I sustained a head injury from a fall on ice one year ago, have no neurological deficits but persistent scalp tenderness; what is the appropriate next step?

Persistent Scalp Tenderness One Year After Head Injury

For isolated scalp tenderness persisting over one year after a fall with no neurological symptoms, no imaging is indicated; instead, evaluate for local soft tissue causes such as scalp neuralgia, periosteal contusion, or localized inflammation, and consider referral to neurology if symptoms persist beyond conservative management.

Clinical Context and Risk Assessment

The timeframe of over one year since injury fundamentally changes the clinical approach. The acute and subacute periods for traumatic intracranial complications have long passed:

• Delayed intracranial hemorrhage occurs within days, not years. The risk of delayed intracranial complications after head trauma is highest within the first 72 hours and exceptionally rare beyond 14 days, even in anticoagulated patients 1.

• Acute traumatic brain injury guidelines do not apply to chronic symptoms. The ACEP clinical policy and ACR appropriateness criteria specifically address evaluation within 24 hours of injury for acute mild TBI 1. Your presentation is now in the chronic phase.

• The absence of neurological deficits is highly reassuring. Guidelines emphasize that patients requiring imaging or intervention present with focal neurologic deficits, altered mental status, persistent vomiting, worsening headache, or decreased Glasgow Coma Scale scores 1, 2. None of these are present in your case.

Why Imaging Is Not Indicated

CT or MRI of the brain is not warranted for isolated scalp tenderness without neurological symptoms one year post-injury:

• No acute intracranial pathology would remain undetected for this duration. Epidural hematomas present rapidly with neurological deterioration, while subdural hematomas typically manifest within days to weeks 3. A clinically significant lesion would have declared itself long ago.

• Imaging guidelines target acute injury detection, not chronic scalp symptoms. The Canadian CT Head Rule and New Orleans Criteria were designed to identify patients at risk for acute intracranial injury requiring neurosurgical intervention within the first 24 hours 1. These decision rules have no validity for chronic symptoms.

• MRI's role is for persistent neurological deficits, not scalp tenderness. While MRI is more sensitive than CT for subtle traumatic lesions and may be indicated when persistent neurological deficits remain unexplained after CT, it is recommended in the acute-to-subacute phase for prognostication, not for isolated scalp symptoms years later 1.

Differential Diagnosis for Chronic Scalp Tenderness

The persistent tenderness is almost certainly a local soft tissue problem, not intracranial pathology:

• Occipital neuralgia or other scalp nerve irritation can cause chronic tenderness and hypersensitivity at the site of prior trauma.

• Periosteal contusion or chronic inflammation of the skull periosteum can persist for months and occasionally longer after blunt trauma.

• Localized soft tissue fibrosis or scar tissue from the initial injury may cause ongoing discomfort with palpation.

• Trigger points or myofascial pain in the scalp or neck musculature can develop after trauma and persist chronically.

Recommended Management Approach

Follow this stepwise approach for evaluation and treatment:

1. Perform a focused physical examination:

   • Palpate the area carefully to characterize the tenderness (point tenderness vs. diffuse, superficial vs. deep)
   • Assess for any scalp masses, depressions, or bony irregularities
   • Examine for signs of local inflammation or skin changes
   • Test sensation in the distribution of occipital and supraorbital nerves
   • Perform a complete neurological examination to confirm absence of deficits

2. Conservative management trial:

   • NSAIDs for anti-inflammatory effect if not contraindicated
   • Local ice or heat application based on patient preference
   • Gentle massage or physical therapy for myofascial components
   • Avoidance of direct pressure or trauma to the area

3. Consider neurology referral if:

   • Symptoms worsen or new neurological symptoms develop
   • Pain becomes severe or functionally limiting
   • Conservative measures fail after 4-6 weeks
   • Patient develops concerning features such as headache pattern changes, visual disturbances, or cognitive symptoms

Critical Red Flags That Would Change Management

Return immediately for evaluation if any of these develop:

• New or worsening headaches beyond the localized tenderness 1, 2
• Repeated vomiting 1, 2
• Confusion, memory problems, or behavioral changes 1, 4
• Focal neurological deficits (weakness, numbness, vision changes) 1, 2
• Seizures 1
• Increased sleepiness or loss of consciousness 1, 4

Common Pitfalls to Avoid

• Do not order imaging for chronic, isolated scalp tenderness without neurological symptoms. This represents low-value care and exposes the patient to unnecessary radiation (CT) or cost (MRI) without clinical benefit.

• Do not dismiss the patient's symptoms as purely psychological. Chronic post-traumatic scalp tenderness has legitimate soft tissue etiologies that deserve evaluation and treatment.

• Do not confuse postconcussive syndrome with isolated scalp tenderness. Postconcussive symptoms include headache, dizziness, cognitive difficulties, mood changes, and sleep disturbances—not isolated scalp tenderness 1, 4. If these broader symptoms are present, the evaluation would differ.