To the Editor:  

I am concerned that the original contribution by CPT Matthew Kozminski, DO,¹ in the September 2010 JAOA does not discuss effective treatment options for soldiers with posttraumatic stress disorder (PTSD) and postconcussion syndrome (PCS). Dr Kozminski¹ clearly describes the challenges of poor follow-up and overusage of headache-abortive medications in soldiers with chronic headache. However, the lack of any discussion of effective ways to treat these soldiers is unfortunate. 

Data from the Department of Defense show that more than 1.6 million military personnel have been deployed to the conflicts in Afghanistan and Iraq since late 2001.² According to Dr Kozminski,¹ more than 95% of soldiers face combat-related posttraumatic headache attributed to PTSD and PCS—and traumatic brain injury (TBI) may be the underlying cause of both of these conditions. If we are to improve the quality of life of these soldiers, treatment plans must be included and investigated in our osteopathic medical literature. 

In cases of PCS, amitriptyline hydrochloride is probably the most commonly used medication. Studies have shown that amitriptyline is effective against such nonspecific symptoms as depression, dizziness, fatigue, insomnia, and irritability.³ Intravenous dihydroergotamine mesylate and metoclopramide hydrochloride may provide relief of refractory chronic posttraumatic headache.⁴ Greater occipital neuralgia frequently responds favorably to greater occipital nerve block using a local anesthetic, which can be combined with an injectable corticosteroid.⁵ A trial comparing either propranolol hydrochloride or amitriptyline alone with both these drugs in combination revealed a high favorable response rate in patients with posttraumatic migraine.⁶ Patients with posttraumatic paroxysmal hemicrania and hemicrania continua have responded favorably to treatment with indomethacin.^7,8 

Donepezil hydrochloride has produced beneficial results in preliminary studies of patients with severe TBI, but this medication has not been studied extensively in patients with PCS.⁹ Treatment with oxiracetam was described as being helpful for patients with PCS.¹⁰ Patients with mild TBI who also met criteria for major depression and were treated with sertraline hydrochloride for 8 weeks achieved substantial remission in depressive symptoms, as well as improvement in cognitive measures.¹¹ An open-label study of 20 patients with depression after TBI showed symptomatic improvements following treatment with citalopram hydrobromide and carbamazepine.¹² 

For symptoms of PTSD, selective serotonin-reuptake inhibitors are first-line treatment.¹³ Tricyclic antidepressants and monoamine oxidase inhibitors have been shown to decrease intrusive nightmares and flashbacks in patients with PTSD.¹⁴ Adverse effects of these medications must be weighed against their benefits. 

A meta-analysis of seven randomized, controlled clinical trials suggested that atypical antipsychotic medications reduce PTSD symptoms compared to placebo.¹³ Anticonvulsant medications that have demonstrated mood-stabilizing properties, including carbamazepine, lamotrigine, and valproic acid, may be effective in managing impulsive behavior, hyperarousal, and flashbacks in patients with PTSD.¹⁵ Prazosin hydrochloride decreased nightmares of patients with PTSD in small randomized studies.¹⁶ 

In addition to pharmacotherapy, there needs to be discussion about psychotherapy, cognitive therapy, and stress management for patients with PTSD and PCS. All of these treatments have shown promise and, for completeness, should be mentioned in any article about chronic headache in soldiers. 

Our soldiers are put in extraordinary situations with extreme stress. As osteopathic physicians, we must understand the causes of their symptoms, as Dr Kozminski¹ describes. However, to optimally address this issue, we must remember to include effective treatment options as part of the discussion.