HIGHWAYS TO HEALING: POST TRAUMATIC HEADACHES AND BRAIN INJURY
A Companion Guide To The Road To Rehabilitation Series
Headache and neck pain are the most common physical complaints following concussion (mild brain injury) and are experienced early after injury by up to 70 percent of persons with these types of injuries; however, for some reason, as yet unidentified, it tends to be a much less common phenomena. Post-concussive headaches may be quite persistent; however, they do not seem to directly relate to injury severity.
The majority of headaches following brain injury generally do not require surgical treatment. Occasionally, complications occur in association with brain as well a head injury, particularly when severe in nature, which produce headache and may require surgical intervention. Through appropriate clinical examination and potentially additional diagnostic tests, these types of conditions can be ruled out.
There are multiple sources of head and neck pain, both inside and outside of the head. The brain itself, interestingly, is not a source of pain. Headache typically results from six major problems: displacement of structures inside the head, inflammation, decreased oxygen or blood flow, soft tissue injury; including muscle spasm with possible secondary nerve entrapment (pinching,), irritation of the brain coverings (meninges) and/or increased pressure within the skull.
Post-traumatic headache, also known as PTHA, is not a diagnosis per se but rather a symptom of an underlying disorder. It is all too often that individuals are simply given a diagnosis of PTHA and no further explanation is made relative to the problem causing the pain. Often PTHA is treated as vascular or migraine headache when, in fact, the great majority of these headaches are not due to migraine but rather to other problems such as referred pain from structures in the neck (although controversy regarding this issues still exists).
It is important for the examining clinician to keep the different mechanism of PTHA in mind. Additionally, the mechanism of injury responsible for the initial insult should also be investigated. Specifically, inquiry regarding history pertaining to three main phenomena: brain injury, cranial or cranial/adnexal trauma (damage to the head or structure in the head but outside the brain), cervical acceleration-deceleration (CAD) insult (also called whiplash injury).
One of the major clues regarding the origin of the headache should come from establishing the symptom profile for the particular headache complaint as well as the pre-injury headache history, as applicable. Just because an individual had "headache" pre-injury does not mean that he or she could not develop a different type of headache or a worsening of the pre-injury condition following trauma.
The major questions relative to the headache profile that need to be asked are expressed in the mnemonic "COLDER": Character, Onset, Location, Duration, Exacerbation and Relief. Other questions that are important are the functional impact of the headache on daily activities, the headache severity and frequency, associated symptoms such as nausea, vomiting, visual changes, among others, and the presence; if any of an aura (a sensory experience signaling a headache onset). With these descriptive clues, your doctor will then be able to conduct a better clinical examination to provide more clues as to the origin of your headache condition.
The major types of headaches seen following trauma include musculo-skeletal headache including temporomandibular joint dysfunction, neuroma/neuralgic (nerve) headache, post-traumatic sympathetic nerve dysfunction, vascular (migraine) headache, as well as, other rare causes of headache including seizure disorders, pneumocephalus (air in the head), cluster and paroxysmal hemicrania (rare headaches, typically associated with very severe pain on one side of the head/face). The potential surgical conditions previously mentioned must also be considered including tension pneumocephalus, communicating hydrocepalus and compressive collections of blood or cerebrospinal fluid (subdural and epidural hematomas, as well as, subdural hygromas).
Appropriate neurodiagnostic tests such as CT or MRI scanning of the brain, plain x-rays, electrodiagnostic studies such as EEGs and vascular studies should be conducted as deemed appropriate by the treating clinician. It should be noted, however, that in general no diagnostic test substitutes for a thorough history (both pre-and post-injury) and physical examination.
Yes. An experienced clinician should be able to determine the underlying cause of your post-traumatic headache condition. 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. Good clinical responses will generally be achieved when the appropriate diagnoses have been made and the treatment prescribed allows you to be optimally compliant. The clinician should also adequately educate you and your family regarding the specific condition, its treatment and prognosis and any significant potential side effects of the proposed treatment. The impact of pain on thinking and behavior can be significant and can, in and of itself, perpetuate disability. Therefore, your treating physician may make recommendations for psychological or pain management referral to assist you in coping better with your pain condition and adjusting to it.
The best physician is one who is experienced in dealing with persons with acquired brain injury, as well as diagnosis and treatment of PTHA. Attempt to find a doctor who will spend adequate time listening to you, taking a history and examining you thoroughly. This may be a neurosurgeon, neurologist, physiatrist, psychiatrist, pain management specialist or family practitioner.
For more information regarding post-traumatic headache diagnosis and treatment, call:
If you are interested in a comprehensive listing of references regarding post-traumatic headache, please call the Brain Injury Association at 1-703-236-6000 or BIAG at 1-888-334-2424.
Nathan D. Zasler, MD is a Fellow of the American Academy of Physical Medicine and Rehabilitation and of the American Academy of Disability Evaluating Physicians, as well as a Certified Independent Medical Examiner. He is chief executive officer and executive medical director of National NeuroRehabilitation Consortium, Inc. Dr. Zasler also serves as medical director of the Concussion Care Centre of Virginia, Ltd.