1. THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI Olli Tenovuo MD, PhD Department of Neurology University of Turku, Finland

2. Background TBI has long been an underestimated area in clinical medicine, especially in regard to its significance for public health. TBI has long been an underestimated area in clinical medicine, especially in regard to its significance for public health. There are still major gaps in our knowledge of some very central issues. One of these is the co-occurrence of chronic pain and TBI. There are still major gaps in our knowledge of some very central issues. One of these is the co-occurrence of chronic pain and TBI.

3. Background The co-morbidity of chronic pain and TBI is highly complex → clear diagnostic and treatment guidelines, applicable at an individual level, cannot be expected. The co-morbidity of chronic pain and TBI is highly complex → clear diagnostic and treatment guidelines, applicable at an individual level, cannot be expected. This should not hamper progression in research and clinical care of these patients. This should not hamper progression in research and clinical care of these patients.

4. The spectrum Chronic pain syndromes after TBI chronic headache chronic headache facial pain facial pain neck pain neck pain shoulder pain shoulder pain pain in the extremities (painful hemisyndrome) pain in the extremities (painful hemisyndrome) rare pain syndromes rare pain syndromes

5. Contents of the presentation A clinical and diagnostically oriented review of the most important pain problems after TBI, especially – chronic headache – chronic facial pain – chronic neck pain – central pain

6. Chronic posttraumatic headache The ICHD-II classification (2004): 1.Headache develops within 7 days after (mild - severe) head injury 2.Headache persists > 3 months after the injury

7. 5.2.2 Chronic posttraumatic headache attributed to mild head injury A. Headache, no typical characteristics known, fulfilling criteria C and D A. Headache, no typical characteristics known, fulfilling criteria C and D B. Head trauma with at least one of the following: B. Head trauma with at least one of the following: 1. Either no loss of consciousness or loss of consciousness for < 30 mins duration 1. Either no loss of consciousness or loss of consciousness for < 30 mins duration 2. GCS ≥ 13 2. GCS ≥ 13 3. Symptoms and/or signs diagnostic of concussion 3. Symptoms and/or signs diagnostic of concussion C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma D. Headache persists for 3 months after head trauma D. Headache persists for 3 months after head trauma The ICHD-II classification

8. Problems in definition The concepts of head injury and brain injury have been mixed The concepts of head injury and brain injury have been mixed The definition of mild HI lacks the duration of posttraumatic amnesia as a criteria The definition of mild HI lacks the duration of posttraumatic amnesia as a criteria ” within 7 days or after regaining consciousness” – in mild injury??? ” within 7 days or after regaining consciousness” – in mild injury??? “persists for 3 months” – but how often does it have to occur? “persists for 3 months” – but how often does it have to occur?

9. The ICHD-II classification 5.2.1 Chronic posttraumatic headache attributed to moderate or severe head injury A. Headache, no typical characteristics known, fulfilling criteria C and D A. Headache, no typical characteristics known, fulfilling criteria C and D B. Head trauma with at least one of the following: B. Head trauma with at least one of the following: 1. Loss of consciousness for > 30 mins 1. Loss of consciousness for > 30 mins 2. GCS < 13 2. GCS < 13 3. Posttraumatic amnesia for > 48 hrs 3. Posttraumatic amnesia for > 48 hrs 4. Imaging demonstration of a traumatic brain lesion (cerebral hematoma, intracerebral and/or 4. Imaging demonstration of a traumatic brain lesion (cerebral hematoma, intracerebral and/or subarachnoid hemorrhage, brain contusion, and/or skull fracture) subarachnoid hemorrhage, brain contusion, and/or skull fracture) C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma D. Headache persists for 3 months after head trauma D. Headache persists for 3 months after head trauma

10. Problems in definition The concepts of head injury and brain injury have been mixed The concepts of head injury and brain injury have been mixed PTA > 48 hrs – why this limit?? PTA > 48 hrs – why this limit?? ”Imaging demonstration of a traumatic brain lesion” – Is skull fracture a brain lesion? Axonal injury or oedema are not brain lesions? ”Imaging demonstration of a traumatic brain lesion” – Is skull fracture a brain lesion? Axonal injury or oedema are not brain lesions? ”Within 7 days…” – what about PTA > 7 days? ”Within 7 days…” – what about PTA > 7 days? ”Persists for 3 months” – at which frequency? ”Persists for 3 months” – at which frequency?

