Guidelines Quick Access
Headaches
Headaches are the most common symptom following mTBI/concussion.238 The pathophysiology of post-traumatic headaches is not well understood.239 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.240 The International Classification of Headache Disorders (ICHD-III) includes diagnostic criteria for both acute and persistent post-traumatic headache following mTBI.241 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.242 Identifying the headache phenotype, can inform management. Post-traumatic headache with migraine-like phenotype often lasts longer and has a worse outcome than a tension-type phenotype.243
In addition to the trigeminal system, the upper cervical nerve roots and upper cervical cord play and important role in headache.244 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.
Headache subtypes typically include migraine-like and tension types but other considerations are occipital neuralgia, medication-overuse headache and cervicogenic headache.249, 250 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.
EBR (Conditional) 250,251
Identification of the headache phenotype can inform management. (children and adults)
EBR (Conditional) 250,251
A qualified health care 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) 249,250,252-254
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)
CBR
The qualified health care 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)
A headache diary is a tool that aims to:
- Help people with post-traumatic headache and their treating health care 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 qualified health care 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.
CBR
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 care professional. (Children and adults)
CBR
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 cervical spine injury. (Children and adults)
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
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.30
CBR
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)
Further Guidance
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. Although the supporting evidence is limited, preventative headache therapy should be considered where headaches are frequent and/or disabling.257, 258 The type of treatment is informed by the headache phenotype i.e. post-traumatic migraine-like headache is managed with a migraine-directed approach. Various treatment algorithms have been proposed,259 although more research is needed to determine their effectiveness. Pharmacotherapy is often used in as part of a multidisciplinary approach, especially when headaches persist or are difficult to manage.
CBR 259
Over the counter analgesics (e.g. paracetamol, ibuprofen, aspirin, naproxen) should be used less than 15 days per month. (Children and adults)
CBR 259
Combination analgesics (i.e. with caffeine or codeine) should be used less than 10 days per month. (Children and adults)
CBR 259
Migraine-specific acute therapies should be trialled 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 259
When headaches are too frequent (e.g. more than 10 days per month) or disabling, prophylactic therapy should be considered. (Children and adults)
Practice Points for Children and Adults
Prophylactic therapy should be guided by headache phenotype.
CBR
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 is recommended. (Children and adults)