Headache is the most common physical symptom after Traumatic Brain Injury (TBI), 75% of which are mild TBI (mTBI) (Walker et al. 2005; Dikmen et al. 2010). Prevalence of PTH in prospective cohort studies ranged from 30-60% at 1 month post injury and 26-65% 1 year post injury (Dikmen et al. 2010, Faux & Sheedy 2005; Hoffman et al. 2011; Lieba-Samal 2011; Lucas et al. 2014; Stovner et al. 2009; Barlow et al. 2010; Eisenberg et al. 2013). PTH affects even more those with 2 or more concussions. 20-40% of individuals have chronic headache with both significant pain and impact over 5 years post injury. Interestingly, headache was more prevalent in those with mTBI (56-69%) vs those with TBI (33-40%) in the ensuing year after sustaining the injury (Hoffman et al. 2011; Lucas et al. 2014).
The International Classification of Headache Disorders (ICHD) is a compendium of all headache-related disorders published by the International Headache Society. It is considered the official classification of headaches by the World Health Organization using explicit diagnostic criteria that are based on clinical and laboratory observations. ICHD classifies PTH as a headache attributed to trauma to the head and/or neck. There are a few criteria specifiers but the main clinical message is that there are no specific features that can help distinguish a headache due to trauma from one that is not related to trauma. A headache can also develop for other reasons (other than mTBI) in the context of having had a post-traumatic head injury. Most PTHs resemble tension-type headaches (TTH) or migraines and so are actually just managed as such. So what is the point of highlighting that the headache – whether it be TTH or Migraine or another type – is associated with trauma if it doesn’t help in clinical management decisions?
Most (38-46%) headaches in the year after mTBI will be migraines. The second highest incidence of headaches are termed “unclassifiable” as they have overlapping features of many different types of headaches listed in the ICHD. The third highest are TTH (9-19%) followed by cervicogenic headaches (6-10%). Cervicogenic headaches is considered by some to be a controversial topic but to satisfy the reader’s curiosity, it states that inflammation in neck structures will create headaches (rather than the headaches being caused by another mechanism) (Lucas et al. 2012; Lucas et al. 2014).
There tends to be 3 groups of PTH patients when judged with respect to how much impact the headaches have on their daily lives:
- Minimal (~48%)
- Worsening (~27%)
- Chronic (~24%)
Risk factors for belonging to the chronic PTH impact group are: female, injured by violence, unemployed prior to injury and prior history of headache.
There tends to be 4 groups of PTH patients as judged by pain scores:
- Minimal (~ 25%): For these patients, the headache is mild and is never really an issue.
- Improving (~7%): For these patients, the headache is initially severe but greatly improves over the course of convalescence.
- Worsening (~37%): The headache starts out mild but progressively worsens with time.
- Chronic (~30%): The headaches start off pretty bad and seem to plateau there.
Risk factors for belonging to the chronic PTH pain group are the same as for the chronic PTH impact group but also includes a prior history of mental health problems. (Stacey et al. 2017)
Educate patients on TBI and concussion.
2. Establish PTH phenotype
What this means is that how would a doctor diagnose this headache if the patient didn’t sustain a TBI? Would it have been called a migraine? A tension-type headache? etc. Once you establish this, you can consider the treatment options that have been found to be helpful for the identified headache.
3. Modify behaviors that worsen headache
Many lifestyle changes can help improve a headache: improve sleep difficulties, limit screen time and/or adjust prescription glasses, improve an unbalanced exercise regimen, improve unhelpful dietary habits, identify faulty energy management strategies, add/improve relaxation strategies, arrange for work/school accommodations, learn about mindfulness and how to apply it to your situation.
4. Identify and treat co-morbid conditions
mTBI patients tend to have many symptoms. Identifying and treating other injuries to the visual, vestibular and musculoskeletal systems that are arising from the same mTBI (or maybe were pre-existing but subclinical – i.e., you always had it but weren’t aware of it because you found other ways to compensate) will help improve headaches.
Those with PTH 1 year out from injury are 5 times more likely to have depression. (Lucas et al. 2016)
5. Provide acute and preventive treatment as necessary
There are a few things to keep in mind about medical management.
a. mTBI patients tend to be more sensitive to medication.
b. mTBI patients tend to have other medical co-morbidities that can make the side effects of certain medications less tolerable.
For example, some popular medications for migraines can adversely affect cognition or accommodation of your visual system. Some can cause symptoms of lightheadness, dry mouth, sweating changes, etc.
c. Education about expectations from medical management.
For example, botox has been used to treat certain types of PTH. In a study by Lucas (2017) headache rate went down by about 43 %. So many people had fewer headaches but they still had headaches despite 8 months of treatment. Also, botox is usually not a first line treatment, so other treatments may be tried (and found wanting) before they are effective.
d. “Natural” Alternatives.
Biofeedback is a non-pharmacological alternative that has been clinically shown to be helpful.
There are neuromodulation devices that employ electromagnetic stimulation to treat certain types of headaches. These provide a “natural” alternative to medication. We will discuss these in another article.
e. Intervene (medically) if there is a compelling reason and the potential benefits outweigh the potential risks.
• For example, if your PTH is so bad that you can’t do any of the therapy that has been recommended, or it disrupts your sleep cycle consistently because the only thing that helps is to ‘sleep it off’, or if any mundane physical/psychological stressor triggers/worsens your PTH, then it’s safe to say that your PTH is the limiting factor in your recovery and then something needs to be done about it.
• However, if your PTH is a nuisance but functionally you are doing okay, then it may be better to stick to treating other problems that have arisen with the concussion as those will often help improve the headache and for many, the headaches seem to improve with time.
• Stacey et al. (2017) showed that social impact of headaches tend not to be as robust as reported pain scores from PTH. That is, many who have PTH do have pain but it doesn’t hold them back from doing what they need to do in life for the most part; for these patients the risks of medications may be relatively higher than the benefits as they have relatively more to lose and less to gain by medical management.
f. Use a multidisciplinary approach.
The more ‘tricks you have in your tool bag’ the more flexible you can be with treatment and challenges that may arise. The more members you have on a team working interdependently, the more strategies will be available to you for treatment.
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Lucas S. Treatment of Chronic Posttraumatic Headache with Onabotulinumtoxin A: Open Label Pilot Study. AHS 59th Annual meeting PS14. 2017.
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Stovner, Lars & Schrader, Harald & Mickeviciene, Dalia & Surkiene, Danguole & Sand, Trond. (2009). Postconcussion headache: Reply to editorial. European journal of neurology : the official journal of the European Federation of Neurological Societies. 16. e14. 10.1111/j.1468-1331.2008.02359.x.
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Research & writing: Dr. Taher Chugh
Last update: December 2018