What is the recommended treatment for a mild head injury with severe headache?

Management of Mild Head Injury with Severe Headache

First-line treatment is nonopioid analgesia with ibuprofen or acetaminophen, but severe headache after mild head injury mandates clinical observation and strong consideration of head CT imaging to rule out intracranial complications before initiating pain management. 1

Immediate Assessment and Risk Stratification

Severe headache following mild traumatic brain injury (mTBI) carries a 1.9% risk of intracranial complications (ICI) in patients with GCS scores 13-15, making neuroimaging consideration essential. 1

When to Obtain Head CT:

• Severe headache, especially with other risk factors (vomiting, loss of consciousness, altered mental status) 1
• Any worsening headache during observation period requires emergent neuroimaging 1
• The risk of missing progressive intracranial injury outweighs radiation concerns in this context 1

Clinical Observation Protocol:

• Monitor for neurological deterioration during initial hours 1
• If symptoms acutely worsen during observation, proceed immediately to emergent CT 1

Acute Pain Management

First-Line Treatment:

Nonopioid analgesics are the cornerstone of acute headache management after mTBI: 1, 2, 3

• Ibuprofen: 400-800 mg every 6 hours (maximum 2.4 g/day) 1
• Acetaminophen: 650-1000 mg every 4-6 hours (maximum 4 g/day) 1
• Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5 g/day) 1

Critical Counseling Point:

Warn patients explicitly about analgesic overuse headache—taking pain medication more than 2-3 days per week can cause rebound headaches that worsen the overall condition. 1, 2, 3

What NOT to Use:

• Avoid opioids (meperidine, butorphanol)—they are not recommended for post-traumatic headache due to dependency risk and lack of efficacy 1, 2, 3
• Do not use 3% hypertonic saline outside research settings—insufficient evidence for benefit beyond immediate administration 1, 2, 3

Management of Persistent or Chronic Headache

If Headache Persists Beyond Acute Phase:

Chronic post-traumatic headache is multifactorial and requires multidisciplinary evaluation. 1, 2, 3

Pharmacological Options for Chronic Management:

• Tricyclic antidepressants (amitriptyline): Start 10-25 mg at bedtime, titrate to 30-150 mg/day as tolerated 4
• Amitriptyline has the strongest evidence for headache prevention in this context 4
• Monitor for drowsiness, weight gain, and anticholinergic effects 4

Non-Pharmacological Interventions:

• Vestibular rehabilitation for patients with dizziness or balance symptoms 1, 2, 3
• Sleep hygiene optimization—inadequate sleep worsens post-traumatic headache 1, 3
• Graded physical exercise with gradual intensity increase 2
• Psychological therapy for emotional symptoms (minimum 1 hour/week for 4+ weeks) 2

Referral Indications:

• Headache persisting beyond 3 months despite initial management 1, 2, 3
• Suspected analgesic overuse headache 1, 2, 3
• Vestibulo-oculomotor dysfunction contributing to symptoms 1, 2, 3
• Sleep disturbances unresponsive to hygiene measures 1, 3

Common Pitfalls to Avoid

• Do not dismiss severe headache as "just a concussion symptom" without imaging—you may miss life-threatening ICI 1
• Do not prescribe opioids for convenience—they worsen outcomes and create dependency 1, 2, 3
• Do not allow unlimited analgesic use—medication overuse headache affects 26-70% of patients and perpetuates the problem 1, 5
• Do not delay multidisciplinary referral for persistent symptoms—early intervention improves outcomes 1, 2, 3

Prognosis and Follow-Up

Most post-traumatic headaches resolve within 3-6 months, but a minority persist for years. 6, 7, 8

• Regular reassessment of headache characteristics and treatment response is essential 3
• Educate patients on warning signs requiring immediate return: sudden severe worsening, fever, neurological changes 3
• Return-to-activity planning should be symptom-guided and gradual 1