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.

• Assessment and diagnosis

  • Diagnosis

    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.

    • Identification of the headache phenotype can inform management (children and adults)

      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

    • An appropriately qualified health professional should take a comprehensive headache history (see Box C) to identify the headache phenotype(s) that most closely resemble(s) the person’s symptoms (children and adults)

      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

    • Box C

      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 history

    • Personal, environmental, work-related, school-related, and physical factors such as neck pain should be identified and addressed as potential headache contributors (children and adults)

      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

    • Establish the degree of headache-related disability (taking a biopsychosocial approach) to assist in preparing a treatment approach (i.e. non-pharmacological and/or pharmacological) (children and adults)

      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

    • The health professionals treating post-traumatic headaches should perform neurological and musculoskeletal examinations, including blood pressure and heart rate monitoring (both lying and standing), cervical spine and vestibulo-ocular system examination (children and adults)

      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

  • Assessment of Headache

    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}

    • People older than 5 years with post-traumatic headache should be encouraged to maintain an accurate headache and medication diary (see Box D) and to bring it to every follow-up visit with their treating health professional (children and adults)

      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

    • Box D

      Box D: Components tracked in a headache diary
      Date	Time (start/finish)	Preceding symptoms	Triggers	Medication (and dosage)	Relief (complete/moderate/none)

  • Further guidance

    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

    See ‘Toolbox’ for resources and tools.

• Management

  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

  • Although most people with post-traumatic headache do not require imaging, brain or cervical spine imaging (MRI or brain CT) is a consideration when neurologic signs or symptoms are suggestive of possible intracranial pathology or significant upper cervical injury (children and adults)

    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

  • Education should be provided to the person with post-traumatic headache on the lifestyle strategies useful for potentially minimising headache occurrence and/or decreasing the impact of headaches when they occur (children and adults)

    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

  • Further guidance

    People with post-traumatic headache may benefit from advice on additional self-regulated intervention and lifestyle strategies to minimise headache occurrence. (See ‘Toolbox’ for resources and tools)

    Additional information is available from Headache Australia.

• Pharmacotherapy

  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.

  • Over the counter analgesics (e.g. acetaminophen, ibuprofen, acetylsalicylic acid, naproxen) should be used less than 15 days per month (children and adults)

    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

  • Combination analgesics (i.e. with caffeine or codeine) should be used less than 10 days per month (children and adults)

    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

  • Migraine-specific acute therapies should be trialed when non-specific acute therapies are incompletely effective. Triptans can be used for migrainous-type headaches less than 10 days per month (children and adults)

    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

  • When headaches are too frequent (e.g. more than 10 days per month) or disabling, prophylactic therapy should be considered (children and adults)

    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

  • Practice point:
    Prophylactic therapy should be guided by headache phenotype.

    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

• Follow-up and referral

  • Post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to a neurologist, headache specialist, paediatrician, or interdisciplinary concussion team/clinic is recommended (children and adults)

    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