Secondary intracranial hypertension (pseudotumor cerebri) presenting as post-traumatic headache in mild traumatic brain injury: a case series

American Headache Society white paper on treatment of post-traumatic headache from concussion in youth

OBJECTIVE

To provide healthcare professionals guidance on youth at risk for prolonged recovery and post-traumatic headache (PTH), and on pharmacologic and non-pharmacologic management of PTH due to concussion and mild traumatic brain injury.

BACKGROUND

Headache is the most common persistent post-concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines.

METHODS

This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society.

RESULTS

Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair-to-poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro-modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective.

CONCLUSIONS

This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth.

Differential diagnosis and theories of pathophysiology of post-traumatic photophobia: A review

BACKGROUND: Photophobia is a common sensory symptom after traumatic brain injury (TBI) that may have a grave impact on a patient’s functional independence, neurorehabilitation, and activities of daily living. Post-TBI photophobia can be difficult to treat and the majority of patients can suffer chronically up to and beyond one year after their injury. OBJECTIVES: This review evaluates the current theories of the pathophysiology of photophobia and the most-common co-morbid etiologies of light sensitivity in TBI to help guide the differential diagnosis and individualized management of post-TBI photophobia. METHODS: Primary articles were found via PubMed and Google Scholar search of key terms including “photophobia” “light sensitivity” “photosensitivity” “photo-oculodynia” “intrinsically photosensitive retinal ganglion cells” “ipRGC” and “concussion” “brain injury” “dry eye”. Due to paucity of literature papers were reviewed from 1900 to present in English. RESULTS: Recent advances in understanding the pathophysiology of photophobia in dry eye and migraine and their connection to intrinsically photosensitive retinal ganglion cells (ipRGC) have revealed complex and multifaceted trigeminovascular and trigeminoautonomic pathways underlying photophobia. Patients who suffer a TBI often have co-morbidities like dry eye and migraine that may influence the patient’s photophobia. CONCLUSION: Post-traumatic photophobia is a complex multi-disciplinary complaint that can severely impact a patient’s quality of life. Exploration of underlying etiology may allow for improved treatment and symptomatic relief for these patients beyond tinted lenses alone.

Post-concussive Dizziness: A Review and Clinical Approach to the Patient

Dizziness is a frequent complaint after head trauma. Among patients who suffer a concussion (mild traumatic brain injury or mTBI), dizziness is second only to headache in symptom frequency. The differential diagnosis of post-concussive dizziness (PCD) can be divided into non-vestibular, central vestibular and peripheral vestibular causes with growing recognition that patients frequently exhibit both central and peripheral findings on vestibular testing. Symptoms that traditionally have been ascribed to central vestibular dysfunction may be due to peripheral dysfunction. Further, our ability to test peripheral vestibular function has improved and has allowed us to identify peripheral disorders that in the past would have remained unnoticed. The importance of the identification of the peripheral component in PCD lies in our ability to remedy the peripheral vestibular component to a much greater extent than the central component. Unfortunately, many patients are not adequately evaluated for vestibular disorders until long after the onset of their symptoms. Among the diagnoses seen as causes for PCD are (1) Central vestibular disorders, (2) Benign Paroxysmal Positional Vertigo (BPPV), (3) Labyrinthine dehiscence/perilymph fistula syndrome, (4) labyrinthine concussion, (5) secondary endolymphatic hydrops, (6) Temporal bone fracture, and (7) Malingering (particularly when litigation is pending). These diagnoses are not mutually exclusive and PCD patients frequently exhibit a combination of these disorders. A review of the literature and a general approach to the patient with post-concussive dizziness will be detailed as well as a review of the above-mentioned diagnostic categories.

Acute and chronic management of posttraumatic headache in children: A systematic review

OBJECTIVES

The goal of this paper is to provide a compilation of the evidence for the treatment of posttraumatic headache (PTH) in the pediatric population. Headache features and timing of therapy were considered.

BACKGROUND

Headache is the most common symptom following mild traumatic brain injury (mTBI), affecting more than 80% of children and adolescents. It is unclear whether treatment for PTH should be tailored based on headache characteristics, particularly the presence of migraine features, and/or chronicity of the headache.

METHODS

Systematic literature searches of PubMed, Embase, Scopus, and Cochrane databases (1985-2021, limited to English) were performed, and key characteristics of included studies were entered into RedCAP^® (Prospero ID CRD42020198703). Articles and conference abstracts that described randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series were included. Participants included youth under 18 years of age with acute (<3 months) and persistent (≥3 months) PTH. Studies that commented on headache improvement in response to therapy were included.

