What is the cause of persistent headache 2 months after a concussion?

From the Guidelines

If you're experiencing persistent headaches two months after a concussion, you should seek medical evaluation from a neurologist who specializes in post-concussion syndrome. These headaches may represent post-traumatic headaches, which can persist for months after the initial injury. Treatment typically involves a multi-modal approach including appropriate pain management with medications such as amitriptyline (10-25mg at bedtime), topiramate (25-100mg twice daily), or propranolol (20-40mg twice daily) 1. Non-medication approaches are equally important, including gradual return to normal activities, regular sleep schedules, stress management, and possibly physical therapy focusing on neck and upper back muscles. Cognitive behavioral therapy may help manage pain perception. Avoid overuse of over-the-counter pain medications like ibuprofen or acetaminophen as they can lead to medication overuse headaches.

Key Considerations

• Persistent headaches at this stage could indicate that you're developing post-concussion syndrome, which may require more specialized care 2.
• The underlying mechanism involves neuroinflammation, autonomic nervous system dysfunction, and potential changes in cerebral blood flow that continue beyond the acute injury phase 3.
• If headaches are severe or accompanied by new symptoms like vision changes, weakness, or confusion, seek immediate medical attention.
• Nonpharmacological interventions, such as oculomotor visual treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment, may be beneficial in managing persistent postconcussion symptoms 4, 5.

Recommendations

• Seek medical evaluation from a neurologist who specializes in post-concussion syndrome.
• Consider a multi-modal approach to treatment, including pain management, non-medication approaches, and possibly physical therapy.
• Avoid overuse of over-the-counter pain medications.
• If symptoms persist or worsen, consider seeking specialized care for post-concussion syndrome.

From the Research

Persistent Headache 2 Months After Concussion

• A concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another 6.
• Management of concussion and persistent post-concussive symptoms (PPCS) relies on identifying underlying symptom generators, and treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments 6, 7.

Treatment Options for Persistent Headache

• There is no specific treatment for persistent headache after concussion, and current evidence does not support a specific treatment 8.
• Amitriptyline has been studied as a potential treatment for headache after traumatic brain injury, but the results were inconclusive due to difficulties with study recruitment and compliance 8.
• Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief, but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist 9.

Analgesic Administration for Acute Headache

• A pilot study found that routine analgesia administration with ibuprofen, acetaminophen, or both was feasible and effective for postconcussive headache management in children and youth 10.
• However, a larger study found that exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion 9.
• Patients on ibuprofen or acetaminophen had significantly less headache days, episodes of headache, and lower headache intensity than did the standard care group, but a larger full-scale randomized controlled trial is required to further assess the efficacy 10.