What is the appropriate evaluation and management for a patient who develops a new or worsening headache after a head injury?

Post-Traumatic Headache: Evaluation and Management

For patients developing new or worsening headache after head injury, immediately assess for red flags requiring emergent neuroimaging (severe/worsening headache, altered consciousness, focal deficits, vomiting), then classify the headache phenotype (tension-type vs migraine) to guide targeted treatment with non-opioid analgesics while avoiding medication overuse. 1, 2

Initial Emergency Department Evaluation

Red Flag Assessment

• Perform emergent head CT in children and adults with severe headache, especially when associated with other risk factors and worsening headache pattern after mild traumatic brain injury (mTBI), following validated clinical decision rules 1
• Children undergoing observation for headache with acutely worsening symptoms require emergent neuroimaging 1
• Additional red flags mandating immediate CT include: repeated vomiting, focal neurologic deficits, abnormal behavior, increased sleepiness or loss of consciousness, seizures, and confusion 1

Timing and Imaging Considerations

• Skull radiographs should not be used in diagnosis of pediatric mTBI or screening for intracranial injury 1
• Do not use biomarkers outside research settings for mTBI diagnosis 1
• For patients with Glasgow Coma Scale 14-15 and isolated severe headache without other risk factors, observation may be appropriate as isolated severe headache alone does not significantly increase intracranial injury risk 1

Headache Phenotype Classification

Diagnostic Framework

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

Two primary phenotypes emerge:

• Tension-type (37-40% of post-traumatic headaches): Bilateral, mild-to-moderate pressure or tightening pain without migraine features (no unilateral throbbing, nausea, photophobia, or worsening with routine activity) 2, 3
• Migraine/probable migraine (29% of post-traumatic headaches): Characterized by prodrome/aura with nausea, vomiting, and sensitivity to light, sound, or smell 1, 3

Associated Conditions to Evaluate

• Cervical strain: Neck pain, stiffness, occipital/suboccipital headache location, tenderness on cervical palpation, limited cervical motion 1
• Vestibulo-oculomotor dysfunction: Dizziness, visual difficulties, eye strain, photophobia, problems with visual focus 1
• Sleep disturbance: New or exacerbated sleep problems that adversely affect recovery 1

Acute Pharmacological Management

First-Line Treatment

Offer non-opioid analgesics with explicit counseling about medication overuse risks 1:

• Ibuprofen: 400-800 mg every 6 hours 2
• Acetaminophen: 650-1000 mg every 4-6 hours 2
• Limit acute treatment to no more than twice weekly to prevent medication-overuse headache 1

Migraine-Specific Agents

For migraine phenotype not responding to NSAIDs 1:

• Triptans (naratriptan, rizatriptan, zolmitriptan, sumatriptan) are appropriate second-line agents
• Contraindicated in uncontrolled hypertension, basilar/hemiplegic migraine, or cardiac disease risk
• Despite appropriateness, only 8% of patients with migraine phenotype after mTBI actually use triptans, representing significant undertreatment 4

Medications to Avoid

Opioids should be avoided due to limited efficacy for headache, dependency risk, and potential for rebound headache 2, 5

Chronic Post-Traumatic Headache Management

Multidisciplinary Approach Required

Chronic post-traumatic headache (>2 months duration) is multifactorial and requires multidisciplinary evaluation 1, 2:

• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrated to 30-150 mg daily) are recommended for chronic tension-type post-traumatic headache 2
• Physical therapy is a core non-pharmacologic strategy, particularly for cervical and musculoskeletal contributors 2
• Vestibular rehabilitation for patients with vestibulo-oculomotor dysfunction 1

Non-Pharmacologic Interventions

• Sleep hygiene optimization: Provide guidance on proper sleep methods to facilitate recovery 1
• Graded aerobic exercise: Refer select patients to medically supervised interdisciplinary teams for individualized aerobic exercise tolerance assessment and prescription 1
• Consider referral to sleep disorder specialist if problems persist despite sleep hygiene measures 1

Discharge Instructions and Follow-Up

Patient Education (Critical to Prevent Chronic Symptoms)

Provide written and verbal instructions at 6th-7th grade reading level 1:

Return to ED immediately if:

• Repeated vomiting
• Worsening headache
• Problems remembering or confusion
• Focal neurologic deficits
• Abnormal behavior
• Increased sleepiness or passing out
• Seizures 1

Postconcussive Symptom Counseling

• Use validated prediction rules to provide prognostic counseling 1
• Inform families about expected symptom course and recovery timeline 1
• Recommend 24-48 hours of relative rest immediately following acute mTBI 1
• Patients experiencing postconcussive symptoms should refrain from strenuous mental/physical activity until symptom-free 1

Follow-Up Timing

• Refer children with chronic headache (>3 weeks or sooner if planning return to sports) to specialist in traumatic brain injury 1
• Early follow-up within 10-14 days for symptom reassessment 1
• Late follow-up at 3-6 months to assess for persistent symptoms requiring specialized intervention 1

Common Pitfalls to Avoid

• Medication overuse: Over 70% of patients use acetaminophen/NSAIDs regardless of headache phenotype, but only 26% with migraine phenotype achieve complete relief, indicating significant undertreatment with appropriate migraine-specific agents 4
• Home observation protocols: Frequent waking or pupil assessment at home is not supported by literature and not recommended for patients with negative CT or deemed too low-risk for imaging 1
• Ignoring cervical contribution: Cervical strain shares common injury mechanisms with concussion; differentiating isolated vs concomitant etiologies is essential for appropriate management 1
• Delayed recognition of chronicity: Approximately 18-33% of post-traumatic headaches persist beyond 1 year; early identification and multidisciplinary referral improves outcomes 3, 6