What are the treatment options for post-concussive headache (post-concussion syndrome)?

From the Guidelines

For post-concussion headaches, I recommend a stepwise approach starting with rest and over-the-counter pain relievers like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or ibuprofen (400-600mg every 6-8 hours with food), as there is insufficient evidence to recommend for or against choosing a specific treatment strategy for posttraumatic headache 1.

Treatment Approach

• Rest in a quiet, dark room and apply cold packs to the head for 15-20 minutes several times daily.
• Stay hydrated and maintain regular sleep patterns.
• If symptoms persist beyond 7-10 days, consult a healthcare provider who may prescribe medications like amitriptyline (starting at 10mg nightly, gradually increasing if needed) or topiramate (starting at 25mg daily, increasing gradually to 50-100mg twice daily).

Non-Pharmacological Interventions

• Physical therapy focusing on neck exercises and gradual return to activities is beneficial, with a "weak for" recommendation for rehabilitation delivered through physical therapy (PT) for the management of migraine and TTH 1.
• Cognitive behavioral therapy can help manage pain perception, although evidence is insufficient to recommend for or against its use for headache management 1.
• Aerobic exercise or progressive strength training received a "weak for" recommendation for the prevention of both migraine and TTH, and can be used in management of TTH and migraines 1.

Medications

• Aspirin–acetaminophen–caffeine has a "strong for" recommendation for acute migraine treatment, but its use for post-concussion headaches is not specifically recommended 1.
• CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, have a "strong for" recommendation for prevention of EM or CM, but their use for post-concussion headaches is not specifically recommended 1.
• Topiramate has a "weak for" recommendation for the prevention of both EM and CM, and may be considered for post-concussion headaches, but its use should be individualized and monitored by a healthcare provider 1.

From the Research

Treatment Options for Post-Concussion Headache

• The treatment for concussion and post-concussion symptoms, including headache, should be individualized based on predominant signs and symptoms 2.
• Pharmaceutical management of post-traumatic headaches may be considered, with some evidence supporting the use of certain medications 3.
• Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief, but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist 4.

Medication-Specific Treatment

• Amitriptyline has been studied as a potential treatment for headache after traumatic brain injury, but current evidence does not support its use as a headache preventive due to difficulties with study recruitment and compliance 5.
• Ibuprofen and acetaminophen have been shown to be effective in reducing headache days, episodes, and intensity in postconcussive youth, with patients on both medications or ibuprofen alone more likely to return to school 1 week post-injury 6.

Multidisciplinary Approach

• A multidisciplinary approach to managing post-concussion syndrome is recommended, including evaluation and management of vestibular-ocular dysfunction, cognitive symptoms, and emotional symptoms 3.
• Treatment should be tailored to the individual's specific needs and may include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and symptom-specific pharmacological therapies 2.