1. Post Traumatic Headaches
Headache is the most common symptom after TBI. Incidence is 71%aftermod-severe at 1 year after injury
There are no evidence based treatment guidelines . the incidence and prevalence is difficult to ascertain as these patients may never seek care.
Post Traumatic Headaches
Dr. Rose Giammarco MD,FRCPC
May 2018

2. 5. Headache attributed to trauma or injury to the head and/or neck
• 5.1 Acute headache attributed to traumatic injury to the head
◦ Acute headache attributed to moderate or severe traumatic injury to the head
◦ Acute headache attributed to mild traumatic injury to the head
• 5.2 Persistent headache attributed to traumatic injury to the head
◦ Persistent headache attributed to moderate or severe traumatic injury to the head
◦ Persistent headache attributed to mild traumatic injury to the head
• 5.3 Acute headache attributed to whiplash1
• 5.4 Persistent headache attributed to whiplash
• 5.5 Acute headache attributed to craniotomy
• 5.6 Persistent headache attributed to craniotomy
ichd 3 was published in 2014 thirty years after the first was published , consists of a classification system of headache disorders that include over 200 ha disorders.
classifies post traumatic ha . Most common of the secondary disorders. As you can see it is broken down into ha att to trauma or injury to the head and or neck and then sub classified into acute moderate and mild , then further sub classified into acute and persistent.
secondary to he'd, whiplash and craniotomy.

3. 5.1.2 Acute headache attributed to mild traumatic injury to the head
Diagnostic criteria:
A Headache fulfilling criteria for 5.1 Acute headache attributed to traumatic injury to the head
B Injury to the head fulfilling both of the following:
1 associated with none of the following:
▪ – loss of consciousness for >30 minutes
▪ – Glasgow Coma Scale (GCS) score <13
▪ – post-traumatic amnesia lasting >24 hours1
▪ – altered level of awareness for >24 hours
▪ – imaging evidence of a traumatic head injury such as skull fracture, intracranial haemorrhage and/or brain contusion
2 associated with one or more of the following symptoms and/or signs:
▪ – transient confusion, disorientation or impaired consciousness
▪ – loss of memory for events immediately before or after the head injury
▪ – two or more of the following symptoms suggestive of mild traumatic brain injury:
◦ – nausea
◦ – vomiting
◦ – visual disturbances
◦ – dizziness and/or vertigo
◦ – gait and/or postural imbalance
◦ – impaired memory and/or concentration.
HA within 7 days or within 7 days of regaining consciousness or DCof anymeds that could impair perception the HA
no single clinical type of HA
migraine is the most common type

4. 5. Headache attributed to trauma or injury to the head and/or neck
• 5.1 Acute headache attributed to traumatic injury to the head
◦ Acute headache attributed to moderate or severe traumatic injury to the head
◦ Acute headache attributed to mild traumatic injury to the head
• 5.2 Persistent headache attributed to traumatic injury to the head
◦ Persistent headache attributed to moderate or severe traumatic injury to the head
◦ Persistent headache attributed to mild traumatic injury to the head
• 5.3 Acute headache attributed to whiplash1
• 5.4 Persistent headache attributed to whiplash
• 5.5 Acute headache attributed to craniotomy
• 5.6 Persistent headache attributed to craniotomy
you will notice there are no specific ha features in the classification, diagnosis is based more on the temporal relation of the trauma and the set of the headache onset
HA must begin within 7 days of the trauma, or within 7 days of regaining cons or 7 days of the pits ability to sensor report pain
Very arbitrary
HA may occur as isolated occurrence or as a constellation of symptoms ,memory dixxc fatigue etc therefore post concussion

5. 5. Headache attributed to trauma or injury to the head and/or neck
• 5.1 Acute headache attributed to traumatic injury to the head
◦ Acute headache attributed to moderate or severe traumatic injury to the head
◦ Acute headache attributed to mild traumatic injury to the head
• 5.2 Persistent headache attributed to traumatic injury to the head
◦ Persistent headache attributed to moderate or severe traumatic injury to the head
◦ Persistent headache attributed to mild traumatic injury to the head
• 5.3 Acute headache attributed to whiplash1
• 5.4 Persistent headache attributed to whiplash
• 5.5 Acute headache attributed to craniotomy
• 5.6 Persistent headache attributed to craniotomy
• Bibliography •
draw your attention to 5.2 persistent ha attributed to TBI mod or mild
must be greater than 3 months in duration
consider the possibility of MOH

6. Clinical no unique clinical features
may be localized to site of injury
hemicranial, holocranial, bilateral
dull, pressing, throbbing, piercing, stabbing,burning
daily, continuous, stabbing, paroxysmal, short,
no single type of HA
most studies found that migraine was the most common type 49-62% in mod to severe TBI
TTHnext most common 37%
unclassifiable 10%
freq of HA days is increased with severe PTH >15 per month
CDH 15% have neck and head injury

