Introduction
Concussion and mild traumatic brain injury (TBI) are very common in pediatrics, and headache is one of the most common and most troubling symptoms following head injury. Persistent posttraumatic headaches (PTH) can also be one of the most challenging headache syndromes to manage. This is a relatively new area of research, and there are few studies to help us determine which treatments are most likely to be effective for a particular child. In this chapter, we will review the current definitions and risk factors for PTH in children and teens. We will discuss PTH in a step-wise manner; (a) a section to help families understand PTH and what they can do to manage these headaches, (b) information that can be used in a primary care setting, and (c) more detailed information that a headache specialist may consider when headaches are disabling and persistent for weeks or months following injury. This chapter will discuss the subacute and chronic phases of PTH. The acute management of concussion and TBI on the sidelines or in the ED, is outside the scope of this book, but the CDC has many resources on this topic on their website, www.cdc.gov/traumaticbraininjury/index.html .
Information about posttraumatic headache for families
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How does posttraumatic headache happen? The mechanisms that lead to headache after trauma are complicated and multifactorial. There is still a lot that medical professionals do not understand about concussion, and persisting symptoms like headache. Head trauma can trigger a cascade of problematic events that include an inflammatory response, and changes in how the nerve cells function and communicate with each other. These initial changes are irritating to the brain and nerves in the head and neck and frequently lead to the perception of pain in the head, or headache. The brain gets to work healing these changes as soon as they happen. However, it often takes weeks for this to occur, which is why the symptoms of concussion may take weeks to resolve. In a subset of people, the healing process does not shut down the pain signals that were initially triggered by the head injury. We believe that for people with prolonged headache after concussion, nerve cells may communicate differently than before the concussion, and the brain can become rewired so that pain becomes the new “normal.” The pain system continues to act as though there is an irritant or ongoing injury even after the irritant (concussion) is resolved and there is no ongoing injury. The brain learns pain, and this can lead to headaches that continue well after the concussion has resolved.
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Steps to feeling better: Initially after a concussion it is important to rest and recover. Good initial concussion care does require meeting with your health care provider, taking frequent breaks, pacing during cognitive activity, and avoiding high-risk contact activities. Most kids with concussion will recover back to normal within 1–2 weeks. However, if symptoms continue for several weeks, continued withdrawal from school and physical activity can cause more harm than good. The more we learn about concussion, the more we learn how important return to physical activity can be, in concussion recovery. If you were an athlete before your concussion, it is helpful to start returning to a routine of regular exercise (without risk of head trauma), starting with light activities that don’t make your symptoms worse, and slowly increasing your activity over time. If your headaches are significantly worsened by physical activity, you may need to build up slowly and recondition yourself, particularly if you have not been doing much physical activity for a long time. It may be helpful to work together with a trainer or physical therapist who knows about “subthreshold exercise” training as a treatment for concussion. You may need to adjust your activity to accommodate your headaches, including avoiding activities with a lot of bouncing. Often running can trigger or worsen headaches, so activities like stationary bike riding and swimming are easier to start with.
It is also important to take care of your body and avoid activities that are known to worsen headaches. You can read the chapters on healthy habits for migraine management for more detail. In brief: get enough sleep, hydrate, eat well, and take care of your emotional health. Children and teenagers are often sleep deprived. It is important to know how much sleep you need at your age, and to try your best to get it. It is important to stay well hydrated and it is important to eat regularly throughout the day with protein and healthy snacks.
It can be very difficult to adjust to the effects that concussion and headache can have on your life. It’s hard because you go from feeling healthy and active, to feeling miserable and experiencing a lot of pain and other symptoms overnight. In addition, concussion cannot be seen by other people. It is easy to identify and care for someone who has a broken leg and needs a cast and crutches. However, there are no outward signs that you are suffering with concussion and posttraumatic headache. You are not alone, but it may feel like it. Posttraumatic headache can make you feel powerless over your body. Talking about how all of this makes you feel and starting to find ways to make yourself feel more powerful and in control of your body and feelings can be very important in recovering and learning to live with the new symptoms. Having someone to help you with this is very important. Consider reaching out to a therapist in your area that can help you with this process.
