Cognitive therapy shows promise in treating PTSD, headaches

  • Researchers examined the efficacy of cognitive behavioral therapy (CBT) for headaches in treating post-traumatic headaches.
  • They found that CBT effectively reduces disability associated with post-traumatic headaches and post-traumatic stress disorder (PTSD) symptoms in veterans.
  • They say the therapy may also reduce costs associated with treating these conditions.

Traumatic brain injury (TBI) is a recognized risk of military service. Those who experience TBI are also at risk of developing post-traumatic headaches.

Research suggests that around 40% of individuals with post-traumatic headaches also have post-traumatic stress disorder (PTSD).

Post-traumatic headache is notoriously difficult to treat. Unlike migraine headaches, which have more defined symptoms, it has no clear symptom pattern and is defined by the cause of the headache — trauma.

There are currently no confirmed frontline treatments for post-traumatic headaches from mild TBI. Both pharmaceutical and behavioral therapies are largely ineffective.

New treatment strategies for PTH from mild TBI could improve the quality of life for veterans and others living with the condition.

Recently, researchers examined two nonpharmacological interventions for post-traumatic headaches — cognitive behavioral therapy (CBT) and cognitive processing therapy (CPT).

They found that CBT for headaches was more effective than usual care at reducing disability associated with post-traumatic headaches and significantly impacted PTSD symptom severity in veterans. Meanwhile, CPT failed to improve headache disability, despite significant reductions in PTSD symptom severity.

Researchers published the findings in JAMA Neurology.


For the study, the researchers recruited 193 post-9/11 combat veterans. Their average age was 39.7 years, and 87% were male.

The participants were split into three groups: one receiving CBT for headaches, another receiving CPT, and the last group — treatment per usual (TPU). The treatments lasted for six weeks.

The CBT focused on relieving disability and stress associated with the headaches via relaxation, setting goals for activities patients wanted to resume, and planning for situations.

Meanwhile, CPT focused on addressing PTSD via strategies to evaluate and change upsetting maladaptive thoughts related to traumas.

TPU varied and consisted of:

  • pharmacotherapies
  • pain management, including Botox injection
  • physical therapy
  • integrative health treatments, including massage and acupuncture

Headache-related disability was measured by the Headache Impact Test 6 (HIT-6). At baseline, participants in the CBT group scored an average of 66.1 points on the HIT-6 scale, while those in the CPT scored 66.1, and TPU participants scored 65.2.

A score of 60 or more is considered “severe,” and the maximum score on the scale is 78.

PTSD was assessed by the PTSD Checklist for DSM-5 (PCL-5). At baseline, the CBT group scored an average of 47.7 points on the scale, while the CPT group scored 48.6 and the TPU group scored 49. Scores of 31-33 or higher indicate PTSD, and the maximum score is 80.

After analyzing the data, the researchers found that HIT-6 scores for those in the CPT group were reduced by an average of 3.4 points compared to those given usual care. This improvement in headache-related disability was maintained six months post-treatment.

PTSD scores for the CPT group also decreased by an average of 6.5 points compared with the usual care group immediately post-treatment, with treatment effects lasting up to 6 months post-treatment.

Meanwhile, those in the CPT group experienced a more modest improvement in headache-related disability, with an average decrease of 1.4 points post-treatment compared with those in the TPU group.

PTSD scores in the CPT group decreased by 8.9 points on average post-treatment compared with those given usual care.

Analysis of the disaggregated scores showed that usual care resulted in a minimal change in headache-related disability — less than one unit change in the average HIT-6 score. However, there was a decrease in PTSD score of 6.8 points among those in the usual care group, which further decreased to 7.7 points 6 months later.


When asked what might explain the different effects of CBT and other treatment options, Don McGeary, Ph.D., ABPP, associate professor at the Department of Psychiatry and Behavioral Sciences at the University of Texas Health San Antonio, and one of the study’s authors, told MNT:

“I believe [CBT for headaches] was effective in this study because we purposefully developed a treatment that would be very broad (i.e., address as many headache mechanisms as possible) and focus on function. When people with any kind of pain condition are able to overcome disability and accomplish more meaningful activities in their lives, then pain becomes easier to manage. This was certainly true in our study.”

Dr. McGeary added that veterans were more likely to complete CBT than CPT. He noted that this was perhaps because CBT is less intensive and doesn’t involve delving into traumas that patients may want to avoid.

The researchers concluded that CBT for headaches effectively treats post-traumatic headaches from mild TBI and PTSD in veterans.

When asked what these findings mean for treating PTSD and its symptoms, Dr. McGeary said CBT could lower treatment costs for PTSD and increase treatment access as psychologists require just two hours of training, and care lasts just 4-8 hours. By comparison, CPT requires rigorous training and over 12 hours of care.

“We are still working on identifying who is likely to benefit and suspect that veterans with less severe PTSD symptoms will benefit from the headache intervention while those with more severe symptoms need to be referred to the gold-standard treatment,” he noted.

He added that due to the simplicity of CBT, it might also be effective in children and adolescents; however, they need to test this first.

Shannon Wiltsey Stirman, Ph.D., associate professor at the Department of Psychiatry and Behavioral Sciences at Stanford University, not involved in the study, told MNT that the therapy may work in other demographics, too.

Dr. Stirman noted that the therapy might benefit people who have experienced intimate partner violence or are reluctant or unable to engage in trauma-focused therapy due to medical issues by providing tools to manage aspects of daily life and PTSD symptoms.

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