What is the recommended treatment for a headache due to concussion?

Treatment of Headache Following Concussion

For headache due to concussion, nonopioid analgesics such as acetaminophen should be used as first-line treatment, while NSAIDs like ibuprofen should be avoided in the acute phase due to bleeding risk. 1, 2

Acute Management (First 48 Hours)

• Initial approach:

  • Relative rest for 24-48 hours, avoiding activities that exacerbate symptoms 1
  • Acetaminophen for pain management 2, 1
  • Avoid NSAIDs and aspirin initially due to theoretical risk of intracranial bleeding 1
  • Avoid alcohol and illicit drugs 1

• Monitoring:

  • Observe for severe or worsening headache, which may indicate intracranial complications requiring emergent neuroimaging 2
  • Children with acutely worsening headache symptoms should undergo emergent neuroimaging 2

Subacute Management (After 48 Hours)

• Pharmacological treatment:

  • After 48 hours when bleeding risk is lower, NSAIDs may be considered if acetaminophen is ineffective 2
  • Counsel patients and families about the risk of analgesic overuse, which can lead to rebound headaches 2
  • Avoid opioids due to risk of dependency and rebound headaches 2

• Activity management:

  • Begin gradual schedule of light aerobic exercise after 24-48 hours of relative rest 1
  • Avoid activities that significantly exacerbate headache symptoms
  • Follow a stepwise return to normal activities, with each stage lasting at least 24 hours 1

Management of Persistent Post-Concussion Headache (>2 Weeks)

• Evaluation:

  • Consider headache pattern and characteristics to determine if it resembles migraine, tension-type, or cervicogenic headache 2
  • Assess for cervical strain which may contribute to occipital/suboccipital headaches 2

• Treatment based on headache pattern:

  • Migraine-like: Consider migraine-specific treatments if headaches persist 2

    • NSAIDs (ibuprofen, naproxen) 2
    • Consider triptans for moderate-severe headaches not responding to NSAIDs 2
    • Non-oral routes of administration if nausea/vomiting present 2

  • Cervicogenic component: Consider referral for physical therapy targeting the cervical spine 2

• Multidisciplinary approach for chronic headache:

  • Refer patients with chronic headache after concussion for multidisciplinary evaluation and treatment 2
  • Consider vestibular rehabilitation for patients with vestibulo-oculomotor dysfunction 2
  • Address sleep disturbances which may exacerbate headaches 2

Important Considerations and Pitfalls

• Avoid:

  • 3% hypertonic saline (insufficient evidence for treatment of acute headache after concussion) 2
  • Prolonged complete rest, which can worsen outcomes 1
  • Premature return to high-risk activities 1
  • Analgesic overuse which can lead to medication-overuse headache 2

• Special populations:

  • Children and adolescents should be managed more conservatively with longer recovery periods 1
  • Approximately 15-20% of concussion patients develop post-concussion syndrome with persistent symptoms 1

• When to refer to specialist:

  • Headaches persisting beyond 3 months 1
  • Multiple concussions in a single season 1
  • Headaches with concerning features or not responding to initial management 2

Following these evidence-based recommendations can help effectively manage post-concussion headaches while minimizing complications and promoting recovery.