Utilizing the Biopsychosocial Model in Concussion Treatment: Post-Traumatic Headache and beyond.

PURPOSE OF REVIEW: To discuss recent literature concerning the application of the biopsychosocial model in the management of concussion and post-concussion headache. RECENT FINDINGS: Current research suggests that the biopsychosocial model is applicable to the concussion management process, particularly management of post-concussion headache. Such application is best illustrated by current active treatment strategies such as exercise, multifaceted rehabilitation, and psychosocial interventions targeting improved patient outcomes. Overall, the biopsychosocial model has significant applications to the management of concussion, particularly post-concussion headache. Presentation and recovery following concussion and post-traumatic headache is multifaceted and includes the continuum of biological, psychological, and social considerations. In order to fully understand the widespread clinical utility and application of such models, there is a continued need for researcher, practitioner, and patient integration and collaboration to determine the most effective assessment and treatment strategies.

Lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa.

OBJECTIVE: Our aim was 1) to reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine. BACKGROUND: Modifiable risk factors for PTHA include stressful life event, sleep disturbances, and medication overuse. Cognitive-behavioral strategies, biofeedback, and relaxation therapy may have an important role in treatment and preventing progression to chronic post-traumatic headache (CPTHA). There is limited literature and a known practice gap for implementation of these techniques. DESIGN/METHODS: An IRB approved project focused on patients who were seen for PTHA and CPTHA. 1) Intervention consisted of lifestyle teaching, cognitive-behavioral therapy and biofeedback, supplemented by decreasing polypharmacy. 2) Patients were followed for 2 years and a retrospective review was conducted for 2 years prior to presentation. 3) Outcome measures included reduction in migraine intensity or frequency, improved quality of life, duty status, and decreased utilization of clinic visits. RESULTS: Over the course of one year, 221 patients were treated for migraines in the Naval Okinawa Neurology Clinic. Of these, 22 active duty service members and 3 Dependents suffered a mild TBI prior to onset. After intervention, there was a 36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared to the 2 years prior to intervention. Twenty-four percent had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year. CONCLUSIONS: An implemented program geared towards reducing polypharmacy was shown to improve safety, quality of life and reduce hospitalizations from the burden of migraines. Our systematic approach resulted in quality of life improvements and decreased use of medical resources. TRIAL REGISTRATION: Authors received the approval of NAVMED West, Okinawa Naval Hospital Institutional Review Board on January 13th, 2016. QI.2016.0021.

Pressure pain thresholds over the cranio-cervical region in headache: a systematic review and meta-analysis.

BACKGROUND: Sensitivity of tissues can be measured by algometry. Decreased pressure pain thresholds over the cranio-cervical area are supposed to reflect signs of sensitization of the trigemino-cervical nucleus caudalis. A systematic review was conducted to assess the current scientific literature describing pressure pain threshold (PPT) values over the cranio-cervical region in patients with migraine, tension-type headache (TTH), and cervicogenic headache (CeH). A literature search was executed in three databases. The search strategy included the following keywords: migraine, TTH, CeH, PPT and algometry. A total of 624 papers was identified of which relevant papers were subsequently assessed for methodological quality. Twenty-two selected papers were assessed by two independent reviewers and the majority of studies scored low risk of bias on the selected items. Mean PPT values of several sites measured in the cranio-cervical region in patients with migraine, chronic TTH and CeH scored lower values compared to controls. The trapezius muscle (midpoint between vertebrae C7 and acromion) was the most frequently targeted site and showed significantly lower PPT values in adults with migraine (pooled standardized mean difference kPa: 1.26 [95%CI -1.71, -0.81]) and chronic TTH (pooled standardized mean difference kPa: -2.00 [95%CI -2.93, -1.08]). Most studies found no association between PPT values and headache characteristics such as frequency, duration or intensity. Further standardization of PPT measurement in the cranio-cervical region is recommended.

Psychological distress, neuroticism and disability associated with secondary chronic headache in the general population - the Akershus study of chronic headache.

