What is the treatment for post-concussion headaches?

Treatment for Post-Concussion Headache

Active, multimodal treatment targeting specific symptom generators is recommended over passive observation, with graded physical exercise, vestibular rehabilitation, manual therapy, and psychological interventions forming the core approach for persistent post-concussion headaches. 1, 2

Acute Phase Management (First 4 Weeks)

First-Line Analgesics

• Use ibuprofen or acetaminophen as first-line treatment for acute headache pain 3
• Counsel patients explicitly about analgesic overuse risks, as rebound headache can perpetuate symptoms 3
• Avoid opioids entirely due to dependence risk and lack of efficacy 3

Early Patient Education

• Provide systematic information about expected symptom trajectory, self-care strategies, and symptom management within the first 4 weeks post-injury 1, 2
• This intervention reduces overall symptom burden and prevents memory problems at follow-up 1

Red Flag Assessment

• Evaluate patients with severe or worsening headaches for intracranial complications with neuroimaging, particularly when accompanied by other risk factors 3

Persistent Headache Management (Beyond 4 Weeks)

Physical Exercise Protocol

• Implement sub-symptom threshold aerobic exercise as a foundational intervention, gradually increasing intensity and complexity over time 1, 2
• Administer at minimum once weekly for 4 weeks 1
• This approach demonstrates positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1

Vestibular Rehabilitation

• Perform vestibular evaluation to identify dizziness, balance problems, or visual disturbances contributing to headache 2
• When vestibular dysfunction is present, implement habituation exercises, adaptation exercises, substitution training, and balance training 1, 2
• Deliver treatment at minimum once weekly for 4 weeks 1
• Evidence shows positive effects on physical functioning and return to activities 2

Cervical Spine Treatment

• Assess for cervicogenic contributions, as neck pathology frequently contributes to post-concussion headache 2
• When neck pain is present, implement spinal mobilization or manipulation by physiotherapists or chiropractors 1, 2
• Manual therapy demonstrates positive effects on pain reduction and readiness to return to activities 2

Visual/Oculomotor Intervention

• Screen for vergence, accommodative, or eye movement dysfunction that may cause headache and visual symptoms 2
• When visual symptoms accompany headache, provide vergence training, accommodative training, and eye movement exercises 1, 2
• Clinical experience indicates improvements in visual symptoms, headache, and fatigue, though controlled trial evidence is limited 1, 2

Psychological Treatment

• Screen for depression, anxiety, and post-traumatic stress that may exacerbate headache 2
• When emotional symptoms are present, offer individual or group therapy at minimum 1 hour weekly for at least 4 weeks 1
• This intervention shows positive effects on overall symptom burden, emotional symptoms, and quality of life 1

Comprehensive Interdisciplinary Approach

For headaches persisting at 1-2 months, implement coordinated treatment from at least two different healthcare disciplines (e.g., physiotherapy, occupational therapy, psychology, neurology) 1, 4

• This comprehensive approach addresses the multifactorial nature of persistent post-concussion headache 3, 4
• Evidence demonstrates positive effects on overall symptom burden, physical functioning, emotional symptoms, quality of life, and work satisfaction 1
• Treatment should include at least 2 interventions delivered minimally once weekly for 4 weeks 1

Critical Pitfalls to Avoid

• Do not wait passively for symptom resolution—active management is recommended when symptoms persist beyond initial injury 1
• Do not overlook analgesic overuse as a perpetuating factor in chronic post-concussion headache 3
• Do not treat all post-concussion headaches identically—identify specific symptom generators (vestibular, cervical, visual, psychological) to guide targeted interventions 2, 5
• Recognize that 15-20% of concussion patients develop persistent symptoms requiring this multimodal approach 4

Evidence Quality Context

The certainty of evidence supporting these interventions ranges from very low to low, with most recommendations being weak 1. However, recommendations are consistent across multiple guidelines, and the shift toward active management reflects clinical consensus that passive observation is inadequate for persistent symptoms 1. The recommendation for oculomotor vision treatment relies primarily on clinical experience rather than controlled trials 1.