What is the management protocol for a patient with a history of chronic headaches, recently diagnosed with a concussion, who has been taking Naproxen (Nonsteroidal Anti-Inflammatory Drug) for over 5 years?

Management of Post-Concussion Headache in a Patient on Long-Term Naproxen

Immediately discontinue naproxen and transition to acetaminophen as the primary acute headache treatment, limiting use to no more than 2 days per week to prevent medication-overuse headache, while simultaneously initiating preventive therapy given the 5-year history of chronic headache use. 1, 2

Critical First Step: Address Medication-Overuse Headache Risk

• After 5 years of regular naproxen use, this patient is at extremely high risk for medication-overuse headache (MOH), which occurs when acute medications are used ≥15 days/month for NSAIDs 1, 2
• MOH paradoxically increases headache frequency and can lead to daily headaches, creating a vicious cycle that reduces responsiveness to all acute treatments 1, 2
• Abrupt withdrawal of the overused medication is preferred (except for opioids), accompanied by patient education about the mechanism of MOH 1

Post-Concussion Headache Management Protocol

Acute Treatment Strategy

• Switch to acetaminophen 1000 mg as first-line acute treatment for post-concussion headache, as NSAIDs like naproxen should be avoided in the acute concussion period due to theoretical bleeding concerns 2, 3
• Strictly limit acetaminophen to no more than 2 days per week (10 days per month) to prevent recurrence of medication-overuse headache 2, 3
• Monitor total daily acetaminophen intake to ensure it does not exceed 4000 mg per day from all sources 2

When Acetaminophen Fails After 2-3 Episodes

• Consider low-dose ibuprofen 400 mg as an alternative NSAID if acetaminophen is ineffective after 2-3 headache episodes, once the acute concussion phase has resolved (typically after 7-10 days) 3
• Avoid triptans entirely in the post-concussion setting, as they are contraindicated in patients with recent head trauma and may worsen outcomes 2

Mandatory Preventive Therapy Initiation

Given the 5-year history of chronic headache requiring daily or near-daily medication, preventive therapy must be initiated immediately rather than relying solely on acute treatment 1

First-Line Preventive Options (Choose Based on Comorbidities)

• Amitriptyline 30-150 mg/day is the preferred first-line agent for patients with mixed migraine and tension-type headache, which is common in chronic headache sufferers 1
• Propranolol 80-240 mg/day has consistent evidence for efficacy in migraine prevention and may be preferred if the patient has no contraindications (asthma, depression, fatigue) 1
• Topiramate has good evidence for chronic migraine prevention and is the only agent proven efficacious in randomized controlled trials specifically for chronic migraine 1

Preventive Therapy Timeline and Expectations

• Efficacy requires 2-3 months for oral agents before determining success or failure 2
• The goal is to reduce attack frequency by ≥50% and restore responsiveness to acute treatments 2
• Continue preventive therapy for at least 6 months once sustained efficacy is achieved with no substantial adverse effects 1

Identify and Manage Modifiable Risk Factors

• Screen for and address: obesity, caffeine overuse, obstructive sleep apnea, psychiatric comorbidities (anxiety, depression), and stress 1
• Implement behavioral interventions: relaxation training, biofeedback, and cognitive-behavioral therapy have strong evidence as first-line preventive options 4
• Consider acupuncture as an adjunctive first-line intervention based on recent positive randomized trial findings 4

Concussion-Specific Considerations

• Rule out red flags requiring urgent neuroimaging: thunderclap headache, progressive worsening, focal neurologic deficits, altered mental status, or fever with neck stiffness 2
• Post-concussion headaches typically resolve within 3 months; if headaches persist beyond this timeframe, reassess for other primary headache disorders 1
• Avoid opioids and butalbital-containing compounds entirely, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 2

Critical Pitfall to Avoid

Do not allow the patient to continue frequent naproxen use or substitute another acute medication at high frequency in response to treatment failure. This perpetuates the medication-overuse headache cycle. Instead, the correct approach is to withdraw the overused medication, transition to limited acute treatment (≤2 days/week), and initiate preventive therapy to break the cycle of chronic headache 1, 2

Follow-Up and Monitoring

• Reassess in 2-4 weeks to evaluate withdrawal symptoms, adherence to frequency limits, and tolerability of preventive therapy 1
• Use a headache diary to track frequency, severity, and medication use, as patients often underreport milder headaches 1
• If preventive therapy fails after adequate trial (2-3 months), consider escalation to onabotulinumtoxinA (the only FDA-approved therapy for chronic migraine prophylaxis) or CGRP monoclonal antibodies 1