What is the recommended treatment for headaches following nasal trauma?

Headaches Following Nasal Trauma: Treatment Recommendations

For headaches following nasal trauma, first seek immediate medical attention if there are signs of brain injury, obvious nasal deformity, or facial fracture, then treat the headache symptomatically with acetaminophen (1000 mg) or ibuprofen (400-800 mg) as first-line therapy, using the same approach as for primary headache disorders. 1

Immediate Assessment and Red Flags

Seek urgent medical evaluation if any of the following are present:

• Signs of brain injury (altered consciousness, confusion, persistent vomiting) 1
• Obvious nasal deformity suggesting fracture 1
• Signs of facial fracture 1
• Headache worsened by Valsalva maneuver 1
• Headache that awakens from sleep 1
• Progressive worsening pattern 1
• Abnormal neurologic examination findings 1

Acute Headache Management

First-Line Pharmacologic Treatment

Use NSAIDs or acetaminophen as initial therapy:

• Ibuprofen 400-800 mg for mild to moderate headache 2, 3
• Acetaminophen 1000 mg as an alternative, though less effective than ibuprofen 4, 5
• Administer medication as early as possible during the headache to maximize efficacy 4

Medication Frequency Limits

• Limit NSAIDs to <15 days per month to prevent medication overuse headache 6
• Limit triptans (if migraine-type headache develops) to <10 days per month 6

If Nausea is Present

• Add metoclopramide 10 mg (oral or IV) for migraine-associated nausea 4, 6
• Consider nonoral routes of administration if vomiting is prominent 4

Post-Traumatic Headache Patterns

Post-traumatic headache is defined as headache beginning within 2 weeks of closed head injury and most commonly resembles either migraine or tension-type headache 1, 7, 8. The treatment approach mirrors that of primary headache disorders 7, 8.

Common presentations include:

• Tension-type headache (most common pattern) 8
• Migraine-type headache (may occur de novo or increase in frequency) 8
• External nasal pain from trigeminal nerve injury 9

Imaging Considerations

MRI head without contrast is the preferred imaging modality if any concerning features are present: 1

• Neurologic signs or symptoms 1
• Headaches associated with vomiting 1
• Increasing frequency, duration, or severity of headaches 1
• Include susceptibility-weighted imaging (SWI) or gradient echo (GRE) sequences to identify hemosiderin deposition from prior trauma 1

Imaging is NOT routinely indicated for uncomplicated post-traumatic headache without red flag features. 1

Preventive Therapy Considerations

Initiate preventive treatment if:

• Two or more headache attacks per month causing disability for 3+ days 4
• Rescue medication use more than twice weekly 4

First-line preventive options:

• Propranolol (best safety data, especially in children) 4, 6
• Amitriptyline if propranolol is contraindicated 4, 6

Medications to Avoid

Do not use the following:

• Opioids (risk of dependency and rebound headaches) 6, 10
• Butalbital-containing medications (risk of dependency and rebound) 6
• Topiramate, valproate, or candesartan in children (adverse effects on growth and development) 4

Non-Pharmacologic Interventions

Implement lifestyle modifications:

• Maintain consistent sleep schedule with adequate hours 4, 6
• Ensure proper hydration throughout the day 4, 6
• Encourage regular moderate-to-intense aerobic exercise 4
• Use a headache diary to identify specific triggers 4
• Consider biofeedback, relaxation techniques, massage, and ice packs 6, 10

Prognosis and Follow-Up

Approximately 20% of patients develop persistent post-traumatic headaches lasting more than 1 year, which may not resolve despite settlement of litigation 8. Monitor headache frequency with a diary for 8-12 weeks to guide treatment decisions 4.

The key clinical pitfall is failing to recognize that post-traumatic headaches require the same treatment approach as primary headache disorders, while remaining vigilant for red flag features that warrant neuroimaging. 1, 7, 8