Diagnosis and Treatment of Posttraumatic Headaches

Posttraumatic headaches can come from many causes including mild traumatic brain injury, cranial injury, and cervical acceleration/deceleration injury.  Because there are limitations in knowing the exact cause of the headache, treatment modalities can be difficult.  Headaches from trauma are generally defined as “acute” or “chronic”.  The onset of the headache must be sooner than 2 weeks following the traumatic event.    The ICD-10 criteria for posttraumatic headaches must indicate that the headache be associated with abnormal neurological examination, a period of amnesia of at least ten minutes, or a loss of consciousness.  This, unfortunately, excludes people who have headaches solely on the basis of a cervical injury.

The most common symptom following a mild traumatic brain injury is a headache.  It is not completely known how many people get these kinds of headaches because many are not reported.  Surveys show that about 30-50 percent of all mild traumatic  brain injury patients will develop a headache.  Milder head injuries are paradoxically associated with more severe headaches than severe head injuries.

The head or the neck can be the originators of headache pain.  Most headaches are associated with cervical injuries when compared to head or brain injuries.  This could be due to the fact that most severe brain injured patients receive prolonged bedrest with paralytic medications, which may alleviate some of the headache issues.  Most people with posttraumatic headaches are males who have been in a motor vehicle accident.  Other causes of PTHA are falls, assaults, and sports injuries with or without the use of alcohol at the time of the injury.  People who suffer from headaches before their injury are no more likely to suffer from a PTHA after their injury.

It is up to the diagnosing doctor to decide if the headache is due to cerebral, cranial or cervical causes.  Certainly, there can be more than one cause of the pain.  Doctors must ask about the character, the onset, the duration, the location, what exacerbates the pain, and what relieves the pain.  Questions about the frequency, time of day and other symptoms should also be asked.

Simple posttraumatic headaches must be differentiated from posttraumatic epilepsy, subdural hematomas, tension pneumoencephalus, epidural hematomas, posttraumatic sinus conditions, cluster headaches, migraines, and sympathetic headaches.  Drug induced or rebound headaches from pain relievers can also be causes of posttraumatic headaches.  Examinations of the patient should include a good neurological exam and a musculoskeletal examination.  There should be palpation of the scalp and neck for trigger points.

Treatment

Many people with posttraumatic headaches have myofascial pain.  The muscles and the fascia around the muscles are sore and inflamed.  This is more common in whiplash injuries than in intracranial injuries.  Lateral force on the head and neck can cause myofascial pain as well.  Trigger points are believed to be caused by excessive amounts of acetylcholine in the affected area.  Pain usually presents on palpation of the trigger point and spreads out from there.  Treatment includes gentle exercises, stretching and improved posture.  Other modalities include ultrasound, acupressure, massage and acupuncture.  Trigger point injections with or without the use of anesthetic medication can help.  Trigger point injections relieve inflammation and increase the circulation to the affected area.  Some practitioners have had success when injecting Botox into the trigger point.  Soft tissue mobilization has been known to help some patients with this problem.

Patients should be assessed so they use better ergonomics at home and at work, along with better head support while sleeping.  Exercise is a critical part of maintaining a relief of the pain; it should include both strengthening and stretching the affected muscles.

Other types of pain include that of occipital neuralgia from injury or inflammation of the occipital nerves.  Occipital neuralgia can be treated with trigger point injections or nerve block with steroids plus or minus analgesics.  In unusual cases, there may need to be surgical decompression of the occipital nerves involved when entrapment is suspected.  Cryoablation of the nerve has been sometimes successful.

Neuromas of the scalp can occur with significant trauma to the cranium.  This is especially occurring following a craniotomy.  Topical capsaicin can be used if there is diffuse scalp pain and local blockage of the neuroma with anesthetics has been tried with some success.  NSAID use, tricyclic antidepressant use, and the use of gabapentin, phenytoin or carbamazepine have been successful.

Some people get headaches because of posttraumatic irritation of facial nerves such as the supraorbital and infraorbital nerves.  Injection of anesthetics or steroids into these nerves has been found to be helpful in some cases.

Twenty percent of all PTHA are migraine-type headaches.  It is treated much like migraines that are not caused by trauma.  Trigger of migraine headaches should be avoided, including triggering foods. Medication can be prophylactic, symptomatic or abortive.  Birth control pills can exacerbate migraine headaches and may have to be stopped until the headaches resolve.

In some cases, the origin of the pain is in the temporomandibular joint.  Usually the pathology surrounds the muscles of mastication and not the joint itself but one must always look for the possibility of intra-articular origin of the pain.  This is treated with jaw exercises and care must be taken to avoid eating anything chewy until the pain resolves.  Almost 80 percent of people can be treated this way rather than doing surgery.  An MRI can show if there is intra-articular pathology as a cause of the headache pain.

Headache pain can be caused by injury to the cervical zygapophyseal joint.  Usually pathology at or above C3-C4 will radiate to the back of the head.  Injections of anesthetic can control this type of pain and joint blocks can be used under fluoroscopic guidance.

Cervical manipulation through chiropractic care has been found to be helpful in traumatic and nontraumatic headache pain.  There are many techniques that seem to work and they can be used by chiropractors, doctors and physical therapists.  A rarer type of pain is called a dysautonomic headache, which is caused by nerve damage on the front and back of the neck during whiplash injuries.  These types of headaches are difficult to treat and usually present with dizziness, blurred vision and tinnitus.

Over the long haul, especially past 6 months, patients learn not to move the neck or head very much, which can worsen their pain.

Patients must learn coping skills along with the necessary exercises and treatment of their pain.  Treatments are best done holistically with minimal use of medication.  Combining pain remedies with psychological support may be necessary.  Pain education seems to help some people while biofeedback and relaxation training helps others.  Imagery, hypnosis, group therapy and cognitive-behavioral therapy have also been found to be helpful.  In particular, combining biofeedback and cognitive-behavioral therapy seems to be effective in many situations of chronic headache pain. 
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