What is Post-traumatic headache?
Nearly 2 million Traumatic Brain Injuries occur in U.S every year. Which leads to significant impact over individuals who siffered from TBH and their families. Headache is most commonly complaint reported in U.S which can occur after mild, moderate or severe injury over head.
Over 30% of people have reported to suffer headache which continued long after a injury.
Post-traumatic headache (PTHA) is defined as a secondary type headache that develops within 7 days after head trauma/ injury (or after regaining consciousness following head trauma). PTHA occurs as a consequence of traumatic brain injury.
On the basis of duration, PTHA can be divided into 2 types:
1.Acute PTHA -that resolves within 3 months, and
2.Persistent PTHA-that occurs for more than 3 months
So basically, when you get a concussion headache is a common symptom but if develop a new headache within 7 days after your head injury the condition is referred as post traumatic headache.
Post traumatic headache is caused due to muscle tensing. Muscle tensing is occurred during head injury/trauma or in some cases when blood vessels get narrow, which are responsible for flowing blood to your head in normal.
What is Traumatic brain injury?
Traumatic brain injury is a non-degenerative, non-congenital insult to the brain from an external mechanical force, leading to permanent or temporary impairment of cognitive, physical, and/or psychosocial functions, with an associated diminished or altered state of consciousness.
In the United States, nearly 1.7 million people undergo TBI every year. TBI can occur due to falls, motor vehicle accidents, and direct injuries to the head.
Traumatic brain injury can be mild, moderate, severe. Its result varies from complete recovery to permanent disability or even death.
What type of Headaches are developed after Traumatic Brain Injury (TBI)
Mainly there are four type of headaches developed after TBI i.e Migraine headaches, Tension-type headaches, Cervicogenic headaches and Rebound headaches. Lets understand each of them one by one below:-
Migraine Headaches
Migraine is a condition when area of brain become hypersensitive and triggers the pain signal to spread out in to other parts of the brain. Its like ripples that spread out when you throw pebble in water. The severity of pain is moderate to high.
Migraine headaches have the following characteristics:-
a. Dull and throbbing sensation on one side of the head.
b. Nausea and Vomitting.
c. Sensitivity to Light and Sound.
d. Warning signals for migraine attack are like seeing bright lights, seeing spots, hearing continuous sound, pressure over ear . This all can be referred as Aura.
Tension Type Headache
Tension Type headache occurs due to muscle tension or muscle spasm. Stress is also one of the major factor to cause tension headache TTH. Tension headache usually occurs later in the day. TTH pain is of mild to moderate severity and patient feels Tight and squeezing sensation over both sides or entire head.
Cervicogenic headaches
These headaches are associated with injuries to the muscle and soft tissues in the neck and back side of head. Nerves which are located in tissue and neck bones have branches that travels and connect to skull and scalp which results in head pain.
The pain usually starts from neck, shoulders and back of head, which travels to top of the head. Even a little neck movement and positioning increase the intensity of pain.
Cervicogenic headaches are not associated with nausea and pain severity can range from mild to severe intensity.
Rebound headaches
Rebound headache is caused by the medicines used to treat headache. Due to regular medicine schedule, missing one or two doses result in a headache.
Caffeine deficiency also results in developing headache. Suppose you are consuming high amount of caffeine regularly if you gradually decrease the caffeine intake you may develop a rebound headache.
Chronic Post-Traumatic Headache (CPTHA)
Post-traumatic headache is classified as chronic (CPTHA) when it continues to occur for more than 2 months after the injury. Chronic post-traumatic headache is the most commonly occurring pain after mild TBI. It occurs in 47–95% of patients of mild TBI and in 20–38% patients of moderate to severe TBI.
One of the primary reason for chronic post traumatic headache can be damage to intra and pericranial tissues which results chronic sensitization of these tissue.
Causes of Chronic Post-Traumatic Headache (CPTHA)
The exact mechanism of post-traumatic headaches is still unknown. But researchers have given various theories to explain the underlying cause of PTHA. Some of the theories are:
1. Impaired descending modulation,
2. Neurometabolic changes,
3. Activation of the trigeminal sensory system,
4. Hyperadrenergic activity,
5. Activation of extracranial dural afferents,
6. Meningeal irritation due to craniotomy.
CPTHA might be a form of central pain resulted due to damage to brain structure which are involved in pain processing.