BACKGROUND: Primary headaches are associated with psychological distress, neuroticism and disability. However, little is known about headache-related disability and psychological distress among people with secondary chronic headaches. METHODS: 30,000 persons aged 30-44 from the general population was screened for headache by a questionnaire. The responder rate was 71%. The International Classification of Headache Disorders with supplementary definitions for chronic rhinosinusitis and cervicogenic headache were used. The Hopkins Symptom Checklist-25 assessed high psychological distress, the Migraine Disability Assessment questionnaire assessed disability, and Eysenck Personality Questionnaire assessed neuroticism. RESULTS: Ninety-five of the 113 eligible participants (84%) completed the self-reported questionnaire. A total of 38 people had chronic post-traumatic headache, 21 had cervicogenic headache, and 39 had headache attributed to chronic rhinosinusitis, while 9 had co-occurrence of chronic post-traumatic and cervicogenic headache. Six persons had miscellaneous secondary chronic headaches. Overall, 49% of those with secondary chronic headache reported high psychological distress, which is significantly higher than in the general population. A high level of neuroticism was significantly more common in those with secondary chronic headache than in the general population. Severe headache-related disability was reported by 69%. 92 persons were followed up after 3 years. A low headache frequency was the only significant predictor of improvement of ≥ 25% in headache days. Having post-traumatic or cervicogenic headache and not headache attributed to chronic rhinosinusitis predicted an increased risk > 25% worsening of headache days or having a severe disability at 3 years follow-up. CONCLUSION: Psychological distress and neuroticism were more common among people with secondary chronic headache than in the general population. Only a high headache frequency was significantly associated with increased headache disability at baseline and a poor prognosis in the long term.

Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury.

OBJECTIVES: To determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) in a prospective longitudinal observational multicentre study. Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression. METHODS: This was a prospective observational study conducted between January 2013 and February 2014 in three trauma centres in the Netherlands. Patients aged 16 years and older with a GCS score of 9-15 on admission to the ED, with loss of consciousness and/or amnesia were prospectively enrolled. Follow-up questionnaires were completed at 2 weeks and 3 months after injury with the Head Injury Symptom Checklist, the Hospital Anxiety and Depression Scale and RTW scale. RESULTS: In total, 628 patients were enrolled in the study, 469 completed the 2-week questionnaire (75%) at 2 weeks and 409 (65%) at 3 months. At 2 weeks, 238 (51%) had developed aPTH and at 3 months 95 (23%) had developed cPTH. Female gender, younger age, headache immediately at the ED and CT scan abnormalities increased the risk for aPTH. Risk factors for cPTH were female gender and headache at the ED. Patients with cPTH were less likely to have returned to work than those without cPTH (35% vs 14%, P=0.001). Patients with aPTH and cPTH more often report anxiety (20% and 28%, P=0.001) and depression (19% and 28%, P=0.001) after trauma in comparison with the group without PTH (10% anxiety and 8% depression). CONCLUSIONS: PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH.

Chronic post-traumatic headache after mild head injury: a descriptive study.

BACKGROUND: The aetiology behind chronic post-traumatic headache (CPTH) after mild head injury is unclear and management is complicated. In order to optimize treatment strategies we aimed to characterize a CPTH population. METHODS: Ninety patients with CPTH and 45 patients with chronic primary headaches were enrolled from the Danish Headache Center. All patients were interviewed about demographic and headache data. They completed the Harvard Trauma Questionnaire (HTQ), Rivermead Post Concussion Symptoms Questionnaire, SF-36 and a headache diary. RESULTS: The CPTH group experienced more cognitive ( P < 0.001) and somatic symptoms ( P = 0.048) and rated their self-perceived health as more affected in terms of physical function ( P = 0.036), physical role function ( P = 0.012) and social function ( P = 0.012) than the control group. Surprisingly, 31% of the CPTH group had a score equal to or above the cut-off score for having post-traumatic stress disorder (PTSD) according to the HTQ. In terms of demographics and headache, the groups were comparable except the CPTH group were more often without affiliation to the labour market ( P < 0.001). CONCLUSIONS: The loss of work capacity and high levels of disability for the CPTH patients suggests directions for further research into what important factors are embedded in the patients' PTSD symptoms and might explain their prolonged illness.

Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey.

