Treatment of Concussion Headache with Benadryl and Ibuprofen
Ibuprofen is appropriate for treating concussion headache, but Benadryl (diphenhydramine) should be avoided as it has no evidence-based role in post-concussion headache management and may unnecessarily expose patients to sedating antihistamine effects without therapeutic benefit. 1
Recommended First-Line Treatment
Use ibuprofen 400-800 mg every 6 hours as the primary treatment for acute post-concussion headache. 1 This recommendation is based on:
- The American Academy of Pediatrics specifically endorses ibuprofen as first-line therapy for post-concussion headache 1
- Naproxen sodium 275-550 mg every 2-6 hours is an equally effective NSAID alternative 1
- Acetaminophen 1000 mg can be used for patients with NSAID contraindications, though it is generally less effective when used alone 1
Evidence Supporting Ibuprofen Use
A pilot randomized controlled trial demonstrated that patients treated with ibuprofen had:
- Significantly fewer headache days compared to standard care 2
- Fewer episodes of headache 2
- Lower headache intensity 2
- Higher rates of return to school at 1 week (61% with ibuprofen alone, 79% with combined ibuprofen and acetaminophen, versus only 21% with standard care) 2
Why Benadryl Should Not Be Used
Diphenhydramine has no established role in concussion headache treatment. The evidence base for post-concussion headache management focuses on NSAIDs, acetaminophen, and specific migraine therapies when headaches develop migraine-like features 1. Benadryl:
- Does not appear in any guideline recommendations for post-concussion headache 1
- Provides sedation without analgesic benefit for headache
- May complicate assessment of concussion-related cognitive symptoms due to its anticholinergic effects
Critical Timing and Frequency Limitations
Begin treatment early in the headache phase for maximum effectiveness, as waiting until pain becomes severe reduces medication efficacy 1. However, limit acute medication use to no more than twice weekly to prevent medication overuse headache 1, which is a significant concern in the post-concussion population.
Medication Overuse Headache Risk
This is a critical pitfall in concussion management:
- 70% of adolescent concussion patients with chronic post-traumatic headache (3-12 months duration) met criteria for probable medication-overuse headache in one study 3
- Only simple analgesics (like ibuprofen and acetaminophen) were overused 3
- 68.5% had resolution or improvement of headaches after discontinuing excessive analgesic use 3
Management of Associated Symptoms
If nausea accompanies the post-concussion headache:
- Add metoclopramide 10 mg or prochlorperazine as adjunctive therapy 1
- These provide both antiemetic effects and synergistic analgesia 4
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 1. This applies to all narcotic analgesics including hydrocodone, oxycodone, and meperidine.
When to Escalate Treatment
If headaches persist beyond the acute phase or develop migraine-like features:
- Consider migraine-specific therapies such as triptans for moderate-to-severe headaches with migraine characteristics 5
- Initiate preventive therapy if headaches occur more than twice weekly 1
- Refer for specialty evaluation if headaches become chronic (>3 months) 3
Pediatric-Specific Considerations
For children and adolescents with post-concussion headache:
- Avoid aspirin due to Reye's syndrome risk 1
- Use ibuprofen or acetaminophen with counseling about analgesic overuse risks 1
- Consider clinical observation and head CT for severe or worsening headache to evaluate for intracranial complications 1
Non-Pharmacologic Adjuncts
Graded aerobic exercise with gradual increases in intensity performed at least once weekly for 4 weeks should be used as an adjunct to pharmacologic treatment 1. Physical therapy is particularly beneficial when cervicogenic features are present 1.