What is the recommended treatment for a headache post concussion?

Treatment of Post-Concussion Headache

For acute post-concussion headache, use ibuprofen 400-800 mg every 6 hours as first-line treatment, with acetaminophen 1000 mg as an alternative for patients who cannot tolerate NSAIDs. 1

Initial Pharmacologic Management

First-Line Options

• Ibuprofen is the preferred first-line agent at doses of 400-800 mg every 6 hours due to its effectiveness in reducing both pain and inflammation associated with post-concussion headache 1
• Naproxen sodium 275-550 mg every 2-6 hours offers a longer duration of action and represents an equally effective NSAID alternative 1
• Acetaminophen 1000 mg should be reserved for patients with NSAID contraindications (renal impairment, GI bleeding history, aspirin sensitivity), though it is generally less effective when used alone 2, 1

Combination Therapy for Migraine-Type Features

• When post-concussion headache exhibits migraine characteristics (throbbing quality, photophobia, phonophobia, nausea), use aspirin-acetaminophen-caffeine combination therapy rather than single-agent treatment 1
• This combination provides synergistic analgesia and is strongly recommended for migraine-like presentations 3, 1

Critical Timing and Administration Principles

• Begin treatment early in the headache phase for maximum effectiveness—waiting until pain becomes severe reduces medication efficacy 1
• Limit acute medication use to no more than twice weekly to prevent medication overuse headache, which can develop with frequent analgesic use and lead to daily refractory headaches 2, 1

Management of Associated Symptoms

Nausea and Vomiting

• When nausea accompanies post-concussion headache, add metoclopramide 10 mg or prochlorperazine as adjunctive therapy 1
• These antiemetics provide both symptom relief and synergistic analgesia through central dopamine receptor antagonism 3
• For children specifically, nonopioid analgesia (ibuprofen or acetaminophen) should be offered with counseling about analgesic overuse risks 2

Pediatric-Specific Considerations

• Avoid aspirin in children and adolescents due to Reye's syndrome risk 1
• For children with severe or worsening headache after concussion, clinical observation and consideration of head CT is warranted to evaluate for intracranial complications 2
• Children with acutely worsening symptoms during observation should undergo emergent neuroimaging 2

Medications to Avoid

• Never use opioids for post-concussion headache as they lead to dependency, rebound headaches, and loss of efficacy without providing superior pain relief 2, 1
• Avoid barbiturate-containing compounds for the same reasons 1
• Do not administer 3% hypertonic saline outside research settings, as evidence does not support its use for acute post-concussion headache 2

When Initial Treatment Fails

Escalation Strategy

• If NSAIDs fail after 2-3 headache episodes, consider whether the headache phenotype is migraine-type and escalate to triptan therapy (sumatriptan, rizatriptan) for moderate-to-severe attacks 3
• For refractory cases, dihydroergotamine (DHE) represents an alternative option 3

Chronic Post-Concussion Headache (>1 month)

• Refer for multidisciplinary evaluation when headaches persist beyond one month, as chronic post-concussion headache is multifactorial and requires comprehensive assessment 2
• Consider analgesic overuse as a contributory factor in persistent cases 2
• Evaluate for comorbid conditions including depression, anxiety, insomnia, and vestibular dysfunction that commonly accompany chronic post-concussion symptoms 4

Non-Pharmacologic Adjuncts

• Physical therapy is recommended for management of post-concussion headache, particularly when cervicogenic features are present 2
• Graded aerobic exercise should be offered in addition to pharmacologic treatment, with gradual increases in intensity performed at least once weekly for 4 weeks 2
• For persistent vestibular dysfunction, vestibular rehabilitation including habituation exercises and balance training should be initiated 2

Common Pitfalls to Avoid

• Do not use acetaminophen alone as first-line therapy—it is significantly less effective than NSAIDs for post-concussion headache 1
• Do not allow patients to escalate medication frequency in response to persistent symptoms, as this creates medication overuse headache; instead transition to preventive strategies 3
• Do not dismiss early symptoms—high early symptom burden (particularly headache and fatigue) is a risk factor for developing chronic post-concussion syndrome 4
• Do not prescribe opioids even for severe pain, as they worsen long-term outcomes and create dependency without providing superior analgesia compared to NSAIDs and combination therapy 2, 1