Headache Post-TBI: A Treatment Challenge

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While PTH often resolves within 3 months, a substantial number of patients experience chronic PTH
While PTH often resolves within 3 months, a substantial number of patients experience chronic PTH

It is estimated that traumatic brain injuries (TBI) affect nearly 1.7 million people annually in the United States.1 The most commonly reported complaint associated with TBI is headache, which can result from mild, moderate, or severe injury. The International Headache Society defines post-traumatic headache (PTH) as one that develops within 7 days following TBI or after regaining consciousness following head trauma. PTH is associated with a range of comorbidities, including psychiatric, cognitive, and sleep-related issues.2 

While PTH often resolves within 3 months, a substantial number of patients experience chronic PTH. The prevalence rate is 47% to 95% in patients with mild TBI, and 20% to 38% in patients with moderate to severe TBI.1 “Mechanisms are unclear and likely multi-factorial,” Vernon B. Williams, MD, founding director of the Center for Sports Neurology and Pain Medicine at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California told Neurology Advisor. “The energy deficit and widespread activation associated with concussion may have some overlap with mechanisms involved with migraine.”

Risk Factors and Symptoms

Factors associated with an increased risk of persistent PTH include female sex, pre-existing headache, and family history of migraine. There does not appear to be a link between injury severity and PTH severity.3 A study published in the Journal of Headache and Pain identified post-traumatic seizure (odds ratio [OR] 2.162; 95% CI, 1.095-6.542; P =.041) and traumatic intracranial hemorrhage (OR 2.854; 95% CI, 1.241-10.372; P =.024) as independent risk factors for moderate to severe headache 36-months post-TBI.4

The most common types of PTH resemble tension-type and migraine headache, with roughly one-third of patients in each group. The former is characterized by “bilateral pain of mild to moderate intensity, which is described as pressing and dull in quality, and is aggravated by emotional stress and tension,” according to a 2014 review of literature on the topic.1 Migraine-type headaches are characterized by “unilateral pain of moderate to severe intensity, pounding, throbbing, drilling, and piercing in quality, which is aggravated by physical activity,” as well as light or noise sensitivity in some cases. Fewer than one-third of patients experience “mixed headache,” which may include overlapping symptoms from different types of headache.

Treatment

Treatment strategies for PTH vary, as there are no US Food and Drug Administration (FDA)-approved medications indicated for the condition and no professional guidelines regarding treatment. “In clinical practice, we may use some of the abortive and preventive migraine medications off label, but we don't know how this can impact the brain's recovery from injury,” Mia T. Minen, MD, MPH, assistant professor of neurology and director of Headache Services at New York University Langone Medical Center in New York, explained in an interview with Neurology Advisor. “We also tend to use non-pharmacologic treatments traditionally used for migraines: cognitive behavioral therapy, biofeedback, and progressive muscle relaxation therapy.” A few studies also support the use of acupuncture and physical therapy.

In addition, Dr Williams offered the following tips regarding the diagnosis and treatment of various types of PTH:

  • Cervicogenic headache deserves more attention in this patient population, as myofascial/muscular, and facet joint-related pain may trigger headache. “Careful assessment of the cervical spine — with consideration for diagnostic imaging and diagnostic injections — may provide insight as well as therapeutic benefit,” he noted.
  • Occipital neuralgia is particularly likely to occur following a forceful injury to the occiput, such as by striking the head upon falling backward. Patients with these types of injuries warrant clinical evaluation. “Location and distribution of pain, a positive Tinel's sign over the occipital nerve, and resolution after occipital nerve block provide historical clues, diagnostic [confirmation], and therapeutic benefits,” Dr Williams advised.
  • Treatment of oculomotor or vestibular dysfunction following concussion may also reduce headache symptoms. Emerging strategies that require further exploration include the use of a cervical collar “after atlas-orthogonal chiropractic treatments, and after craniosacral therapy — reportedly to address cervical micro-instability, misalignment, and CSF flow changes, respectively,” he said.

Recovery

While there are no widely accepted validated screens for PTH disability, a recent study on which Dr Minen was a co-investigator found an association between the presence and frequency of PTH and symptom severity scores on the Sport Concussion Assessment Tool (SCAT-3), which is the most important predictor for recovery following concussion.5

Factors associated with the PTH recovery process include the “severity of TBI, stress, post-traumatic stress disorder and other psychiatric comorbidities, sociocultural and psychosocial factors, litigation, base rate misattribution, expectation as etiology, and chronic pain,” Dr Minen and colleagues observed in a recent review.6

In addition, they conducted a retrospective chart review of patients who had been treated for PTH in an emergency department.7 Their findings show that “these patients may continue to suffer from pain, and that the pain needs to be adequately treated in the ED and considered when planning for discharge,” she said. “We also found that few patients are referred for outpatient follow-up even though research has shown that follow-up care can help with recovery.”

Ultimately, further research is needed to elucidate underlying mechanisms involved in PTH and establish evidence-based treatment options.

References

  1. Defrin R. Chronic post-traumatic headache: clinical findings and possible mechanisms. J Man Manip Ther. 2014; 22(1):36-44. doi:10.1179/2042618613Y.0000000053
  2. Minen MT, Boubour A, Walia H, Barr W. Post-concussive syndrome: a focus on post-traumatic headache and related cognitive, psychiatric, and sleep issues. Curr Neurol Neurosci Rep. 2016;16(11):100. doi:10.1007/s11910-016-0697-7
  3. Post-traumatic headache. National Headache Foundation. www.headaches.org/2007/10/25/post-traumatic-headache. Updated October 25, 2007. Accessed June 26, 2017.
  4. Chang-Ki Hong, Jin-Yang Joo, Yu Shik Shim, et al. The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study. J Headache Pain. 2017;18(1):48. doi:10.1186/s10194-017-0755-9
  5. Begasse de Dhaem O, Barr WB, Balcer LJ, Galetta SL, Minen MT. Post-traumatic headache: the use of the sport concussion assessment tool (SCAT-3) as a predictor of post-concussion recovery. J Headache Pain. 2017;18(1):60. doi:10.1186/s10194-017-0767-5
  6. Fraser F, Matsuzawa Y, Lee YSC, Minen M. Behavioral treatments for post-traumatic headache. Curr Pain Headache Rep. 2017;21(5):22. doi:10.1007/s11916-017-0624-x
  7. Minen M, Shome A, Femia R, Balcer L, Grudzen C, Gavin NP. Emergency Department concussion revisits: Chart review of the evaluation and discharge plans of post-traumatic headache patients. Am J Emerg Med. 2017;35(2):365-67. doi:10.1016/j.ajem.2016.10.076
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