Targeted dietary interventions to reduce pain in persistent post-traumatic headache among service members: Protocol for a randomized, controlled parallel-group trial.

INTRODUCTION: Post-traumatic headache (PTH) is common after traumatic brain injury (TBI), especially among active-duty service members (SMs), affecting up to 35% of patients with chronic TBI. Persistent PTH is disabling and frequently unresponsive to treatment and is often migrainous. Here, we describe a trial assessing whether dietary modifications to increase n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and reduce n-6 linoleic acid (LA), will alter nociceptive lipid mediators and result in clinical improvements in persistent PTH. METHODS: This prospective, randomized, controlled trial tests the efficacy, safety, and biochemical effects of targeted, controlled alterations in dietary n-3 and n-6 fatty acids in 122 adult SMs and military healthcare beneficiaries with diagnosed TBI associated with actively managed persistent frequent (>8 /month) PTH with migraine. Following a 4-week baseline, participants are randomized to one of two equally intensive dietary regimens for 12 additional weeks: 1) increased n-3 EPA + DHA with low n-6 LA (H3L6); 2) usual US dietary content of n-3 and n-6 fatty acids (Control). During the intervention, participants receive diet arm-specific study oils and foods sufficient for 75% of caloric needs and comprehensive dietary counseling. Participants complete daily headache diaries throughout the intervention. Clinical outcomes, including the Headache Impact Test (HIT-6), headache hours per day, circulating blood fatty acid levels, and bioactive metabolites, are measured pre-randomization and at 6 and 12 weeks. Planned primary analyses include pre-post comparisons of treatment groups on clinical measures using ANCOVA and mixed-effects models. Similar approaches to explore biochemical and exploratory clinical outcomes are planned. CLINICALTRIALS: gov registration: NCT03272399.

The behavioral presentation of an individual with a disordered sense of self.

There is increased recognition that the brain processes a "sense of self" (best understood as a sense of "mineness") in the right hemisphere association area and which can be distorted due to neurologic injury. Although there are numerous descriptions of types of disorders of the self (e.g., asomatognosia, anosognosia, mirror misidentification disorder, Capgras syndrome, schizophrenia), there are few descriptions of the subjective experiences of individuals with traumatic brain injury (TBI) who experience a reduced sense of self. This article presents a longitudinal case study of a woman in her early 40s with a primarily right hemisphere TBI and disorder of the self who had difficulties relating her experiences from the perspective of the self. Subjective interviews, neuropsychological test scores, and objective personality testing illustrate how she reported her experiences of a diminished sense of self, and how this sense of self improved over the normal course of recovery following the TBI. This case demonstrates clinically relevant information regarding how individuals with a reduced "sense of self" (i.e., "mineness") associated with a right hemisphere TBI may report their subjective experiences and perform on objective testing.