Mechanisms of change in posttraumatic headache–related disability: A mediation model

Abstract Objective To explore whether the association between change in headache management self‐efficacy and posttraumatic headache–related disability is partially mediated by a change in anxiety symptom severity. Background Many cognitive–behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache–related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. Methods This study is a secondary analysis of veterans ( N = 193) recruited to participate in a randomized clinical trial of cognitive–behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self‐efficacy and headache‐related disability, along with partial mediation through change in anxiety symptoms was tested. Results The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self‐efficacy and headache‐related disability ( b = −0.45, p < 0.001; 95% confidence interval [CI: −0.58, −0.33]). The total effect of change of headache management self‐efficacy scores on change in Headache Impact Test‐6 scores was significant with a moderate‐to‐strong effect ( b = −0.57, p = 0.001; 95% CI [−0.73, −0.41]). There was also an indirect effect through anxiety symptom severity change ( b = −0.12, p = 0.003; 95% CI [−0.20, −0.04]). Conclusions In this study, most of the improvements in headache‐related disability were related to increased headache management self‐efficacy with mediation occurring through change in anxiety. This indicates that headache management self‐efficacy is a likely mechanism of change of posttraumatic headache–related disability with decreases in anxiety explaining part of the improvement in headache‐related disability.