Headache after concussion

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Vision therapy: Occlusion, prisms, filters, and vestibular exercises for mild traumatic brain injury

A number of treatment approaches have been advocated for persistent visual complaints following mild traumatic brain injury. These include devices such as binasal occlusion, yoked prisms, vertical prisms, and filters, as well as vestibular training. We discuss the rationale and the evidence for each of these approaches. Binasal occlusion has been advocated for visual motion sensitivity, but it is not clear why this should help, and there is no good evidence for its symptomatic efficacy. Base-in prisms can help manage convergence insufficiency, but there are few data on their efficacy. Midline shift is an unproven concept, and while the yoked prisms advocated for its treatment may have some effect on egocentric neglect, their use in mild traumatic brain injury is more questionable. A wide variety of posttraumatic symptoms have been attributed to vertical heterophoria, but this is an unproven concept and there are no controlled data on the use of vertical prisms for mild traumatic brain injury symptoms. Filters could plausibly ameliorate light intolerance but studies are lacking. Better evidence is emerging for the effects of vestibular therapy, with a few randomized controlled trials that included blinded assessments and appropriate statistical analyses. Without more substantial evidence, the use of many of these techniques cannot be recommended and should be regarded as unproven and in some cases implausible.

Stress and lasting symptoms following injury: Results from a 4-month cohort of trauma patients recruited at the emergency department

INTRODUCTION

Recent research suggests that up to 20% of minor trauma patients admitted to the emergency department (ED) will suffer from non-specific chronic conditions over the subsequent several months. Thus, the present study assessed the correlates of symptoms that persisted at 4 months after an ED visit and, in particular, evaluated the associations between these symptoms and self-reported stress levels at ED admission and discharge.

METHOD

This study was a prospective observational investigation conducted in the ED of Bordeaux University Hospital that included patients admitted for minor trauma. All participants were contacted by phone 4 months after presentation at the ED to assess the occurrence of post-concussion-like symptoms (PCLS).

RESULTS

A total of 193 patients completed the follow-up assessment at 4 months; 5.2% of the participants suffered from post-traumatic stress disorder (PTSD) and 24.5% suffered from PCLS. A multivariate analysis revealed an association between PCLS and stress level at discharge from the ED (odds ratios [OR]: 2.85, 95% confidence interval [CI]: 1.10-7.40).

CONCLUSIONS

The risk of PCLS at 4 months after an ED visit for a minor injury increased in association with the level of stress at discharge from the ED. These results may improve the quality of life for the millions of patients who experience a stressful injury event every year.

CGRP-dependent and independent mechanisms of acute and persistent post-traumatic headache following mild traumatic brain injury in mice

Background

Acute and persistent post-traumatic headache are often debilitating consequences of traumatic brain injury. Underlying physiological mechanisms of post-traumatic headache and its persistence remain unknown, and there are currently no approved therapies for these conditions. Post-traumatic headache often presents with a migraine-like phenotype. As calcitonin-gene related peptide promotes migraine headache, we explored the efficacy and timing of intervention with an anti- calcitonin-gene related peptide monoclonal antibody in novel preclinical models of acute post-traumatic headache and persistent post-traumatic headache following a mild traumatic brain injury event in mice.

Methods

Male, C57Bl/6 J mice received a sham procedure or mild traumatic brain injury resulting from a weight drop that allowed free head rotation while under minimal anesthesia. Periorbital and hindpaw tactile stimulation were used to assess mild traumatic brain injury-induced cutaneous allodynia. Two weeks after the injury, mice were challenged with stress, a common aggravator of migraine and post-traumatic headache, by exposure to bright lights (i.e. bright light stress) and cutaneous allodynia was measured hourly for 5 hours. A murine anti- calcitonin-gene related peptide monoclonal antibody was administered after mild traumatic brain injury at different time points to allow evaluation of the consequences of either early and sustained calcitonin-gene related peptide sequestration or late administration only prior to bright light stress.

Results

Mice with mild traumatic brain injury, but not a sham procedure, exhibited both periorbital and hindpaw cutaneous allodynia that resolved by post-injury day 13. Following resolution of injury-induced cutaneous allodynia, exposure to bright light stress re-instated periorbital and hindpaw cutaneous allodynia in injured, but not sham mice. Repeated administration of anti-calcitonin-gene related peptide monoclonal antibody at 2 hours, 7 and 14 days post mild traumatic brain injury significantly attenuated the expression of cutaneous allodynia when evaluated over the 14-day post injury time course and also prevented bright light stress-induced cutaneous allodynia in injured mice. Administration of anti-calcitonin-gene related peptide monoclonal antibody only at 2 hours and 7 days after mild traumatic brain injury blocked injury-induced cutaneous allodynia and partially prevented bright light stress-induced cutaneous allodynia. A single administration of anti-calcitonin-gene related peptide monoclonal antibody after the resolution of the peak injury-induced cutaneous allodynia, but prior to bright light stress challenge, did not prevent bright light stress-induced cutaneous allodynia.

