Post-Traumatic Headache Management
Indications for Emergent Head CT
Obtain emergent non-contrast head CT in any patient with post-traumatic headache who meets validated clinical decision rule criteria, with an especially low threshold for imaging in patients on anticoagulants or antiplatelet agents. 1
High-Risk Features Requiring Immediate CT (ACEP Level A - with LOC or PTA):
- Headache (especially severe or worsening) 1
- Vomiting 1
- Age >60 years 1
- Drug or alcohol intoxication 1
- Short-term memory deficits 1
- Physical trauma above the clavicles 1
- Post-traumatic seizure 1
- GCS <15 1
- Focal neurologic deficit 1
- Any coagulopathy (warfarin, NOACs, clopidogrel, ticagrelor) 1
Moderate-Risk Features Requiring CT Consideration (ACEP Level B - without LOC or PTA):
- Severe headache 1
- Age ≥65 years 1
- Basilar skull fracture signs 1
- Dangerous mechanism (ejection from vehicle, pedestrian struck, fall >3 feet/5 stairs) 1
Special Populations:
Anticoagulated/Antiplatelet Patients: The threshold for initial CT is extremely low due to 3.9% risk of intracranial hemorrhage versus 1.5% in non-anticoagulated patients. 1 Delayed hemorrhage occurs in up to 6% of cases, though a single Class II study found only 0.6% delayed ICH rate in warfarin patients with negative initial CT (2 deaths, no neurosurgical interventions required). 1
Pediatric Patients: Observe and consider CT for severe headache, especially with other risk factors; emergent neuroimaging is mandatory for acutely worsening symptoms during observation. 1
First-Line Pharmacologic Therapy
Treat post-traumatic headache based on its phenotype using the same medications as for primary headache disorders, as there is no high-quality evidence supporting TBI-specific pharmacotherapy. 2, 3, 4
Acute/Abortive Treatment:
For Migraine-Like PTH:
- NSAIDs (ibuprofen, naproxen) as first-line 2, 4, 5
- Avoid analgesic overuse (limit to <10 days/month) to prevent medication-overuse headache 2, 4
For Tension-Type PTH:
- Acetaminophen or NSAIDs 2, 4, 5
- Physical therapy and thermal modalities for cervicogenic component 4, 5
Prophylactic Treatment (for frequent or persistent PTH):
First-Line Preventive Agents:
- Tricyclic antidepressants (amitriptyline) - addresses comorbid sleep disturbance 2, 4, 5
- Antiepileptic medications (topiramate, valproate) for migraine-like features 2, 5
Critical Timing: Aggressive early treatment prevents "windup" and chronification; once daily headaches establish, the cycle becomes significantly harder to interrupt. 2
Non-Pharmacologic Management
Implement a multimodal approach combining the following evidence-based interventions:
- Relative rest for 24-48 hours immediately post-injury 1
- Cognitive behavioral therapy 4, 5
- Biofeedback and relaxation techniques 4, 5
- Physical therapy, especially for cervicogenic components 4, 5
- Gradual return to aerobic exercise under medical supervision for persistent symptoms 1
Common Pitfalls to Avoid
Never dismiss headache in anticoagulated patients: Even minimal trauma warrants CT given the 3.9% ICH risk versus 1.5% in non-anticoagulated patients. 1 The presence of NOACs or antiplatelet agents (excluding aspirin alone) carries similar risk. 1
Never allow analgesic overuse: Rebound headaches from medication overuse significantly complicate diagnosis and treatment; limit acute medications to <10 days per month. 2, 4
Never delay aggressive treatment: Post-traumatic headaches that persist beyond 2 months become chronic in 30-50% of cases and are much harder to treat once established. 2, 3 Early prophylaxis prevents chronification. 2
Never ignore comorbidities: Post-traumatic stress disorder, insomnia, depression, and anxiety frequently coexist and must be addressed for successful headache management. 2, 5
Follow-Up and Prognosis
Most post-traumatic headaches resolve within days to weeks, but 30-50% persist for at least 3 months. 3 Up to 25% of patients develop long-term chronic headaches. 4 Risk factors for persistence include female gender, younger age, history of migraines, greater injury severity, and psychological comorbidities. 5
Discharge counseling must include: warning signs of serious injury, expected symptom course, activity modification instructions, return-to-play/school guidelines, and clear follow-up plans. 1