Veterans and Headache: a War of Endurance

By Maya Coseo

At the end of 2020, over 1.6 million veterans sought headache treatment at the U.S. Department of Veterans Affairs (VA). More than half a million had migraine, and tens of thousands experienced post-traumatic headache, among other headache conditions.

“That works out to about 14% of all veterans getting care in the VA [having] at least one headache disorder,” says Jason Sico, MD, MHS, FAHA, FAAN, FANA, FACP, the national director of the VA’s Headache Centers of Excellence program. But the number of veterans with headache disease is believed to be higher than statistics show.

What makes headache such a concern for veterans?

While genetics factor in, service-specific cirumstances increase the likelihood of veterans developing a headache disorder. Circumstances include exposure to traumatic brain injury (TBI) and post-concussive syndrome, which can result from being near explosions or other battlefield injuries. Post-traumatic headache is the most common symptom veterans have post-TBI and up to 90% develop headaches from it, per Sico.

Beyond being at increased risk of headache disease, veterans also must contend with the nuances of the VA system and bias against “invisible” diseases. Kate Benson, who served in the U.S. Coast Guard, now helps run a veterans chronic pain support group for U.S. Pain Foundation. She has lived with chronic migraine since puberty and was diagnosed as a teenager. She struggled to get treatment while serving.

“The military sure doesn’t like people who are not working at top condition. And if you look fine, you should be working perfectly,” Benson says.

Members of the military may feel pressured to put on a strong and stoic front despite pain; external stigma is worsened by internalized shame.

In the majority male veteran community, this is only amplified. Robert Shapiro, MD, PhD, FAHS, is the founder of Headache on the Hill, an annual advocacy event where participants meet with lawmakers to drive change in federal policy decisions. He explains that men are less likely to seek headache treatment partly because it’s “typically discredited in our conversations as [being] a suitable or acceptable cause for limiting our activities or functionality.”

Unforeseen dangers also cause headache

While acute injuries are a well-known cause of veteran health issues, environmental factors are gaining increasing attention.

Robert Cowan, MD, FAHS, FAAN, a board member of the Alliance for Headache Disorders Advocacy (AHDA), recently began to research burn pits. These are spaces “usually adjacent to a military base, in which enemy and other contraband and garbage are burned [continuously, using] jet fuel,” he says.

Burn pits were used during the Persian Gulf through the Afghanistan war. The characteristic presentation of burn pit exposure is “primarily headache and respiratory issues,” says Cowan.

Cowan, Shapiro, and Sico each say that exposure to burn pits increases the likelihood of nonspecific headache, meaning symptoms don’t meet criteria for one condition. This causes difficulty in treatment, as does the fact that burn pits are largely unstudied; Cowan is researching their effects with funding from private donors.

“Historically, my understanding is that the VA has been very reluctant or cautious about this,” says Shapiro. While he says he understands the reason for their reluctance, he believes that veterans potentially exposed to hazardous materials during deployment “shouldn’t be held hostage to the time and effort it takes to prove or disprove that the association is significant.”

Another issue, Cowan explains, is that “I don’t even think we know what data we need.” Existing data, which goes back to the 1990s, is unanalyzed.

A model for improved migraine and headache care

The Headache Centers of Excellence program, which Sico directs, was created in 2018 in part thanks to efforts by the AHDA and Headache on the Hill.

Around that time, the VA had only three certified headache medicine providers. Currently, that number is closer to 12.

There are now 14 centers across America, and Headache on the Hill continues to advocate for more funding and centers. According to Shapiro, after the recent Headache on the Hill event, 90% of House representatives, who signed a letter to the Appropriations Committee supporting increased funding for the Headache Centers of Excellence programs, had met with advocates. This demonstrates why it’s critical to “[advocate] on behalf of the issues that you believe are important,” he says.

Sico is proud of the Headache Centers of Excellence work and services, which focus on multidisciplinary care, including: support groups, yoga, sleep medicine, trigger point injections, health psychologists, and innovative therapies like CGRP-inhibitors and neuromodulation, among others.

Sico stresses the importance of treating the entire body while managing headache symptoms. Doctors cannot forget patients’ individuality, either; effective treatment plans must consider the individual’s values and preferences. Patients have “a life, they have ambition, they have goals,” Sico says.

The Headache Centers of Excellence also partner with other VA programs like the Polytrauma System of Care. Health care providers working in this department include vestibular rehabilitation specialists, who help with dizziness or balance problems, to speech language pathologists and neuropsychologists who assist with speech, memory, or concentration difficulties. Helping those who have served us isn’t optional. In the meantime, Kate Benson says veterans appreciate “anyone who tries to understand.” 

Did you know?

Migraine and cluster headache management is complex. Increasingly, people are using a multimodal toolbox approach to managing both migraine and cluster headache. In addition to managing lifestyle factors and having access to acute and preventive medicines, there are a handful of FDA-cleared, noninvasive, drug-free medical devices available, some of which veterans have unique access to. Talk to your VA provider to see if newer innovative therapies would be beneficial for your own toolbox.