Conclusions

We used a clinically relevant mild traumatic brain injury event in mice along with a provocative stimulus as novel models of acute post-traumatic headache and persistent post-traumatic headache. Following mild traumatic brain injury, mice demonstrated transient periorbital and hindpaw cutaneous allodynia suggestive of post-traumatic headache-related pain and establishment of central sensitization. Following resolution of injury-induced cutaneous allodynia, exposure to bright light stress re-established cutaneous allodynia, suggestive of persistent post-traumatic headache-related pain. Continuous early sequestration of calcitonin-gene related peptide prevented both acute post-traumatic headache and persistent post-traumatic headache. In contrast, delayed anti-calcitonin-gene related peptide monoclonal antibody treatment following establishment of central sensitization was ineffective in preventing persistent post-traumatic headache. These observations suggest that mechanisms involving calcitonin-gene related peptide underlie the expression of acute post-traumatic headache, and drive the development of central sensitization, increasing vulnerability to headache triggers and promoting persistent post-traumatic headache. Early and continuous calcitonin-gene related peptide blockade following mild traumatic brain injury may represent a viable treatment option for post-traumatic headache and for the prevention of post-traumatic headache persistence.

Abbreviations

CA Cutaneous allodynia CGRP Calcitonin gene-related peptide mTBI Mild traumatic brain injury PTH Post-traumatic headache APTH Acute post-traumatic headache PPTH Persistent post-traumatic headache

Change in Headache Suffering and Predictors of Headache after Mild Traumatic Brain Injury: A Population-Based, Controlled, Longitudinal Study with Twelve-Month Follow-Up

Headache attributed to traumatic injury to the head (HAIH) is claimed to be the most common sequela following mild traumatic brain injury (MTBI), but epidemiological evidence is scarce. We explored whether patients with MTBI had an increase in headache suffering following injury compared with controls. We also studied predictors of headache.

The Trondheim MTBI follow-up study is a population-based, controlled, longitudinal study. We recruited patients exposed to MTBI and controls with minor orthopedic injuries from a trauma center and a municipal outpatient clinic, and community controls from the surrounding population. Information on headache was collected through questionnaires at baseline, and 3 and 12 months post-injury. We used a generalized linear mixed model to investigate the development of headache over time in the three groups, and logistic regression to identify predictors of headache.

We included 378 patients exposed to MTBI, 82 trauma controls, and 83 community controls. The MTBI-group had a larger increase in odds of headache from baseline to the first 3 months post-injury than the controls, but not from baseline to 3–12 months post-injury. Predictors for acute HAIH were female sex and pathological imaging findings on computed tomography (CT) or magnetic resonance imaging (MRI). Predictors for persistent HAIH were prior MTBI, being injured under the influence of alcohol, and acute HAIH. Patients who experience HAIH during the first 3 months post-injury have a good chance to improve before 12 months post-injury. Female sex, imaging findings on CT or MRI, prior MTBI, and being injured under the influence of alcohol may predict exacerbation of headache.

Preliminary Use of the Physical and Neurological Examination of Subtle Signs for Detecting Subtle Motor Signs in Adolescents With Sport-Related Concussion

Sensitive examination tools are needed to optimize evaluation after sports-related concussion. The Physical and Neurological Examination of Subtle Signs was preliminarily examined for sensitivity to motor changes in a pilot cohort of adolescents aged 13-17 yrs with sports-related concussion. A total of 15 adolescents (5 female adolescents) with sports-related concussion were evaluated up to three times: within 2 wks of injury, approximately 1 mo later (mean, 35 days between visits), and for those not recovered at the second visit, again after clinical recovery (mean, 70 days between the first and last visits for all participants). Comparison data were acquired from 20 age- and sex-matched healthy control athletes with no history of concussion who were evaluated twice (mean, 32 days apart). Main effects of group, time, and interaction effects were evaluated with an analysis of covariance, which controlled for socioeconomic status, times tested, and days between testing sessions. Adolescents with concussion had poorer Physical and Neurological Examination of Subtle Signs performance than controls did at all time points. Performance improved between visits within the concussion group, with no change within the control group. These findings suggest that the Physical and Neurological Examination of Subtle Signs merits additional study in larger cohorts and in combination with other markers of injury to facilitate an enhanced understanding of sports-related concussion and recovery.

[Pathogenetic aspects of the use of cytoflavine in the treatment of сhronic post-traumatic headache]

AIM

To evaluate the results of using cytoflavin in the treatment of chronic post-traumatic headache and analyze possible mechanisms for implementation of therapeutic effects of the drug.

MATERIAL AND METHODS

The study included 76 patients (23 men and 53 women) aged 29 - 57 years (mean age - 38.2 ± 8.3). All patients received standard basic therapy with simple or combination analgesics. In addition to standard treatment, 36 patients received cytoflavin in the dosage of two tablets twice a day for 30 days. Results and сonclusion. At the beginning, at the end and 25 days after the completion of treatment, the intensity and frequency of headache as well as the severity of asthenic and depressive symptoms were analyzed. As a result of treatment in the cytoflavin group, there was a significant regression of asthenic and depressive symptoms, which was consistent with the previous studies. Positive changes in the indicators analyzed were correlated with the decrease in the frequency of cephalalgia. Since cytoflavin has no analgesic properties, the results are indirect evidence for the significance of psychopathological factors in the pathogenesis of chronic post-traumatic headache.

Post traumatic headache (PTH) in a cohort of UK compensation claimants

AIM

To explore post traumatic headache characteristics and risk factors in compensation claimants by observational retrospective cohort analysis.

