Behavioral, non-pharmacological intervention modalities to alleviate persistent headache attributable to traumatic brain injury: A systematic review of patient pain outcomes in the context of the mutual maintenance model

Background: Persistent post-traumatic headache (PPTH) is a disabling sequela of traumatic brain injury (TBI). Many individuals seek behavioral interventions to supplement pharmacological treatment. This systematic review describes behavioral interventions for treatment of PPTH and psychosocial factors related to outcomes in adults. Methods: A systematic search for behavioral interventions for adult patients who suffered headache attributable to mild TBI was conducted across PubMed, CINAHL, Scopus, PsycINFO and Cochrane Library in June 2024. Studies were excluded if they (a) did not evaluate outcomes related to PPTH pain; (b) evaluated pediatric populations; (c) used animal models; (d) evaluated interventions other than behavioral modalities; and (e) TBI was moderate or severe. Risk of bias was assessed for included randomized controlled trials (RCTs) using Cochrane's Risk of Bias II (RoB2). Results: The search and evaluation process identified 12 articles evaluating 2293 individuals with PPTH. Study designs included randomized controlled trials (n = 4) and observational studies (n = 8). Behavioral intervention modalities included cognitive behavioral therapy (n = 5), education/counseling (n = 3), exercise (n = 2) and integrated managed care (n = 2). Three included RCTs were assessed to have low risk of bias and one had some concerns of potential bias. Conclusions: Cognitive behavioral interventions within interdisciplinary systems of care may be the optimal combination. Mutual maintenance may explain and contextualize the high comorbidity between PPTH and affective distress. Treatment for PPTH in adults with mild TBI should incorporate treatment for psychological distress. Trial Registration: This systematic review was registered in Prospero (CRD42024556014).