Pediatric Annals

Special Issue Article 

Posttraumatic Headache

Raquel Langdon, MD; Sharief Taraman, MD

Abstract

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61–e68.]

Abstract

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61–e68.]

Mild traumatic brain injury (mTBI) is common among youth in the United States; it is estimated to occur in almost 700 of 100,000 children younger than age 15 years.1 A recent publication evaluating the point of health care entry for children with concussion within one health network found that 81.9% of patients had their first visit for concussion within the primary care setting, 11.7% in the emergency department (ED), and only 5.2% in specialty care clinics, illustrating that pediatricians and primary care physicians need to be well-equipped to manage mTBI and sequelae.2 One of the most common complaints after mTBI is that of posttraumatic headache (PTH). Although most patients will have resolution of their symptoms within a few weeks, up to 30% of concussion patients can go on to have more prolonged recovery trajectories with postconcussive symptoms still present at 3 months postinjury.3–5 Although there are no established guidelines for the management of pediatric PTH, early and appropriate management of acute PTH in a primary care setting is proposed to minimize disability and prevent prolonged recovery.

Definitions

The terms concussion and mTBI are often used interchangeably, even though concussion is defined as a clinical syndrome that may overlap with mild, moderate, and severe TBI, which has historically been based on the Glasgow Coma Score (GCS). In this article, we refer to postconcussive headache as PTH.

The International Classification of Headache Disorders6 categorizes PTH according to the severity of the injury (mild, moderate, or severe) and duration of headaches (acute and persistent). An acute PTH is defined as headache onset within 7 days of injury, whereas a persistent PTH is defined as a headache lasting more than 3 months postinjury (Table 1).6

The International Classification of Headache Disorders

Table 1:

The International Classification of Headache Disorders

Pathophysiology

Although the exact underlying mechanisms for PTH are unknown, the pathophysiology of concussions and mTBI are postulated to contribute to or cause PTH. The cascade of neurometabolic changes that occurs after injury are complex and have been extensively described (Figure 1). Traumatic biomechanical forces disrupt cell membrane integrity and distort axons. This leads to axonal transport and connectivity impairment. Simultaneously, there is also a decrease in cerebral blood flow and resultant brain energy dysfunction (Figure 2).7 Excitotoxic cell damage, inflammation, genetics, and psychologic influences have also been explored in the development of posttraumatic clinical syndromes.6,8–10

The neurometabolic cascade of concussion. Reprinted with permission from Giza and Hovda.7

Figure 1.

The neurometabolic cascade of concussion. Reprinted with permission from Giza and Hovda.7

Schematic of injury in traumatic brain injury. Reprinted with permission from Giza and Hovda.7

Figure 2.

Schematic of injury in traumatic brain injury. Reprinted with permission from Giza and Hovda.7

Clinical Features

PTH often mimics migraine or tension-type headaches (Table 2). In a prospective study, the clinical characteristics of PTH that persisted for more than 3 months in children after mTBI included 61% with daily headaches, 39% that fulfilled the criteria for migraine, and 9% with tension-type headaches.11 Often, patients may have multiple PTH types. If premorbid headaches existed, the preexisting headache type (ie, migraine) is usually magnified after head injury.

Characteristics of Migraine and Tension-Type Headaches

Table 2:

Characteristics of Migraine and Tension-Type Headaches

Most children who sustain a mTBI recover within a few weeks; however, a subset of patients experience persistent symptoms. In comparison to extracranial injuries (ECI), such as a bone fracture, mTBI patients are more likely to have persistent symptoms after 3 months. In 2010, Barlow et al.3 observed 670 patients who presented to the ED with mTBI and compared them to 197 patients presenting with ECI. At 3 months, 11% of patients with mTBI continued to be symptomatic, whereas only 0.5% of the ECI group continued to have symptoms related to their injury.3 In another study, almost 30% of children age 5 to 18 years were still symptomatic 3 months after sustaining a concussion, with headache commonly reported.4 Prolonged loss of consciousness or amnesia, prior concussive symptoms lasting longer than 1 week, female gender, initial symptom severity, presence of headache, sensitivity to noise, fatigue, answering questions slowly, and greater than four errors on the Balance Error Scoring System tandem stance within the first 4 weeks, as well as premorbid history of attention-deficit/hyperactivity disorder (ADHD), mood disorders, and migraines, have emerged as contributory factors for prolonged postconcussive recovery.5,12,13 Furthermore, these comorbid conditions, such as preexisting headaches, ADHD, learning disabilities, insomnia, and mood disorders complicate concussion recovery and may contribute to PTH. If not adequately addressed, they are likely to render treatment of PTH less effective.

