Post-Traumatic Headache

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Headache is the most common and among the most prevalent prolonged symptoms following concussion. The vast majority of people with post-traumatic headache improve within days or weeks; however, for some individuals, headaches may persist beyond this time frame up to months or years1-3. The International Classification of Headache Disorders (ICHD-III)4 includes diagnostic criteria for both acute (see Appendix 6.1) and persistent post-traumatic headache following mTBI (see Appendix 6.2).

Post-traumatic headache is classified as a secondary rather than primary headache subtype. Headache subtypes are then based upon clinical characteristics that best fit primary headache categories (i.e. migraine- or tension-type headaches).3 In line with this, diagnostic criteria for the common phenotypes of post-traumatic headache are provided in Appendix 6.3, and individual treatment pathways for these classes of primary headaches can be found in Algorithm 6.1. 

Comorbid conditions such as post-traumatic stress disorder (PTSD) contribute to the complexity of managing post-traumatic headache.3,7-9 Accordingly, post-traumatic headache should not be treated as an isolated condition5 and the management of symptoms is based upon clinical experience and expert opinion.4

Frequent use of analgesics/acute headache medications may lead to or perpetuate chronification of headaches, also known as medication overuse (“rebound”) headache.10 Accordingly, it is important to provide clear instructions on the maximal allowable daily dosing and monthly frequency of medication consumption. Combination analgesics, narcotic analgesics, ergotamines, triptans, and diclofenac potassium oral solution can be utilized no more than 10 days per month to avoid medication overuse (rebound) headache. Patients should be encouraged to accurately monitor the frequency and quantity of their acute headache medication use (ie. through use of a Medication Diary). The ICHD-III criteria for Medication Overuse in Headache is presented in Appendix 6.5.

References supporting introduction:

  1. Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85(7):619-627.
  2. Sawyer K, Bell KR, Ehde DM, et al. Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms. Arch Phys Med Rehabil. 2015;96(11):2000-2006. doi:10.1016/j.apmr.2015.07.006
  3. Lew HL, Poole JH, Guillory SB, Salerno RM, Leskin G, Sigford B. Persistent problems after traumatic brain injury: The need for long-term follow-up and coordinated care. J Rehabil Res Dev. 2006;43(2):vii-x
  4. (IHS) HCSotIHS. The International Classification of Headache Disorders 3rd Edition (Beta version). 2016; https://www.ichd-3. org/. 
  5. Theeler B, Lucas S, Riechers RG, Ruff RL. Post-traumatic headaches in civilians and military personnel: a comparative, clinical review. Headache. 2013;53(6):881-900.
  6. Yilmaz T, Roks G, de Koning M, et al. Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emerg Med J. 2017;34(12):800-805. doi:10.1136/emermed-2015-205429
  7. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22. 
  8. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Posttraumatic stress disorder mediates the relationship between mild traumatic brain injury and health and psychosocial functioning in veterans of Operations Enduring Freedom and Iraqi Freedom. J Nerv Ment Dis. 2009;197(10):748-753
  9. Roper, L. S., Nightingale, P., Su, Z., Mitchell, J. L., Belli, A., & Sinclair, A. J. (2017). Disability from posttraumatic headache is compounded by coexisting posttraumatic stress disorder. Journal of pain research, 10, 1991–1996. https://doi.org/10.2147/JPR.S129808
  10. Baandrup L, Jensen R. Chronic post-traumatic headache--a clinical analysis in relation to the International Headache Classification 2nd Edition. Cephalalgia. 2005;25(2):132-138.

 

Assessment of Post-Traumatic Headache
6.1

Delayed brain imaging (brain CT or MRI) should be considered when neurologic signs or symptoms are suggestive of possible intracranial pathology and/or there are progressive/worsening symptoms without indications of other cause.

Level of Evidence C
Last updated  
6.2

The primary care provider should take a comprehensive headache history (see Table 6.1) in order to identify the headache subtype(s) that most closely resemble(s) the patient’s symptoms.

