Management of Headache After Traumatic Fall to Face
For headache following a traumatic fall to the face, immediately assess for severe or worsening headache requiring head CT imaging, then treat with nonopioid analgesics (ibuprofen or acetaminophen) while avoiding opioids and monitoring for warning signs of intracranial complications. 1, 2
Immediate Risk Stratification and Imaging Decisions
Obtain head CT imaging if the patient presents with severe headache, especially when accompanied by other risk factors such as vomiting, loss of consciousness, altered mental status, or Glasgow Coma Scale (GCS) scores of 13-15, as these patients carry a 1.9% risk of intracranial complications requiring further management. 1, 2
Any worsening headache during observation requires emergent neuroimaging to rule out life-threatening intracranial injury—this is non-negotiable. 1, 2, 3
Facial trauma from falls can distribute energy to the cervical spine and cranium, making associated brain injury possible even when facial fractures are the primary concern. 1
Do not dismiss severe headache as "just a concussion symptom" without imaging, as this may miss intracranial complications that affect mortality. 2
Acute Pain Management Protocol
Start with nonopioid analgesics as first-line treatment: ibuprofen 400-800 mg every 6 hours or acetaminophen 650-1000 mg every 4-6 hours. 1, 2, 3
Never prescribe opioids for post-traumatic headache—they are not recommended and worsen outcomes while creating dependency risk. 1, 2, 3
Warn patients explicitly about analgesic overuse: taking pain medication more than 2-3 days per week can cause rebound headaches that worsen the overall condition. 1, 2, 3
Do not use 3% hypertonic saline outside research settings, as evidence does not support its use for acute post-traumatic headache. 1, 3
Assessment for Associated Injuries
After stabilizing life-threatening issues (airway, breathing, circulation), perform a secondary survey including: 1
- Palpation for facial bone tenderness, particularly frontal bone (requires high-energy trauma to fracture)
- Visual acuity testing and cranial nerve evaluation
- Assessment for cerebrospinal fluid leak
- Evaluation for cervical spine injury, as neck injury commonly accompanies facial trauma 1
Management of Persistent or Chronic Headache
If headache persists beyond 3 months, refer for multidisciplinary evaluation as chronic post-traumatic headache is multifactorial and requires comprehensive management. 1, 2, 3
Consider tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrating to 30-150 mg/day) for chronic prevention when headache pattern resembles tension-type. 2, 4
Evaluate for analgesic overuse as a contributory factor in patients with chronic headache, as this is a common pitfall. 1, 3
Refer patients with persistent vestibulo-oculomotor dysfunction (dizziness, balance problems) to vestibular rehabilitation programs. 1, 3
Implement proper sleep hygiene methods, as adequate sleep facilitates recovery and may reduce headache frequency. 1, 3
Follow-Up and Return to Activity
Regularly reassess headache characteristics and treatment response, educating patients on warning signs requiring immediate return: sudden severe worsening, fever, or new neurological changes. 2, 3
Return-to-activity planning should be symptom-guided and gradual, not time-based. 2
Post-traumatic headache is very common (cumulative incidence up to 91% over one year) and often persistent, with up to 49% meeting criteria for migraine or probable migraine. 5, 6
Key Clinical Pitfalls to Avoid
Risk factors for developing persistent headache include: older age, insomnia, headache present at the emergency department, other pain, and vertigo—these patients need closer monitoring. 7
The notion that litigation prolongs symptoms is not valid; most patients have favorable prognosis for resolution, though a small percentage will have persistent symptoms beyond three years. 8
Assertive early treatment may prevent chronicity and disability, making prompt intervention critical. 5