Can Tension-Type Headaches Result from Head Trauma?
Yes, tension-type headaches are a well-recognized consequence of head trauma, accounting for approximately 37% of all post-traumatic headaches, making them one of the two most common phenotypes following concussion, whiplash, or blunt head/neck injury. 1
Epidemiology and Clinical Presentation
Headache is the most common symptom following closed head injury, persisting beyond 2 months in 60% of patients, and tension-type headache represents approximately 37% of all post-traumatic headache presentations. 2, 1
Post-traumatic headaches are typically heterogeneous in nature, often including both tension-type pain and intermittent migraine-like attacks, rather than presenting as a single pure headache phenotype. 2
The cumulative incidence of new or worse headache following mild traumatic brain injury reaches 91% over the first year, with tension-type headache accounting for up to 40% of these cases. 3
Mechanism and Associated Conditions
Cervical strain is a critical concussion-associated condition that frequently coexists with post-traumatic headache, particularly when the headache is occipital or suboccipital in location, because injury to cervical structures leads to somatosensory dysfunction and aberrant signaling along cervical afferent pathways. 4
Differentiating isolated cervical strain from concomitant etiologies such as whiplash-associated disorder is essential because cervical strain and concussion share common injury mechanisms, and this distinction determines appropriate management. 4
Post-traumatic headache rarely occurs in isolation—cervical pain is a frequent accompaniment, and headache is often one component of the broader postconcussive syndrome that includes cognitive, behavioral, and somatic problems. 2
Diagnostic Approach
By definition, any new headache developing within 1 week after head trauma (or within 1 week after regaining consciousness) qualifies as post-traumatic headache, and if it persists beyond 2 months post-injury, it is classified as chronic post-traumatic headache. 2, 1
Clinical presentations of post-traumatic tension-type headache are phenomenologically similar to primary tension-type headache, which is why treatment approaches are typically based on protocols for primary headache disorders despite the different etiology. 2, 1
Patients with cervical strain should be evaluated for clinical signs including pain/tenderness in the cervical spine (midline, paraspinal, and suboccipital muscle palpation), weakness with paracervical strength testing, limitation of cervical motion, and pain with cervical motion. 4
Treatment Algorithm
If aggressive treatment is initiated early, post-traumatic headache is less likely to become a permanent problem, because once "windup" occurs, the cycle of ongoing headaches becomes significantly more difficult to interrupt. 2
Acute symptomatic treatment with acetaminophen (1000 mg) or ibuprofen (400-800 mg) should be used as first-line therapy for post-traumatic tension-type headache. 5
Preventive therapy should be initiated if two or more headache attacks per month cause disability for 3+ days or if rescue medication use exceeds twice weekly, with propranolol or amitriptyline as first-line preventive options. 5
Treatment requires both "peripheral" and "central" measures, with simple analgesics such as nonsteroidal anti-inflammatory agents for short-term treatment and tricyclic antidepressants for chronic pain being most effective in patients without structural damage. 6
Critical Pitfalls to Avoid
Rebound headaches may develop from overuse of analgesic medications and can significantly complicate the diagnosis and treatment of post-traumatic headache, making it essential to monitor medication frequency closely. 2
Delayed recovery may result from inadequately aggressive or ineffective treatment, analgesic overuse causing rebound phenomena, or comorbid psychiatric disorders including post-traumatic stress disorder, insomnia, substance abuse, depression, or anxiety. 2
Although most post-traumatic headache resolves within 6-12 months after injury, approximately 18-33% persists beyond 1 year, and more than one-third of patients report persistent headache across all follow-up periods in the first year, warranting assertive early treatment to avoid chronicity and disability. 1, 3
Non-pharmacologic interventions including maintaining a consistent sleep schedule, ensuring proper hydration, encouraging regular moderate-to-intense aerobic exercise, and using a headache diary to identify triggers should be incorporated into the treatment plan. 5