What is the recommended treatment for a headache post concussion?

Management of Post-Concussion Headaches

For post-concussion headaches, acetaminophen (1000 mg) or ibuprofen (400 mg) should be used as first-line treatment, with careful monitoring for analgesic overuse that can lead to rebound headaches. 1, 2

Initial Assessment and Management

Acute Phase (First 48 Hours)

• Acetaminophen (1000 mg) should be used as first-line treatment in the immediate post-concussion period 1, 2
• Avoid NSAIDs like ibuprofen in the first 48 hours due to potential bleeding risk 2
• Monitor for severe or worsening headache, which may indicate intracranial complications requiring emergent neuroimaging 1

After 48 Hours

• Ibuprofen (400 mg) can be introduced if acetaminophen is ineffective 1, 2
• Alternating acetaminophen and ibuprofen may be more effective than either medication alone for reducing headache days and intensity 3

Warning Signs Requiring Urgent Evaluation

• Acutely worsening headache symptoms
• Severe headache with other risk factors
• Headache that interferes with sleep
• New neurological symptoms

These symptoms warrant consideration for emergent neuroimaging to evaluate for intracranial complications 1, 2

Preventing Medication Overuse Headache

Medication overuse is a significant concern in post-concussion headache management:

• Up to 70% of adolescents with chronic post-traumatic headaches meet criteria for medication overuse headache 4
• Provide clear counseling about limiting analgesic use to ≤15 days/month for simple analgesics 1, 2
• Avoid opioids completely due to high risk of dependency and rebound headaches 2
• Nearly 70% of patients experience headache improvement after discontinuing overused analgesics 4

Activity Management

1. Initial relative rest for 24-48 hours, avoiding activities that exacerbate symptoms 2
2. Gradual return to light aerobic exercise following the 24-48 hour rest period 2
3. Progress through a 5-stage return to activity protocol:
   • Symptom-limited activity
   • Light aerobic exercise
   • Sport-specific exercise
   • Non-contact training drills
   • Full-contact practice

Each stage should last a minimum of 24 hours, with return to the previous stage if symptoms recur 2

Treatment Based on Headache Pattern

Headache characteristics should guide treatment approach:

• Migraine-like headaches: Consider NSAIDs (after 48 hours) and potentially triptans for moderate-severe headaches if persistent 2, 5
• Tension-type headaches: Acetaminophen (1000 mg) or ibuprofen (400 mg) 1
• Cervicogenic headaches: Consider referral for physical therapy targeting the cervical spine 2

Management of Chronic Post-Concussion Headaches

For headaches persisting beyond 3 months:

• Refer for multidisciplinary evaluation and treatment 1, 2
• Consider vestibular rehabilitation for patients with vestibulo-oculomotor dysfunction 1, 2
• Address sleep disturbances that may exacerbate headaches 2, 6
• Implement a biopsychosocial approach including exercise, multifaceted rehabilitation, and psychosocial interventions 6

Common Pitfalls to Avoid

1. Analgesic overuse: Limit use to prevent rebound headaches
2. Premature return to high-risk activities: Increases risk of second-impact syndrome
3. Opioid use: Avoid due to dependency risk and rebound headaches
4. 3% hypertonic saline: Not recommended due to insufficient evidence 1
5. Neglecting psychological factors: Anxiety and depression can worsen post-concussion symptoms 6

Remember that approximately 15-20% of concussion patients develop post-concussion syndrome, with most experiencing symptom resolution within 7-10 days, but about 10% may have symptoms persisting beyond 3 months 2.