Professor Don McGeary, PhD, associate professor in the Department of Psychiatry and Behavioral Sciences and associate professor and vice chair of the Department of Rehabilitation Medicine at the University of Texas Health San Antonio, talks about treating traumatic brain injuries, or TBIs, in Veterans.
Interview conducted by Ivanhoe Broadcast News in July 2022.
What’s the study called?
MCGEARY: The title of the study is a randomized controlled trial of a cognitive behavioral therapy for post-traumatic headache.
What direction did you guys decide to go, regarding the study?
MCGEARY: The initial direction we decided to go was to do something very complicated. The reason why we were considering complication is because we were dealing with a complicated syndrome. Post-traumatic headache in this case, which is a headache that develops after an injury to the head or neck, always appears, at least among Veterans, in the context of other problems, the most common of which is post-traumatic stress disorder. When you have multiple problems, the way people have tried to solve that so far is by cramming multiple treatments together into one comprehensive treatment. But there are several different difficulties and downsides to approaching treatment that way. What we decided to do was to try one straightforward, simple treatment. So, it was an eight session non-pharmacological intervention, so there was no medication involved. It was just a system of self-management. So, that comes in three or four different components. So, one is to teach patients to identify their headache, to know more about it, understand it a little bit better, teach them how to prevent anything that would trigger the headache. Teach them how to manage stress, because stress management in general is important to headache management and then, finally teach them how to engage in activity and just to be more active in their lives.
How did this very basic idea start?
MCGEARY: We started with a framework that was developed by one of our collaborators, Don Penzien, who is at Wake Forest University now. He developed a manual for non-pharmacological management of migraine headache that he had tested a little bit. We looked through the manual, and the way it came about was, as we were looking through the manual, we kept thinking of components that we needed to add, but we could never come up with a good rationale for stacking more stuff on top of what was already there. So, I took some time and sat down with a couple of colleagues. We trimmed it out, we added a couple of novel components to the manual and just set it loose. The combination of all that is a behavioral manual that takes about two hours to train. Just for a little bit of context, for some of the more complicated, PTSD-focused, manualized interventions, it takes two weeks to a couple of months to get someone trained to a certain level of competency. For our manual, it was simple enough. We showed them a one-hour PowerPoint presentation, did one hour of didactic training, and then set them loose.
How was this implemented, how was the training utilized? And what were some of the great reactions that you got from the patients?
MCGEARY: Once we got the study up and running, the way we designed the study was we wanted to, one, make sure that what we were doing is better than what the VA is already doing. So, here, in San Antonio and now this is proliferated across the country, we have polytrauma system of care and here we have a polytrauma rehabilitation center. The purpose of these centers is to do exactly what I described earlier, which is to address polytrauma. It is exactly as the name suggests, individuals who show up with trauma related symptoms or trauma related problems, multiple poly problems. So, they have multiple problems. We wanted to compare against usual care. That was one thing we did in this study. We just looked at individuals as they were making their way through the V.A. system. When we characterized our usual care, we realized that folks were getting medications, they were getting injections, they were getting complementary and integrative health treatments, acupuncture, massage, those kinds of things. Some of them were getting psychotherapy already, and we compared that to our treatment. But then we also wanted to compare against a standard gold, standard PTSD treatment.
Which is?
MCGEARY: A cognitive processing therapy. One of our collaborators was Dr. Patricia Resick is at Duke University. She was one of the individuals who developed cognitive processing therapy, and she collaborated with us.
What was this study like?
MCGEARY: With this one, we were comparing our behavioral intervention to usual care in the VA and to cognitive processing therapy, which is a gold standard treatment for post-traumatic stress disorder. And the reason why we did that, adding cognitive processing therapy is because for these headaches, there was a theory abounding that PTSD was really driving these headaches. And that’s an important consideration because we, as I mentioned when we started these kinds of headaches in these kinds of pain, trauma conditions show up often in the context of PTSD. So, it makes a lot of sense that PTSD could not only be driving the pain and how pain is experienced, but also probably driving the poor response to treatment that we were seeing in these patients. So, we wanted to test a formal PTSD intervention as part of this. So, we compared all three arms to one another. And I’ll give you the general findings first and then talk a little bit about some patient experiences. So, we found a few things that were surprising. First, we found that this simple, easy to implement, easy to train headache intervention worked well. It worked better honestly than I thought it would because of the low dose. I wasn’t sure that it would have that big of an impact with these behavioral interventions, they’re very dose dependent. So often, the more you do, the better off the patients are.
