An Interview with Dr. Russell Packard

Nathan Zasler, MD, Brain Injury Professional

Dr. Russell Packard graduated from the University of California, Irvine with an M.D. in 1971. He then did a year of Internal Medicine Internship, a Psychiatry Residency and then a Neurology Residency, all at US Navy Facilities. He subsequently became Board Certified in both Psychiatry and Neurology. He was the Director of a Headache and Head Injury Clinic in Pensacola, Florida until 2000, when he joined the faculty at Texas Tech University as a Professor of Psychiatry and Neurol­ogy until 2005. He was Professor of Neurology and Vice Chair of the Department of Psychiatry at the University of North Texas until 2007, when he decided to reenter private practice in Palestine, Texas. He is a Fellow of the American College of Physicians and the American Academy of Neurology. He has written over 100 professional papers and chapters in his career, mainly on headache and head injury. He was presented with Awards for Excellence in Neurologic Education from Texas Tech and the American Academy of Neurology in 2003, and was chosen as one of America’s Top Physicians in 2009.

Good afternoon Dr. Packard this is Dr. Nathan Zasler. I’m looking forward to interviewing you re­garding the topic of “Post-trau­matic Headache” (PTHA) given your clinical background in this area of post-TBI care and your historical contribution to the scientific literature in this area. I have a number of questions I’d like to go over with you today, so if you’re ready to go, I’m sure the readers of “Brain Injury Professional” will be interested in your thoughts and insights.

Where do you see our knowledge relative to post-traumatic head­ache, relative to what it was a decade ago?

Well, I think now there is more acceptance that there really are mild trau­matic brain injuries, concussions and headaches that result from those injuries. I know 10 years ago there were battles about whether mild trau­matic brain injury and concussion were even real entities, but I think since concussion in sports and combat injuries have come to the front over the past 10 years or so it has brought more acceptance to this whole area.

Okay… thank you for that thought. Certainly, you would agree that we see post-traumatic headache not just after mild injury, but also after moderate to severe. In terms of the general evaluation of per­sons with traumatic brain injury who present with complaints of post-traumatic headache, what do you see as the greatest area of deficit in the general medical community?

Well, from what I’ve seen there is often an inadequate history from the patient and more of an emphasis on imaging. Consequently, when the imaging is normal, which it most often is, the patient is sometimes told there is nothing wrong with them, even though there clearly is.

All too often if people don’t find anything (or at least that is what they conclude), they will diagnose the problem as psychogenic. Do you often see that as a conclusion that is drawn incorrectly by people who don’t take the time to elicit an adequate history, do an appropriate physical exam, and find nothing on the imaging?

I literally see it all the time and I have for years. Or even that the patient is just seeking compensation or malingering

As far as patients that get referred to you from other clinicians, do you typically feel that those patients have undergone an adequate physical exam, looking at the types of pain generators that are typi­cally responsible for post-traumatic headache or do you see that as one of the deficits in the context of the typical community physician evaluation for PTHA?

I think that has generally been inadequate and I say that because patients that I’ve seen will often say nobody even tested their neck range of motion, felt their neck muscles or head, or looked for trigger points to find the pain generators that are often very obvious when a careful exam is performed.

Thank you for those thoughts. My next question, Dr. Packard, is what has been your experience with the way PTHA is treated in the general medical community?

I’ve not seen a lot of successful treatments for patients prior to the time that they are referred to me. One of the first things that I usually go over with patients are goals of treatment… not only from my point of view but what are the patient’s goals of treatment? What are they after? If they want a total cure and you are working to make the headaches less fre­quent and less severe, you may never satisfy the patient. If you get on the same page, where you both are working to make the headaches less frequent and less severe, then I think you will be pretty successful most of the time.

Good point. How often do you see migraine as the cause of head­ache after trauma versus other types of headache disorders that we see post-traumatically such as tension headache, cervicogenic headache, and as related to that, do you find that it makes a dif­ference as far as peoples’ training background (i.e. neurologist vs. physiatrist vs. neurosurgeon) as far as how often they make a diag­nosis of a particular type of headache disorder?

It is really kind of like the diagnosis of migraine in general because when I see patients referred for headache evaluations, many times, they have al­ready been diagnosed as “sinus,” dental problems or cluster headache, and after a careful history, they have typical migraine. So, the diagnoses really vary. I don’t see very many that I would call pure post-traumatic migraine. What I do see are people who have had migraines and their migraine is ag­gravated by trauma. I also see people who have a rather typical migraine headache that is mixed in with neck pain and/or a tension headache, and have a pattern of chronic daily headache.