11. And further critique… Why should the TBI severity be included in the criteria? Why should the TBI severity be included in the criteria? The time limits are artificial and do not base on any evidence The time limits are artificial and do not base on any evidence The role of frequent extracerebral causes (especially concomitant neck injury) has been neglected The role of frequent extracerebral causes (especially concomitant neck injury) has been neglected - should the research of posttraumatic headache really be based on these criteria?

12. An alternative definition Chronic posttraumatic headache = Headache that usually develops within 3 months after an injury to the head or neck and is not better explained with non-traumatic causes after a thorough clinical history and examination, including appropriate imaging and laboratory studies. After developing, the headache should occur at least weekly for at least 6 months. A new official definition for clinical and research purposes should be made urgently, including the definition for various subtypes.

13. How common is chronic posttraumatic headache? The figures have been very variable, depending on the study population, protocol and headache criteria The figures have been very variable, depending on the study population, protocol and headache criteria The available data suggest that headache follows head injury in 50 to 80% of patients acutely and continues in 20 to 30% 1 to 2 years later (Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury increases the risk of chronic daily headache. A population-based study. The available data suggest that headache follows head injury in 50 to 80% of patients acutely and continues in 20 to 30% 1 to 2 years later (Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury increases the risk of chronic daily headache. A population-based study. Neurology® 2007;69:1169–1177)

14. Subacutely… 100 sequential admissions with mild TBI (as defined by American Congress of Rehabilitation Medicine, 1993), and 100 matched minor injury controls with nondeceleration injuries 100 sequential admissions with mild TBI (as defined by American Congress of Rehabilitation Medicine, 1993), and 100 matched minor injury controls with nondeceleration injuries 15.34% of those with minor head injury continued to complain of persistent posttraumatic headache at 3 months compared to 2.2% of the minor injury controls 15.34% of those with minor head injury continued to complain of persistent posttraumatic headache at 3 months compared to 2.2% of the minor injury controls (Faux S, Sheedy J. (Faux S, Sheedy J. A Prospective Controlled Study in the Prevalence of Posttraumatic Headache Following Mild Traumatic Brain Injury. Pain Med 2008, Epub ahead of print)

15. And in the long run… A Norwegian study compared the prevalence of headache in a cohort with previous hospitalization for head injury (22 yrs earlier) and matched controls A Norwegian study compared the prevalence of headache in a cohort with previous hospitalization for head injury (22 yrs earlier) and matched controls In multivariate conditional regression analysis among 192 responding case/control pairs, there was no evidence of higher odds of headache > 1 day per month (odds ratio, OR 1.04, 95% CI 0.56–1.92, p = 0.90) compared with controls. In multivariate conditional regression analysis among 192 responding case/control pairs, there was no evidence of higher odds of headache > 1 day per month (odds ratio, OR 1.04, 95% CI 0.56–1.92, p = 0.90) compared with controls. (Nestvold K, Staven M. Headache 22 Years after Hospitalization for Head Injury Compared with Matched Community Controls. Neuroepidemiology 2007; 29:113–120)

16. Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627. The type of posttraumatic headache

17. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619– 627.

