What are the treatment options for post-concussion headaches?

Post-Concussion Headache Treatment

Start with nonopioid analgesics (ibuprofen 400-800 mg every 6 hours or acetaminophen 650-1000 mg every 4-6 hours) as first-line treatment for acute post-concussion headache, but critically warn patients to limit use to 2-3 days per week maximum to prevent medication overuse and rebound headaches. 1, 2, 3

Acute Phase Management (First 48 Hours)

First-Line Analgesic Treatment

• Ibuprofen or acetaminophen are the only recommended medications for acute pain relief, with opioids explicitly contraindicated due to lack of efficacy and risk of dependence 1, 2, 3
• Dosing: Ibuprofen 400-800 mg every 6 hours OR acetaminophen 650-1000 mg every 4-6 hours 3
• Critical counseling point: Using pain medication more than 2-3 days per week causes rebound headaches that worsen the overall condition 1, 3
• Research shows these medications provide short-term relief but do not reduce headache presence at 7 days post-injury 4

Red Flags Requiring Emergent Imaging

• Any acutely worsening headache during observation requires emergent neuroimaging 1, 5
• Severe headache carries a 1.9% risk of intracranial complications even with GCS 13-15, making CT consideration essential when combined with vomiting, altered mental status, or focal neurologic deficits 1, 5

Initial Rest Period

• Implement moderate physical and cognitive rest for 24-48 hours only 3
• Prolonged strict rest beyond 48 hours is counterproductive and delays recovery 3

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

Graded Return to Activity

• Begin graded aerobic exercise below the symptom exacerbation threshold after the initial 24-48 hour rest period 1, 3
• Exercise should involve gradual increase in intensity and complexity, performed minimally 1 time per week for 4 weeks 1
• Each step in the return-to-activity protocol requires a minimum of 24 hours before progression 3

Persistent/Chronic Headache (Beyond 3-4 Weeks)

Multidisciplinary Evaluation Required

• Chronic post-concussion headache is multifactorial and mandates referral for multidisciplinary evaluation, with analgesic overuse considered as a contributory factor 1, 2, 5
• Consider referral to a TBI specialist if symptoms persist beyond 3 weeks 3

Specific Interventions Based on Clinical Phenotype

For vestibular symptoms:

• Vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training, administered minimally 1 time per week for 4 weeks 1, 2

For neck pain contributing to headaches:

• Manual therapy (spinal mobilization or manipulation) performed by physiotherapists or chiropractors 1, 2

For visual/oculomotor symptoms:

• Oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 2

For emotional symptoms:

• Psychological treatment including individual or group therapy, at least 1 hour per week for minimum 4 weeks 2

Pharmacologic Prevention for Chronic Headache

• Tricyclic antidepressants (amitriptyline) may be considered for chronic management, starting with 10-25 mg at bedtime and titrating to 30-150 mg/day as tolerated 3, 5
• Note: A clinical trial showed significant compliance challenges with amitriptyline in this population, with 49% of participants taking no medication throughout the study period 6

Sleep Hygiene Optimization

• Provide guidance on proper sleep hygiene methods to facilitate recovery 1
• If sleep problems persist despite appropriate sleep hygiene, refer to a sleep disorder specialist 1

Critical Pitfalls to Avoid

• Never dismiss severe headache as "just a concussion symptom" without imaging, as this may miss life-threatening intracranial complications 3, 5
• Never prescribe prolonged rest beyond 48 hours, as it worsens outcomes and delays recovery 3
• Never prescribe opioids for post-concussion headache, as they worsen outcomes and create dependency 1, 3, 5
• Never allow analgesic use more than 2-3 days per week, as this causes medication overuse headache that compounds the problem 1, 3

Early Patient Education

• Systematically offer early information and advice within the first 4 weeks after concussion regarding symptom management, expected recovery course, and self-care 1, 2
• This intervention reduces overall symptom burden at 2 weeks and decreases the number of patients experiencing memory problems and functional impairment 1