OBJECTIVE: This study's objective is to characterize the therapeutic effect of peripheral nerve blocks of the scalp for children and adolescents with post-traumatic headaches. BACKGROUND: Headaches are the most frequently reported persistent symptoms following a pediatric mild traumatic brain injury, may be challenging to treat, and can transform into debilitating chronic headaches. The beneficial use of peripheral nerve blocks of the scalp has been reported for adults with post-traumatic headaches. METHODS: Retrospective case series on all patients <18 years of age treated between January 2012 and June 2013 in the mild traumatic brain injury clinic with a nerve block. The main outcome measure was the proportion of patients with a good therapeutic effect, defined by the duration of the block being >24 hours and/or repeat blocks requested. A data extractor blinded to main outcome measures performed the chart review. A patient satisfaction survey was also sent to all patients to assess the recalled experience with the interventions received. RESULTS: A total of 62 nerve blocks were performed on 28 patients for 30 injuries that led to post-traumatic headaches. The mean (standard deviation) age was 14.6 (1.7) years. The first nerve blocks were performed a mean (standard deviation) of 70 (54.2) days post-injury. The therapeutic effect was good in 93% of patients with 71% reporting immediate complete relief of their headaches; the mean percent headache reduction was 94%. Most (91%) would recommend a nerve block for post-traumatic headaches. CONCLUSION: The ease with which peripheral nerve blocks of the scalp can be performed combined with the immediate relief experienced by patients makes them a potential addition to the armamentarium of headache management strategies for children and adolescent with post-traumatic headaches.

Cognitive behavioural treatment for the chronic post-traumatic headache patient: a randomized controlled trial.

BACKGROUND: Chronic post-traumatic headache (CPTH) after mild head injury can be difficult to manage. Research is scarce and successful interventions are lacking.To evaluate the effect of a group-based Cognitive Behavioural Therapy (CBT) intervention in relation to headache, pain perception, psychological symptoms and quality of life in patients with CPTH. METHODS: Ninety patients with CPTH according to ICHD-2 criteria were enrolled from the Danish Headache Center into a randomized, controlled trial. Patients were randomly assigned to either a waiting list group or to a nine-week CBT group intervention. At baseline and after 26 weeks all patients completed the Rivermead Post Concussion Symptoms Questionnaire, SF-36, SCL-90-R and a headache diary. RESULTS: The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms. The waiting-list group experienced no change in headache but, opposed to the treatment group, a significant decrease in somatic and cognitive symptoms indicating a spontaneous remission over time. CONCLUSIONS: Our primarily negative findings confirm that management of patients with CPTH still remains a considerable challenge. Psychological group therapy with CBT might be effective in an earlier stage of CPTH and in less severely affected patients but our findings strongly underline the need for randomized controlled studies to test the efficacy of psychological therapy.

Post-traumatic stress disorder in U.S. soldiers with post-traumatic headache.

OBJECTIVE: To determine the impact of post-traumatic stress disorder (PTSD) on headache characteristics and headache prognosis in U.S. soldiers with post-traumatic headache. BACKGROUND: PTSD and post-concussive headache are common conditions among U.S. Army personnel returning from deployment. The impact of comorbid PTSD on the characteristics and outcomes of post-traumatic headache has not been determined in U.S. Army soldiers. METHODS: A retrospective cohort study was conducted among 270 consecutive U.S. Army soldiers diagnosed with post-traumatic headache at a single Army neurology clinic. All subjects were screened for PTSD at baseline using the PTSD symptom checklist. Headache frequency and characteristics were determined for post-traumatic headache subjects with and without PTSD at baseline. Headache measures were reassessed 3 months after the baseline visit, and were compared between groups with and without PTSD. RESULTS: Of 270 soldiers with post-traumatic headache, 105 (39%) met screening criteria for PTSD. There was no significant difference between subjects with PTSD and those without PTSD with regard to headache frequency (17.2 vs 15.7 headache days per month; P = .15) or chronic daily headache (58.1% vs 52.1%; P = .34). Comorbid PTSD was associated with higher headache-related disability as measured by the Migraine Disability Assessment Score. Three months after the baseline neurology clinic visit, the number of subjects with at least 50% reduction in headache frequency was similar among post-traumatic headache cases with and without PTSD (25.9% vs 26.8%). CONCLUSION: PTSD is prevalent among U.S. Army soldiers with post-traumatic headache. Comorbid PTSD is not associated with more frequent headaches or chronic daily headache in soldiers evaluated at a military neurology clinic for chronic post-traumatic headache. Comorbid PTSD does not adversely affect short-term headache outcomes, although prospective controlled trials are needed to better assess this relationship.

