POST-TRAUMATIC HEADACHE

What is Post-Traumatic Headache?
Post-traumatic headache (PTH) is defined by the International Headache Society as: “a headache developing within seven days of the injury or after regaining consciousness.” Different types of headache have been described, but the most common headache resembles migraine (moderate to severe in intensity, pulsating, associated nausea/vomiting or light/sound sensitivity, worsened with routine activity), and tension-type headache (mild to moderate in intensity, non-pulsating headache with either light or sound sensitivity but no nausea or vomiting). PTH is commonly associated with many symptoms including dizziness, insomnia, poor concentration, memory problems, sensitivity to noise or bright lights, fatigue as well as mood and personality changes like depression and nervousness.

Several studies show that the headache usually resolves within three months, however, in 18-65% of cases, it may last longer and is then referred to as persistent PTH. A number of factors may increase the risk of persistent PTH including pre-existing headache, being female and family history of migraine. Severe head trauma does not necessarily cause prolonged headaches as patients with mild head trauma can suffer for months or years.

What Causes PTH and How Do We Investigate It?
The cause of PTH is not well understood but could relate to the release of certain chemicals, swelling of important brain structures or even brain shrinkage. Most patients with mild PTH do not need extensive testing other than a good history and neurologic exam. With more severe injuries, a CT or an MRI scan might be done to rule out a brain bleed.

How Do We Treat Post-Traumatic Headache?
Head-injured patients can experience difficulty performing daily activities, may miss school or work, and have a lower quality of life. An approach looking at all aspects of the patient’s symptoms is best. Medication is the most effective treatment for PTH and treatment will depend on the type of headache. Some medications, like anti-inflammatories or pain medicines, including those for migraine (triptans), are used in the first few weeks. However, if the headache persists and remains moderate to severe, adding in preventative medication should be considered—especially to avoid rebound headache (over-using pain medicines). The most commonly used preventives for PTH are antidepressants, blood pressure pills, and anti-seizure medicines.

Non-Drug Treatments of Post-Traumatic Headache
Other non-drug treatments include physical therapy, biofeedback/relaxation therapy, nerve stimulators, and cognitive-behavioral therapies. Education about PTH is an important part of the management. Since psychological problems may trigger headache or persistent headaches may exacerbate emotional problems, providing psychological support is crucial.

References
Ana Marissa Lagman-Bartolome MD, Headache Medicine Fellow, Department of Pediatric Neurology, Hospital for Sick Children and Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada.

New Investigator and Trainee Section of the American Headache Society