What are the management options for post-traumatic headaches?

Post-Traumatic Headache Management

Start with nonopioid analgesics (ibuprofen 400-800 mg every 6 hours or acetaminophen 650-1000 mg every 4-6 hours) for acute pain, but immediately obtain head CT if severe headache is present, especially with other risk factors, and transition to tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrating to 30-150 mg/day) for chronic headaches lasting beyond 3 months. 1, 2

Immediate Assessment and Risk Stratification

Severe headache following mild traumatic brain injury carries a 1.9% risk of intracranial complications in patients with GCS scores 13-15, making neuroimaging essential rather than optional. 1, 2 This risk is significant enough that dismissing severe headache as "just a concussion symptom" without imaging can miss life-threatening complications. 2

Red Flags Requiring Emergent CT Imaging:

• Severe headache at presentation, particularly with vomiting, loss of consciousness, or altered mental status 1, 2
• Any worsening headache during observation period requires emergent neuroimaging 1, 2
• Progressive headache despite initial treatment 1

Acute Pain Management (First 3 Months)

Nonopioid analgesics are the cornerstone of acute management: 1, 2

• Ibuprofen 400-800 mg every 6 hours 2
• Acetaminophen 650-1000 mg every 4-6 hours 2

Critical Pitfall to Avoid:

Warn patients explicitly that taking pain medication more than 2-3 days per week causes analgesic overuse headache, which worsens the overall condition through rebound mechanisms. 1, 2, 3 This is one of the most common reasons for treatment failure and must be addressed at the first visit. 1

Never prescribe opioids for post-traumatic headache—they worsen outcomes, create dependency, and are not recommended for headache therapy. 1, 2, 4

Chronic Post-Traumatic Headache Management (Beyond 3 Months)

Chronic post-traumatic headache is multifactorial and requires multidisciplinary evaluation. 1, 2 The treatment approach depends on the predominant headache phenotype, but pharmacological prevention should be initiated early to prevent "windup" and permanent chronification. 5

First-Line Pharmacological Prevention:

Tricyclic antidepressants, specifically amitriptyline, are the first-line preventive treatment: 2, 3, 4

• Start with 10-25 mg at bedtime 4
• Titrate gradually to 30-150 mg/day as tolerated 2, 3, 4
• Monitor for drowsiness, weight gain, and anticholinergic symptoms 4
• Amitriptyline has the most consistent evidence for efficacy in headache prevention 4

Alternative Preventive Medications for Migraine-Like Phenotypes:

If the headache pattern resembles migraine, consider: 3

• Angiotensin receptor blockers 3
• Lisinopril 3
• Topiramate 3
• Valproate 3

Non-Pharmacological Interventions

These should be implemented alongside pharmacotherapy, not as alternatives: 2, 6

• Graded aerobic exercise tailored to avoid symptom exacerbation 2, 3
• Vestibular rehabilitation for persistent vestibulo-ocular dysfunction 2, 3
• Sleep hygiene optimization as sleep disturbance is a major comorbidity 2
• Cognitive behavioral therapy and relaxation techniques 6, 7
• Physical therapy for cervicogenic components 3, 6

Emerging Behavioral Approach:

Graded exposure to headache triggers (stress, light flicker, loud noise) may reduce sensitization and improve outcomes, though this requires specialized psychological intervention. 7

Return-to-Activity Planning

Return to school or work must be symptom-guided and gradual: 1

• Avoid cognitive and physical overexertion while encouraging prompt return to prevent deleterious effects of prolonged absence 1
• Educational supports should be monitored and adjusted continuously until academic performance returns to preinjury levels 1
• Students with prolonged symptoms despite active treatment require formal evaluation by a pediatric mTBI specialist 1

When to Refer for Multidisciplinary Evaluation

Refer immediately if: 1, 2

• Headaches persist beyond 3 months despite appropriate treatment 1, 2
• Analgesic overuse is suspected as a contributory factor 1, 2
• Significant comorbid psychiatric symptoms (post-traumatic stress disorder, depression, anxiety) are present 6, 5
• Daily persistent headache pattern develops 6

Common Clinical Pitfalls

Do not use 3% hypertonic saline for acute headache treatment outside research settings—there is insufficient evidence. 1

Aggressive early treatment prevents chronification—once "windup" occurs, the cycle becomes much harder to interrupt. 5

Analgesic overuse headache complicates diagnosis and treatment significantly; always assess medication frequency at every visit. 1, 5

Prognosis Considerations

Post-traumatic headache persists beyond 2 months in 60% of patients and can account for 4% of all secondary headache disorders when chronic. 5, 8 Risk factors for chronicity include history of migraines, female gender, younger age, greater injury severity, and co-occurring anxiety or depression. 6 Regular reassessment of headache characteristics and treatment response is essential, with education on warning signs requiring immediate return (sudden severe worsening, fever, neurological changes). 2