What is the recommended medication for headache after a concussion?

Medication Management for Post-Concussion Headaches

Medication use is not recommended for headache management in the first 4 hours after concussion, and there is currently no evidence-based research supporting the use of any medication in the treatment of concussed pediatric athletes. 1

Acute Medication Management

The 2010 American Academy of Pediatrics guidelines clearly state that there is no evidence demonstrating the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen in alleviating symptoms or shortening the course of concussion 1. Furthermore:

• NSAIDs and aspirin should be avoided immediately after suspected head injury due to theoretical risk of intracranial bleeding
• One animal study found chronic ibuprofen administration worsened cognitive outcomes after traumatic brain injury 1
• Medication use to control persistent concussion symptoms indicates incomplete recovery
• Before considering return to play, any medications used to reduce symptoms must be stopped, and the athlete must remain symptom-free off medication 1

Evidence for Medication Use After Initial Period

More recent research provides some guidance for medication use after the initial post-injury period:

• A 2017 pilot study found that patients on acetaminophen, ibuprofen, or both had significantly fewer headache days, episodes, and lower headache intensity compared to standard care groups 2
• Patients receiving both ibuprofen and acetaminophen (79%) or ibuprofen alone (61%) were more likely to return to school within one week post-injury compared to acetaminophen alone (33.3%) or standard care (21.1%) 2

Warning About Medication Overuse

A critical consideration in post-concussion headache management is the risk of medication overuse:

• 70.1% of adolescents with chronic post-traumatic headaches (3-12 months duration) met criteria for probable medication-overuse headache 3
• 68.5% of these patients had resolution or improvement of headaches after discontinuing analgesics 3
• A 2022 study found that exposure to ibuprofen, acetaminophen, or both in the acute phase did not decrease the risk of headache at 7 days post-concussion 4

Treatment Algorithm for Post-Concussion Headaches

1. First 4 hours after injury:

   • Avoid all medications, particularly NSAIDs and aspirin 1
   • Focus on cognitive rest and symptom monitoring 1

2. After initial 4 hours:

   • For mild to moderate headaches: Consider acetaminophen or ibuprofen for short-term relief 2, 4
   • For more severe or persistent headaches: Consider alternating acetaminophen and ibuprofen 2
   • Monitor for medication effectiveness and avoid overuse (limit to <15 days/month) 3

3. For persistent headaches (>2 weeks):

   • Evaluate headache phenotype (migraine vs. tension-type) 5
   • For migraine-like headaches: Consider appropriate migraine-specific treatments 5
   • Implement non-pharmacological approaches including behavioral treatments 6

Non-Pharmacological Management

Given the limited evidence for medication efficacy and risks of medication overuse, non-pharmacological approaches should be emphasized:

• Cognitive rest, including temporary school accommodations 1
• Behavioral treatments including graded exposure to headache triggers 6
• Regular sleep schedule, meals, and adequate hydration
• Gradual return to physical activity as symptoms allow

Key Pitfalls to Avoid

1. Medication overuse: Limit analgesic use to prevent medication-overuse headache 3
2. Premature return to activity: Ensure complete symptom resolution before return to play 1
3. Inadequate cognitive rest: Communicate with schools about necessary accommodations 1
4. Overlooking headache phenotypes: Different headache types may require different approaches 5
5. Prolonged medication use: Any medications used to control symptoms must be stopped before return to play 1

Remember that continued medication use to control concussion symptoms indicates incomplete recovery, and athletes must be symptom-free off medication before returning to play 1.