A diagnosis of postconcussion syndrome should be considered in children with PTH and a constellation of cognitive, physical, sleep, and emotional symptoms persisting longer than typical recovery (Figure 3).

Features of postconcussion syndrome.

Figure 3.

Features of postconcussion syndrome.

Assessment

Comprehensive history, physical, and neurologic examinations are critical in ruling out potential life-threatening etiologies in pediatric patients presenting after a head injury. Historical information should focus on prior history of head injuries including timing and duration of postinjury symptoms, preinjury headache characteristics, and how the headache pattern has changed following injury, as well as any known history of mood disorders, sleep disorders, or cognitive/learning disorders. Screening is recommended for potential risk factors suggestive for persistent PTH or prolonged recovery that are mentioned above. A detailed medication history is especially important as patients with PTH are at particularly high risk for medication overuse headache (MOH) with up to 70% of adolescents with chronic PTH of more than a 3-month duration also meeting criteria for probable MOH.8,14

The most important aspects of the physical examination include screening for presence of focal neurologic deficits, evaluating neck range of motion and assessment for cervical injury, funduscopic examination, eye-tracking with specific attention given to presence of convergence insufficiency or excess, a brief cognitive assessment, and evaluation of coordination and balance. The Balance Error Scoring System is helpful to use to standardize the evaluation of balance examination (Figure 4).15

Balance Error Scoring System. Assessing postural stability with eyes closed and hands on hips in the following positions for 20 seconds in each position: (A) flat surface; (B) 10-cm foam block; (1) double-leg stance; (2) single-leg stance on nondominant foot; (3) tandem leg stance with dominant foot forward. Reprinted with permission from Bell et al.15

Figure 4.

Balance Error Scoring System. Assessing postural stability with eyes closed and hands on hips in the following positions for 20 seconds in each position: (A) flat surface; (B) 10-cm foam block; (1) double-leg stance; (2) single-leg stance on nondominant foot; (3) tandem leg stance with dominant foot forward. Reprinted with permission from Bell et al.15

An error is defined as opening the eyes, lifting the hands off of the hips, stepping, stumbling or falling out of position, lifting the forefoot/heel, abducting the hip by >30 degrees, or failing to return to test position in under 5 seconds.

Guidelines for the appropriate use of computed tomography (CT) imaging following head trauma have previously been established, and it is important to note that most pediatric patients may be closely observed without neuroimaging.16 CT is recommended if GCS is less than or equal to 14, signs of altered mental status are present, there is a palpable skull fracture, or signs of basilar skull fracture. CT may be considered with the presence of scalp hematoma (occipital, temporal, or parietal), history of loss of consciousness greater than or equal to 5 seconds, severe mechanism of injury, the patient is not acting normally (according to the parent), history of vomiting, severe headache, or worsening of symptoms or signs after ED observation.16

Management

Currently, there are no established guidelines for the management of pediatric PTH, as well as no randomized controlled trials comparing efficacy of headache medications. In practice, the approach to treatment may vary widely among clinicians. A 2012 systematic review of all articles published between 1985 and 2009 on interventions for PTH found that there was insufficient evidence to recommend any specific treatment.17

As such, the typical management involves treating PTH similarly to how one would treat a primary headache disorder (eg, chronic migraine or chronic tension-type headache) with lifestyle modifications, abortive medications, and preventive medications. Lifestyle modifications for headaches may involve ensuring good sleep hygiene, adequate hydration, regular meals, exercise, avoidance of headache triggers, and stress management.

