Risk Factors and Management Strategies for Posttraumatic Headaches  

Headaches after head trauma are frequent with many potential pathophysiologic pathways including neuroinflammation, impaired descending neuromodulation, cortical spreading depression, calcitonin gene-related peptide (CGRP)-dependent pathways, and metabolic changes. This variety of mechanisms, which may all be present may explain the highly heterogenous presentations and treatment responses of posttraumatic headache.  

The International Classification of Headache Disorders 3 defines posttraumatic headache as occurring within within seven days of either the injury, waking up from the injury, or stopping medications that would have affected their ability. There is some controversy with these criteria, particularly regarding the 7-days window, which has higher specificity but a correlated loss of sensitivity.  

Over the lifespan, approximately 4.7% of men and 2.4% of women will have a posttraumatic headache, although this is likely much higher in athletes and military personnel. After brain injury,  headache is among the most common and debilitation symptoms occurring in approximately 90% of people with brain injury and lasting for 1 year in 50 % to 60% of those individuals. These headaches are often accompanied by dizziness, lightheadedness, balance problems, cognitive symptoms, mood changes, and sleep and arousal symptoms. 

As with any headache disorder, the key to diagnosis is history—first to establish that a trauma occurred as well as the timing and severity of that trauma. Understanding any pretraumatic history of headache is also essential. Now post traumatic headache is a secondary headache disorder which means that we have to ask patients for red flags. 
Evidence of risk factors for posttraumatic headache is sparse. Historically what has been observed is that lower age, female gender, history of prior TBI, history of prior headache, and comorbid psychiatric disorders might all pretend a higher risk. 

Currently there are no therapies approved for the indication of posttraumatic headache. The goals of treatment are to treat by phenotype and to break the headache cycle as early as possible. It is important to consider comorbidities, nonheadache posttraumatic symptoms, and the need to return to activity. Comparative efficacy analysis is not available at this time regarding which treatments are most effective for treatment of posttraumatic headache.  

To avoid MOH, it is recommended to prescribe treatments in limited quantities for limited periods of time. This will alert the clinician to overuse and also provides information about the frequency of people’s headaches. It is still critical to evaluate use of over-the-counter medications with patients regularly.  

It is important to exercise caution when choosing preventive migraine therapies based upon individuals’ symptoms and needs. For example, topiramate has cognitive side effects making it a poor choice for someone with cognitive symptoms. Athletes may want to avoid beta blockers as these could prevent them from returning to physical activity.  

Vestibular abnormalities and autonomic abnormalities triggered by eye movement and body movement warrant a careful oculomotor examination and when possible, balance examination and formal vestibular and autonomic testing. If positional headaches occur, evaluation for cerebrospinal fluid disorders is needed. Autonomic headaches can also be positional and reported as lightheadedness or tachycardia. Tilt-table testing is ideal in this circumstance, but if it is not possible, simply increasing fluids and compression to see if there is a response can be diagnostic. 

Treatment of posttraumatic headache is often not successful with many individuals having headache for more than 1 year. For those with migraine-type headaches, only 25% respond to treatments, whereas with tension-type posttraumatic headache, approximately 70% responded to treatment. Many people relay on over-the-counter medications because the prescriptions given were not adequate.  

Posttraumatic headache is common and debilitating with poorly understood risk factors. A systematic and phenotypic approach to diagnosis and management is recommended. It is essential to rule out any red flags of secondary headache, treat early and adequately, and monitor for medication overuse headache.