The larger dose and the dose dependent and dose in this case, is not…
MCGEARY: Is the amount of time you spend involved in the treatment. Having more sessions, longer sessions can usually lead to better results. In this case, they were all very brief. I was a little bit concerned about the brevity of the treatment. It was about four 30-to-45-minute sessions. So, you’re talking about a dose of about four to six hours of behavioral treatment, whereas for standard PTSD interventions, you’re really looking at between 12 to 18 hours. So, this was noticeably shorter than what we’re used to in trauma populations.
What were you guys doing?
MCGEARY: What we were doing was teaching people to cope with their headaches better and ultimately teach people that they do have some control over the headaches that they’re experiencing. I think that’s the real mechanism that drove the change. So, not only did we see better headache outcomes from this headache treatment, which was sort of expected, we showed PTSD improvements that were comparable to a gold standard PTSD treatment, and that was very unexpected. I never in a million years thought that the PTSD would improve to the same extent it did for cognitive processing therapy, which is gold standard and disseminated throughout the VA. I think that there are a couple of reasons why that could have happened. One, it could be that the headache and the PTSD do truly move together. So, if the headache got better, the PTSD got better or vice versa, except in the cognitive processing therapy arm, the PTSD treatment arm, PTSD improved, but the headache didn’t. And that’s very interesting. So, it could be that. It could also be that there are groups of veterans who just need to learn how to cope better, and this treatment helped them do that. I think one other thing this treatment did is we had a much better contact rate, lower dropout in the headache treatment that we had in cognitive processing therapy. PTSD treatments can be tough. If you’ve ever seen it, ever done it, it can be a very hard thing to do now. It’s very valuable. It’s very effective. But it can be hard for folks to stick with, especially our veterans, because of the traumas they have to recall and deal with.
Let’s pretend I’m a veteran and I’m going in for treatment. and I’m in there for half an hour, 45 minutes. What precisely are you doing with me?
MCGEARY: We would spend a little bit of time learning what triggers your headaches. We find out what your triggers are and see what we can do to work around those triggers. We’ll teach you how to relax, because we know that just calming down the central nervous system will make your headaches easier to manage. So, we’ll do that, too. But we’ll spend a little bit of time planning for activity. We want you to be active. We don’t want you when you have a headache to curl up in your closet and avoid people. We want you to be actively engaged in life because most of our veterans want to do that, so we spend time planning around that. But more than anything else, we would spend time cheerleading our patients. That’s important because we want them to recognize their successes. We want them to know that this chronic problem that has been disabling them and for traumatic brain injury, one of the most, if not the most disabling component of traumatic brain injury, is headache. So, when they have been dealing with this disabling problem for years, we want them to recognize when they are able to overcome it and get something done. I think that helps them take ownership of their headache. That’s what I believe really drive their improvement.
Are you eliminating, for the time being, the pharmacological aspect of it?
MCGEARY: Right. I would say the most notable example of an outcome for something like this, I was sitting in a collaborator’s office at the Poly Trauma Center in the VA, Dr. Carlos Jaramillo, who is a collaborator, co-investigator on the study. Carlos and I were sitting and talking, and a patient came into the office and had a bag of meds and he just said, “Hey, doc, I just want to drop these off.” Carlos’ response was, “Well, what are you doing? Why?” The veteran’s response was, “I just finished doing, like, this weird headache study room. I just sat down, met with someone, talked about my headaches. I don’t think I need my meds anymore.” We just thought, “Oh, that’s fantastic.” I mean, that’s what you go for with these kinds of things. Of course, that’s one example. We’ve had other examples of veterans telling us that they’ve been able to spend more time with their families and that’s very important. When you look at suicide risk in the veteran population, that’s something we’re very attentive to right now in the military as well. One of the driving factors for suicide risk is a perception of oneself as a burden to others. I think especially for military veterans who are used to being part of the team, bringing the team up. No one wants to drag their team or their family down. When they feel like a burden, that leaves them feeling like they’re dragging folks down, which can promote suicide risk. There was one study I did several years ago with a collaborator who’s now at the Baylor College of Medicine, where we found that kind of burdensomeness increases suicide risk six-fold. So, when you can make it so that veterans feel like they can be more active, can do more with a family, can pull their weight and be part of the family unit, the work unit, friend unit, it helps them cope better.
What was the reaction of you and your colleagues when you got the first inkling that this was going to work?
MCGEARY: We were very surprised. I mean, we were excited and the primary reason I think we were excited was because we were overcoming our own frustration with these headaches. Keep in mind, up to this point, there’s no front-line treatment for these things. So, no one had found a medicine, no one had found a therapy, no one had found a behavioral intervention that could do anything credible enough that we would say this is the frontline treatment. Usually, what you would do is listen to the veteran talk about his or her headache, and then you would send them off to whatever headache medication or headache therapy seemed to match what they were talking about. But you didn’t know what the outcomes were. This is the first time we saw, oh, OK, this might be a thing that works.
