Posttraumatic Headache Management Update from Virtual Scottsdale Headache Symposium 2020
At the Virtual Scottsdale Headache Symposium 2020 held on November 21st, 2020, Dr. Juliana VanderPluym, MD, FAHS of the Mayo clinic reviewed current knowledge on management of posttraumatic headache, providing a step-by-step approach as follows below.
1. Posttraumatic headache is a secondary headache attributed to trauma or injury to the head or neck, occurring within 7 days of injury (or regaining consciousness or discontinuing medication that may have kept the headache from being diagnosed). Posttraumatic headache may be further subclassified as acute (within 3 months of injury) or persistent (occurring >3 months after injury).
2. Although not the only posttraumatic symptom, posttraumatic headache is the most common, occurring in up to 90% of traumatic brain injury (TBI), most debilitating (increasing likelihood of job loss fourfold for adults), and may last over 1 year after the trauma.
3. As with any headache, history is key to diagnosis. Determining onset and duration of the headache as well as whether any headache was present before injury is important to assessing whether this is a new condition or exacerbation of a pre-existing headache disorder. It is also important to determine the headache phenotype, whether it is more like a tension-type headache, migraine, or other headache disorder. At present, treatment choices are based on headache phenotype.
4. Ruling out other secondary causes with the mnemonic I-FLOP is essential, and if any red flags are present, further diagnostic work up, including neuroimaging should be done. Red flags include:
- Intractable vomiting
- Focal neurologic signs or symptoms
- Level of awareness
- Orthostatic headache
- Progressively worsening headache
5. Risk factors for poor prognosis of posttraumatic headache include female sex, prior history of headache, comorbid psychiatric disorders, a migraine-like phenotype, sleep disturbances, headaches that are present immediately after injury or present with continuous pain.
6. There are no treatments specific to posttraumatic headache, and treatment choice is driven by headache phenotype. It is important to initiate acute treatment early as this is usually when the symptom burden is higher. Early acute treatment may also help to prevent chronification of the headache, which is why preventive treatments are often considered early in the course of treatment. Development of medication overuse headache is common and careful management of medication use is imperative to avoid this. Choice of treatments include:
- acetominophen
- nonsteroidal anti-inflammatories should be avoided in the first 24 hours of injury
- steroid tapers
- nerve blocks
- trigger point injections
For posttraumatic headache with migraine-like features: triptans, dihyroergotamine, and antiemetics are used. There are no data for use of -gepants or -ditans for treament of posttraumatic headache yet
7. Because posttraumatic headache often becomes chronic, some people have argued for early initiation of preventive treatment. People with more than 8 headache days per month for more than 1 month are candidates for preventive treatments including cranial nerve blocks, onabotulinumtoxinA injections, transcranial magnetic stimulation, and behavioral treatments. Other treatments may be considered; however, caution should be taken when using:
- tricyclic antidepressants in people with autonomic issues
- topiramate in people with cognitive symptoms
- beta-blockers in athletes
- sedating medications in those with fatigue
- steroids in those with significant emotional dysregulation or sleep difficulties and in athletes, for whom this treatment may violate anti-doping regulations