What is the best way to manage concussion headaches?

Management of Concussion Headaches

For concussion headaches, ibuprofen (400-800 mg) or acetaminophen (1000 mg) should be used as first-line treatment, with alternating both medications providing superior relief compared to either medication alone. 1, 2

First-Line Pharmacologic Management

• Acetaminophen and NSAIDs:

  • Ibuprofen 400-800 mg every 6-8 hours (not exceeding 2400 mg daily)
  • Acetaminophen 1000 mg every 6 hours (not exceeding 4000 mg daily)
  • Note: Lower doses of acetaminophen (500-650 mg) have not shown statistically significant improvement 2
  • Consider alternating ibuprofen and acetaminophen for enhanced efficacy 1

• Important caution: Limit analgesic use to 2-3 days per week to prevent medication overuse headache, which can paradoxically worsen concussion headaches 3

  • 70.1% of adolescents with chronic post-traumatic headaches (3-12 months duration) met criteria for medication overuse headache in one study 3
  • 68.5% of these patients had resolution or improvement of headaches after discontinuing analgesics 3

Non-Pharmacologic Approaches

• Physical Therapy: Beneficial for headache management with a "weak for" recommendation 2

  • Combination of thermal methods, trigger point massage, and mobilization/manipulation techniques
  • More effective than sham interventions or medications alone for reducing headache frequency and intensity

• Exercise Therapy: Recommended with a "weak for" recommendation 2

  • Aerobic exercise 2-3 times weekly for 30-60 minutes
  • Upper-body progressive strength training 3 times weekly for 30 minutes
  • Benefits include improved headache control, weight management, and reduced vascular risk

Management Algorithm

1. Initial Treatment:

   • Start with ibuprofen 400-800 mg OR acetaminophen 1000 mg for mild to moderate headaches
   • For severe headaches, consider alternating both medications

2. If Initial Treatment Fails:

   • For persistent headaches, consider referral to physical therapy
   • Add aerobic exercise program when symptoms allow
   • Evaluate for medication overuse headache if symptoms persist beyond 3 months

3. For Refractory Cases:

   • Consider metoclopramide for headaches with associated nausea 4
   • Evaluate for other headache types (migraine, tension-type) that may require specific treatment
   • Consider neurology referral for persistent symptoms beyond 3 months

Special Considerations

• Medication Overuse Risk: Monitor analgesic use carefully, as overuse can lead to chronic post-traumatic headaches 3

  • Educate patients to limit analgesic use to prevent this complication
  • If medication overuse is suspected, implement analgesic detoxification

• Timing of Intervention: Early intervention with appropriate analgesia may decrease persistent symptoms 5

• Monitoring: Track headache frequency, intensity, and medication use with a headache diary

• Return to Activity: Patients using both ibuprofen and acetaminophen (79%) or ibuprofen alone (61%) were more likely to return to school within one week compared to acetaminophen alone (33.3%) or standard care without analgesics (21.1%) 1

The evidence suggests that proper analgesic management, combined with appropriate non-pharmacologic therapies, can effectively manage concussion headaches while minimizing the risk of medication overuse headache and facilitating faster return to normal activities.