attention specifically to migraine, in a cohort of more than 550,000 veterans diagnosed with the condition. They found that it was common for veterans to be treated for migraine and to have many comorbid conditions associated with it, including non-headache pain disorders, mental health disorders, and sleep disorders, among other findings.

“The current studies … by providing baseline and dynamic statistics, will help to guide our clinical evaluations and will provide a background upon which best care and science can be delivered for this most deserving group of patients,” wrote Alan Finkel, University of North Carolina, Chapel Hill, US, in an editorial on the companion papers.

Both papers, along with the accompanying editorial, appeared in the November 1, 2022 issue of Neurology.

A long-standing interest in the health of veterans
Sico told Migraine Science Collaborative that he has a strong family connection to the military, with both of his grandfathers having served in the Korean War. He first became familiar with the VHA while in medical school, after one of his grandfathers suffered a stroke. Seeing the high level of care provided by the VHA left a lasting impression on him.

Now, as the National Lead of the Headache Centers of Excellence Research and Evaluation Center within the VHA, Sico is embracing its tripartite mission of improving clinical care, quality, and delivery; implementing educational initiatives; and conducting research.

“The VA and I are big proponents of a learning healthcare system, where we could leverage the information, the data, and the electronic health record systems in the clinics to understand the quality of care being delivered, with an eye towards the disparities: What are the gaps in care? How can we do a better job for individual veterans?” Sico said.

“All of these 1.5 million veterans living with headache are grandpas and aunts and uncles who share their story about how headache is impacting their life, the ability to spend time with their loved ones,” Sico continued. “One of the most fulfilling parts of my day is knowing that I care for those who have served our way of life and our country.”

Like Sico, Seng was also affected by what she saw in the veteran population during her training. A clinical psychologist and researcher, Seng saw the impact of migraine and felt compelled to do something about it.

“When I was in my training at West Haven, very few people were interested in headaches. People were interested in chronic musculoskeletal pain more broadly, as chronic pain is such a significant burden. But I met a lot of veterans with headache and saw that it, too, had a substantial burden, especially cluster headache and migraine. It made me realize how big of a problem it is in our veteran population and how much work still needed to be done,” Seng said.

“So I went to Yeshiva University and the Montefiore Headache Center, where I honed my skills and got to work with some amazing headache mentors. Then, a decade later, when Congress funded the Headache Centers of Excellence, I was ready to come back and spend a portion of my time dedicated to the veteran community I fell in love with while I was training.”

Lots of headache, lots of migraine, lots of gender differences
Both studies used data from the VHA Headache Centers of Excellence Administrative Data Cohort, created from the electronic health record used by more than 1,000 VHA healthcare facilities. The study included any veteran with at least one inpatient or outpatient visit for a headache – migraine, tension-type headache, post-whiplash headache, and others forms – between the fiscal years of 2008 and 2019.

There were 1,524,960 veterans with a headache diagnosis included in the general headache paper, with a subset of 567,121 veterans with migraine included in the migraine-specific paper. Both cohorts were predominantly male (roughly 83% in the general headache paper, 72% in the migraine-specific paper) and white. Men were older than women at the time of first diagnosis in both the general headache cohort (a mean of 52 years vs. 42 years, respectively) and the migraine-specific cohort (46 years vs. 40 years, respectively).

In the general headache study, the incidence rate of any type of headache was higher in women than men, ranging from 4,283 to 7,155 headache disorders per 100,000 veterans for women (adjusted for age), compared to a range of 2,897 to 4,386 per 100,000 for men. Further, 77% of men had a diagnosis of headache not otherwise specified, meaning they did not receive a diagnosis of a specific type of headache, compared to 68% of women. In addition, men had higher rates of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Alarmingly, one-third of women reported military sexual trauma. And, while men showed lower rates of military sexual trauma, 3.2% still reported it, showing that this is an important factor for healthcare providers to consider in their veteran patients who are men.

The findings specifically with regard to migraine were similar to those for headache in general. For instance, migraine was more common in women, with 60% of women receiving a migraine diagnosis at some point during the 12-year study period, compared to 32% of men. And, once again, a higher proportion of men had TBI, and a higher proportion of women reported military sexual trauma, in the migraine study.

With regard to healthcare utilization, men had fewer encounters with healthcare professionals per fiscal year compared to women, for both headache in general (an average of 0.8 visits for men compared to 1.2 visits for women) and for the migraine cohort (1.37 visits for men vs. 1.62 visits for women). Furthermore, compared to women, a smaller proportion of men visited a neurologist for their headache (21% vs. 27% for women) or for migraine (37% vs. 38% for women). In contrast, emergency department utilization was higher for women in both the headache (23% vs. 20% for men) and migraine (23% vs. 17% for men) cohorts. For both studies, primary care was the most common setting for headache care.

Finally, the migraine study also reported that some comorbidities were common, especially overweight/obesity (80% of the entire study cohort), non-headache pain disorders (62%), and mental health disorders (49%).

Important challenges ahead
For Seng, one challenge the results highlight is to better identify people who have migraine, particularly early on, and particularly men, considering they were less likely to utilize the healthcare system.

“We’re hoping to really help men identify and present their symptoms more clearly. We need to let men know these symptoms they’re experiencing are migraine, and that you should talk to your doctor,” she said.

“Sometimes it’s more difficult to believe a man has a migraine because it’s traditionally thought of as a ‘woman’s disease,’ but 6% of the whole US [general] population are men with migraine. That’s pretty notable,” Sico said.

“I think men are less in tune with how to articulate different aspects of their headache. If I’m observing an exam to help improve patient and provider communication, unless you specifically ask about how bright lights or loud sounds affect your headache, they may not bring it up,” Sico said.

In many cases, a little communication can go a long way.

“You don’t need to know what type of headache you have. Talking with someone who could help make that diagnosis, sharing with them how the headache makes you feel, where it is in the head – this helps you figure out what type of headache or headaches someone may have. From there, you can come up with the best diagnosis, then craft a treatment plan that is evidence based, but that also resonates with the veteran’s values and preferences,” Sico explained.

Seng was surprised by the rates of emergency department utilization, which were higher than expected.

“We’re looking forward to trying to figure out how we can help people who present to the emergency department get into ambulatory care, so that we can help them manage their migraines, meaning they don’t get to the point where they re-present to the emergency department. It’s not the ideal place for care,” Seng said.

Finally, the results have relevance to all neurologists who take care of patients with headaches and concussion after civilian injuries.

“Although civilian neurologists may not see the higher rates of PTSD, chronic daily headache, and very frequent severe headaches, especially in men, seen in active-duty service members and veterans, it is important for all neurologists to be aware of these issues. There are similarities in headache phenomenology and presentation,” Finkel noted in his editorial.

Lincoln Tracy is a researcher and freelance writer from Melbourne, Australia. You can follow him on Twitter @lincolntracy.

References

Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008–2019.
Sico et al.
Neurology. 2022 Nov 1; 99(18): e1993-e2005.

Frequency, Demographics, Comorbidities, and Health Care Utilization by Veterans With Migraine: A VA Nationwide Cohort Study.
Seng et al.
Neurology. 2022 Nov 1; 99(18): e1979-e1992.

Headaches in Veterans: Different or the Same?
Finkel AG.
Neurology. 2022 Nov 1; 99(18): 779-780.