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Expert commentary

by Deena Kuruvilla, MD, FAHS

The title of this abstract is Prevalence of Headache and Comorbidities Among Men and Women Veterans Across the Veterans Health Administration – a 10 Year Cohort Study. The lead author is Brenda T. Fenton PhD. The Headache Centers of Excellence (HCoE) headache cohort is comprised of national health systems data, including diagnostic codes, healthcare and medication utilization, and geographic distribution of 1.4 million veterans with at least one headache diagnoses, according to the International Classification of Headache Disorders.

These diagnoses were found within the electronic health record from fiscal years 2008 to 2018. Logistic regressions evaluated gender differences in headache diagnosis, history of traumatic brain injury, post-traumatic stress disorder, and non-headache pain conditions. In the results section, the authors highlight that approximately 16% of veterans cared for within the Veterans Health Administration had a documented headache disorder. Men represented 83% of this cohort. The most common diagnosis that was given to patients in this cohort was headache, not otherwise specified. Migraine was diagnosed in 36% of the headache disorders seen in this cohort during this time period. A history of traumatic brain injury was documented in 5% of headache cases, while the rate of headache and not otherwise specified was significantly higher in men compared to women.

It was similar, however, across gender, in those with a traumatic brain injury diagnosis, coming in at 85%. A migraine diagnosis was higher in women overall, as well as in a subset of veterans with traumatic brain injury. Post-traumatic headache was diagnosed in around 3% of the entire cohort. If we further narrowed the cohort down to those with traumatic brain injury, a rate of 72% of men had post-traumatic stress disorder. The most common comorbid pain conditions for both genders were limb pain and back pain. Women had significantly higher rates of pelvic pain and systemic pain.

While several studies exist which confirm migraine is more prevalent among women in the United States population1, less research has been conducted within the Veterans Healthcare Administration (VHA) looking at gender differences among people with headache disorders. Existing VHA studies have examined the various headache diagnoses that exist among veterans based on gender. The same studies have confirmed that headache diagnoses are more prevalent among women, especially a diagnosis of migraine2. This particular study by Fenton et al., highlights three major gaps within the VHA for headache care: 1. headache education among providers, 2. healthcare providers need to provide more specific diagnoses than headache not otherwise specified and 3. A multidisciplinary approach to headache care in order to tailor care based on the individual patient.

Currently working with the VHA, I have observed that the vast majority of veteran patients with headache are evaluated by primary care followed by neurology and physiatry. Primary care may be the best initial target to increase headache education as they see the vast majority of these patients. In fact, studies have been conducted which have shown improved practice among primary care providers with structured headache education 3,4–5.

Several tools have been published to assist in the accurate diagnosis of headache disorders. These tools include the International classification of headache disorders developed by the International Headache Society3 and the ID migraine screener developed to improve migraine recognition in primary care6. These tools may be instated within an electronic medical record (EMR) to easily assist in the diagnosis of migraine and other headache disorders. In the non-VHA world, accurate ICD codes are of utmost importance for accurate treatment coverage and reimbursement by payers.

Finally, many studies exist that highlight that headache is comorbid with conditions such as depression, anxiety and sleep disorders1. This study shows that female veteran patients have a higher prevalence of psychiatric comorbidities and male veterans have a higher prevalence of post-traumatic stress disorder. For these reasons, ancillary services such as psychiatry and psychology must be readily available within each VHA headache clinic.

 


References

  1. Buse, D. C. et al. Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: results of the migraine in America symptoms and treatment (MAST) study. J. Headache Pain 21, 23 (2020).
  2. Carlson, K. F. et al. Headache Diagnoses Among Iraq and Afghanistan War Veterans Enrolled in VA: A Gender Comparison. Headache: The Journal of Head and Face Pain vol. 53 1573–1582 (2013).
  3. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia vol. 38 1–211 (2018).
  4. Braschinsky, M. et al. Structured education can improve primary-care management of headache: the first empirical evidence, from a controlled interventional study. J. Headache Pain 17, 24 (2016).
  5. Braschinsky, M. et al. Structured education to improve primary-care management of headache: how long do the benefits last? A follow-up observational study. Eur. J. Neurol. 25, 497–502 (2018).
  6. Lipton, R. B. et al. A self-administered screener for migraine in primary care. Neurology vol. 61 375–382 (2003).
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