Symptoms / clinical features of Chronic Post-Traumatic Headache (CPTHA)
Chronic Post-Traumatic Headache does not have specific symptoms of its own, rather it presents with clinical features of various types of primary headache, mainly tension-type and migraine headaches (each in about one third of individuals).
Post traumatic headache pain feels like migraine and severity of pain can very from moderate to high.
Individuals suffers diverse symptoms such as:
- nausea,
- vomiting,
- headache after physical activity and stress,
- headache exacerbated by light and sound,
- impaired cognitive and psychosocial functions.
Some Individuals experiences bilateral dull pain of mild to moderate intensity while suffer from unilateral pain of moderate to severe intensity which can be pounding, throbbing, drilling, and piercing in nature. Patients with whiplash injuries suffer pain similar to tension-type and migraine-type headaches.
According to some researches, patients with persistent PTH may undergo post-traumatic stress disorder or symptoms of anxiety and depression. Some patients with PTH might suffer from autonomic dysfunction symptoms such as orthostatic intolerance and bladder incontinence.
How to diagnose Chronic Post-Traumatic Headache?
Post-traumatic headaches, like other primary headaches are diagnosed clinically. Diagnostic imaging such as MRI, CT scan and laboratory tests are not necessary to diagnose a case of Chronic Post-Traumatic Headache. Patients with PTHA after TBI show no structural abnormalities on brain imaging. But new onset headache after TBI requires imaging to rule out other causes of headaches. Computed tomography (CT) of the head without contrast is required to rule out acute cerebral haemorrhage, especially in the elderly. Cerebral magnetic resonance imaging (MRI) can rule out ischemic infarction and masses. Any acute change in neurologic status or sudden change in frequency and intensity of headache may require additional imaging to rule other causes of headache.
Clinical Characteristics of CPTHA
So far, there is no single major characteristic identified for CPTHA. Rather, CPTHA shows the clinical features of various type of primary headache i.e Tension Type Headache and Migraine. The pain is distributed all over the head. Patients suffering from CPTHA reported the below regions of pain:-
a. Temple –82%
b. Forehead –76%
c. Neck –76%
d. Back of Head –53%
e. Eye–47%
f. Vertex– 29%
Patients suffering from tension type CPTHA have bilateral pain from mild to moderate intensity.
Treatment / Management of Chronic Post-Traumatic Headache
Treatment of post traumatic headache includes:
- oral medications,
- musculoskeletal manipulation and treatment,
- interventional procedures,
- behavioral therapy
- Acute treatment includes oral and intravenous non-steroidal anti-inflammatories (NSAIDs), triptans, and IV antiemetic medication.
- Preventive therapy consists of tricyclic antidepressants (TCAs), anticonvulsants, and gabapentin.
- For acute episodic tension-like PTHA treatment is NSAIDs.
- Herbal and vitamin supplements help in migraine like PTHA.
What can be the Differential Diagnosis of post traumatic headache?
- Tension headache
- Migraine headache
- Neuralgias/neuromas
- Cervicogenic headache
- Medication overuse headache
- Craniomandibular headache
- Ischemic/hemorrhagic stroke
- Aneurysm
- Cervical artery dissection
- Hydrocephalus
- Cerebral neoplasm
- Temporal arteritis
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Complications of Post-traumatic headaches
Post-traumatic headaches can be a psychosocial obstacle for patients returning to their baseline activity before TBI. Up to 35% of PTHA patients do not return to work after 3 months. Patients are also at an increased risk of developing opioid dependence.
Rehabilitation of Post-traumatic headaches patients
Physicians should reassure patients that post-traumatic headaches are not life-threatening. There is no specific clinical presentation for PTHA. Patients should be aware that PTHA may take characteristics of primary and other secondary headaches.
Life Style changes to prevent headaches
Sometimes individual’s lifestyle can be one of the factor triggering headache or make headache worse. Making some lifestyle changes can prevent the headache and helps to identify the headache triggers. Try below:-
- Get adequate and enough sleep.
- Exercise regularly. Do daily exercise for around 1 hour like walking, cycling, swimming, weigh lifting, aerobics and stretching. If the severity of headache increase after any particular exercise consult with your doctor/health care advisor. Exercise helps in improving sleep pattern and decrease triggers. You feel more energetic and decrease in stress.
- Avoid or Limit the caffeine intake.
- Stop or avoid smoking
- Food habits:- Certain foods can trigger a headache like alcohol, cheese, packed food, MSG food additive (monosodium glutamate).
- Long hours of working or Driving without break.