Can Chronic Tension-Type Headaches Result from Head Trauma?
Yes, chronic tension-type headaches are a well-established consequence of head trauma, occurring in approximately 37-40% of patients with post-traumatic headache, and they represent one of the most common phenotypes of chronic post-traumatic headache. 1, 2
Evidence for Post-Traumatic Tension-Type Headaches
Post-traumatic headache is defined as headache beginning within 2 weeks of closed head injury, and when it persists beyond 2 months, it becomes chronic post-traumatic headache. 1, 3
A prospective study of children with closed head injury found that 4% developed chronic episodic tension-type headaches following trauma. 1
In adults with chronic post-traumatic headache following cranio-cervical trauma, 37-40% were specifically diagnosed with tension-type headache according to International Headache Society criteria. 2, 4
The clinical picture is often mixed, with most patients exhibiting features of both tension-type and migraine-like headaches simultaneously, making pure tension-type presentation less common than combined phenotypes. 5, 4
Key Clinical Characteristics
Headache persists for more than 2 months in 60% of patients after closed head injury, and rarely occurs in isolation—cervical pain is a frequent accompaniment. 3
Paradoxically, milder traumatic brain injuries are more likely to result in chronic headaches than severe injuries. 5
The cumulative incidence of new or worse headache after mild TBI reaches 91% over one year, with 58% reporting persistent problems at 12 months. 6
More than one-third of patients report persistent headache across all follow-up periods in the first year after injury. 6
Treatment Implications
The American Academy of Neurology emphasizes that chronic post-traumatic headache is multifactorial and requires multidisciplinary evaluation. 7
For acute management, nonopioid analgesics (ibuprofen 400-800 mg every 6 hours or acetaminophen 650-1000 mg every 4-6 hours) should be used, with explicit warnings about analgesic overuse headache. 7
For chronic tension-type post-traumatic headache, tricyclic antidepressants like amitriptyline (starting 10-25 mg at bedtime, titrating to 30-150 mg/day) are recommended based on their efficacy in tension-type and migraine prevention. 7, 8
Non-pharmacological interventions including vestibular rehabilitation, sleep hygiene optimization, and graded physical exercise should be incorporated. 7
Critical Pitfalls
If aggressive treatment is not initiated early, post-traumatic headache is more likely to become permanent—once "windup" occurs, the cycle is much more difficult to interrupt. 3
Analgesic rebound-withdrawal headache commonly complicates chronic post-traumatic headache and must be corrected rapidly, as it can protract the headache and render other treatments inefficient. 4
Opioids should be avoided as they worsen outcomes and create dependency. 7, 8
Age ≤60 years is a risk factor for persistent post-traumatic headache. 6