Post-traumatic headaches in civilians and military personnel: a comparative, clinical review.

Post-traumatic headache (PTH) is the most frequent symptom after traumatic brain injury (TBI). We review the epidemiology and characterization of PTH in military and civilian settings. PTH appears to be more likely to develop following mild TBI (concussion) compared with moderate or severe TBI. PTH often clinically resembles primary headache disorders, usually migraine. For migraine-like PTH, individuals who had the most severe headache pain had the highest headache frequencies. Based on studies to date in both civilian and military settings, we recommend changes to the current definition of PTH. Anxiety disorders such as post-traumatic stress disorder (PTSD) are frequently associated with TBI, especially in military populations and in combat settings. PTSD can complicate treatment of PTH as a comorbid condition of post-concussion syndrome. PTH should not be treated as an isolated condition. Comorbid conditions such as PTSD and sleep disturbances also need to be treated. Double-blind placebo-controlled trials in PTH population are necessary to see whether similar phenotypes in the primary headache disorders and PTH will respond similarly to treatment. Until blinded treatment trials are completed, we suggest that, when possible, PTH be treated as one would treat the primary headache disorder(s) that the PTH most closely resembles.

Behavioral treatment for post-traumatic headache after mild traumatic brain injury: Rationale and case series.

BACKGROUND: Headache is among the most common persistent symptoms after mild traumatic brain injury (mTBI). Currently available treatments have limited efficacy. OBJECTIVE: To present a rationale for a novel behavioral treatment approach and a supporting case series with a multiple baseline design. METHOD: Pervasive avoidance of common headache triggers may be maladaptive, promoting sensitization and restricting life participation. Graded exposure to triggers that are prone to sensitization (e.g., stress, light flicker, loud noise) may represent an alternative behavioral approach to treating chronic headaches after mTBI. The present study reports on a series of physician-referred patients (N = 4, aged 28-48, enrolled at 9-19 months post-injury) with persistent headache attributed to mTBI. They participated in an 8-session manualized treatment with a registered psychologist. Patients completed a daily headache diary before, during, and after treatment, as well as pre- and post-treatment assessments with a battery of questionnaires. RESULTS: All patients finished treatment and no adverse events were reported. Improvement was variable across measures of headache frequency/intensity, headache trigger avoidance, post-concussion symptoms, disability, and patient global impression of change. CONCLUSION: Future directions for behavioral management of headache triggers as a potential treatment for chronic post-traumatic headaches after mTBI are discussed.

Cervicogenic headache (CEH) six years after whiplash injury.

The main objective of the present investigation was to clarify the long-term natural course of cervicogenic headache (CEH) after whiplash injury. Whiplash patients (n=587) were initially followed up for a year after their emergency service consultation. De novo unilateral CEH seemed to be present in 8% (n=48) at six weeks and in 3% (n=20) at one year. Previous car accidents, pre-existing headache, and neck pain were more frequent among individuals with chronic CEH than in those without CEH at one year. Patients affected by headache with CEH characteristics at one year were followed up for five more years, at the end of which seven (35%) still had such headache, although the attack frequency had reduced appreciably. Forward radiating pain could still generally be precipitated from areas along the occipital tendons ipsilaterally. Increased tenderness in these areas could also be found on the previously symptomatic side in the patients who were now asymptomatic.

Cogniphobia in Mild Traumatic Brain Injury.

Cogniphobia refers to avoidance of mental exertion out of a fear of developing or exacerbating a headache. Headaches are very common after mild traumatic brain injury (mTBI) and often become chronic. Cogniphobia is hypothesized to contribute to poor cognitive test performance and persistent disability in some patients with mTBI. Eighty patients with mTBI and post-traumatic headaches were recruited from specialty outpatient clinics. They completed a battery of questionnaires (including a cogniphobia scale) and neuropsychological tests (the National Institutes of Health Toolbox Cognition Battery and the Medical Symptom Validity Test) at 2-3 months post injury, in a cross-sectional design. Participants with more severe headaches reported higher levels of cogniphobia. Cogniphobia was associated with lower performance on memory testing (but not other cognitive tests), independent of headache severity. Participants who avoided mental exertion also tended to avoid physical activity and traumatic stress triggers. The findings provide preliminary support for the role of cogniphobia in persistent cognitive difficulties after mTBI, and suggest that cogniphobia may reflect a broader avoidant coping style.