In the setting of a patient where intracranial hemorrhage is felt to be low risk, has been excluded, or outside of the acute presentation window, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are typically used as the first-line pharmacological agents to abort PTH. The dosage for ibuprofen is 10 mg/kg every 6 hours, and 5 to 10 mg/kg every 12 hours for naproxen.18 NSAIDs should be limited to no more than 3 days per week and no more than two doses in the same day to avoid MOH. Acetaminophen at 15 mg/kg/dose may also be considered in patients with a contraindication to NSAID use. If there is an inadequate response to NSAIDs19,20 and the headache is accompanied by migrainous features, serotonin agonists, commonly referred to as triptans, may be used and are generally well-tolerated in children. Examples of such medications include sumatriptan and rizatriptan. An oral dose of sumatriptan for children age 6 to 11 years is 25 mg; a single dose for children older than age 12 years is 50 mg and can increase to 100 mg if needed. The maximum dose is 200 mg per 24 hours. An oral dose of rizatriptan is 5 mg for less than 40 kg and 10 mg if greater than 40 kg.20 To avoid MOH, triptans should be restricted to no more than 2 days per week or nine doses per month. In the acute setting of mTBI, caution should be used when administering triptans as there may be a theoretical risk of vasoconstriction and exacerbation of cerebral hypoperfusion. Potential side effects of triptans may include hot or cold flashes, facial flushing, paresthesia, chest pain, and fatigue.

The American Academy of Neurology recommends that preventive medications be considered in patients with headaches occurring at a frequency of greater than twice per week, headaches that are severe resulting in debilitation and interference with normal routines, as well as in patients who do not respond well to abortive medications. In addition to the lifestyle modifications mentioned above, nonpharmacologic strategies such as use of heat or ice packs, behavioral therapy, relaxation techniques, biofeedback, and learning of coping skills have been shown to improve chronic headaches in children and adolescents.21–23

Preventive medications are generally selected based on analysis of risk/benefit and on presence of comorbidities; for example, tricyclic antidepressants may be considered for a patient with PTH and insomnia. Amitriptyline is often titrated slowly over several weeks up to 1 mg/kg per day and dosed at bedtime due to its potential sedative effects. Other potential side effects include dry mouth, dry eyes, lightheadedness, constipation, and increased appetite. Amitriptyline may also prolong the QT interval. Antiepileptics are also often used as preventive medications for headaches with topiramate approved for migraine prophylaxis in patients age 12 years and older with an effective dose of 2 to 4 mg/kg per day.21 Side effects of topiramate include paresthesias, drowsiness, decreased appetite, metabolic acidosis, increased risk for nephrolithiasis, impaired sweating, and memory or language dysfunction.

There are emerging data to suggest a role for melatonin for the treatment of persistent PTH. Use of melatonin in children with persistent PTH at doses of 3 to 10 mg has demonstrated positive effects in up to 75% of participants in one study population.11 Another developing treatment strategy is the use of peripheral nerve blocks. A retrospective chart review of patients with PTH (mean age 15 years) showed a positive response with 64% of patients reporting a long-term response, improved quality of life, and decreased postconcussion symptom scores after the procedure.24,25

Patients who fail outpatient therapy have been shown to benefit when treated with various combinations of ketorolac alone, ketorolac and metoclopramide, prochlorperazine, or ondansetron monotherapy in an ED setting.26 Opiates for the treatment of pediatric headache are not indicated and likely increase the risk for chronic pain and MOH.18 In addition, patients treated with opiates in an ED setting are more likely to return due to rebound of headache symptoms.27

In addition to PTH treatment, early education on mTBI and the anticipated recovery trajectory has been shown to improve clinical outcomes. In a study25 evaluating the impact of early intervention on outcomes after mTBI, children seen at 1 week after head injury were given an information booklet outlining symptoms associated with mTBI and suggested coping strategies. Children who were seen 3 months after injury did not receive the booklet. Overall, the study found that children who did not receive the educational intervention reported more symptoms 3 months after injury.25

Prescribed cognitive and physical rest after concussion continues to be debated. Although there is evidence supportive of a short duration of rest in the acute phase of concussion, more prolonged periods of activity restriction beyond 2 to 3 days postinjury may place patients at risk for prolonged symptomatic recovery and adjustment disorder with depression and/or anxiety.28,29 A 2010 study randomized children and young adults age 11 to 22 years presenting to the ED after concussion to either strict rest for 5 days or rest for 1 to 2 days followed by a gradual increase in activity, and found more daily postconcussive symptoms in the strict rest group (total symptom score over 10 days, 187.9 vs 131.9, P < .03) and slower recovery trajectories.30 Mild-to-moderate exercise rehabilitation programs have also demonstrated improvements in postconcussive symptom scores.31 Proactive management of concussion may help facilitate prevention of transformation of acute PTH to chronic PTH. Active management of concussion recovery uses graduated return to cognitive and physical activities. A multimodal treatment paradigm incorporating physical rehabilitation and cognitive-behavioral therapies should be considered for patients with persistent PTH32,33 (Figure 5).