CASE RESULTS

Medicolegal reports on 116 consecutive compensation claimants aged 41.9 ± 15.0 years were reviewed 21 ± 14 months after injury. Eighty eight had suffered head and neck injuries, 21 reported only neck injury and seven had "other injuries". Ninety four percent of the head injuries were "mild". The incidence of post traumatic headache following neck injury did not differ from that following head and neck injury, and none of the "other injuries" cases developed post traumatic headache. We anticipated that all head and neck injury claimants would seek compensation for post traumatic headache, but 25% denied developing headache. Post traumatic headache was very strongly correlated with a past history of primary headache ( p < 0.0001) but no other risk factors were identified. Post traumatic headache semiology was consistent with "migraine" or "probable migraine" in 90% of cases. Headache resolved in 30% of claimants between 3 and 24 months after injury but 70% continued to suffer headaches at the time of assessment. Forty one percent of claimants had received no treatment for post traumatic headache in primary care.

CONCLUSIONS

Our data suggest that post traumatic headache is essentially "migraine" provoked by head or neck concussion. It is not clear why so many post traumatic headache sufferers receive poor or inadequate treatment for this condition.

Prevention of post-concussion-like symptoms in patients presenting at the emergency room, early single eye movement desensitization, and reprocessing intervention versus usual care: study protocol for a two-center randomized controlled trial

Background

Recent data suggest that 10–20% of injury patients will suffer for several months after the event from diverse symptoms, generally referred to as post-concussion-like symptoms (PCLS), which will lead to a decline in quality of life. A preliminary randomized control trial suggested that this condition may be induced by the stress experienced during the event or emergency room (ER) stay and can be prevented in up to 75% of patients with a single, early, short eye movement desensitization and reprocessing (EMDR) psychotherapeutic session delivered in the ER.

The protocol of the SOFTER 3 study was designed to compare the impact on 3-month PCLS of early EMDR intervention and usual care in patients presenting at the ER. Secondary outcomes included 3-month post-traumatic stress disorder, 12-month PCLS, self-reported stress at the ER, self-assessed recovery expectation at discharge and 3 months, and self-reported chronic pain at discharge and 3 months.

Methods

This is a two-group, open-label, multicenter, comparative, randomized controlled trial with 3- and 12-month phone follow-up for reports of persisting symptoms (PCLS and post-traumatic stress disorder). Those eligible for inclusion were adults (≥18 years old) presenting at the ER departments of the University Hospital of Bordeaux and University Hospital of Lyon, assessed as being at high risk of PCLS using a three-item scoring rule. The intervention groups were a (1) EMDR Recent Traumatic Episode Protocol intervention performed by a trained psychologist during ER stay or (2) usual care. The number of patients to be enrolled in each group was 223 to evidence a 15% decrease in PCLS prevalence in the EMDR group.

Discussion

In 2012, the year of the last national survey in France, 10.6 million people attended the ER, some of whom did so several times since 18 million visits were recorded in the same year. The SOFTER 3 study therefore addresses a major public health challenge.

Trial registration

Clinical Trials. NCT03400813. Registered 17 January 2018 – retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2902-2) contains supplementary material, which is available to authorized users.

Potential for the development of light therapies in mild traumatic brain injury

Light affects almost all aspects of human physiological functioning, including circadian rhythms, sleep-wake regulation, alertness, cognition and mood. We review the existing relevant literature on the effects of various wavelengths of light on these major domains, particularly as they pertain to recovery from mild traumatic brain injuries. Evidence suggests that light, particularly in the blue wavelengths, has powerful alerting, cognitive and circadian phase shifting properties that could be useful for treatment. Other wavelengths, such as red and green may also have important effects that, if targeted appropriately, might also be useful for facilitating recovery. Despite the known effects of light, more research is needed. We recommend a personalized medicine approach to the use of light therapy as an adjunctive treatment for patients recovering from mild traumatic brain injury.

Emergency room intervention to prevent post concussion-like symptoms and post-traumatic stress disorder. A pilot randomized controlled study of a brief eye movement desensitization and reprocessing intervention versus reassurance or usual care

Up to 20% of patients presenting at an emergency room (ER) after a stressful event will for several months suffer from very diverse long-lasting symptoms and a potentially significant decline in quality of life, often described as post concussion-like symptoms (PCLS). The objectives of our randomized open-label single-center study were to assess the feasibility of psychologist-led interventions in the context of the ER and to compare the effect of eye movement desensitization and reprocessing (EMDR) with reassurance and usual care. Conducted in the ER of Bordeaux University Hospital, the study included patients with a high risk of PCLS randomized in three groups: a 15-min reassurance session, a 60-min session of EMDR, and usual care. Main outcomes were the proportion of interventions that could be carried out and the prevalence of PCSL and post-traumatic stress disorder (PTSD) three months after the ER visit. One hundred and thirty patients with a high risk of PCLS were randomized. No logistic problem or patient refusal was observed. In the EMDR, reassurance and control groups, proportions of patients with PCLS at three months were 18%, 37% and 65% and those with PTSD were 3%, 16% and 19% respectively. The risk ratio for PCLS adjusted for the type of event (injury, non-injury) for the comparison between EMDR and control was 0.36 [95% CI 0.20-0.66]. This is the first randomized controlled trial that shows that a short EMDR intervention is feasible and potentially effective in the context of the ER. The study was registered at ClinicalTrials.gov (NCT03194386).

