What is the best course of action for a patient with a persistent headache and resolving neck stiffness after a minor head injury, who has been taking acetaminophen (Tylenol) with some relief?

Post-Traumatic Headache Management

Continue acetaminophen 1000 mg every 6 hours as needed for the next 3-5 days, add ibuprofen 400-600 mg every 6-8 hours if acetaminophen alone provides insufficient relief, and reassure the patient that her symptoms are consistent with post-concussive headache which typically resolves within 3 months. 1, 2

Clinical Assessment and Diagnosis

Amy's presentation is consistent with post-traumatic tension-type headache following minor head injury:

• The pressure sensation behind the eyes and band-like tightness around the temples, along with neck stiffness, are classic features of tension-type headache that commonly occurs after head trauma 3
• The absence of red flag symptoms (no nausea, vomiting, visual changes, neurological deficits, or progressive worsening) makes serious intracranial pathology highly unlikely 4
• Neuroimaging is not indicated in patients with nonacute headache and normal neurologic examination, even with persistent symptoms 4

Recommended Treatment Approach

First-Line Therapy

• Acetaminophen 1000 mg every 6 hours as needed remains the appropriate first-line treatment, as it has demonstrated efficacy for tension-type headache with an NNT of 10 for achieving pain-free or mild pain at 2 hours 1
• Since Amy reports improvement from 6-7/10 to 4/10 with acetaminophen, this indicates partial response and supports continuing this medication 1

Second-Line Addition if Needed

• Add ibuprofen 400-600 mg every 6-8 hours if acetaminophen alone provides insufficient relief, as NSAIDs are recommended first-line treatment for mild to moderate headaches and can be combined with acetaminophen 5, 6
• The combination of acetaminophen plus an NSAID provides synergistic analgesia without the risks associated with other medication classes 7

Discontinue Inappropriate Medication

• Stop using sumatriptan immediately - triptans are indicated for migraine, not post-traumatic tension-type headache, and Amy has no history of migraines 4, 5
• Inappropriate use of triptans can lead to medication-overuse headache if used more than 10 days per month 5

Important Management Considerations

Medication Frequency Monitoring

• Limit acute headache medication use to no more than 2-3 days per week to prevent medication-overuse headache, which can develop with frequent use (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 5
• If headaches persist beyond 2-3 weeks requiring frequent medication, consider preventive therapy rather than escalating acute treatment 6

Expected Timeline and Prognosis

• Post-concussive symptoms including headache typically resolve within the first 3 months after injury 2
• Most patients have favorable prognosis for complete resolution, though a small percentage may have persistent symptoms beyond three months 3
• The improving neck stiffness and resolved scalp tenderness are positive prognostic indicators 2

Avoid These Common Pitfalls

• Do not prescribe opioids or butalbital-containing medications - these lead to dependency, rebound headaches, and eventual loss of efficacy 4, 5
• Do not delay treatment - medications are most effective when taken early during headache episodes 7, 5
• Do not overlook total daily acetaminophen intake - ensure total does not exceed 4000 mg per day from all sources 8

When to Escalate Care

Red Flags Requiring Urgent Evaluation

• Development of new neurological symptoms (weakness, numbness, vision changes, balance problems) 4
• Headache that progressively worsens despite treatment 4
• New onset nausea, vomiting, or changes in mental status 4
• Headache that awakens patient from sleep or worsens with Valsalva maneuver 4

Follow-Up Recommendations

• Reassess in 1-2 weeks if symptoms persist or worsen despite appropriate treatment 2
• Consider referral to neurology if symptoms persist beyond 3 months or if headaches become more frequent requiring daily medication 2, 3