Post-traumatic Headaches

The posttraumatic headache does not have to occur following a severe injury, nor does it have to come from a blow to the head.  Most researchers believe that posttraumatic headaches mainly come from the neck rather than the head.  In order to be defined as a posttraumatic headache (PTHA), the headache must come on within two weeks of the trauma or upon the person’s return to consciousness.  Acute PTHA resolves itself within eight weeks, while a chronic PTHA lasts longer than 8 weeks.  A posttraumatic headache is a common complication of a mild traumatic brain injury.  Many cases of PTHA involve a whiplash type of injury. 

There are several different types of posttraumatic headache, including the following;

  • Posttraumatic tension headache
  • Posttraumatic migraine headache
  • Posttraumatic cluster headache Temporomandibular joint headache
  • Neuropathic headache

Posttraumatic Tension Headache

This is the most common type of headache found to be secondary to trauma.  It is similar to the type of tension headache that occurs in the absence of trauma.  The headache can be episodic, occurring fewer than fifteen days per month and lasting from thirty minutes to up to seven days.  It is a non-pulsating headache, pressure-type headache that is mild to moderate in degree. It usually doesn’t prohibit the doing of activities of daily living.  The pain is almost always bilateral and does not change with activity.  There is no vomiting, nausea, or photophobia with this type of headache but it can affect one’s appetite.   

The pain feels like a tight band is surrounding the head and feels like an aching pain.  The pain may be unilateral but is usually bilateral or occipito-nuchal, bi-frontal, bi-temporal, or on the vertex of the head.  It can extend down to the back or shoulders.  More females get this type of headache than males and it varies in intensity according to a number of factors, including emotional stress and physical activity.  The treatment is usually the taking of analgesic medications many times per day.  These patients can also experience cluster headaches and/or migraine headaches.  Headaches are usually a daily occurrence, occurring all day. 

Patients with chronic headaches usually have some element of anxiety and depression although it is not known whether the mental symptoms predated or postdated the onset of trauma.  There are often no physical findings, leading some doctors to refer to these types of headache as psychogenic in origin. 

These types of headaches can be due to an acceleration/deceleration injury, a fall from slipping or from a sports-related injury.  The muscles of the neck and shoulders  receive micro-tears and strain.  The end result is myofascial pain that radiates to the head.  Muscle contraction on a tonic basis contributes to a lack of circulation in the small arteries supplying the muscle.  This causes pain hormones to be released by the muscle.  The patient is often found with shrugged shoulders, holding the head so as to reduce unnecessary movements of the head.  Often, these patients have tenderness in the paraspinal muscles, the cervical muscles and in the shoulder muscles as well. 

The mechanisms of muscle injury include the following:

  • Low grade muscle inflammation
  • Ischemia to the muscles
  • Tearing of ligaments of tendons during the trauma

There are usually trigger points at various places in the head or neck and shoulders that elicit headache pain when pressed on.  When trigger points are identified, there can be increased weakness, fatigue and stiffness of the associated muscles.  When the patient stiffens the neck to avoid moving the head, this actually contributes to muscle fatigue and spasm, making the headache worse.  These people often have poor posture, which also worsens the headache syndrome. 

Chronic posttraumatic headache patients often have poor sleep.  People wake up more frequently and do not get the deep, stage 4 sleep that many people get at night.  These symptoms can be improved by giving the patient tricyclic antidepressants before bedtime.  The worse the pain, the greater is the negative impact on sleep. 

Cervical spondylosis or degeneration of parts of the cervical spine is also seen frequently in those with tension headaches following trauma.  Some patients experience autonomic symptoms such as a lack of appetite, photophobia, dizziness, and hyperirritability.  There is generalized sympathetic nervous system arousal, with elevations of both epinephrine and norepinephrine.  There are decreased levels of serotonin, which probably contributes to depression and anxiety.  

People with posttraumatic headaches secondary to mild traumatic brain injury often report their pain is between 7 and 10 on a ten-point scale of pain perception.  Even when going through pain-reducing therapy, they function much better but tend to still rate their pain as high. 

In evaluating a patient for a PTTHA, the muscular findings are more obvious than any nerve-related findings.  There are trigger points, muscle stiffness and decreased range of motion of the neck due to pain.  There is often pain on the anterior neck muscles and evidence of jaw misalignment when they open their mouths. 

Treatment of a posttraumatic tension headache involves NSAID therapy with naproxen, ibuprofen, ketoprofen or ketorolac.  Ketorolac (Toradol) can be given orally or by IM injection.  COX-2 inhibitors are also good for treating these types of headaches.  Some doctors also prescribe muscle relaxants to ease muscle tension associated with tension headaches.  These include Methocarbamol, Carisoprodol, chloroxazone, orphenadrine, chlorzoxazone and others.  Tricyclic antidepressants are also commonly used for the management of chronic posttraumatic headaches.  SSRI medication can help some of the depression and anxiety associated with tension headaches.  Klonopin or clonazepam help with muscle contractions and pain from muscle stiffness as well.  Be aware of medications causing rebound headaches. 

Posttraumatic Migraines

These can occur in the absence of a previous migraine or a family history of migraine headaches.  It is similar to the type of headache seen in mild traumatic brain injury and can be related to acid-base distu With migraines, there is often the presence of neurological symptoms such as transient amnesia, vertigo, visual and hearing deficits, as well as the risk for seizures.  There is a relationship between the trigeminovascular system which results in hyperemia (increased blood flow) to the brain.  Symptoms commonly associated with these types of migraines include vertigo, disequilibrium, dizziness and intolerance of motion.  These finding can also occur in the absence of an actual headache. 

Prevention of posttraumatic migraine includes giving valproic acid, beta blockers or verapamil. Triptan medications are helpful in the management of migraines that are currently occurring. 

The incidence of cluster headaches following head trauma is about 6-10 percent.  These headaches are more chronic and less episodic than cluster headaches unassociated with trauma.  This is fortunately not as common as other types of posttraumatic headaches. 

rbances, serotonergic differences, low magnesium, and excessive release of sympathomimetic hormones and excitatory amino acids.  Different levels of cervical injury to the discs and bones contribute to different areas of the head involved in headache.  This type of headache is a referred pain from nerves supplying the neck area.  These headaches can be brought on by pushing on various areas of the C-spine and are generally treated with steroid or anesthetic injections to the sensitive areas.   These measures are, however temporary and things like radiofrequency neurotomy or radiofrequency denaturation of the occipital nerve may have to be done in order to permanently relieve the pain.

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