7. Clinical no single type of HA migraine most common49-62% TTH 37%
DH 15% have neck and head injury
no correlation with imaging
cluster, Hemicrania,SUNCT,Numular,
Primary Stabbing
no single type of HA
most studies found that migraine was the most common type 49-62% in mod to severe TBI
TTHnext most common 37%
unclassifiable 10%
freq of HA days is increased with severe PTH >15 per month
CDH 15% have neck and head injury
no correlation between imagine abn after severe TBI and PTH

8. PTH BEWARE SECONDARY HEADACHES! Secondary Headaches
Subdural. Epidural (LOC)
Dissection(fluctuating signs,neck pain)
CSF leaks (orthostatic HA)
CVThrombosis
Carotid Cavernous fistula(conjunctival injection, orbital bruit)
Skull fractures
Neuralgia
TMJ
MOH
However the clinician should be aware in the early stages of the assessment to have an index suspicion fr the secondary causes of headache in the ti patient. Causes of ha may include
Any focal signs evaluate orthostatic ha
neck pain
orbital bruits, conjunctival injections suggesting fistula
occipital neuroagia,TMJ
danish study 44% had MOH

9. Pathopyhsiology
TBIresults in chronic inflammation that can press for years and be permanent
in autopsy studies reactive microglia are noted in 28%
neuroinflammation is accompanied by disruption of the neuromuscular unit and extravasation of serum proteins thru BBB
TBI causes diffuse injury to cerebral microvasculature that can persist for years
unknown

10. Headache Phenotypes
Migraine and probable migraine 49-62% (mod- severeTBI
TTH next 37% mTBI
cluster, hemicrania continua, CPH,SUNCT,Numular,Primary Stabbing
In the more chronic long term stages the headaches all generally resemble a more common phenotype. with migraine being the most common,

11. Chronic PTH 1. psychological reaction 2.depression/anxiety 3.PTSD
4.stress/poor coping/occupation/relationships
5.sleep disorder
6.MOH
chronic pth may occur as a result of other factors, Often these patient have other co morbid conditions,
Moniter for veg features of depression, sleep disorders and ti go and in hand and may contribute to chronicity of headache.
MOH

12. Evaluation 1. HISTORY/PHYSICAL 2.CT: bone windows MRI: SWI
LP open pressure
get an eye witness account site of injury
CSF rhinorrhea
racoon eyes
LOC at scene
organ trauma
assoc fetures
med history
cognitive or psych symptoms

13. Potential Risk Factors
>40
low socioeconomic status
low education
low IQ
mild head injury
PTH depression/stress
preexisting psychopathology and work history
these are suggested risk factors for slow recovery from ti headaches. no conclusive studies, but repeated small studies have suggested under age 60, prior history of ha increased in Mild ti
1 month after MTBI 30-90%have chronic HA

14. Treatment No Guidelines!
Principles
Follow the phenotype
Elavil,(did better) Valproic acid, (44% 24-50% improve)Topamax,Inderal,Botox, Nerveblocks(peds 93% improve)
Triptans, NSAIDS,Analgesics
Treat early, stratified care,
Treat the associated symptoms, nausea, insomnia, depression
Avoid MOH!!!
Close followup and diaries
No guidelines
Historically 'comes with the territory'
expert opinion
>70%analgesics/otc/nsaids less than 5% triptans or specific therapy
Ped study retro ONB 93% relief 71%
retro study valproate 100 pts 30 days 44% 24-50% improvement
elavil subgroup analysis treated depression ha 'better'

15. Natural History PTH Stacy et al. J Neurotrauma apr 2017
316 pts followed mo.
HA over 5 years with mod-severe
72%male,73%white,55% MVA,pre injury HA 17%
disability HA was high
av HApain(scale 1-10) at 60 months with significant disability
>50% matched migraine profile
study looked at natural history of BI pats with ha over 5 years 316 puts prospectively enrolled and followed
significant impact on daily life
20% presented with new or worse 5 years with overall 5 years

16. CLINICAL PEARLS
Identify the headache type to allow you to determine the treatment indicated.
Set limits for medication use to minimize chances of MOH
Adopt the use of headache diaries for patients to quantify headaches and medication use
Consider prophylactic meds and adjunvent Rx as needed i.e. antiemetics, sleep aids, nerve blocks

17. CLINICAL PEARLS
Address lifestyle changes as part of treatment regimens, exercise, diet, sleep, smoking etc.
Be aware of assoc features of depression, anxiety comorbidities and Rx as needed
Provide realistic expectations
Follow up

18. References
1. Gladstone, Jonathan. From Psychoneurosis to ICHD-2.Current Review;Clinical Science. Headache
2.Lucas,Sylvia. Post traumatic Headache;Clinical Characterization and Management. Curr Pain Headache Rep