Headaches Forcing Soldiers Out of Duty

New research from Johns Hopkins indicates that headaches are among the top reasons for medical evacuation of military personnel from Iraq and Afghanistan, and for ongoing depletion of active-duty ranks in those countries. Just one-third of soldiers sent home because of headaches return to duty in either location.

“Everyone gets headaches, and there are generally physical or psychological stressors that contribute to them,” said lead investigator Steven P. Cohen, MD, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and a colonel in the US Army Reserves. “War amplifies all stressors, which may be why headaches take such a great toll in soldiers overseas.”

The findings, published online in Cephalalgia, highlight one of the fastest-growing causes of medical evacuations from the two prolonged military conflicts. They are a significant and worrisome contributor to the depletion of military units overseas, Cohen noted.

Overall, neurological illness is one of the top 3 causes of non-combat-related loss of unit strength in Operations Iraqi Freedom and Enduring Freedom, and headaches are the most common neurological complaint in the war zones. Cohen and his team found that post-concussion headaches and migraines were the most common forms of headache requiring evacuation. Physical trauma led to almost half of the debilitating headaches, they determined.

Cohen said that a significant number of headaches were the result of damage to or pressure on the occipital nerve, located in the back of the head. This is often caused by the heavy Kevlar helmets soldiers are required to wear on patrol and for long periods.

“Everyone who goes on patrol wears a Kevlar helmet,” Cohen said in a statement. “They are heavy. They are hard to wear. But if you get a headache from your helmet, you still must wear it. If you can’t tolerate your helmet, you can’t do your job. It would be too dangerous. So these folks end up being evacuated and not returning to duty.”

In the study, Cohen and colleagues reviewed the medical records of all 985 military personnel—roughly one in 1000 soldiers deployed in the regions—medically evacuated from Iraq and Afghanistan between 2004 and 2009 with a primary diagnosis of headache. Around 67% never returned to the war zone, the researchers found. Those most likely to return were officers, whose jobs are often less physically taxing, and women.

Only 1 in 5 of those whose headaches were associated with physical trauma, such as post-concussion headaches, returned to duty, while nearly half of those who were evacuated with tension headaches went back to the war zone.

For those headache sufferers who also had a diagnosis of a psychiatric illness or traumatic brain injury, the return to duty rate was among the lowest. Those whose headaches were treated with narcotic pain killers were also far less likely to return to work in a war zone.

Although headaches can be difficult to diagnose, Cohen said he doesn’t believe that soldiers are exaggerating symptoms in hopes they will be sent home from war.

“Headaches can really be tough to manage,” said Cohen, who is also director of chronic pain research at Walter Reed National Military Medical Center. “When people have bad headaches, they often can’t think or work. They’re incapacitated. That doesn’t work in a war zone.”

In light of the study results, researchers stress the importance that military doctors understand how headaches affect those on the ground and make efforts to treat them more successfully where they are, rather than turn to evacuation. Better guidelines for the management of headaches, both on the ground and post-evacuation, could help retain soldiers on active duty in war zones, they noted, and better design of helmets could reduce strain on the occipital nerve and prevent at least 1 common type of headache.