Headaches are the most common symptom following mTBI/concussion.198 The pathophysiology of post-traumatic headaches is not well understood.199 While most people with post-traumatic headache improve within days or weeks, headaches may persist beyond this time frame, up to months or years in some individuals.200 The International Classification of Headache Disorders (ICHD-III) includes diagnostic criteria for both acute and persistent post-traumatic headache following mTBI.201 In most people, headaches can be well managed using simple analgesics (NSAIDS and paracetamol). Some people, however, have significant morbidity due to post-traumatic headache.202 Identifying the headache phenotype, can inform management. Post-traumatic headaches with migraine-like phenotype often lasts longer and has a worse outcome than a tension-type phenotype.203
In addition to the trigeminal system, the upper cervical nerve roots and upper cervical cord play and important role in headache.204 Careful examination of the cervical spine as well as the head and neck can help to identify factors commonly associated with headache after mTBI/concussion such as facet joint injury and occipital neuralgia. When identified occipital nerve blocks, peripheral nerve blocks, and/or cervical physiotherapy can lead to rapid improvements in headache.
Although physical activity has been demonstrated to increase the rate of recovery following mTBI/concussion and in migraine,128, 205 the evidence for its effectiveness in post-traumatic headache is limited. Regardless, gradual introduction of exercise is recommended.175 As worsening of headache is commonly reported with exercise, headache can impede graded return to activity.151 Here, the involvement of a physiotherapist or exercise physiologist can help graded introduction of exercise working with the medical specialist. Sometimes, there is significant fear and anxiety about the effect of activity on a patient’s headaches which limits recovery. This can lead to avoidance of physical activity (kinesiophobia), cognitive activity (cogniphobia),177 and sensory stimuli (such as noise and light). As this is often associated with significantly increased disability and the involvement of a psychologist or behavioural occupational therapist can be helpful.177
Caution should be taken to avoid medication overuse (defined as 15 days a month or more use of simple analgesics or 10 days a month or more of combination analgesics or triptans), which can contribute to persistent post-traumatic headaches.206 Pharmacotherapy is usually guided by the headache phenotype as well as effective management of comorbidities i.e. amitriptyline can be useful for headache as well as insomnia.
Headache subtypes typically include migraine-like and tension types but other considerations are occipital neuralgia, medication-overuse headache and cervicogenic headache.207, 208 Identification of headache subtypes can help to guide management. Specialist assessment of headache should be considered in children less than 5 years of age and in people whose cognitive disability may impede assessment.
Box C: Important components to include in the focussed headache history – Headache frequency
– Headache duration
– Headache location
– Headache intensity
– Quality of the pain (pressure, throbbing, stabbing)– Associated symptoms (e.g. nausea/vomiting)
– Precipitating/provoking factors
– Alleviating factors
– Previous treatment experiences and responses to date (including benefits and side-effects)
– Previous headache historySource: Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. A headache diary is a tool that aims to:
- help people with post-traumatic headache and their treating health professional to identify the frequency, duration, and severity of the headaches
- aid in identifying the type, frequency, and amount of acute headache medications used
- help to recognise potential headache triggers
- guide treatment decisions and evaluate response to treatment
- help the health professional identify possible medication overuse headache.
In children under 5 years of age, a headache diary is not helpful and behavioural observations such as irritability may be the main indicator of headache.212, 213
Box D: Components tracked in a headache diary Date Time
(start/finish)Preceding symptoms Triggers Medication
(and dosage)Relief
(complete/moderate/none)Source: Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 EBR (conditional) 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
207. Yilmaz T, Roks G, de Koning M, Scheenen M, van der Horn H, Plas G, et al. Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emerg Med J. 2017;34(12):800-5. doi: 10.1136/emermed-2015-205429.
208. Nordhaug LH, Linde M, Follestad T, Skandsen ON, Bjarko VV, Skandsen T, et al. Change in headache suffering and predictors of headache after mild traumatic brain injury: a population-based, controlled, longitudinal study with twelve-month follow-up. J Neurotrauma. 2019;36(23):3244-52. doi: 10.1089/neu.2018.6328.Adapted29 EBR (conditional) 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 EBR (conditional)207-211 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
207. Yilmaz T, Roks G, de Koning M, Scheenen M, van der Horn H, Plas G, et al. Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emerg Med J. 2017;34(12):800-5. doi: 10.1136/emermed-2015-205429.
208. Nordhaug LH, Linde M, Follestad T, Skandsen ON, Bjarko VV, Skandsen T, et al. Change in headache suffering and predictors of headache after mild traumatic brain injury: a population-based, controlled, longitudinal study with twelve-month follow-up. J Neurotrauma. 2019;36(23):3244-52. doi: 10.1089/neu.2018.6328.
209. Dumke HA. Posttraumatic headache and its impact on return to work after mild traumatic brain injury. J Head Trauma Rehabil. 2017;32(2):E55-E65. doi: 10.1097/HTR.0000000000000244.
210. Meltzer KJ, Juengst SB. Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity. Brain Inj. 2021;35(1):41-7. doi: 10.1080/02699052.2020.1857438.
211. Silverberg ND, Martin P, Panenka WJ. Headache trigger sensitivity and avoidance after mild traumatic brain injury. J Neurotrauma. 2019;36(10):1544-50. doi: 10.1089/neu.2018.6025.Adopted29 EBR (conditional)207-211 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
207. Yilmaz T, Roks G, de Koning M, Scheenen M, van der Horn H, Plas G, et al. Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emerg Med J. 2017;34(12):800-5. doi: 10.1136/emermed-2015-205429.
208. Nordhaug LH, Linde M, Follestad T, Skandsen ON, Bjarko VV, Skandsen T, et al. Change in headache suffering and predictors of headache after mild traumatic brain injury: a population-based, controlled, longitudinal study with twelve-month follow-up. J Neurotrauma. 2019;36(23):3244-52. doi: 10.1089/neu.2018.6328.
209. Dumke HA. Posttraumatic headache and its impact on return to work after mild traumatic brain injury. J Head Trauma Rehabil. 2017;32(2):E55-E65. doi: 10.1097/HTR.0000000000000244.
210. Meltzer KJ, Juengst SB. Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity. Brain Inj. 2021;35(1):41-7. doi: 10.1080/02699052.2020.1857438.
211. Silverberg ND, Martin P, Panenka WJ. Headache trigger sensitivity and avoidance after mild traumatic brain injury. J Neurotrauma. 2019;36(10):1544-50. doi: 10.1089/neu.2018.6025.Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 The Headache Impact Test (HIT6, adult) and Paediatric Migraine Disability Assessment Tool (PedMIDAS, children) may also assist in the assessment of headaches
A headache diary can be downloaded from Headache Australia (below)
Maintaining consistent bedtime and wake time, moderating triggers (e.g screen time, neck position when using screens), consuming consistent meals with no skipped or delayed meals, good hydration, regular low-intensity cardiovascular exercise, use of relaxation, stress-management, and mindfulness-based strategies may provide relief from post-traumatic headache.29
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adapted29 People with post-traumatic headache may benefit from advice on additional self-regulated intervention and lifestyle strategies to minimise headache occurrence.
Additional information is available from Headache Australia.
People may use acute headache medications to try to reduce the severity, duration, and disability associated with individual headache attacks. The use of these medications needs to be limited in frequency to minimise the potential for medication overuse (rebound) headache.
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. Adopted29
CBR 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.Adopted29,30