Chronic headaches after traumatic brain injury: Diagnostic complexity associated with increased cost

Issue title: Why Military Neurorehabilitation Research is Relevant to Everyone

Guest editors: David X. Cifu and Sidney R. Hinds

Article type: Research Article

Authors: McGeary, Donald^{a; b; c; d; *} | Swan, Alicia A.^{c; d} | Kennedy, Eamonn^{e; f; g} | Dismuke-Greer, Clara E.^h | McGeary, Cindy^a | Sico, Jason J.^{i; j; k; l} | Amuan, Megan E.^{e; f} | Manhapra, Ajay^{m; n; o; p} | Bouldin, Erin D.^{e; f; q} | Watson, Paul^r | Kenney, Kimbra^s | Myers, Maddy^f | Werner Jr., J. Kent^{t; u} | Mitchell, James L.^{v; w} | Carlson, Kathleen^{x; y} | Delgado, Roxana^{b; u; z} | Esmaeili, Aryan^aa | Pugh, Mary Jo^{e; f}

Affiliations: [a] Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA | [b] South Texas Veterans Health Care System, San Antonio, TX, USA | [c] Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, USA | [d] Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA | [e] Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, USA | [f] Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA | [g] Department of Neurology, School of Medicine, University of Utah, Salt Lake City, UT, USA | [h] Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA | [i] VA Connecticut Healthcare System, West Haven, CT, USA | [j] Headache Centers of Excellence Research, Education, Evaluation, and Engagement Center (RE3ACH), Veterans Health Administration, West Haven, CT, USA | [k] Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA | [l] Departments of Neurology and Internal Medicine, Yale School of Medicine, New Haven, CT, USA | [m] Section of Pain Medicine, Department of Physical Medicine and Rehabilitation Sciences, Hampton VA Medical Center, Hampton, VA, USA | [n] New England Mental Illness Research Education and Clinical Center (MIRECC), West Haven, CT, USA | [o] Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA | [p] Departments of Physical Medicine and Rehabilitation Services, Eastern Virginia Medical School, Norfolk, VA, USA | [q] Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, TX, USA | [r] Northumbria University Northern Hub for Veterans and Military Families Research, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK | [s] Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA | [t] Walter Reed National Military Medical Center, Bethesda, MD, USA | [u] School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA | [v] Academic Department of Military Rehabilitation (ADMR), Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK | [w] Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK | [x] Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA | [y] Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, USA | [z] School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, USA | [aa] Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, Menlo Park, CA, USA

Correspondence: [*] Address for correspondence: Donald McGeary, PhD, ABPP, Professor with Tenure and Vice Chair for Research, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA. Tel.: +1 210 567 5454; E-mail: mcgeary@uthscsa.edu.

Abstract: BACKGROUND:Chronic headache after traumatic brain injury (TBI) is a common, yet disabling, disorder whose diverse clinical characteristics and treatment needs remain poorly defined. OBJECTIVE:To examine diagnostic coding patterns and cost among military Veterans with comorbid chronic headache and TBI. METHODS:We identified 141,125 post-9/11 era Veterans who served between 2001 and 2019 with a headache disorder diagnosed after TBI. We first identified patterns of Complex Headache Combinations (CHC) and then compared the patterns of healthcare costs in 2022-dollar values in the three years following the TBI diagnosis. RESULTS:Veterans had diverse individual headache and CHC diagnoses with uniformly high cost of care. Post-whiplash and post-TBI CHCs were common and consistently associated with higher costs after TBI than those with other types of headache and CHCs. Post-TBI migraine had the highest unadjusted mean inpatient ($27,698), outpatient ($61,417), and pharmacy ($4,231) costs, which persisted even after adjustment for confounders including demographic, military, and clinical characteristics. CONCLUSION:Headache diagnoses after TBI, particularly those diagnosed with post-traumatic headache, are complex, and associated with dual high cost and care burdens. More research is needed to examine whether this higher expenditure reflects more intensive treatment and better outcomes or refractory headache with worse outcomes.

Keywords: Post-traumatic headache (PTH), health care costs, Veterans, traumatic brain injuries (TBI), mild TBI (mTBI), rehabilitation

DOI: 10.3233/NRE-230277

Journal: NeuroRehabilitation, vol. 55, no. 3, pp. 303-317, 2024