A multimodal treatment paradigm incorporating physical rehabilitation and cognitive behavioral therapies. NSAIDs, nonsteroidal anti-inflammatory drugs; PTH, posttraumatic headache.

Figure 5.

A multimodal treatment paradigm incorporating physical rehabilitation and cognitive behavioral therapies. NSAIDs, nonsteroidal anti-inflammatory drugs; PTH, posttraumatic headache.

Conclusion

In summary, headache is a common complaint in the pediatric patient after mTBI. Thorough history taking and physical examination are crucial in excluding secondary etiologies of headache, and to determine need for neuroimaging. Most children with PTH will recover within a few weeks; however, a subset may continue to experience persistent headache symptoms. Although there are no established guidelines currently to direct management of PTH, a multifaceted and individualized treatment approach is recommended, as well as lifestyle modifications, use of abortive and preventive medications when indicated, counseling on medication overuse, and rehabilitation strategies to facilitate return-to-school and activities. Future research is needed to determine the efficacy of treatments and optimal approach to care in these patients.

References

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The International Classification of Headache Disorders

Classification Acute PTH Persistent PTH
Description Headache of less than three months' duration caused by traumatic injury to the head Headache of greater than three months' duration caused by traumatic injury to the head
Diagnostic criteria <list-item>

Any headache fulfilling criteria C and D

</list-item><list-item>

Traumatic injury to the headhas occurred

</list-item><list-item>

Headache is reported to have developed within 7 days after one of the following: <list-item>

The injury to the head

</list-item><list-item>

Regaining of consciousness following the injury to the head

</list-item><list-item>

Discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head

</list-item>

</list-item><list-item>

Either of the following: <list-item>

Headache has resolved within 3 months after the injury to the head

</list-item><list-item>

Headache has not yet resolved but 3 months have not yet passed since the injury to the head

</list-item>

</list-item><list-item>

Not better accounted for by another ICHD-3 diagnosis

</list-item>
<list-item>

Any headache fulfilling criteria C and D

</list-item><list-item>

Traumatic injury to the head has occurred

</list-item><list-item>

Headache is reported to have developed within 7 days after one of the following: <list-item>

The injury to the head

</list-item><list-item>

Regaining of consciousness following the injury to the head

</list-item><list-item>

Discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head

</list-item>

</list-item><list-item>

Headache persists for >3 months after the injury to the head

</list-item><list-item>

Not better accounted for by another ICHD-3 diagnosis

</list-item>

Characteristics of Migraine and Tension-Type Headaches

Classification Migraine Tension
Location Unilateral or bilateral (often frontal or temporal) Bilateral, frontal
Quality Throbbing Pulsating Band-like pressure Tightening Pressure (nonpulsating)
Severity Moderate to severe Mild to moderate
Duration 4–72 hours Typically 30 minutes
Associated symptoms Aura Photophobia and phonophobia Nausea and/or vomiting Aggravated by physical activity; patients prefer lying in dark, quiet room Not aggravated by routine physical activity such as walking or climbing stairs No nausea or vomiting (anorexia may occur) No more than one of photophobia or phonophobia
Authors

Raquel Langdon, MD, is the Co-Director, Pediatric Headache, Center for Neurosciences and Behavioral Health, Children's National Health System; and an Assistant Clinical Professor, Child Neurology, George Washington University. Sharief Taraman, MD, is the Assistant Division Chief, Department of Pediatric Neurology, Children's Hospital of Orange County; and an Assistant Clinical Professor, Department of Pediatrics, University of California-Irvine.

Address correspondence to Sharief Taraman, MD, Department of Pediatric Neurology, Children's Hospital of Orange County, 505 S. Main Street, Suite 1200, Orange, CA 92868; email: staraman@choc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20180131-01

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