What is the treatment for postconcussion headache?

Treatment for Postconcussion Headache

For postconcussion headache, implement a multimodal approach starting with nonopioid analgesics (ibuprofen or acetaminophen) for acute pain, followed by brief rest (24-48 hours only), then graded physical exercise below symptom threshold, with multidisciplinary evaluation for headaches persisting beyond 3-4 weeks. 1, 2, 3

Acute Phase Management (First 24-48 Hours)

Pain Control

• Administer nonopioid analgesics as first-line treatment: ibuprofen 400-800 mg every 6 hours or acetaminophen 650-1000 mg every 4-6 hours 1, 3
• Avoid opioids entirely—they worsen outcomes and create dependency 3
• Warn patients explicitly about analgesic overuse: taking pain medication more than 2-3 days per week causes rebound headaches that worsen the overall condition 1, 3, 4
• In adolescents, routine analgesia (ibuprofen or acetaminophen) significantly reduces headache days, headache episodes, and headache intensity compared to no treatment 5

Initial Rest Period

• Implement moderate physical and cognitive rest for 24-48 hours only to allow initial recovery during the acute neurometabolic cascade 2, 6
• Avoid prolonged strict rest beyond 48 hours—this actually worsens outcomes and delays recovery 1, 2, 6

Red Flags Requiring Immediate Imaging

• Obtain head CT for severe headache, especially when combined with vomiting, altered mental status, or focal neurologic deficits 1, 3
• Severe headache carries a 1.9% risk of intracranial complications in patients with GCS 13-15 1, 3
• Any worsening headache during observation requires emergent neuroimaging 1, 3

Subacute Phase (After 48 Hours to 3-4 Weeks)

Graded Physical Exercise

• Begin graded aerobic exercise below the symptom exacerbation threshold after the initial 24-48 hour rest period 2, 6
• Exercise should be performed at least once weekly for a minimum of 4 weeks 2
• Gradually increase intensity and complexity over time as symptoms allow 2
• Avoid high-intensity physical activity during recovery—this is detrimental 1, 6
• In adolescents specifically, there is sufficient evidence to recommend exercise as appropriate therapy for acute concussion 1

Structured Return to Activity Protocol

• Each step should take a minimum of 24 hours before progression 2, 6
• Progress through: light aerobic exercise → sport-specific exercise → non-contact drills → full contact practice → return to competition 2, 6
• If symptoms recur, return to the previous asymptomatic level and rest 24 hours before attempting progression again 6

Chronic/Persistent Headache (Beyond 3-4 Weeks)

Multidisciplinary Evaluation

• Chronic postconcussion headache is multifactorial and requires multidisciplinary evaluation and treatment 1, 3
• Consider referral to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks 2
• 15-20% of concussion patients develop persistent symptoms requiring this approach 1, 6

Specific Interventions Based on Symptom Generators

• Vestibular rehabilitation for patients with persistent vestibular dysfunction: otolith manipulating procedures, habituation exercises, adaptation exercises, and balance training 1, 2
• Manual therapy for neck and spine, especially when neck pain is present 1, 2
• Psychological treatment including cognitive behavioral therapy 1, 7
• Vision therapy for oculomotor dysfunction 7
• Cognitive rehabilitation for persistent cognitive symptoms 7

Pharmacological Management for Chronic Headache

• First assess for and address analgesic overuse headache—70% of adolescents with chronic postconcussion headache may have medication overuse contributing to symptoms 4
• Analgesic detoxification results in headache resolution or improvement in 68.5% of cases 4
• Consider tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrating to 30-150 mg/day) for chronic management 3
• Dihydroergotamine (DHE) with metoclopramide achieved good to excellent response in 88% of patients with postconcussion syndrome in one study, though this is less commonly used currently 8

Common Pitfalls to Avoid

• Do not dismiss severe headache as "just a concussion symptom" without imaging—this may miss life-threatening intracranial complications 1, 3
• Do not prescribe prolonged rest beyond 48 hours—this is counterproductive and delays recovery 1, 2, 6
• Do not allow analgesic overuse—counsel patients that using pain medication more than 2-3 days per week causes rebound headaches 1, 3, 4
• Do not return patients to full activity while taking medications for concussion symptoms 6
• Do not rely solely on patient-reported symptoms without objective assessment 2, 6

Evidence Quality Considerations

The 2023 PM&R consensus statement found mixed results for most interventions, with sufficient evidence only for exercise in adolescents 1. The 2021 JAMA Network Open systematic review assigned only weak recommendations for most nonpharmacological treatments based on very low to low certainty evidence 1. However, the consistent finding across guidelines is that strict rest is detrimental and graded exercise is beneficial 1, 2, 6. The CDC pediatric guideline provides the strongest evidence for nonopioid analgesia and the importance of avoiding analgesic overuse 1.