What is the recommended treatment for headaches resulting from intracranial contusion?

Treatment of Headache from Intracranial Contusion

The primary treatment for headaches resulting from intracranial contusion should focus on appropriate pain relief with acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs), while simultaneously addressing the underlying cause of the contusion. 1

Initial Assessment and Management

• Assess for signs of increased intracranial pressure (ICP) such as worsening headache, visual changes, altered mental status, or focal neurological deficits, as these may indicate deterioration requiring urgent intervention 2
• MRI of the brain with contrast should be performed to evaluate the extent of contusion and rule out complications like subdural hematoma or cerebral venous thrombosis 1
• Small or asymptomatic hematomas associated with contusion should be managed conservatively while symptomatic hematomas with significant mass effect may need surgical intervention 1

Pharmacological Management

First-line Treatments

• Acetaminophen and/or NSAIDs are recommended as first-line therapy for pain relief in post-contusion headaches 1, 3
• Despite the widespread use of over-the-counter medications, studies show they provide complete relief in only a minority of patients with post-traumatic headache 3

Second-line Treatments

• For headaches with migrainous features (which are common after brain injury), migraine-specific treatments such as triptans may be considered 3, 4
• Opioid medications may be required for adequate pain relief in severe cases but should be avoided for long-term management 1

Preventive Treatments

• For persistent or recurrent headaches, preventive therapy should be considered based on the headache phenotype 4
• Topiramate may be beneficial for prevention of post-traumatic headache with the added benefit of potentially reducing ICP through carbonic anhydrase inhibition 5
• When selecting preventive medications, consider comorbidities and avoid medications that could exacerbate symptoms 4

Management of Specific Complications

Secondary Intracranial Hypertension

• If signs of increased intracranial pressure develop (papilledema, 6th cranial nerve deficit), consider treatment with acetazolamide or topiramate to reduce ICP 5
• In severe cases of increased ICP, lumbar puncture may be therapeutic as well as diagnostic 5

Post-Treatment Rebound Headache

• Patients should be monitored for rebound headache after treatment, which may indicate successful treatment of the underlying condition 1
• Rebound headaches are usually self-limited and can be managed conservatively 1
• Acetazolamide may be prescribed to lower CSF production in cases of rebound headache 1

Follow-up Recommendations

• Early review for complications should occur within 24-48 hours after any intervention 1
• Regular follow-up assessments should evaluate:
  • Headache severity on a 0-10 scale 1
  • Time able to spend upright before needing to lie down 1
  • Associated symptoms such as cognitive or vestibular complaints 1

Non-Pharmacological Approaches

• Thermal and physical modalities may provide additional relief for post-traumatic headaches 6
• Cognitive behavioral approaches can be helpful for managing chronic post-traumatic headache 6
• For patients who have been bedbound, orthostatic rehabilitation should be considered to address deconditioning 1

Important Considerations and Pitfalls

• Post-traumatic headaches often present as mixed headache disorders with features of both tension-type and migrainous headaches, requiring treatment tailored to the predominant characteristics 6
• Headaches may persist long-term in up to 25% of patients following brain injury, requiring ongoing management 6
• Medication overuse headache is a risk in this population and should be monitored for in patients using frequent analgesics 1
• Avoid medications that could potentially lower CSF pressure or reduce blood pressure in patients with features of intracranial hypotension 1