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Some mornings they start at the top of Sgt. Chris Muhlbauer's neck, spider-web their way up the back of his skull and spread until his entire head pounds.
These headaches happen maybe three times a week. Sometimes Tylenol helps. Sometimes nothing does for days.
Some mornings the Army Reserve staff sergeant is fine and then — boom! — it's like an IED has gone off near his temples, and all he wants to do is close the shades tightly and crawl back under the covers.
And sometimes, when the pain gets really bad, Muhlbauer feels his head pulling away from his body, and then he's floating, his head slowly drifting away from the rest of him — like a balloon in a gentle breeze.
“Oh, my gosh, it's so strange,” he says. “You are looking down at your body and saying, ‘What the hell is this?'”
This is Muhlbauer's reality: chronic headaches, persistent pain intertwined with short-term memory loss, an acute sensitivity to bright lights and loud noises — all hallmarks of a mild traumatic brain injury.
This is the stubborn legacy of Muhlbauer's three tours of duty in Iraq, where the 37-year-old drove dozens of trucking missions over IED-infested roads and suffered a series of potential brain injuries, likely complicated by post-traumatic stress disorder.
Increasingly, this is normal. In an initial screening, 828 Nebraska and western Iowa veterans — nearly one out of every five local vets tested — showed some sign of a potential brain injury after deploying to Afghanistan or Iraq, where makeshift bombs that jar troops' brains are the enemy's weapon of choice.
The Omaha VA Medical Center's new Polytrauma Clinic, which opened in September, has quickly filled as Muhlbauer, of Louisville, and more than 200 other young vets seek treatment for headaches, insomnia, personality changes and a grab bag of other symptoms often tied to a traumatic brain injury.
Military and medical officials now regard that injury, commonly known as TBI, as a serious, nationwide medical problem, one that affects an estimated 320,000 American veterans. Many of them will be in pain long after the final shot is fired.
“This is the great, unrecognized, signature injury of this war,” said Mark Showers, the VA clinic's occupational therapist. “I don't know what the final number of these injuries are going to be, but it's going to be really, really high.”
Like many of the Nebraska and western Iowa vets treated at the VA clinic, Muhlbauer isn't even sure how he hurt his head.
On his first or second deployment — he can't remember which — he was trucking a load of equipment down an Iraqi road when an IED exploded behind him. The force of the impact destroyed his tires and hurt his ears, but he walked away thinking himself lucky and unharmed.
On other occasions, he hit gigantic craters in the pavement while speeding down an Iraqi road, trying to avoid attacks. He hit his head on the ceiling of his 18-wheeler so many times he lost count.
Muhlbauer also remembers slipping while working on his truck and banging himself on the head with a metal pry bar, hard enough that he saw stars.
“Maybe it was one of these, maybe it wasn't,” he said. “Maybe it was all of the above. I don't know.”
Muhlbauer knows this: Before going to war, he could remember names and dates with ease. Now he punches all important information into his BlackBerry, knowing that if he doesn't, it will vanish from his memory.
He sometimes notices he's being unnecessarily short with his daughters, ages 7 and 4, treating them as if they are Army grunts instead of children.
He also hurt his shoulder in Iraq, making it hard to lift things or do previously routine chores while working for the City of Omaha's Public Works Department. He sometimes can't sleep. When he goes to restaurants, he sits between his daughters and faces the door, as if to protect them from an attack.
Several VA doctors and therapists interviewed said there is sometimes no way to tell how many of a veteran's medical problems are related to a mild TBI and how many are triggered or worsened by post-traumatic stress disorder.
“Imagine being blown up by an IED,” Showers said. “You are going to have a brain injury. You are going to have traumatic stress. It's a severe, life-altering event, and it happens in the brain, this black box no one has dared to enter.”
At the VA Polytrauma Clinic, a team of doctors, therapists and medical health professionals works together, attacking the symptoms of a brain injury from different angles in the hope the joint effort will succeed.
If a veteran is having problems sleeping, for example, one specialist might teach him or her relaxation techniques, while another helps the vet with memory strategies, allowing the release of pent-up emotion, said Dr. Jill Champley, the clinic's speech pathologist.
Other clinic employees might work to keep the veteran's day organized, reducing the amount of stress, while another might help manage the veteran's pain. A case manager checks in frequently, reminding the veteran of appointments and asking how he or she is doing.
The overarching goal: Use some combination of medicine, therapy and rehabilitation to help the veteran return to normal, or as close as he or she can get.
“That's where the veteran, I think, gets so much better care than he might have in the past,” Champley said. “We're talking to each other. We're discussing the case all day long.”
The joint effort would have been unlikely in the earlier years of the war, when “having your bell rung” meant shaking it off and heading back into battle.
But the Department of Defense and military leaders have started to react to skyrocketing suicide rates and medical research suggesting that untreated PTSD and brain injuries, often tied together, are prompting serious mental, behavioral and health issues for a growing number of recently returned service members.
Now, service members are tested before and after deployments so doctors can compare the memory and brain function of a veteran to his earlier test results. During a deployment, a soldier is now often temporarily removed from duty if he suffers even a mild concussion, and is supposed to be benched permanently if he suffers three.
Polytrauma clinics meant to combat the brain injury problem have been opened in or near VA hospitals across the country in the past two years. Many of these clinics are bracing for a deluge of patients this year, as troops begin to return home from the surge in the Afghan war.
The historical stigma associated with post-traumatic stress disorder is also fading, the VA doctors said, allowing more veterans who might have both a brain injury and PTSD feel comfortable walking into the clinic and asking for help.
Simply convincing the veterans to show up seems the most important step in the recovery process.
With proper treatment, 90 percent of veterans suffering from a mild traumatic brain injury can get back to normal brain functioning within a year or two, says Joni Dittbrenner, the clinic's social worker.
Without treatment, problems can linger a lifetime and grow far worse if the veteran is battling PTSD or suffers another head injury.
A severe brain injury often changes a person's personality and can make it impossible to do simple tasks like buttoning a shirt.
“You peel back the layers like an onion, and the mild cases are just a few layers,” Dittbrenner said. “The tough cases, you start to peel back the layers and you keep finding more layers.”
Muhlbauer seems committed to peeling the layers off his own injuries.
He gets physical therapy for his shoulder. In a recent session, he strained to lift 2- and 3-pound weights while a physical therapist urged him on.
He's had two MRIs, quit drinking, worked on techniques to sleep better and weaned himself off most of the pain medications he used to need to make it through the day.
He gets acupuncture at the polytrauma clinic. And, on Wednesday nights, he meets with a PTSD group, veterans from Vietnam, Iraq and Afghanistan who swap stories and lean on one another for support.
All this work appears to be working: His headaches have decreased in severity and frequency, and he feels better than when he returned from Iraq last spring.
He's still hoping for the day, someday soon, when he won't have to worry about a headache webbing its way up the back of his skull.
When the reservist runs into other soldiers in his unit, he urges them to come to the VA clinic and get help.
“I tell them, ‘Go get checked. You have the same symptoms I have. I've got issues, too, and I'm trying to get them taken care of.'”
Contact the writer:
402-444-1064, matthew.hansen@owh.com
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