Posttraumatic headache treatment

Definition of white matter hyperintensities


Headache is nearly ubiquitous after head injury and often the most debilitating symptom.  The typical TBI-related headache may involve the entire head and may be associated with neck stain or focal pain over the posterior or occipital part of the head.  In most patients with mild injury the headaches largely resolve after 2-3 months, but up to 30% or more of patients with a mild TBI may have symptoms including headaches 6 months after the injury [add: Hou when a minor head injury, Stulemeijer, van der Werf Early prediction, Norrie J, Heitger M, Leathem J, et al. Mild traumatic brain injury and fatigue: a prospective longitudinal study].  It is thought that trauma to neuron cells causes inflammatory and other changes that are seen in other types of headaches [add Packard and Ham 1997].  The factors that have been shown to worsen the severity of posttraumatic headaches including a previous history of headaches, 

Patients with migraine headaches prior to the TBI may find an acute worsening of their headache frequency and severity.  Migraines are a specific type of headache, typically affecting only one side of the head at a time with association with nausea and light sensitivity, and migraines are typically episodic, meaning they occur with intensity and then resolve after a number of hours.  When patients with TBI and a history of migraine headaches experience a worsening of their migraines, we typically continue treatment with migraine medication, including triptans, anti-inflammatories, and caffeine for acute headaches and migraine preventative agents including magnesium, riboflavin, beta-blockers, topiramate, nortriptyline, and anti-seizure medications.

Post-traumatic headaches are often associated with neck pain that can occurred during head trauma.  Neck muscles, ligaments, and tendons are common sources of pain, and there is a close association between cervical neck pain and chronic headaches.  The typical treatments for cervical neck pain, including massage, relaxation exercises, physical therapy, trigger point injections, and muscle relaxant medications are employed in patients with post-traumatic headache associated with neck pain.

Occipital neuralgia refers to nerve-related pain of the occipital nerves that travel from the upper cervical spine, between layers of muscles and soft tissues, and under the scalp to innervate a large part of the head.  Any compression of the occipital nerve can result in head pain over the posterior part of the that can be associated with tenderness of the occipital nerve and neck pain.  Treatment targets hyperactivity of the occipital nerve by directly blocking the nerve, quieting its activity with neuropathic pain medications, or modulating its activity with pulsed radiofrequency treatments performed under ultrasound.



White matter describes the deep regions of the brain that contain the axons or "wiring" of the brain, connecting different areas of the brain and allowing for normal cognitive function.

Post-Traumatic Headache
MRI brain - structural, functional
Headache prevention
Magnesium glycinate 400 mg at night
Riboflavin/B2 400 mg at night
Nortriptyline 20 mg nightly
Topiramate 25 mg twice daily
Nurtec  75 mg every other day
Depakote 100 mg twice daily
Aimovig monthly injection
Acute headache treatment
Ibuprofen 200-600 mg as needed
Sumatriptan 50 mg as needed
Nurtec 75 mg as needed
Ubrelvy 100 mg as needed
Tramadol 50 mg
Cervical neck pain trigger
Instashiatsu neck massager (Amazon)
Physical therapy
Home physical therapy exercises