Posttraumatic Headache: Classification by Symptom-Based Clinical Profiles

There are currently no accepted therapies for posttraumatic headache (PTH). In order to meet the urgent need for effective therapies for PTH, we must continue to address fundamental gaps in our understanding of the clinical course and impact of PTH. Here we examine the existing schema used to characterize the clinical characteristics of PTH, including the International Classification of Headache Disorders (ICHD). There remain unresolved questions about whether to classify patients based on the extent of brain injury or on clinical symptom profiles. There also remain problematic issues of definition such as continuous headache, and chronic daily headache with features of "embedded" migraine-type within these headaches, which will need to be studied further. We make the case that a symptom-based classification is needed to begin an examination of these unresolved questions, and to establish clinically relevant endpoints for research and clinical trials for effective therapies.

Headache following head injury: a population-based longitudinal cohort study (HUNT)

Background

Headache is the most frequent symptom following head injury, but long-term follow-up of headache after head injury entails methodological challenges. In a population-based cohort study, we explored whether subjects hospitalized due to a head injury more often developed a new headache or experienced exacerbation of previously reported headache compared to the surrounding population.

Methods

This population-based historical cohort study included headache data from two large epidemiological surveys performed with an 11-year interval. This was linked with data from hospital records on exposure to head injury occurring between the health surveys. Participants in the surveys who had not been hospitalized because of a head injury comprised the control group. The head injuries were classified according to the Head Injury Severity Scale (HISS). Multinomial logistic regression was performed to investigate the association between head injury and new headache or exacerbation of pre-existing headache in a population with known pre-injury headache status, controlling for potential confounders.

Results

The exposed group consisted of 294 individuals and the control group of 25,662 individuals. In multivariate analyses, adjusting for age, sex, anxiety, depression, education level, smoking and alcohol use, mild head injury increased the risk of new onset headache suffering (OR 1.74, 95% CI 1.05–2.87), stable headache suffering (OR 1.70, 95% CI 1.15–2.50) and exacerbation of previously reported headache (OR 1.93, 95% CI 1.24–3.02). The reference category was participants without headache in both surveys.

Conclusion

Individuals hospitalized due to a head injury were more likely to have new onset and worsening of pre-existing headache and persistent headache, compared to the surrounding general population. The results support the entity of the ICHD-3 beta diagnosis “persistent headache attributed to traumatic injury to the head”.

Impact of Body Mass Index on Postconcussion Symptoms in Teenagers Aged 13 to 18 Years

CONTEXT

Adolescent obesity and sports-related concussion are rising in prevalence, yet there is minimal research exploring the relationship between these two conditions.

OBJECTIVE

To assess the impact of body mass index (BMI) percentile on duration of recovery and reported symptoms after sports-related concussion in adolescents.

DESIGN

Retrospective chart review at a regional concussion program located at an academic medical center. Medical records of all patients aged 13 to 18 years treated from March 2006 through January 2012 were reviewed. Two hundred fifty-two patients met the inclusion criteria of sports-related concussion and having BMI data.

MAIN OUTCOME MEASURES

Outcome variables included reported emotional symptoms, sleep-related symptoms, physical symptoms (headache), and time to recovery after a concussion. Explanatory variables in this analysis were BMI percentile and sex.

RESULTS

More male patients were obese and overweight than were females (42% vs 27%, p = 0.02). There was no statistically significant difference in recovery time between obese and overweight patients and others. Obese and overweight patients were more likely than healthy-weight patients to report symptoms of irritability (p = 0.05) and impulsivity (p = 0.01), and less likely to report headache (p = 0.03).

CONCLUSION

After concussion, irritability and impulsivity may be more likely than headaches in overweight and obese patients. There was no difference in recovery time between obese and healthy-weight teens. These findings may have importance in the evaluation, treatment, and anticipatory guidance of patients with concussions.

Post-Concussive Syndrome: a Focus on Post-Traumatic Headache and Related Cognitive, Psychiatric, and Sleep Issues

PURPOSE OF REVIEW

Post-traumatic headache (PTH) is a secondary headache disorder following traumatic brain injury. We sought to examine the recent literature on PTH and associated cognitive, psychiatric, and sleep conditions to understand the latest findings about the associated conditions and available screening tools, and to understand the available treatment options for PTH.

RECENT FINDINGS

Up to one third of PTH patients may have depression and about one quarter may have insomnia. Anxiety and cognitive issues are also common. While there are few studies examining abortive medications for PTH, recent studies of preventive medications examine the efficacy of topiramate, and topiramate may be better than other oral preventive medications. Other currently investigated treatments include nerve blocks, onabotulinum toxin A, transmagnetic stimulation, and behavioral therapy (biofeedback). Due to an expanded focus on and knowledge of concussion and PTH, comorbid psychiatric, cognitive, and sleep issues have become more widely acknowledged and studied. However, more high-quality studies must be conducted to examine the underlying pathophysiology of PTH and associated symptoms and to determine the most effective abortive and preventive treatment options.

Associations Between Traumatic Brain Injury History and Future Headache Severity in Veterans: A Longitudinal Study

OBJECTIVE

To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes.

DESIGN

Prospective cohort study.

SETTING

Department of Veterans Affairs (VA) outpatient clinics.

PARTICIPANTS

Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders.

RESULTS

Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (β [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (β [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (β [SE]=.66 [.09], P<.001) and longitudinal analyses (β [SE]=.18 [.09], P=.04).

CONCLUSIONS

Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache.

Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review

Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.

