The purpose of this study is to evaluate if theta burst stimulation (TBS) can reduce chronic headaches caused by a traumatic brain injury (TBI). TBS is a safe, drug-free brain stimulation technique that uses magnets to create electricity and stimulate nerve cells in the brain. After repeated TBS sessions, the increased stimulation of nerve cells can alter the way the brain communicates with itself (by creating new neural pathways) which, in turn, can reduce pain symptoms. Participants in this study will complete a baseline assessment followed by four weeks of daily home headache assessment. Participants will then receive four weeks of TBS administered three times per day and three days per week. After TBS is completed, participants will complete an additional four weeks of daily home headache assessment and return for a one-month follow-up assessment. Participation is expected to last three months.

The primary objective of this study is to investigate the safety and efficacy of theta burst stimulation (TBS) for the management of post-traumatic headaches to improve outcomes and quality of life for individuals who have suffered a traumatic brain injury (TBI). To improve tolerability and logistical burden, we have developed a novel design whereby participants will receive three doses of TBS on alternate days of the week. This design will allow us to assess efficacy while leveraging an accelerated treatment course (nine stimulation sessions per week). We have three specific aims:

Specific Aim 1. To determine the efficacy and safety of TBS for the treatment of post-traumatic headache among individuals who have sustained a mild TBI. Hypothesis 1a: TBS will be safe, well-tolerated, and reduce the number of headache days. Hypothesis 1b: TBS will improve function and quality of life outcomes.

Specific Aim 2: To determine the efficacy and safety of an accelerated time-course of TBS for the management of post-traumatic headache. Hypothesis 2a: The accelerated-time course will be safe, well-tolerated, and improve quality of life outcomes. Hypothesis 2b: The accelerated time-course will produce greater and faster improvement in headache symptoms than that reported in the literature for standard repetitive transcranial magnetic stimulation (rTMS) protocols.

Specific Aim 3: To examine the durability of treatment response to accelerated TBS during a one-month observational period. Hypothesis 3: Accelerated TBS will result in enduring treatment response of post-traumatic headache symptoms over the follow-up period.

This study will be an open-label pilot study and will enroll 20. Participants will complete four weeks of pre-intervention headache assessment via Ecological Momentary Assessment (EMA). Participants will then receive TBS intervention three times a week for four weeks. TBS will be administered in 10-minute sessions, three times per day with 20 minutes between sessions. TBS intervention will be completed using the Magstim Horizon Performance Transcranial Magnetic Stimulation (Magstim Company, Ltd.) device or the MagVenture MagPro X100 with MagOption Transcranial Magnetic Stimulation device (MagVenture, Inc.). Both devices are FDA-cleared to provide TBS for the treatment of Major Depressive Disorder and will be used off-label for this study. After TBS intervention, participants will complete an additional four weeks of EMA headache assessment and return for a one-month follow-up assessment. Participants will be assessed with multiple instruments and at multiple timepoints including interviews, questionnaires, and cognitive functioning assessments.

Inclusion Criteria:

• Veterans receiving services through the MVAHCS

• History of mild TBI according to VA/DoD Clinical Practice Guidelines (2009) with one or more of the following criteria present after head injury:

  • Loss of consciousness between 0-30 minutes
  • Post-traumatic amnesia between 0-24 hours
  • Alteration of consciousness/mental state up to 24 hours
  • Glasgow Coma Score between 13-15 (best available score within first 24 hours)

• Post-traumatic headaches defined by International Classification for Headache Diagnosis 3rd Edition (ICHD-3) guidelines with the following criteria present:

  • Headaches developing within seven days following trauma or injury to the head and/or neck
  • Headaches persisting beyond three months

• Chronic daily headaches defined by clinical standards with the following criterion present:

  o 15 or more headache days per month

• Men and women 18-75 years of age

• Possess a smartphone and agree to download and use the EMA application on their personal device

• Capable and willing to provide voluntary informed consent

Exclusion Criteria:

• History of moderate or severe TBI according to VA/DoD Clinical Practice Guidelines (2009) with one or more of the following criteria present after head injury:

  • Loss of consciousness greater than 30 minutes
  • Post-traumatic amnesia greater than 24 hours
  • Worst Glasgow Coma Scale less than 13 within the first 24 hours unless invalidated upon review (e.g., attributable to intoxication, sedation, systemic shock)
  • Abnormal structural imaging

• Current (within six months of enrollment) psychosis and mania

• Current (within one month of enrollment) substance dependence with the exclusion of opioids

• Personal history of epilepsy or seizure disorder

  o Does not include seizures therapeutically-induced by ECT or identified as a single seizure event (based on the principal investigator's judgement)

• Metal particles in the eye or head (exclusive of the mouth) (e.g., shrapnel, fragments from welding or metalwork, etc.)

• Implanted medical device above the clavicle (e.g., aneurysm clips, shunts, stimulators, cochlear implants, electrodes, etc.)

• Significant neurological disorder or insult that would impact risk (based on the principal investigator's judgement and research literature)

• Current use of medications with significant potential for lowering seizure threshold

• Current benzodiazepine usage at a dose higher than 3mg of lorazepam or equivalent

• Electroconvulsive therapy (ECT) or cortical energy exposure within one month of enrollment (including participation in any other neuromodulation treatments or studies)

• Current (within one month of enrollment) participation in another interventional study that would impact the results of this research

• Inadequate communication (e.g., language barrier)

• Women who are pregnant, trying to become pregnant, or breastfeeding

• Women of childbearing age/potential who are not using a medically-accepted form of contraception when sexually active

Final data sets may be made available upon written request and subject to sponsor approval.