Posttraumatic headache treatment

What is a post-traumatic headache?

 

After a post-traumatic brain injury, headaches are the most ubiquitous and often the most debilitating symptom. Traumatic brain injury-related headaches present like migraines, involving the entire head with associated neck strain or focal pain over the posterior or occipital part of the head.  Generally, patients with a mild traumatic brain injury have headaches that resolve after 2-3 months. However, up to 30% or more of patients often have symptoms including headaches that persist for up to 6 months after their injury. These headaches can be debilitating, interfering with the day-to-day lives of traumatic brain injury patients. 

 

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What causes post-traumatic headaches?

 

After a traumatic brain injury, many biochemical changes can be observed underlying the posttraumatic symptoms typically seen after a head injury. In a study done by Packard and Ham, trauma to the neurochemical processes and the primary biochemicals in our brains were observed, causing inflammation and silence of the neuron (Packard and Ham, 1997).

 

Patients with migraine headaches prior to the TBI may find an acute worsening of their headache frequency and severity. When patients with TBI and a history of migraine headaches experience a worsening of their migraines, we typically continue treatment with typical 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.

What are the symptoms of a post-traumatic headache? 

Post-traumatic headaches (PTH) are defined as a headache that develops within seven days of an injury or loss of consciousness. While PTH can vary in their presentation, most headaches after a head trauma resemble migraines.  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.  Often these migraines are characterized as moderate to severe in intensity, sensitivity to light and sound, nausea and vomiting, and more. Additionally, post-traumatic headaches are often associated with neck pain that can occur 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.  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.

Tracking your post-traumatic headaches

Given the various presentations of a headache, it is useful to track the symptoms, duration, and care of the headaches in order to determine appropriate classification and care for your headache. You can track these characteristics with a headache diary similar to that provided by the national headache foundation. 

Treatment for post-traumatic headaches

Medical evaluation for patient with post-traumatic headache

  • MRI brain - structural and 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

  • Caffeine

  • Sumatriptan 50 mg as needed

  • Nurtec 75 mg as needed

  • Ubrelvy 100 mg as needed

  • Tramadol 50 mg


Cervical neck pain trigger

References

Packard, R.C. and Ham, L.P. (1997), Pathogenesis of Posttraumatic Headache and Migraine: A Common Headache Pathway?. Headache: The Journal of Head and Face Pain, 37: 142-152. https://doi.org/10.1046/j.1526-4610.1997.3703142.x