What is the best treatment for post-concussion headaches?

Management of Post-Concussion Headaches

For post-concussion headaches, a multidisciplinary approach including nonopioid analgesics, graded physical exercise, vestibular rehabilitation, and psychological treatment is recommended, with consideration for interdisciplinary coordinated rehabilitation in persistent cases. 1, 2

Initial Management of Acute Post-Concussion Headaches

• Nonopioid analgesics (ibuprofen or acetaminophen) should be offered as first-line treatment for painful headaches after concussion 1
• Patients should receive counseling regarding the risks of analgesic overuse, including rebound headache 1
• Ibuprofen, acetaminophen, or alternating both medications has shown effectiveness in reducing headache days, episodes, and intensity compared to standard care 3
• Opioids are not recommended for post-concussion headache management 1
• 3% hypertonic saline is not recommended for treatment of acute headache outside of research settings 1

Evaluation of Severe or Worsening Headaches

• Patients with severe or worsening headache after concussion should be evaluated for intracranial complications 1
• Neuroimaging should be considered for severe headache, especially when associated with other risk factors 1
• Emergent neuroimaging is indicated for acutely worsening headache symptoms during observation periods 1

Management of Persistent Post-Concussion Headaches

Physical Interventions

• Graded physical exercise should be offered to patients with persistent symptoms 1, 2

  • Implement sub-symptom threshold aerobic exercise with gradual increase in intensity/complexity 2
  • This approach has shown positive effects on overall symptom burden, physical functioning, and quality of life 1

• Vestibular rehabilitation should be offered to patients with persistent vestibular symptoms 1, 2

  • This includes habituation exercises, adaptation exercises, and balance training 2
  • Vestibular rehabilitation has demonstrated positive effects on physical functioning and return to activities 1, 2

• Manual therapy (spinal mobilization/manipulation) should be considered for patients with neck pain contributing to headaches 1, 2

  • This approach has shown positive effects on pain reduction 1, 2

Visual/Oculomotor Interventions

• Oculomotor vision treatment should be offered to patients with persistent visual symptoms 1, 2
  • This includes vergence training, accommodative training, and eye movement exercises 2
  • Clinical experience suggests improvements in visual symptoms, headache, and fatigue 1

Psychological Interventions

• Psychological treatment should be offered to patients with emotional symptoms 1, 2
  • Individual or group therapy administered at least 1 hour/week for a minimum of 4 weeks 1
  • This approach is associated with positive effects on overall symptom burden and emotional symptoms 1, 2

Pharmacological Considerations for Persistent Headaches

• For migraine-like post-concussion headaches, triptans may be considered, as they have shown efficacy in treating migraine headaches 4, 5
  • In military populations with post-traumatic headaches, 75% of patients showed positive response to triptans 5
• Amitriptyline is commonly prescribed for persistent post-concussion headaches, though research on its efficacy is limited 6, 7
• Female patients and those with higher initial symptom severity are more likely to require medication intervention 7

Comprehensive Approach for Persistent Symptoms

• Interdisciplinary coordinated rehabilitation should be implemented for persistent post-concussion symptoms 1, 2

  • This involves treatment from at least two different healthcare disciplines (e.g., physiotherapists, psychologists, neurologists) 1
  • This comprehensive approach has shown positive effects on overall symptom burden, physical functioning, and quality of life 1, 2

• Chronic headache after concussion is likely multifactorial and requires multidisciplinary evaluation and treatment 1

  • Consider analgesic overuse as a potential contributory factor 1
  • Pre-existing conditions, particularly migraine, may influence post-concussion headache presentation and treatment response 5

Important Considerations and Pitfalls

• Early patient education regarding symptom management and expected recovery course is essential 1, 2
• Medication compliance can be challenging in concussion populations, particularly among younger patients 6
• Post-concussion headaches often phenotypically resemble migraine, especially in patients with pre-existing migraine history 5
• Treatment variability is high in clinical practice, particularly for refractory post-concussion headaches 8
• Evidence supporting most interventions is of low to moderate certainty, with recommendations generally being weak but consistent across guidelines 1, 2