Can a tension-type headache occur after head trauma?

Can Tension-Type Headaches Result from Head Trauma?

Yes, tension-type headaches can and do occur after head trauma, representing approximately 37-40% of all chronic post-traumatic headache presentations. 1

Epidemiology and Clinical Recognition

Post-traumatic tension-type headache is one of the most common chronic headache patterns following closed head injury:

• Approximately 37-40% of patients who develop post-traumatic headache are diagnosed with a chronic tension-type phenotype, making it among the most prevalent chronic post-traumatic headache presentations 1
• In pediatric populations, 4% of children with closed head injury progress to chronic episodic tension-type headache 1
• Headache is the single most common postconcussive symptom reported in both adults and children within 3 days of injury 2
• Headache persists for more than 2 months in 60% of patients following closed head injury 3

Diagnostic Framework

The American Association of Neurological Surgeons formally recognizes headache/migraine as one of five primary concussion subtypes (not merely an associated symptom), alongside cognitive, ocular-motor, vestibular, and anxiety/mood subtypes 4, 2

Post-traumatic headache is defined as headache beginning within 2 weeks of closed head injury; when persisting beyond 2 months, it is classified as chronic post-traumatic headache 1

Key diagnostic requirements include:

• Primary diagnosis of concussion from closed head injury or transmitted forces to the brain 4
• Exclusion of psychiatric/neurological disability preventing accurate self-report 4
• Exclusion of medical conditions or substances confounding assessment 4

Clinical Presentation Distinguishing Features

Post-traumatic tension-type headache typically presents with:

• Bilateral, mild to moderate pain with pressing or tightening quality 4, 5
• Pain radiating in a band-like fashion from forehead to occiput 6
• Absence of migraine features (no unilateral throbbing, nausea, photophobia, or aggravation by routine physical activity) 4, 5, 6
• Frequent radiation to neck muscles 6

Critical Distinction: Cervical Strain Co-occurrence

Cervical strain commonly co-occurs with concussion-related headache, especially when pain is occipital or sub-occipital, because injury to cervical structures produces somatosensory dysfunction and abnormal signaling along cervical afferent pathways 7

Evaluate for:

• Cervical spine tenderness (midline, paraspinal, sub-occipital) 7
• Weakness on paracervical strength testing 7
• Limited cervical range of motion 7
• Pain provoked by cervical movement 7

Important Clinical Pitfall

Trauma-induced headaches are usually heterogeneous in nature, often including both tension-type pain and intermittent migraine-like attacks 3. Multiple concussion subtypes may contribute to a patient's clinical presentation; subtypes are not mutually exclusive 4. A patient may present with predominantly tension-type features but later develop migraine or anxiety/mood subtypes 4.

Treatment Algorithm

Acute Symptomatic Treatment

First-line acute therapy is acetaminophen (approximately 1000 mg) or ibuprofen (400-800 mg) 7

Alternative acute options with explicit caution:

• Ibuprofen 400-800 mg every 6 hours 1
• Acetaminophen 650-1000 mg every 4-6 hours 1
• Critical warning: Use of pain relievers more than twice weekly places patients at risk for progression to chronic daily headache 6
• Opioid medications should be avoided because they are associated with poorer outcomes and increased risk of dependency 1

Preventive Therapy Indications

Preventive medication is indicated when:

• Patient experiences ≥2 headache episodes per month causing disability for ≥3 days, OR
• Rescue medication is used more than twice per week 7

First-line preventive agents: propranolol or amitriptyline 7

Specific preventive dosing:

• Amitriptyline: initiated at 10-25 mg at bedtime, titrated to 30-150 mg per day 1
• Amitriptyline is the most widely researched prophylactic agent for frequent headaches 6
• Alternative evidence-based options include venlafaxine and mirtazapine 8

Non-Pharmacologic Interventions (Mandatory Components)

A comprehensive treatment plan must incorporate:

• Regular sleep schedule maintenance 7
• Adequate hydration 7
• Regular moderate-to-intense aerobic exercise 7
• Headache diary to identify and avoid triggers 7
• Vestibular rehabilitation 1
• Optimization of sleep hygiene 1
• Graded physical-exercise programs 1

Physical therapy is suggested for management of tension-type headache 4

Prognosis and Treatment Timing

If aggressive treatment is initiated early, post-traumatic headache is less likely to become a permanent problem 3. Once "windup" of post-traumatic headaches occurs, the cycle of ongoing headaches is more difficult to interrupt 3. Most patients have favorable prognosis for symptom resolution, but a small percentage will have persistent symptoms after three years 9.

The American Academy of Neurology states that chronic post-traumatic headache is a multifactorial condition requiring a multidisciplinary evaluation approach 1.