What is the recommended treatment for headaches in patients with traumatic brain injury (TBI)?

Treatment of Headaches in Patients with Traumatic Brain Injury

For patients with traumatic brain injury (TBI), nonopioid analgesics such as ibuprofen or acetaminophen should be offered as first-line treatment for headaches, with careful counseling about the risks of analgesic overuse including rebound headache. 1, 2

Acute Headache Management

• Nonopioid analgesics (ibuprofen or acetaminophen) are the recommended first-line treatment for painful headaches after TBI 1, 2
• Opioids are not generally recommended as therapy for post-traumatic headaches 1
• 3% hypertonic saline should not be administered for treatment of acute headache outside of a research setting 1
• Patients with severe or worsening headache should be evaluated for intracranial injury (ICI), especially when associated with other risk factors 1, 2
• Emergent neuroimaging is indicated for patients with acutely worsening headache symptoms 1

Chronic Headache Management

• Chronic post-traumatic headache is likely multifactorial and requires multidisciplinary evaluation and treatment 1
• Consider analgesic overuse as a potential contributory factor in chronic headaches after TBI 1
• Post-traumatic headaches often present with mixed features of tension-type headache (37%) and migraine (29%), requiring targeted treatment approaches 3, 4
• Despite the diverse nature of post-traumatic headaches, over 70% of patients self-treat with acetaminophen or NSAIDs, which provide complete relief for only a minority of patients 5
• Only 8% of patients with migraine/probable migraine phenotype use triptans, suggesting potential undertreatment 5

Comprehensive Management Approach

• For patients with persistent vestibulo-oculomotor dysfunction contributing to headaches, referral to a program of vestibular rehabilitation may be beneficial 1, 2
• Proper sleep hygiene methods should be implemented to facilitate recovery and potentially reduce headache frequency 1
• For persistent sleep problems that may exacerbate headaches, referral to a sleep disorder specialist should be considered 1
• Cognitive dysfunction should be evaluated within the context of headache symptoms, as ongoing headache pain can produce disruption in cognitive processing 1
• Behavioral treatments including graded exposure to headache triggers (stress, light, noise) may be helpful for chronic post-traumatic headaches 6

Special Considerations

• Post-traumatic headaches are extremely common, with studies showing up to 91% cumulative incidence over one year after mild TBI 7
• Headaches tend to persist in a significant portion of patients, with approximately 18-33% experiencing headaches beyond one year after injury 3, 4
• Younger age (≤60 years) appears to be a risk factor for post-traumatic headaches 7
• Early, assertive treatment may be warranted to prevent chronicity and disability 7
• Paradoxically, milder TBI is associated with higher likelihood of developing headaches 4

Monitoring and Follow-up

• Regular assessment of headache characteristics, frequency, and response to treatment is essential 1
• Patients should be educated about warning signs requiring immediate medical attention, such as worsening headache 2
• For patients with chronic headaches unresponsive to initial management, referral to headache specialists or neurologists is appropriate 1
• More than one-third of patients report persistent headaches throughout the first year after injury, highlighting the need for ongoing management 7