What is the best management approach for a patient with chronic daily headaches and a history of head trauma?

Management of Chronic Daily Headaches with History of Head Trauma

This patient requires urgent neuroimaging with MRI brain with and without contrast, given his history of head trauma, new-onset daily headaches at age 33, and progressive worsening—all red flags that mandate exclusion of secondary causes before considering primary headache management. 1, 2

Critical Red Flags Present in This Case

Your patient presents with several concerning features that elevate the urgency of evaluation:

• New-onset chronic daily headaches in a 33-year-old male – While not over 50, the daily pattern with recent worsening over 2 weeks is atypical for primary headache disorders 1
• History of head trauma with three syncopal events in 2019 – Post-traumatic headaches can develop or worsen months to years after injury, and no follow-up imaging has been performed in 5 years 3, 4
• Progressive worsening pattern – Headaches increasing in severity over the past 2 weeks is a red flag for secondary causes including mass lesions, subdural collections, or other structural abnormalities 1, 5
• Short-duration episodes (3-5 minutes) occurring multiple times daily – This pattern is unusual for typical migraine or tension-type headache and raises concern for secondary etiologies 1

Immediate Diagnostic Approach

Neuroimaging is mandatory before proceeding with primary headache treatment:

• MRI brain with and without contrast is the preferred study – Superior to CT for detecting masses, chronic subdural collections, ischemia, and other structural abnormalities that may result from remote head trauma 2, 5
• Your decision to order MRI without contrast should be upgraded to include contrast – Given the history of trauma and progressive symptoms, contrast is essential to exclude neoplasm, vascular malformations, or other enhancing lesions 2
• Non-contrast CT is insufficient in this case – While appropriate for acute trauma evaluation, it has limited sensitivity for chronic post-traumatic changes and other secondary causes 5

Laboratory Evaluation

Your laboratory workup is appropriate and comprehensive:

• TSH, CBC, CMP, A1c, and lipids – These appropriately screen for metabolic, endocrine, and systemic causes of headache 5
• Consider adding ESR/CRP – While the patient is young for giant cell arteritis, inflammatory markers can identify other systemic inflammatory conditions contributing to headache 1

Post-Traumatic Headache Considerations

If imaging excludes secondary causes, this patient likely has chronic post-traumatic headache:

• Post-traumatic headaches occur in 60% of patients after closed head injury and can persist beyond 2 months – The patient's 2019 head trauma with three syncopal events represents significant injury despite normal CT at that time 3
• Delayed onset or worsening is well-documented – Post-traumatic headaches can develop or worsen months to years after the initial injury, making the temporal relationship less obvious 4, 6
• Mixed headache phenotype is typical – Post-traumatic headaches usually present with features of both tension-type and migraine-like attacks, consistent with this patient's pressure-type pain with occasional sharp components 3, 4
• Early aggressive treatment is critical – Once "windup" occurs with daily headaches, the cycle becomes more difficult to interrupt 3

Addressing Medication Overuse Risk

This patient is at moderate risk for medication overuse headache:

• Current Excedrin use (once weekly) is below the threshold – Medication overuse headache requires regular intake of combination analgesics on ≥10 days/month for ≥3 months 1, 7
• However, daily headaches create vulnerability – Patients with frequent headaches often escalate analgesic use, leading to medication overuse headache and central sensitization 7
• Counsel explicitly against increasing Excedrin frequency – Warn that using combination analgesics more than 2-3 times per week can perpetuate and worsen headaches 7

Treatment Plan After Imaging

If MRI excludes secondary causes, initiate prophylactic therapy immediately:

First-Line Prophylactic Options:

• Topiramate 25-50 mg daily, titrating to 50-100 mg daily – This is the only medication with proven efficacy in randomized controlled trials for chronic migraine and is appropriate for post-traumatic headache with migraine features 1, 8
• Amitriptyline 25-50 mg at bedtime – Particularly effective for post-traumatic headache and addresses comorbid sleep disturbance common after head injury 1, 3, 6
• Propranolol 80-240 mg daily (if no contraindication from PVCs) – Effective for post-traumatic migraine, though requires cardiology clearance given his PVC history 6

Acute Treatment:

• NSAIDs (ibuprofen 400-800 mg or naproxen 500-550 mg) for acute episodes – Limit to ≤2 days per week to prevent medication overuse 8, 7
• Consider triptans if migraine features predominate – However, use cautiously and infrequently (≤2 days per week) to avoid medication overuse headache 1, 7

Address Contributory Factors

Untreated nasal congestion and allergies may be exacerbating headaches:

• Initiate intranasal corticosteroid (fluticasone or mometasone) – Chronic rhinosinusitis and untreated allergies can trigger or worsen headaches 7
• Consider oral antihistamine (cetirizine or loratadine) – Seasonal allergies are a modifiable trigger that should be addressed 7

Mandatory Follow-Up Strategy

Establish structured follow-up to prevent chronification:

• Headache diary starting immediately – Document frequency, duration, severity, triggers, and medication use daily to guide treatment adjustments 1
• Re-evaluate in 2-3 weeks after imaging results – Assess response to any initiated treatments and adjust prophylaxis as needed 8
• Neurology referral if no improvement within 2-3 months – Patients with post-traumatic headache refractory to initial management require specialist evaluation 2, 9
• Screen for post-traumatic stress disorder, depression, and anxiety – These comorbidities are common after head trauma and significantly impair headache treatment effectiveness 3, 4

Common Pitfalls to Avoid

• Do not assume primary headache disorder without imaging – The combination of head trauma history, new-onset daily headaches, and progressive worsening mandates exclusion of secondary causes 1, 2
• Do not delay prophylactic therapy once secondary causes are excluded – Early aggressive treatment prevents central sensitization and chronification of post-traumatic headache 3
• Do not allow escalation of acute medication use – Counsel explicitly about medication overuse headache risk, as this is the most common cause of treatment failure in chronic daily headache 7
• Do not ignore the 5-year gap since last imaging – Delayed complications of head trauma, including chronic subdural hematoma, can present years after injury 4