What is the treatment for post-concussion headaches?

Treatment of Post-Concussion Headaches

A comprehensive treatment approach for post-concussion headaches should include a combination of non-pharmacological interventions such as graded physical exercise, vestibular rehabilitation, manual therapy for neck pain, and psychological treatment, with careful use of medications to manage symptoms. 1

Initial Management (First 24-48 Hours)

• Begin with a brief period of 24-48 hours of relative rest (not complete bed rest) 1
• Avoid activities that worsen headache symptoms 1
• Avoid NSAIDs and aspirin immediately after injury due to theoretical risk of intracranial bleeding 1
• Monitor for warning signs of more serious injury (worsening headache, repeated vomiting, seizures, increasing confusion) 1

Non-Pharmacological Interventions

Graded Physical Exercise

• Implement light aerobic exercise at subsymptom threshold (walking, stationary cycling) 1, 2
• Gradually increase intensity as tolerated 2
• Exercise has shown positive effects on overall symptom burden, physical functioning, and emotional symptoms 2

Vestibular Rehabilitation

• Recommended for patients with persistent vestibular dysfunction 2, 1
• Includes otolith manipulating procedures, habituation exercises, adaptation exercises, and balance training 2
• Should be administered at least once weekly for 4 weeks 2

Manual Therapy for Neck and Spine

• Consider for patients with neck pain contributing to headaches 2, 1
• Includes mobilization and manipulation of spine performed by physiotherapists or chiropractors 2
• Has shown positive effects on physical functioning and pain 2

Psychological Treatment

• Cognitive behavioral therapy can be beneficial for emotional symptoms 1, 3
• Graded exposure to headache triggers (stress, light, noise) may reduce sensitization 4

Pharmacological Management

For mild to moderate headaches:

• NSAIDs (after initial 24-48 hour period) 2
• Acetaminophen (though less effective as a single agent) 2

For moderate to severe headaches:

• Migraine-specific medications (triptans) if headache has migraine features 2
• Combination analgesics containing caffeine 2

For headaches with nausea:

• Consider antiemetics like metoclopramide or prochlorperazine, which may also provide analgesic effects 2

Important: Avoid opioid analgesics for chronic post-concussion headaches as they can lead to dependency, rebound headaches, and eventual loss of efficacy 2

Interdisciplinary Approach for Persistent Symptoms

For patients with persistent post-concussion headaches (lasting >2-4 weeks):

• Consider referral to interdisciplinary rehabilitation team 2, 1
• Comprehensive assessment to identify specific headache generators 3
• Tailored combination of physical, cognitive, and psychological interventions 3

Monitoring and Follow-up

• Each step in return to activity should take minimum 24 hours 1
• If symptoms return, drop back to previous asymptomatic level and try again after 24 hours 1
• Monitor for development of chronic headache patterns requiring specialized management 3

Common Pitfalls to Avoid

• Prescribing complete rest until all symptoms resolve (can prolong recovery) 1
• Returning to activities too quickly (can exacerbate symptoms) 1
• Using medications to mask symptoms for premature return to activities 1
• Failing to address cervicogenic components of headache 3
• Neglecting psychological aspects of persistent symptoms 1, 3

The evidence suggests that active management of post-concussion headaches is more effective than passive approaches, with a combination of targeted interventions addressing specific symptoms showing the best outcomes for reducing headache burden and improving quality of life 2.