Headaches in patients with previous head injuries: A population-based historical cohort study (HUNT)

Background Headache attributed to head injury is claimed to be among the most common secondary headache disorders, yet available epidemiological evidence is scarce. We evaluated the prevalence of headache among individuals previously exposed to head injury by a comparison to an uninjured control group. Methods This population-based historical cohort study used data from hospital records on previous exposure to head injury linked to a large epidemiological survey with data on headache occurrence. Participants without head injury, according to hospital records, were used as controls. The head injuries were classified according to the Head Injury Severity Scale (HISS) and the International Classification of Headache Disorders (ICHD-3 beta). Binary logistic regression was performed to investigate the association between headache and head injury, controlling for potential confounders. Results The exposed group consisted of 940 individuals and the control group of 38,751 individuals. In the multivariate analyses, adjusting for age, sex, anxiety, depression and socioeconomic status, there were significant associations between mild head injury and any headache, migraine, chronic daily headache and medication overuse headache. Conclusion Headache was more likely among individuals previously referred to a hospital for a mild head injury compared to uninjured controls.

Headache Prevalence at 4-11 Years After Deployment-Related Traumatic Brain Injury in Veterans of Iraq and Afghanistan Wars and Comparison to Controls: A Matched Case-Controlled Study

OBJECTIVE

Evaluate the extent and severity of headache following deployment-related TBI (D-TBI) in veterans of the Iraq (OIF) and Afghanistan (OEF) wars over a follow-up period of 4-11 years with comparison to age, sex, race, and time of deployment matched controls.

BACKGROUND

TBI has been recognized as the "signature Injury" of the OEF/OIF campaigns occurring in 14-20% of deployed soldiers. Currently, there are very few data on the longer term follow-up of soldiers with D-TBI. This study deals with prevalence and severity of headache and headache burden at 4-11 years following D-TBI for OEF/OIF veterans with comparison to controls without D-TBI.

METHODS

This is a matched case controlled-study. All subjects were recruited from Operation New Dawn (OND), a voluntary program for OEF/OIF Veterans at the Oklahoma VAMC designed to assist with re-integrating into civilian life. On entry into OND a medical questionnaire was administered that included a brief screen for D-TBI, and those with a possible D-TBI were referred to a TBI clinic, For this study, the first 500 TBI clinic patients who were found to have had a D-TBI (TBIS) were matched by age, sex, race, and time of deployment to control subjects (CS), drawn from the 4411 OND program members with no D-TBI, creating a pool of 500 TBIS/CS pairs. From this pool, 55 pairs (11%) were randomly selected for this study. Data were collected from both TBIS and CS by telephone interview with questionnaires regarding the DTBI, headache, depression, and PTSD. TBI severity was measured by duration of loss of consciousness (LOC) as: [a] Very Mild (VMTBI, dazed only, no LOC), [b] Mild (MTBI, LOC 1-30 minutes), and [c] Moderate-Severe (MSTBI, LOC > 30 minutes). Intensity for individual headaches was measured by disability produced by the headache as: [a] Disabling (must be in bed), [b] Severe (50-90% decrease in activity), or [c] Mild-Moderate (>50% of usual activity possible). Statistical analysis employed Fisher's exact test and odds ratio.

RESULTS

The 55 TBIS/CS pairs were segregated by severity of TBI for the TBIS. For the TBIS there were no significant differences among these three subgroups as to mechanism producing the TBI (blast injury or direct head trauma). Comparing TBIS vs CS for phenotypic classification of headaches, for TBIS - 89% had migraine, 2% probable migraine, 9% had tension, and 0% had no headaches, while for CS - 36% had migraine, 15% probable migraine, 27% tension, and 22% no headache (P < .0001). Migraine with aura occurred in 38% of TBIS and 6% of CS (P < .0001). As to headache frequency, for TBIS - chronic daily headache (CDH) occurred in 44%, frequent headache in 33%, and infrequent or no headache in 23%, while for CS - CDH occurred in 7%, frequent headache in 13%, and infrequent or no headache in 80% (P < .0001). For TBIS, 54% had severe or disabling headache ≥2 days/week as opposed to only 16% of CS (OR 6.13 [2.5-14.9]). As to onset of most severe and frequent headaches, this occurred shortly after TBI in 89% of TBIS while only 27% of CS reported most severe headaches starting during deployment. There was no correlation of severity of headache problem with severity of TBI. Comparing TBIS at 4-7 vs 8-11 years after injury, there was no difference in frequency or severity of headache between these groups.

CONCLUSIONS

At 4-11 years after D-TBI for TBIS, or after deployment for CS, the TBIS as compared to CS suffered much more frequent and severe headaches. For TBIS, there was no relation of headache intensity or phenotype to severity or cause of the TBI, and the Headache Burden has not improved over time up to 11 years after D-TBI. The process initiated by the D-TBI that relates to the headache has a prolonged effect up to and beyond 11 years.

The gaming of concussions: a unique intervention in postconcussion syndrome

OBJECTIVE

To present the case of 2 adolescent high school student-athletes who developed postconcussion syndrome with protracted and limiting visual complaints that markedly affected academic, social, and athletic activity for a year after the onset of symptoms. Both had significant improvement soon after a unique intervention was administered.