18. The profile of posttraumatic headache

19. Chronic posttraumatic headache Periodic / daily Episodic Continuous Cervical / occipital Frontal, frontotemporal, ribbon-like, variable Without cervical signs With cervical signs Neck-derived headache Psychogenic Idiopathic Analgetics ≥ 3 days / week Medication overuse headache Yes No Orofacial dysfunction Visual dysfunction Hormonal insufficiency

20. Chronic episodic posttraumatic headache Migrainous (with migrainous characteristics) Migrainous (with migrainous characteristics) Neuritic (with neuralgic signs and localization) Neuritic (with neuralgic signs and localization)

21. Chronic periodic posttraumatic headache Muscular source (with muscular signs and localization) Muscular source (with muscular signs and localization) Migrainous (with characteristics of prolonged migraine) Migrainous (with characteristics of prolonged migraine) Cervical (with cervical signs, precipitating factors, cervical / frontal localization) Cervical (with cervical signs, precipitating factors, cervical / frontal localization)

22. Some important notes… The spectrum of acute and subacute posttraumatic headaches is much wider The spectrum of acute and subacute posttraumatic headaches is much wider In a minor but significant portion of patients, the clinical history, examination and consultations reveal no clear causes for the persisting headache. In a minor but significant portion of patients, the clinical history, examination and consultations reveal no clear causes for the persisting headache. In many of these, the headache clearly accompanies tiredness or fatigue. Treating a sleep problem or fatigue may offer a relief. In many of these, the headache clearly accompanies tiredness or fatigue. Treating a sleep problem or fatigue may offer a relief.

23. Some important notes… continued The often underdiagnosed post-traumatic hormonal insufficiency may also cause headache, and must be kept in mind as a treatable cause. The often underdiagnosed post-traumatic hormonal insufficiency may also cause headache, and must be kept in mind as a treatable cause. Cervicogenic headaches are underdiagnosed – suggestive features: Cervicogenic headaches are underdiagnosed – suggestive features: – rotatory injury mechanism – acute neck pain and restricted movements – weakness, numbness or pain in the extremities – cervical pain and impaired mobility persist for weeks after the injury

24. Some important notes… continued Clinical signs of cervicogenic headache: asymmetrically impaired cervical mobility asymmetrically impaired cervical mobility pain or tingling produced by rotation or flexion – extension pain or tingling produced by rotation or flexion – extension local tenderness in palpation of the C I-II vertebrae local tenderness in palpation of the C I-II vertebrae Further evaluation should preferably happen with functional cervical MRI, which is able to show eventual disruptions of the alar or transverse ligaments

25. Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and impact direction in whiplash injuries: associations with MRI- verified lesions of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005 Nov;22(11):1294-302

26. Chronic neck pain after TBI Is usually accompanied by headache, at least intermittently Is usually accompanied by headache, at least intermittently May stem from bony or soft tissue injuries May stem from bony or soft tissue injuries The clinical assessment should include detailed injury reconstruction, skilled examination of the cervical function and neurological examination of the cranial nerves and upper extremities The clinical assessment should include detailed injury reconstruction, skilled examination of the cervical function and neurological examination of the cranial nerves and upper extremities

27. Chronic neck pain after TBI Sensory disturbances in the upper extremities or C I-II region should raise a suspicion of nerve root injury or posttraumatic syringomyelia Sensory disturbances in the upper extremities or C I-II region should raise a suspicion of nerve root injury or posttraumatic syringomyelia Imaging of traumatic lesions in the cervical spine requires expertise and normal results do not necessarily mean normal anatomy Imaging of traumatic lesions in the cervical spine requires expertise and normal results do not necessarily mean normal anatomy An experienced physiotherapist or specialist in physical medicine is invaluable An experienced physiotherapist or specialist in physical medicine is invaluable

28. Chronic facial pain after TBI May have multiple aetiologies, such as: Trigeminal injury Trigeminal injury Orofacial dysfunction Orofacial dysfunction Sinus disturbance Sinus disturbance Upper cervical lesions Upper cervical lesions Orbital lesions Orbital lesions Atypical facial pain Atypical facial pain

29. Irritation to structures innervated by the cervical sensory nerves can activate the trigeminal nucleus along with the trigeminovascular system and result in referred pain to the anterior or frontal aspect of the head