Context

Headache subtypes would typically include migrainous type and tension type but other considerations would be occipital neuralgia, medication overuse headache and cervicogenic headache. Alongside headache history, the primary care provider should consider whether the patient has certain risk factors related to a higher likelihood of the patient experiencing post traumatic headache including:

  • Female gender
  • Younger age
  • Imaging abnormalities on a CT scan or MRI
  • Headache when presenting at the emergency department
  • Injury occurring when under the influence of alcohol

References supporting context:

  1. Yilmaz, T., Roks, G., de Koning, M., Scheenen, M., van der Horn, H., Plas, G., Hageman, G., Schoonman, G., Spikman, J., & van der Naalt, J. (2017). Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emergency Medicine Journal. 2017; 34(12), 800–805.
  2. Nordhaug, L. H., Linde, M., Follestad, T., Skandsen, Ø. N., Bjarkø, V. V., Skandsen, T., & Vik, A. Change in headache suffering and predictors of headache after mild traumatic brain injury: A population-based, controlled, longitudinal study with twelve-month follow-up. Journal of Neurotrauma. 2019; 36(23), 3244– 3252.

 

Level of Evidence B
Last updated  
6.3

Primary care providers and healthcare professionals treating patient’s headaches should perform neurological and musculoskeletal examinations including the cervical spine and vestibular system.

Level of Evidence C
Last updated  
6.4

6.4a: Establish the degree of headache-related disability (taking a biopsychosocial approach) to assist in preparing a treatment approach (i.e., non-pharmacological and/or pharmacological).

6.4b: Personal, environmental, work-related, school-related, and physical factors such as neck pain should be identified and addressed as potential headache contributors.

6.4c: Functionally limiting or atypical headache symptoms should be considered for referral to an interdisciplinary concussion clinic, neurologist or headache clinic.

Level of Evidence B
( bullets A and B )
Level of Evidence C
( bullet C )
Last updated  
Non-Pharmacological Treatment of Post-Traumatic Headache
6.5

Education should be provided to the patient on the lifestyle strategies (see Appendix 6.6 and Table 6.2) useful for potentially minimizing headache occurrence and/or decreasing the impact of headaches when they occur (i.e., maintaining consistent bedtime and wake time, consuming consistent meals with no skipped or delayed meals, good hydration, regular low-intensity cardiovascular exercise, use of relaxation, stress-management, and mindfulness-based strategies).

Level of Evidence C
Last updated  
Pharmacological Treatment of Post-Traumatic Headache
6.6

All patients with post-traumatic headache should be encouraged to maintain an accurate headache and medication diary (see Appendix 6.4) and to bring it to every follow-up visit with their clinician.

Context

The headache diary will:

  • Help patients and their clinicians identify the frequency, duration, and severity of the headaches
  • Aid in identifying the type, frequency, and amount of acute headache medications used
  • Help to recognize potential headache triggers
  • Guide treatment decisions and evaluate response to treatment
  • Help the provider identify possible medication overuse headache

 

Level of Evidence C
Last updated  
6.7

Patients may use acute headache medications to try to reduce the severity, duration, and disability associated with individual headache attacks. The use of these medications need to be limited in frequency to minimize the potential for medication overuse (rebound) headache:

  1. Over the counter analgesics (e.g., acetaminophen, ibuprofen, acetylsalicylic acid, naproxen) should be used less than fifteen days per month.
  2. Combination analgesics (i.e., with caffeine or codeine) should be used less than 10 days per month.
  3. Many post-traumatic headaches are migrainous in nature and are responsive to migraine-specific triptans. Triptans should be used less than 10 days per month.

 

Level of Evidence C
Last updated  
6.8

Migraine-specific acute therapies should be trialed when non-specific acute therapies are incompletely effective. Triptans can be used for migrainous-type headaches less than 10 days per month.

Level of Evidence C
Last updated  
6.9

Due to a multiplicity of potential adverse consequences (addiction, dependency, rebound headache), narcotic analgesics should be avoided or restricted solely to “rescue therapy” for acute attacks when other first- and second-line therapies fail or are contraindicated. When utilized, narcotics should be stringently restricted to no more than twice weekly.

Level of Evidence C
Last updated  
6.10

When headaches are too frequent (e.g., more than 10 days per month) or disabling, prophylactic therapy should be considered.