Therapeutic Exercise Training to Reduce Chronic Headache in Working Women: Design of a Randomized Controlled Trial.

BACKGROUND: Cervicogenic headache and migraine are common causes of visits to physicians and physical therapists. Few randomized trials utilizing active physical therapy and progressive therapeutic exercise have been previously published. The existing evidence on active treatment methods supports a moderate effect on cervicogenic headache. OBJECTIVE: The aim of this study is to investigate whether a progressive, group-based therapeutic exercise program decreases the intensity and frequency of chronic headache among women compared with a control group receiving a sham dose of transcutaneous electrical nerve stimulation (TENS) and stretching exercises. DESIGN: A randomized controlled trial with 6-month intervention and follow-up was developed. The participants were randomly assigned to either a treatment group or a control group. SETTING: The study is being conducted at 2 study centers. PATIENTS: The participants are women aged 18 to 60 years with chronic cervicogenic headache or migraine. INTERVENTION: The treatment group's exercise program consisted of 6 progressive therapeutic exercise modules, including proprioceptive low-load progressive craniocervical and cervical exercises and high-load exercises for the neck muscles. The participants in the control group received 6 individually performed sham TENS treatment sessions. MEASUREMENTS: The primary outcome is the intensity of headache. The secondary outcomes are changes in frequency and duration of headache, neck muscle strength, neck and shoulder flexibility, impact of headache on daily life, neck disability, fear-avoidance beliefs, work ability, and quality of life. Between-group differences will be analyzed separately at 6, 12, and 24 months with generalized linear mixed models. In the case of count data (eg, frequency of headache), Poisson or negative binomial regression will be used. LIMITATIONS: The therapists are not blinded. CONCLUSIONS: The effects of specific therapeutic exercises on frequency, intensity, and duration of chronic headache and migraine will be reported.

Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache.

BACKGROUND: Cervicogenic headache is a secondary headache that has a source in the upper cervical spine. There is a small but growing body of evidence to establish effectiveness of radiofrequency (RF) neurotomy, and the pulsed RF (PRF) procedure for management of cervicogenic headache. OBJECTIVE: To investigate the clinical utility of RF neurotomy, and PRF ablation for the management of cervicogenic headache. STUDY DESIGN: Systematic review. METHODS: The review included relevant literature identified through searches of PubMed, Cochrane, Clinical trials, U.S. National Guideline Clearinghouse and EMBASE from 1960 to January 2014.The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized control trials and the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and poor based on the quality of evidence. OUTCOMES MEASURED: The primary outcome measures were reduction in pain scores and improvement in quality of life. RESULTS: The primary outcome measures were headache relief and improved quality of life. Twenty five studies were identified for full text review of these, 9 studies met inclusion criteria. There were 5 non-randomized, among them 4/5 were of moderate quality, 3/5 showed RF ablation and 1/5 showed PRF as an effective intervention for cervicogenic headache. There were 4 randomized trials among them 2/4 were of high quality, 3/4 investigated RF ablation as an intervention for CHA, 1/4 investigated PRF ablation as an intervention for CHA and none of the randomized studies showed strong evidence for RF and PRF ablation as an effective intervention for CHA. LIMITATIONS: In the selected studies there were inconsistencies between randomized trials, flaws in trial design, and gaps in the chain of evidence. CONCLUSION: There is limited evidence to support RF ablation for management of CHA as there are no high quality RCTs and/ or multiple consistent non-RCTs without methodological flaws. There is poor evidence to support PRF for CHA as there are no high quality RCTs or Non-RCTs.

The effects of headache on clinical measures of neurocognitive function.