Why don’t the traditional meds work for them?
MCGEARY: It’s so hard to tell. I think one of the reasons why is because the mechanisms for post-traumatic headache are different than for primary headache. A primary headache is something like migraine, which has its own underlying causes or tension type headache, which has its own underlying causes. We have a good sense of what the generators are that cause these headaches to be. Post-traumatic headache or headache attributable to a mild traumatic brain injury is what’s called a secondary headache. It’s called secondary because the headache is believed to be secondary to some other cause. In this case, the cause is a head injury. Now, a head injury is not always the cause of a migraine headache or a true event or a tension type headache. Head injury is its own thing because the mechanism is different. The front-line treatments for these primary headaches for migraine tension-type headache may not work for many people because it’s addressing a completely different mechanism.
Did you have two or three groups during this? And if so, what were the other ones doing that were not receiving the correct treatment?
MCGEARY: The three groups that we had were the usual care groups. So, those were folks who just navigated the VA medical system the way they usually would for their headache. We tracked that. So, we looked at all the different treatments they got through the VA and just monitored their progress over time. We had our headache group and then the other was cognitive processing therapy and cognitive processing therapy, is what’s described as a cognitive therapy. So, it’s an opportunity to examine thoughts a person has about trauma, to think about their traumatic experience and the conclusions that they draw from it, the assumptions that they make about themselves, about the world around them, and about other people because of their trauma, and help them identify when those thoughts are unrealistic and revise those thoughts. It requires a lot of practice, but it’s a very effective treatment for post-traumatic stress disorder.
Where is the study right now in terms of being implemented on a wider basis?
MCGEARY: We have received funding to do a follow up study, which is a dissemination study and a multi-site trial. I am now the principal investigator of what I call Project March, which is our opportunity to take the treatment that we discovered in our previous trial and implement it at seven different sites across two different medical systems nationwide. So, the medical systems are the military health system and the VA health care system. We have three or four VA’s, three or four military treatment facilities who are working with us from Hawaii all the way to the East Coast. We are looking at a sample size of about six to 700 participants. The goal for that study is to see if we can replicate the outcomes from the original trial, determine whether or not there are differences in systems among individuals and geographic differences in how people respond and really tweak the treatment to make it easier to disseminate and especially to provide over video teleconferencing because that’s a novel arm for this new trial, is to see if we can deliver just as effective in a treatment through Zoom as we could in person. And of course, not only is that important during the pandemic, but when you’re working in the veterans’ health care system, that’s important for rural veterans who don’t have access to the treatment care that a lot of urban dwelling veterans do. So, if we can reach them in their homes with this treatment and it’s just effective as in-person, then we can bring a novel first of its kind, intervention for headache related to traumatic brain injury to these rural veterans who wouldn’t be able to access it otherwise.
I have a nephew, who was not in the military, but he had a stroke in a sense. He had a brain bleed when he was six months old, he was plagued with headaches. And I’m talking about, also, two people who might be in an auto accident with a head injury. Does this at all encompass these kinds of patients or only VA people?
MCGEARY: I believe that this treatment will help individuals with any kind of head injury, whether it’s military related from a motor vehicle accident, from a fall or a sports injury. The reason why I can say that so confidently is because one the mechanisms that we’re relying on are general, it’s nothing specific to veterans. I think it resonates well with the veterans and military service members. But I think it could help civilians. It could help children and adolescents because it’s a simple protocol and because it’s a behavioral treatment and not a medication. The side effect profile for this is, my headache might have gotten a little bit worse because I was reading something that’s the extent of the risk associated with this treatment. You can apply it to many different populations with very little concern about risk and see whether it works. I do think that’s a genuine next step in the progression of implementing this treatment is to see how far it goes. I bet if we worked with adolescents, at least children, possibly that it’s simple and straightforward enough that if we can cheerlead them the way we cheerlead our veterans and let them know, hey, you have control over your headaches, I think we would see a similar improvement for them. It’s just as important, if not more so for young folks because they have so much life to engage in and that’s our primary goal. If your headache is less intense than it was or less frequent than it was, that’s great. I’m happy to hear that we had many people who were telling us that their headache frequency was cut in half. I’m much more interested in did you feel like you were able to go out and spend more time with your family? Did you feel like you could go back to work? Do you feel like you could go back to school? That’s what I want to see, because when those things happen, a person has a much better quality of life. That’s what we shoot for.
END OF INTERVIEW
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