Headache complexity (number of symptom features) differentiates post-traumatic from non-traumatic headaches

Ann I. Scher*, James S. McGinley, R. J. Wirth, Richard B. Lipton, Heidi Terrio, Lisa A. Brenner, Wesley R. Cole, Karen Schwab

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background: Post-traumatic headaches are a common sequela of mild traumatic brain injury (concussion). It is unclear whether or how these headaches differ phenotypically from primary headaches. Objective: Determine whether there is an overarching unobserved latent trait that drives the expression of observed features of post-traumatic headache and other headaches. Methods: Data from this post-hoc analysis come from the Warrior Strong Cohort Study conducted from 2010 through 2015. Approximately 25,000 soldiers were screened for concussion history at routine post-deployment health assessments. A random sample was invited to participate, enrolling 1567. Twelve observed headache phenotypic features were used to measure “headache complexity”, the latent trait of clinical interest, using single factor confirmatory factor analysis. We compared headache complexity between groups and determined whether headache complexity predicted accessing medical care for headache. Results: Of 1094 soldiers with headaches, 198 were classified as having post-traumatic headache. These headaches were compared to those in the other soldiers (647 without concussion history and 249 with concussion history). Soldiers with post-traumatic headache had greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The confirmatory factor analysis showed good model fit (χ2 (51) = 95.59, p = 0.0002, RMSEA = 0.03, comparative fit index = 0.99, and Tucker-Lewis index = 0.99), providing empirical support for the headache complexity construct. Soldier groups differed in their mean headache complexity level (p < 0.001) such that post-traumatic headache soldiers had greater headache complexity compared to non-concussed soldiers (standardized mean difference = 0.91, 95% confidence interval: 0.72–1.09, p < 0.001 and to concussed soldiers with coincidental headaches standardized mean difference = 0.75, 95% confidence interval: 0.53–0.96, p < 0.001). Increasing headache complexity predicted medical encounters for headache (odds ratio = 1.87, 95% confidence interval: 1.49–2.35, p < 0.001) and migraine (odds ratio = 3.74, 95% confidence interval: 2.33–5.98, p < 0.001) during the year following deployment. Conclusions and relevance: The current study provided support for a single latent trait, characterized by observed headache symptoms, that differentiates between concussive and non-concussive headaches and predicts use of medical care for headache. The single trait confirmatory factor analysis suggests that post-traumatic headaches differ from non-concussive headaches by severity more than kind, based on the symptoms assessed. ClinicalTrials.gov

Original languageEnglish
Pages (from-to)582-592
Number of pages11
Issue number5
StatePublished - Apr 2021
Externally publishedYes


  • Concussion
  • cohort study
  • epidemiology
  • post-traumatic headache
  • traumatic brain injury


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