OBJECTIVE: To examine effects of preseason baseline headache and posttraumatic headache (PTH) on neurocognitive function. DESIGN: Retrospective repeated measures study with headache groups formed regarding baseline headache score (0 = negative headache; 1-6 = positive headache) and day 1 postinjury headache score (0 = no headache; 1-2 = mild headache; 3-6 = moderate-severe headache). SETTING: Clinical athletic training setting and sports medicine research laboratory. PARTICIPANTS: High-school and collegiate athletes with a concussion. INDEPENDENT VARIABLES: Preseason baseline headache, PTH, test-day. MAIN OUTCOME MEASURES: A Graded Symptom Checklist (GSC) was used to assess symptoms. The Automated Neuropsychological Assessment Metrics (ANAM) and the Standardized Assessment of Concussion (SAC) were used to assess neuropsychological function and mental status. The Balance Error Scoring System (BESS) was used to assess postural stability. RESULTS: Both baseline headache groups displayed a higher symptom endorsement and higher symptom severity at day 1 postinjury and improved by day 7 postinjury. The positive headache group reported an even greater increase in symptom severity and presence (P < 0.05). ANAM revealed deficits in both groups 1 day postinjury. All PTH headache groups displayed a difference in symptom number and severity with the increase being magnified by headache severity (P < 0.05). Individuals reporting moderate-severe PTH displayed increased deficits subacutely but improved by 5-7 days postinjury on overall neuropsychological performance, reaction time, and working memory (P < 0.05). Deficits were observed for all ANAM measures except simple reaction time 1 (SRT 1) and match to sample subacutely and improved over time (P < 0.05). The SAC yielded an interaction (P < 0.05) for baseline headache. The BESS yielded no significant findings. CONCLUSIONS: Clinicians should consider headache when assessing concussion and during preseason baseline assessments because headache may affect symptom presence and other clinical measures of concussion.

Characteristics and treatment of headache after traumatic brain injury: a focused review.

Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH). Although most PTH resolves within 6-12 mos after injury, approximately 18-33% of PTH persists beyond 1 yr. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Although there is no universally accepted protocol for treating PTH, many clinicians treat PTH as if they were managing primary headache. As a result of the heterogeneity in the terminology and paucity in prospective, well-controlled studies in this field, there is a definite need for conducting double-blind, placebo-controlled treatment trials in patients with PTH.

Prevalent musculoskeletal pain as a correlate of previous exposure to torture.

AIM: To research possible associations between previous exposure to specific torture techniques and prevalent pain in the head and face, back, and feet. METHODS: 221 refugees, 193 males and 28 females, previously exposed to torture in their home country, were subject to a clinical interview at a rehabilitation clinic for torture victims. The interview focused on exposure to torture and somatic symptoms prevalent at examination. RESULTS: The mean number of times imprisoned was 2.3; the mean number of months imprisoned was 19.7; the mean duration from initial imprisonment to final release was 3.7 years; and the mean duration from final release to preliminary interview was 8.4 years. The most frequent physical torture method reported was beating (92.3%) and the main mental torture method was deprivation (84.6%). Pain in the head and face was found to be strongly associated with torture against head and face (OR 3.89, 95% CI 1.49-10.20) and with the cumulative number of physical torture methods exposed to. Pain in the back was associated with sexual torture (OR 2.75, 95% CI 1.07-7.12). Besides beating of the lower extremities (OR 5.98, 95% CI 2.47-14.48), the strongest predictor for pain in the feet was general abuse of the whole body (OR 5.64, 95% CI 1.93-16.45). CONCLUSION: In spite of many factors being potentially co-responsible for prevalent pain, years after the torture took place it presents itself as strongly associated with specific loci of pain, with generalized effects, and with somatizing.

The effectiveness of cognitive-behavioural therapy for post-traumatic headaches.

Post-traumatic headache is one of the most common symptoms following mild and moderate head injury. Psychological factors are believed to play a role in the cause, maintenance and relief from chronic post-traumatic headache. This research evaluated the effectiveness of a multi-dimensional cognitive-behavioural approach towards rehabilitation of post-traumatic headaches. The sample included 20 participants with post-traumatic headaches from an original sample of 41. Participants acted as their own controls. Outcome measures consisted of self-rating questionnaires to assess headache severity, intensity, duration, functioning and emotional well-being. Emotional and functional headache characteristics were studied using a multi-dimensional investigation which included relatives' perceptions of the sufferers headaches. The intervention proved effective and beneficial for the 20 therapy participants. It is concluded that cognitive-behavioural therapy provides a useful supplement to the treatment of post-traumatic headache.