Is a computed tomography (CT) head scan indicated for worsening headache following a concussion?

From the Guidelines

A CT head scan is recommended for a patient experiencing worsening headaches following a concussion, as it is the most sensitive imaging modality for detecting intracranial hemorrhage and other serious complications within the first 24 to 48 hours after injury. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of prompt imaging in patients with worsening symptoms after a concussion 1. The study highlights that a normal CT scan, combined with a normal neurologic examination, has a very low risk of deterioration, and patients can be safely discharged. However, worsening headaches may indicate a developing complication that requires urgent intervention.

Key Considerations

• The CT scan should be performed promptly to rule out serious complications such as intracranial hemorrhage, cerebral contusion, or cerebral edema.
• After the CT scan, the patient should continue with standard post-concussion care, including relative rest for 24-48 hours, followed by gradual return to activities as tolerated.
• Acetaminophen (500-1000mg every 6 hours as needed) can be used for pain relief, avoiding NSAIDs and aspirin initially due to bleeding risk.
• Adequate hydration and sleep hygiene measures should also be implemented.
• If the CT is negative but symptoms persist, follow-up with a neurologist may be warranted for further evaluation and management of post-concussion syndrome.

Imaging Modalities

• CT is the test of choice to evaluate for intracranial hemorrhage during the first 24 to 48 hours after injury, as it is faster, more cost-effective, and easier to perform than MRI 1.
• MRI provides the ability to detect cerebral contusion, petechial hemorrhage, and white matter injury at a level superior to CT, but is more appropriate if imaging is needed for an athlete 48 hours or longer after an injury 1.

From the Research

CT Head for Worsening Headache Post Concussion

• The use of CT head for worsening headache post concussion is not explicitly mentioned in the provided studies 2, 3, 4, 5.
• However, study 6 discusses the importance of neuroimaging, including CT, in the diagnosis of intracranial hemorrhage, which can be a cause of worsening headache post concussion.
• Study 2 mentions that uncertainties associated with complaints after concussion include the need for neuroimaging, but does not specifically address the use of CT head for worsening headache.
• Study 4 discusses the classification and treatment of posttraumatic headache, but does not mention the use of CT head as a diagnostic tool.

Diagnostic Approaches

• Study 3 examines the association between provider training on clinical recommendations for the management of post-traumatic headache and provider clinical practice, patient behaviors, and symptom recovery.
• Study 5 provides a roadmap for evaluating and treating postconcussion syndrome, including the use of clinical evaluation and treatment protocols, but does not specifically address the use of CT head.
• Study 2 seeks expert opinion on how to evaluate and manage patients with headache following concussion, but does not provide a clear recommendation on the use of CT head.

Treatment and Management

• Study 4 recommends the use of migraine-specific acute therapy for the treatment of posttraumatic headache, and considers preventive therapy when headache is frequent, disabling, or refractory to acute therapies.
• Study 3 demonstrates the feasibility of training on the management of headache following concussion to change provider practices and promote timely care.
• Study 5 emphasizes the importance of considering premorbid conditions, psychosomatic issues, secondary gains, and litigations when evaluating and treating patients with postconcussion syndrome.