Level of Evidence C
Last updated  
6.11

Post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to a neurologist, headache specialist, or interdisciplinary concussion clinic is recommended.

Level of Evidence C
Last updated  
Assessment (Table 6.1)
Important Components to Include in the Focused Headache History
Assessment (Appendix 6.3)
Diagnostic Criteria for Selected Primary Headache Types from the International Classification of Headache Disorders, 3rd Edition (ICHD-III Beta)
appendix-6-3.pdf
Assessment (Appendix 3.4)
Core Components to Include in the Neurologic and Musculoskeletal Exam
appendix-3-4.pdf
Management (Appendix 6.6)
Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence
appendix-6-6.pdf
Management (Table 6.2)
Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence
Assessment (Appendix 6.5)
International Classification of Headache Disorders (ICHD-III) Beta: Medication-Overuse Headache
appendix-6-5.pdf
Management (Appendix 6.4)
Headache Diary
appendix-6-4.pdf
Management (Appendix 6.7)
Prophylactic Therapy
appendix-6-7.pdf
Assessment (Appendix 6.1)
International Classification of Headache Disorders, 3rd Edition (ICHD-III Beta): Acute Headache Attributed to Traumatic Injury to the Head
appendix-6-1.pdf
Assessment (Appendix 6.2)
International Classification of Headache Disorders, 3rd Edition (ICHD-III Beta): Persistent Headache Attributed to Traumatic injury to the Head
appendix-6-2.pdf
Global Overview Of Assessment And Management (Algorithm 6.1)
Assessment and Management of Post-Traumatic Headache Following mTBI
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Ashina, H., Iljazi, A., Al-Khazali, H. M., Ashina, S., Jensen, R. H., Amin, F. M., Ashina, M., & Schytz, H. W. Persistent post-traumatic headache attributed to mild traumatic brain injury: Deep Phenotyping and Treatment Patterns. Cephalalgia. 2020;40(6), 554-564. 

STROBE: 15/23 

Associated with recommendations 6.2, 6.7, and 6.8

Sawyer K, Bell KR, Ehde DM, et al. Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms. Arch Phys Med Rehabil. 2015;96(11):2000-2006. 

DOWNS & BLACK: 16/32

Associated with recommendation 6.2

Maruta, J., Lumba-Brown, A., & Ghajar, J. Concussion subtype identification with the RIVERMEAD post-concussion symptoms questionnaire. Frontiers in Neurology. 2018; 9.  

STROBE: 17/23

Associated with recommendation 6.2

McGeary DD, Resick PA, Penzien DB, et al. Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study. Cephalalgia. 2020;40(11):1155-1167.

STROBE: 21/23

Associated with recommendation 6.2

Dumke, H. A. Posttraumatic headache and its impact on return to work after mild traumatic brain injury. Journal of Head Trauma Rehabilitation. 2017; 32(2).  

STROBE: 17/23

Associated with recommendation 6.4 bullets A and B

Meltzer, K. J., & Juengst, S. B. Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity. Brain Injury. 2021; 35(1), 41-47.  

STROBE: 15/23

Associated with recommendation 6.4 bullets A and B

Nordhaug, L. H., Linde, M., Follestad, T., Skandsen, Ø. N., Bjarkø, V. V., Skandsen, T., & Vik, A. Change in headache suffering and predictors of headache after mild traumatic brain injury: A population-based, controlled, longitudinal study with twelve-month follow-up. Journal of Neurotrauma. 2019; 36(23), 3244-3252.  

Quality Rating: STROBE: 19/23

Associated with recommendation 6.4 bullets A and B

Silverberg, N. D., Martin, P., & Panenka, W. J. Headache trigger sensitivity and avoidance after mild traumatic brain injury. Journal of Neurotrauma. 2019; 36(10), 1544-1550. 

STROBE: 20/23

Associated with recommendation 6.4 bullets A and B

Yilmaz, T., Roks, G., de Koning, M., Scheenen, M., van der Horn, H., Plas, G., Hageman, G., Schoonman, G., Spikman, J., & van der Naalt, J. (2017). Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emergency Medicine Journal. 2017; 34(12), 800-805.  

STROBE: 16/23

Associated with recommendation 6.4 bullets A and B