How about tension headache and cervicogenic headache… in prac­tice, do you see these headache sub-types commonly after trauma?

I think, very often, there is a tension or muscle contraction headache com­ponent to PTHA. From my point of view, most people with just tension type headaches don’t even come into the doctor. They actually take over-the-counter remedies and just go on with life but I do think they are mixed in with posttraumatic headaches a lot. I think there is often a cervicogenic neck component as well to PTHA.

As a neurologist, what role do you feel invasive pain management techniques or interventional pain management more specifically, have in treatment of post-traumatic headache, based on your exten­sive clinical experience with that population?

I, personally, have not seen it as being very helpful and, again the popula­tion I see often tends to be people who have had those procedures and they didn’t work… so it may be a little bit skewed, but the ones that do seem to get some brief relief usually have the pain return. On the other hand, if there is a fairly specific neck injury that you can pinpoint and somebody can treat that specific area, then I think that they may do better with that type of approach. If it is just an injection because they have a “headache,” they do not seem to be very helpful.

Cleary, then, it is important to not just treat the symptom of pain but to try to identify what the pain generator or generators are and treat those more directly. In this context, how much do you think cervical pain generators potentially perpetuate or aggravate other kinds of PTHA such as migraine or tension headache?

I think they are a big part actually, even in patients without trauma who come in with a migraine. Migraine patients will often say that their head­aches start at the back of their neck or after they’ve had the migraine their neck still hurts. After an injury, I think the neck is often part of that injury and it tends to keep the whole process going in a vicious cycle: neck pain triggers the headache and the headache tightens up the neck muscles.

Often times, patients are referred with headache diagnosis labels that are potentially self-prophysizing such as chronic posttraumat­ic headache or intractable posttraumatic headache because they haven’t responded to prior treatment. Would you agree that physi­cians who are looking at these kind of patients shouldn’t neces­sarily be locked into those kinds of labels and should relook at their diagnosis to make sure they were appropriately diagnosed in the first place. The unfortunate thing is that all too often, doctors whip out a prescription pad and write for an opiate…what are your thoughts on that trend?

I do agree with that and I have seen many patients referred and the only treatment they have ever had have been opiates and they have never been tried on preventative medicine or trigger point injections or even a trial of physical therapy.

It might be helpful for readers to understand the kinds of folks that you see. Do you see a combination of people more acute­ly and tertiary care referrals with more chronic post-traumatic headache or traditionally more of the latter.

I tend to see people who have persistent headaches for weeks or months. I do also get some referrals now of people who have had accidents and go to the emergency room and are referred directly to me, so I think I see more newly injured patients now than I used to, but in general, I still see more that have had their headaches for weeks or months and haven’t improved.

In your prior practice setting, you were seeing more chronic cases?

Yes. I used to be the director of a headache and head injury clinic both in private practice and at Texas Tech and referrals would often be the most refractory and persistent cases.

In general, based on your years of experience, how do you feel pa­tient’s fare relative to prognostically if their diagnosed and treated appropriately?

I think they do pretty well. I think I’ve had pretty good success working with this group and I’ve worked with them for a long time, and I think the key is going back to the beginning, like we talked about… getting a good history and exam and identifying the type or types of headache that you want to target your treatment to.

I totally concur with that and just to throw my two cents in here. Often times, the current health care system structure doesn’t neces­sarily lend itself to taking that kind of time with patients and that’s why you end up with people grabbing their prescription pad and writing for an opiate… which is of course covering up the symptom and not addressing the cause.

You mention something there that I think is really important and I have often discussed this in talks that I have given. I think the most important thing with these patients is just giving them time, and very often, the pa­tients have stated, “you’re the very first doctor I’ve had that has actually listened to me”. I always appreciate that because I do spend time with them and I think that is very important.

I think that is a very salient point to end on because I think that ultimately, we are not practicing the art of medicine if we are not taking the time to elicit an adequate history as you shared with us and get a good physical exam and, ultimately, that the art of touch, which you eluded to, and people not even touching their patients might seem surprising to some people reading this, that you have many clinicians that aren’t even examining patients but, unfortu­nately, that does happen and I think your point is very well made there as far as taking the time in doing so. I’d like to thank you on behalf of myself, as the editor of this issue, as well as our readers of “Brain Injury Professional” for taking the time to talk with me today. Thank you very much Dr. Packard.