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Consideration of this subject brings us to the intersection of some of the most critical issues challenging the migraine treatment community. With Memorial Day fading in the rear view mirror, we at AMD began to reflect on a number of these issues and thought looking at Traumatic Brain Injury (TBI) may be as good a place as any to enter the ongoing controversy. Yes, TBI, because of its startling presence in both the military and civilian worlds, TBI could prove a very opportune place indeed.
First, let’s consider some basic metrics to get our bearings. Starting with civilians. In the US alone, 1.7 million people suffer a TBI annually. Head pain is judged to be the most common symptom subsequent to a head injury. It is estimated about 50% of people who have had a concussion report head pain for > two months. This is labeled post-concussion syndrome. The headache associated is often named Post Traumatic Headache (PTH). Even after a relatively mild head injury the pain is documented (in some cases) to persevere for years. About 25% of post-concussion, or PTH, head pain patients report migraine symptoms similar to that of migraine without aura. These civilian numbers were really cobbled together as no precise longitudinal data exists right now. Nonetheless, let’s go out on a limb. 50% of TBI annually (850000) report significant head pain, 25% of these patients further report non aura migraine like symptoms ( 212500). Taken out 10 years that’s about 2 million, 125 thousand sufferers on the civilian side.
The military side is also disturbing. Since the U.S. went to war in Afghanistan in 2001 and Iraq in 2003, about 2.5 million members of the various branches, and related Reserve and National Guard units have been deployed in the Afghanistan and Iraq wars, according to Department of Defense data. More than a third of these patriots have deployed more than once. How many of these troops have suffered TBI? This is hard to quantify. At the high end of the range the Rand Corporation estimates 400,000. At the low end of the range sits the DOD at 50,000 troops. Given what we now know about the effects of battlefield concussion, our troops unwillingness to report injury, and the high costs associated with treating veterans for years to come, we favor the higher estimate. Add them together, and that’s a lot of people.
Based on the above, and other compelling arguments, our first point; Traumatic Brain Injury and Post Traumatic Headache Deserve a Well-Defined Place on the Spectrum of Migraine Disorders. We do not mean to imply nothing is being done. Many distinguished minds are tackling this problem. However, Post traumatic headache has no defining clinical features, and as a result is classified as a secondary headache disorder in the International Classification of Headache Disorders, third edition-beta (ICHD-3). This implies another primary disorder in close temporal relation is known to cause the headache or fulfills other criteria for causation by that disorder. The new headache is coded as a “secondary headache” attributed to the causative disorder. Some may disagree. There is little secondary about it. This is an appropriate segue to our second point.
Failure in classification is a direct result of the fact that many professionals fail to take migraine disease, or the spectrum, seriously. The leading doctors in the areas of neurology and related disciplines have themselves stated that migraine disease is grossly misunderstood and misdiagnosed. In fact, 60% of women and 70% of men with migraine have eluded proper diagnosis. This medical ignorance and corresponding inaccurate writings unfortunately perpetuate the myths and misunderstandings about migraine, and ultimately convey this to the general public. In order to begin to remedy this situation, we support the following; A Re-Ordering of the Classification of Headache Disorders to Include the Migraine Spectrum and Associated Variants is Overdue. By changing the language we can transform the perception of the disease. As a new, more accurate paradigm is introduced and endorsed, based on solid science, eventually both professional and lay attitudes can be effected.
Finally. a familiar refrain. One that is presently being heard at the ongoing American Headache Society Scientific Meeting in San Diego. Greater Funding for Research is Greatly Needed. For example it was Adm. Mike Mullins, Chairman of the US Joint Chiefs of Staff who recognized the TBI problem in our veterans, convened the “Grey Team”, led by Dr. Christian Macedonia, and changed the face of battlefield medicine. MRIs are now present close to the battlefield and can evaluate a soldier without sending him home. Something like this needed money and clout to be realized.
We, collectively professionals, migraineurs and related sufferers, have the respect and the numbers to bring enormous power to bear on this multi-faceted problem. Use this month to reflect on how this change can be made. The Grey Team story is a compelling one. But you also have your own story to tell. Pledge that this month you will refine your story and tell it to three people of influence. An email to Senator asking for an increase in NIH funding, posting your story on social media, use your imagination. 36 million voices, as we have said before, can be mighty loud!