Headache and neck pain are the most common physical complaints following traumatic brain injury. Post-traumatic headache (PTHA) may be quite persistent; however, it cannot be positively correlated with severity of injury. Often, injured persons will seek medical care following concussion and/or cervical whiplash injury only to be diagnosed with “post-traumatic headache”. Don’t accept PTHA as a diagnosis ….it is a term that neither identifies the headache generators or guides treatment.
There are multiple sources of post-traumatic head and neck pain. The brain matter itself is not a source of pain as it does not have pain receptors. “PTHA” is often treated as migraine headache, when, in fact, the great majority of them are due to other post-traumatic headache pain generators. It is therefore not surprising that many patients treated for migraine post trauma do not get better due to the fact that they may not have migraine as an underlying cause of their headache disorder.
It is important for the examining clinician to keep the different mechanisms of these types of headaches in mind and understand the importance of taking a thorough headache history preinjury to examining the patient in question. As part of this history, genetic loading risk variables and preinjury headache history are significant as is understanding the mechanism of injury that resulted in the headache condition.
There are three main mechanisms by which trauma can trigger headache and they may occur individually or in combination, including:
- Cerebral or brain injury
- Cranial injury (damage to the head or structures in the head but outside the brain)
- Cervical whiplash injury
One of the major clues for the examiner relative to the origin of the headache should come from establishing the symptom profile for that particular headache. The major questions relative to the headache profile that need to be asked are expressed in the pneumonic “COLDER”: Character, Onset, Location, Duration, Exacerbation, and Relief. Other descriptors including the frequency, severity, associated symptoms, and presence/absence of aura, degree of functional disability associated with headache episodes, as well as, the time of day that headaches come on are all important parameters to inquire about.
The major types of headaches seen following trauma include musculoskeletal headache (including referred cervical myofascial pain, jaw/TMJ disorders, upper cervical vertebrae malalignment, referred facet mediated pain, and bruxing), neuroma and neuralgic (nerve) headache, tension type headache, migraine headache, as well as less common headache disorders that evaluating clinicians need to be familiar with such as late blood clots between the brain and skull, “syndrome of the trephined” and trigeminal autonomic cephalalgias or TACs, among other subtypes .
In this clinician’s experience, the most common cause of head pain (headache) after trauma is cervical injury with referred pain into the head. Clinicians and patients must also be adequately educated about medication overuse headache (MOH) as well as medication-induced headache (MIH) as such education optimizes compliance and reduces risk of headache chronification.
With the appropriate time taken in acquiring an adequate pre-injury and post-injury history, and headache description, as well as conducting a focused clinical evaluation and as necessary ordering appropriate diagnostic testing, the adept clinician should be able to determine the underlying cause for the condition. In my experience, many patients that we see on referral have never been appropriately examined and no one “touched” them in the context of an appropriate face/head/neck and shoulder exam. Once the appropriate diagnosis is made, treatment should be instituted in a holistic fashion with a sensitivity to maximizing the benefit/risk ratio of any particular intervention, prescribing treatment that can be optimally complied with and educating the patient and family regarding the disorder, its treatment and prognosis.
Multiple studies demonstrate that ongoing litigation has little to no effect on the persistence of headache complaints. A small number of patients will develop intractable post-traumatic headache. In this practitioner’s experience, when properly treated, most PTHA is not permanent and/or disabling over the long term. Prognosis must be based on understanding the cause of the headache rather than on a non-specific diagnosis such as PTHA.
Understanding the diversity of possible pain generators and taking the time to conduct a good interview and perform an appropriately focused physical assessment will lead to the best outcomes. Our experience is that holistic, multidisciplinary care works best with this often challenging post-traumatic complaint. In that context, even patients years out from injury with headache chronification can be helped if they find the right treatment team.
Bottom line is that if you suffer from headaches after a physical trauma you need to make sure you are in the right hands, figuratively and literally.
Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM, CBIST
Founder, CEO & CMO, Concussion Care Centre of Virginia, Ltd.
Medical Director, Tree of Life
Professor, affiliate, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
Professor, Visiting, Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia
Chief Editor, Brain Injury
Chief Editor, NeuroRehabilitation
Vice-Chair Emeritus, IBIA
Chair, Emeritus, IBIA