BACKGROUND

A 14-year-old female soccer and softball player sustained 2 concussions in the same week. She had persistent symptoms for a year that affected her grades and precluded athletic participation. A 15-year-old male football player sustained a concussion during an altercation with 2 other male adolescents. He continued to have symptoms 1 year later, with a marked decrease in academic performance and restriction from athletics. Both adolescents reported blurry vision, photophobia, and associated headache as significant components of the postconcussion syndrome.

DIFFERENTIAL DIAGNOSIS

Concussion, postconcussion syndrome, skull fracture, subdural hematoma, epidural hematoma, second-impact syndrome, and visually sensitive migraine.

TREATMENT

Both patients were advised to obtain computer gaming glasses to use throughout the day. The female patient was diligent in her use of the glasses, with marked lessening of symptoms. The male patient was less accepting of the glasses but did report lessening of symptoms when using the glasses.

UNIQUENESS

We hypothesized that postconcussion syndrome with marked visual complaints would respond to and improve with decreased stimulation of the visual system. This was attempted with the addition of computer gaming glasses. Both adolescent athletes responded well to the filtering of visual stimuli by off-the-shelf computer gaming glasses.

CONCLUSIONS

Postconcussion syndrome is a persistent condition with a myriad of symptoms. Two young athletes developed postconcussion syndrome with prominent visual symptoms that lasted a year. The addition of computer gaming glasses markedly lessened symptoms in both patients.

Characteristics of posttraumatic headache following mild traumatic brain injury in military personnel in Iran

OBJECTIVES

The primary goal of this study was to evaluate the incidence and characteristics of posttraumatic headache attributed to mild brain injury in military personnel in Iran within a prospective and observational study design.

METHODS

A prospective observational descriptive study was conducted with a cohort of military personnel under military education during a 6-month period at the Military Education Center in Isfahan, Iran. 322 military personnel under education were selected randomly and were given a 13-item mild brain injury questionnaire accompanied with affective disorders and headache questionnaires and were reevaluated after a 3-month interval.

RESULTS

A total of 30 (9.3 %) of the 322 military personnel met criteria for a mild brain injury. Among them, 18 personnel (60 %) reported having headaches during the 3-month reevaluation. PTHs defined as headaches beginning within 1 week after a head trauma were present in 5.6 % of military personnel under study during 6 months. In total, 67 % of posttraumatic headaches (PTH) were classified as migrainous or possible migrainous features. Patients with affective disorders such as posttraumatic stress disorder and depression were at a higher risk for developing PTH following mild brain injury (p < 0.05). PTH did not relate to demographic factors such as age or type of trauma.

CONCLUSIONS

Posttraumatic headache attributed to mild brain injury is a common disorder in military personnel. Migrainous features are predominant among them in comparison with the general population. PTH is not related to a type of trauma, but has association with affective disorders.

Post-traumatic headaches in civilians and military personnel: a comparative, clinical review

Post-traumatic headache (PTH) is the most frequent symptom after traumatic brain injury (TBI). We review the epidemiology and characterization of PTH in military and civilian settings. PTH appears to be more likely to develop following mild TBI (concussion) compared with moderate or severe TBI. PTH often clinically resembles primary headache disorders, usually migraine. For migraine-like PTH, individuals who had the most severe headache pain had the highest headache frequencies. Based on studies to date in both civilian and military settings, we recommend changes to the current definition of PTH. Anxiety disorders such as post-traumatic stress disorder (PTSD) are frequently associated with TBI, especially in military populations and in combat settings. PTSD can complicate treatment of PTH as a comorbid condition of post-concussion syndrome. PTH should not be treated as an isolated condition. Comorbid conditions such as PTSD and sleep disturbances also need to be treated. Double-blind placebo-controlled trials in PTH population are necessary to see whether similar phenotypes in the primary headache disorders and PTH will respond similarly to treatment. Until blinded treatment trials are completed, we suggest that, when possible, PTH be treated as one would treat the primary headache disorder(s) that the PTH most closely resembles.

Posttraumatic headaches in civilians, soldiers, and athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After mild head injury, more than 50% of people develop a postconcussion syndrome which has been controversial for more than 150 years. Headache is estimated as present in 30% to 90% of patients after mild head injury. Most headaches are of the tension type, although migraines can increase in frequency or occur acutely or chronically de novo. A review is provided of headaches in civilians, soldiers after blast trauma, athletes, and post-craniotomy including pathogenesis. The treatments are the same as for the primary phenotypes.

A prospective study of prevalence and characterization of headache following mild traumatic brain injury

BACKGROUND

Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI).

METHODS

We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache.

RESULTS

Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods.

CONCLUSIONS

Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.

Treatment of mild traumatic brain injury by epidural saline and oxygen injection: report of two cases

Mild traumatic brain injury (mTBI) is a common complication of minor head injury and a serious problem in the Iraq war returnees. Effective treatment is not yet available. We have treated 23 patients with chronic post-traumatic headache by epidural saline and oxygen injection (ESOI) with efficacy of 96 %. Among them, ten cases were cured. Two out of these cured cases fulfilled the criteria of mTBI and their improvement were objectively demonstrated by a TriIRIS C9000 (Hamamatsu Photonics K.K.) that can monitor the accommodation and convergence function simultaneously. We show the treatment protocol of ESOI and the clinical courses of the two cases in this paper. Both had symptoms somewhat similar to those of spontaneous intracranial hypotension. However, their intracranial pressure was not low and their symptoms were relieved immediately after removal of cerebrospinal fluid (CSF). Although symptoms of mTBI are believed to be attributed to brain damage, some symptoms may not be derived from brain damage itself, but from CSF circulation abnormalities. This is the first report of successfully treated mTBI by ESOI. The effectiveness of the treatment can be verified objectively by monitoring eye function. The outcome suggests that war returnees with mTBI can be treated -successfully by ESOI.