RESULTS

Twenty-seven unique studies met criteria for inclusion describing abortive pharmacologic therapies (9), preventative pharmacotherapies (5), neuromodulation (1), procedures (5), physical therapy and exercise (6), and behavioral therapy (2). Five RCTs were identified. Studies that focused on abortive pharmacotherapies were completed in the first 2 weeks post-mTBI, whereas other treatment modalities focused on outcomes 1 month to over 1-year post-injury. Few studies reported on migrainous features (7), personal history of migraine (7), or family history of migraine (3).

CONCLUSIONS

There is limited evidence on the timing and types of therapies that are effective for treating PTH in the pediatric population. Prospective studies that account for headache characteristics and thoughtfully address the timing of therapies and outcome measurement are needed.

Diagnosis of idiopathic intracranial hypertension - the importance of excluding secondary causes: A systematic review

BACKGROUND

Idiopathic intracranial hypertension is characterized by increased intracranial pressure without any pathological findings on neuroimaging, except for signs of high intracranial pressure. Before diagnosing idiopathic intracranial hypertension secondary causes of increased intracranial pressure should be excluded.

OBJECTIVE

to characterize the phenotype of patients with secondary intracranial hypertension and to identify possible risk factors for secondary intracranial hypertension.

METHODS

We have systematically searched the PubMed database. The publications were analyzed according to the patient phenotype, age, gender, comorbidities, body mass index/weight status, and additional medication. The results are summarized in four categories: medication, infection, hormonal induced intracranial hypertension and miscellaneous groups of diseases related to sIH.

RESULTS

We identified 105 eligible papers which included 272 cases. There were 49.6% pediatric cases. Among the adult group,70.9% were women. A total of 40.4% of all cases were obese or overweight, 27% among adults and 13.4% among pediatric cases. Increased BMI and recent weight gain, anemia, renal diseases and hypertension were the most frequent comorbidities related to sIH.

CONCLUSION

Among sIH patients, 40.4% were obese or overweight; two thirds were women. We recommend that even patients with a typical IIH phenotype should be screened for secondary causes.

Acupuncture for hearing loss after traumatic brain injury: A protocol for systematic review of randomized controlled trial

BACKGROUND

This study aims to systematically assess the effectiveness and safety of acupuncture on hearing loss (HL) after traumatic brain injury (TBI).

METHODS

In this study, the following databases will be retrieved from inception up to the May 1, 2019: PUBMED, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database. All databases will be retrieved without any language restrictions. Two reviewers will independently carry out article selection, data collection, and risk of bias evaluation. Any disagreements will be solved by a third reviewer through discussion.

RESULTS

This study will systematically investigate the effectiveness and safety of acupuncture for treating HL after TBI through evaluating HL assessment, hearing threshold, quality of life, and adverse events.

CONCLUSION

The expected findings of this study will provide latest evidence for assessing the effectiveness and safety of acupuncture for HL after TBI.

ETHICS AND DISSEMINATION

This study is supposed to be published in a peer-reviewed journal. No ethical approval is needed because this study will based on the literature analysis, but not the individual patient.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019133417.

Imaging Post-Traumatic Headache

PURPOSE OF REVIEW

Headache is a frequent and debilitating symptom after mild traumatic brain injury, yet little is known about its pathophysiology and most effective treatments. The goal of this review is to summarize findings from imaging studies used during the clinical evaluation and research investigation of post-traumatic headache (PTH).

RECENT FINDINGS

There are no published recommendations or guidelines for when to acquire imaging studies of the head or neck in patients with PTH. Clinical acumen is required to determine if imaging is needed to assess for a secondary cause of headache which may have been precipitated or unmasked by the trauma. Several guidelines for when to image the patient with mild traumatic brain injury (mTBI) in the emergency setting consider headache among the deciding factors. In the research arena, imaging techniques including proton spectroscopy magnetic resonance imaging, diffusion tensor imaging, magnetic resonance morphometry, and functional neck x-rays have been employed with the goal of identifying diagnostic and prognostic factors for PTH and to help understand its underlying pathophysiologic mechanisms. Results indicate that changes in regional cortical thickness and damage to specific white matter tracts warrant further research. Future research should interrogate whether these imaging findings contribute to the classification and prognosis of PTH. Current research provides evidence that imaging findings associated with PTH may be distinct from those attributable to mTBI. A variety of imaging techniques have potential to further our understanding of the pathophysiologic processes underlying PTH as well as to provide diagnostic and prognostic indicators. However, considerable work must be undertaken for this to be realized.