Cerebrospinal fluid volume–depletion headaches in patients with traumatic brachial plexus injury

Object

Patients with brachial plexus injury (BPI) present with a combination of motor weakness/paralysis, sensory deficits, and pain. Brachial plexus injury is generally not believed to be associated with headaches. However, CSF leaks may be associated with CSF volume–depletion (low-pressure) headaches and can occur in BPI secondary to nerve root avulsion. Only a few cases of headaches associated with BPI have been reported. It is unknown if headaches in patients with BPI occur so rarely, or if they are just unrecognized by physicians and/or patients in which the focus of attention is the affected limb. The aim of this study was to determine the prevalence of CSF volume–depletion headaches in patients with BPI.

Methods

All adult patients presenting at the Mayo brachial plexus clinic with traumatic BPI were asked to complete a questionnaire addressing the presence and quality of headaches following their injury. The patients' clinical, injury, and imaging characteristics were subsequently reviewed.

Results

Between December 2008 and July 2010, 145 patients completed the questionnaire. Twenty-two patients reported new onset headaches occurring after their BPI. Eight of these patients experienced positional headaches, suggestive of CSF volume depletion. One of the patients with orthostatic headaches was excluded because the headaches immediately followed a lumbar puncture for a myelogram. Six of the other 7 patients with positional headaches had a clear preganglionic BPI. The available imaging studies in these 6 patients revealed evidence of CSF leaks: pseudomeningoceles (n = 5), CSF tracking into soft tissues (n = 3), CSF tracking into the intraspinal compartment (n = 3), CSF tracking into the pleural space (n = 2), and low-positioned cerebellar tonsils (n = 2).

Conclusions

In this retrospective study, 15.2% of patients (22 of 145 patients) with traumatic BPI suffered from a new-onset headache. Seven of these patients (4.8%) experienced postural headaches clearly suggestive of CSF volume depletion likely secondary to a CSF leak associated with the BPI, whereas the other 15 patients (10.3%) suffered headaches that may have represented a variant of CSF depletion headaches without a postural characteristic or a headache from another cause. These data suggest that CSF volume–depletion headaches occur in a significant proportion of patients with BPI and have been underrecognized and underreported.

Posttraumatic headache

Headache is a common symptom after traumatic head injury and is a frequent feature of the postconcussive syndrome. A variety of headache subtypes can be precipitated by head trauma, although posttraumatic headaches most often resemble migraine or tension-type headache. A lack of clinical trials limits evidence-based treatment recommendations for both acute and chronic posttraumatic headaches. However, numerous pharmacologic and nonpharmacologic interventions can be used to successfully manage posttraumatic headaches. This article reviews the classification, epidemiology, prognosis, and pathophysiology of headaches after head trauma and provides a practical clinical approach for evaluating and treating patients with posttraumatic headaches.

Posttraumatic headache in military personnel and veterans of the iraq and afghanistan conflicts

OPINION STATEMENT

Headaches, particularly migraine, are common in US servicemembers (SMs) who are deployed to or have returned from theaters of combat operations in Iraq and Afghanistan. Concussions and exposure to explosive blasts may be a significant contributor to the increased prevalence of headaches in military veterans. Concussions, usually due to blast exposure, occur in approximately 20% of deployed SMs, and headaches are a common symptom after a deployment-related concussion. Posttraumatic headaches (PTHAs) in US SMs usually resemble migraines, and posttraumatic stress disorder (PTSD) and depression are common comorbidities. Treatment of PTHAs in SMs is based upon the treatment setting, whether the headaches are acute or chronic, the headache phenotype, and associated comorbidities. No randomized, controlled clinical trials evaluating the efficacy of therapies for PTHAs have been completed. Pharmacologic and nonpharmacologic management strategies should be selected on an individual basis. Acute therapy with NSAIDs or triptans and prophylactic therapy in acute and chronic settings using valproate, nortriptyline, amitriptyline, propranolol, topiramate, or botulinum toxin are discussed. Triptans and topiramate may be particularly effective in SMs with PTHA. Management of PTHA and other features of the posttraumatic syndrome should be multidisciplinary whenever possible.

Pediatric posttraumatic headache: two cases using steroids as abortive therapy

Pediatric traumatic brain injury is a common occurrence, and even an ostensibly mild injury may result in disabling posttraumatic headaches. The headache may result in a number of subsequent unremitting symptoms refractory to many standard headache therapies. Current treatment recommendations are sparse because there is a lack of clinical trial data recommendations and outcomes. From these 2 cases, we report the effectiveness of steroids for severe posttraumatic headache, along with recommended treatment strategies for acute pain management and prevention.

Characterization of headache after traumatic brain injury

BACKGROUND

Headache is a common and persistent symptom following traumatic brain injury (TBI). Headaches following TBI are defined primarily by their temporal association to injury, but have no defining clinical features. To provide a framework for treatment, primary headache symptoms were used to characterize headache.

METHODS

Three hundred and seventy-eight participants were prospectively enrolled during acute in-patient rehabilitation for TBI. Headaches were classified into migraine/probable migraine, tension-type, or cervicogenic headache at baseline and 3, 6, and 12 months following TBI.

RESULTS

Migraine was the most frequent headache type occurring in up to 38% of participants who reported headaches. Probable migraine occurred in up to 25%, tension-type headache in up to 21%, then cervicogenic headache in up to 10%. Females were more likely to have endorsed pre-injury migraine than males, and had migraine or probable migraine at all time points after injury. Those classified with migraine were more likely to have frequent headaches.

CONCLUSIONS

Our data show that most headache after TBI may be classified using primary headache criteria. Migraine/probable migraine described the majority of headache after TBI across one year post-injury. Using symptom-based criteria for headache following TBI can serve as a framework from which to provide evidence-based treatment for these frequent, severe, and persistent headaches.

Characteristics of acute posttraumatic headache following mild head injury

BACKGROUND

To examine the prevalence and characteristics of acute posttraumatic headache (APTH) attributed to mild head injury within a prospective, observational study design.

METHODS

We recruited 100 patients with acute mild head injury as defined in the International Classification of Headache Disorders, 2nd Edition (ICHD-2) presenting to the department of trauma surgery at the Medical University of Vienna. Patients underwent a detailed telephone interview between days 7 and 10 and between days 90 and 100 after the injury.

RESULTS

The prevalence of APTH was 66%. APTH had occurred within 24 hours after the trauma in 78% and lasted for a median of 3.0 days. Headache was unilateral in 45%. Aggravation by physical activity, nausea and photo-/phonophobia was present in 49%, 42% and 55%, respectively. The prevalence of APTH was related to conditions of chronic pain (excluding headache), pre-existing episodic headache, number of posttraumatic symptoms, anxiety and depression. At follow-up at 90-100 days, posttraumatic headache had abated in all patients.

CONCLUSIONS

APTH attributed to mild head injury is a common but self-limiting condition frequently showing migrainous features. Participants with chronic pain other than headache, pre-existing headache and affective disorders are at higher risk of developing APTH. None of the patients developed chronic posttraumatic headache.

Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study

BACKGROUND

he effectiveness of medical therapies for chronic post-traumatic headaches (PTHs) attributable to mild head trauma in military troops has not been established.

OBJECTIVE

To determine the treatment outcomes of acute and prophylactic medical therapies prescribed for chronic PTHs after mild head trauma in US Army soldiers.

METHODS

A retrospective cohort study was conducted with 100 soldiers undergoing treatment for chronic PTH at a single US Army neurology clinic. Headache frequency and Migraine Disability Assessment (MIDAS) scores were determined at the initial clinic visit and then again by phone 3 months after starting headache prophylactic medication. Response rates of headache abortive medications were also determined. Treatment outcomes were compared between subjects with blast-related PTH and non-blast PTH.

RESULTS

Ninety-nine of 100 subjects were male. Seventy-seven of 100 subjects had blast PTH and 23/100 subjects had non-blast PTH. Headache characteristics were similar for blast PTH and non-blast PTH with 96% and 95%, respectively, resembling migraine. Headache frequency among all PTH subjects decreased from 17.1 days/month at baseline to 14.5 days/month at follow-up (P = .009). Headache frequency decreased by 41% among non-blast PTH compared to 9% among blast PTH. Fifty-seven percent of non-blast PTH subjects had a 50% or greater decline in headache frequency compared to 29% of blast PTH subjects (P =.023). A significant decline in headache frequency occurred in subjects treated with topiramate (n = 29, -23%, P = .02) but not among those treated with a low-dose tricyclic antidepressant (n = 48, -12%, P = .23). Seventy percent of PTH subjects who used a triptan class medication experienced reliable headache relief within 2 hours compared to 42% of subjects using other headache abortive medications (P = .01). Triptan medications were effective for both blast PTH and non-blast PTH (66% response rate vs 86% response rate, respectively; P = .20). Headache-related disability, as measured by mean MIDAS scores, declined by 57% among all PTH subjects with no significant difference between blast PTH (-56%) and non-blast PTH (-61%).

CONCLUSIONS

Triptan class medications are usually effective for aborting headaches in military troops with chronic PTH attributed to a concussion from a blast injury or non-blast injury. Topiramate appears to be an effective headache prophylactic therapy in military troops with chronic PTH, whereas low doses of tricyclic antidepressants appear to have little efficacy. Chronic PTH triggered by a blast injury may be less responsive to commonly prescribed headache prophylactic medications compared to non-blast PTH. These conclusions require validation by prospective, controlled clinical trials.

Post-traumatic headache: is it for real? Crossfire debates on headache: pro

Mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Even though between 30% and 90% of patients develop post-traumatic headache, post-traumatic headache remains a very controversial disorder. Particularly when it comes to chronic post-traumatic headache following mild closed head injury and headache attributed to whiplash injury. Some experts are disputing its existence as a genuine disorder. Indistinct disease classification, unresolved pathophysiological mechanism, and the role of accident-related legal issues further fuel this controversy. The complex combination of pain and neuropsychological symptoms needs further research in understanding the underlying pathophysiological mechanisms associated with the acute headache following trauma but more so the mechanisms associated with the development of chronic pain in some patients. Investigators should refrain from oversimplifying these complex mechanisms as hysteric exaggeration of everyday complains and from implying greed as motivation for this potentially very disabling disease.