As you are recovering, it is important to be realistic with your activities. As you learn to adjust to how you feel, you may not be able to take all of the classes you want to take or do all the after school activities you want to do right away. While you learn how to manage your symptoms, you have to give yourself time. You are going to need extra time to take care of yourself because you need time for sleep, exercise, and going to additional doctor’s appointments or therapy appointments. If you don’t give yourself this time, and instead fill it with honors classes and other clubs, you are not giving your body what it needs and you are likely to prolong your symptoms. You may need to have a period of months or even a school year where you shift your priorities. That doesn’t mean you will not be able to return to other activities or classes in the future but taking this time will allow you to recovery more fully and with a greater chance of success. However, it is equally important to continue with some of the things that are important to you, as we know that curling up in a ball on the couch in a dark room and stopping all normal activity will actually make symptoms last longer.
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How to navigate school : Returning to school for a full day when you are suffering with headaches can be very difficult. There are many things in the school environment that make headaches worse-it is loud, bright, and you are there for long hours. However, returning to school as normally and regularly as possible, will ultimately help your symptoms improve and get you back to doing the things you need and want to do. There are going to be days that you really don’t feel well, and it may be necessary to skip a few hours or the full day. If this occurs with high frequency, though, you will fall behind and get out of your routine, which is worse overall for your headaches. It is helpful to have some tricks, for the time when you don’t feel well in school, that can help you feel better and allow you to return to class without having to go home. Sometimes having rest periods built into the day can be helpful. Having some treatments to use at the nurse’s office like cool compresses, a dark resting spot, meditation, as well as medication can also be beneficial. You may need adjustments in your schoolwork on days when you don’t feel well to help allow the additional rest needed. Overall, it is important to speak with your school about the symptoms you are still having and what types of activities might make them worse. It is helpful to have an agreement with the school about certain accommodations you may need, usually done with a 504 plan. If your school is not familiar with options for management of school work after concussion, the CDC “Heads Up” concussion program has on-line resources everyone can access and use. ( www.cdc.gov/headsup/ .)
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Long term prognosis . While the majority of people recover within 3 months after concussion, there are people who continue to have headaches long after sustaining a concussion. Even these people can ultimately get better, even after a year or more. It is best to plan for the worst and hope for the best. There are many techniques available to help manage headaches that range from different lifestyle measures, alternative therapies, and medication. Speak with your doctor about what is right for you. There is no reason to suffer with headaches for months or years waiting for them to resolve. The longer your brain spends with pain, the more it gets used to it. Intervening with these therapies will not prolong recovery and may in fact speed up the resolution of the headaches; and if it doesn’t, and you continue to have headaches, you will learn more quickly about how to cope with them and return to your life where you are in control.
Information for primary care clinicians
What is “posttraumatic headache”?
The CDC defines a TBI as “disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.” The formal definition of PTH by the International Classification of Headache Disorders-3 is a headache that develops within 7 days of TBI that is not “better accounted for by another diagnosis.” The headache that occurs after a TBI can have many different characteristics, including migrainous (accompanied by photophobia, phonophobia, nausea, vomiting), tension type symptoms, or occipital neuralgia, but PTHs may also be more difficult to characterize than primary headache syndromes. PTH is also often associated with other postconcussion symptoms including mood changes, problems with balance, sleep disturbance, and cognitive changes. These other concussion symptoms may also exacerbate headache frequency and severity, which can complicate the management of PTH.
It can be helpful to attempt to determine if the PTH fits into a “subclass” of headache using ICHD-3 criteria. Almost all the primary headache syndrome phenotypes, migraine, tension, cluster, primary stabbing headaches have been described after head trauma. The majority of PTH in children meet criteria for migraine. In addition, identifying migrainous phenotype in a patient can aid in prognostication. Patients with migrainous PTH often have more symptoms from the concussion, including lower cognitive scores and poorer balance on testing, and thus greater disability. Interestingly, cervicogenic headache is more common in PTH patients, seen in up to 20%, than in the general pediatric headache population, which is not surprising given the likelihood of neck trauma or whiplash associated with mild TBI.
Most children who sustain a concussion will recover to baseline within a few weeks without significant sequelae, and this information is vital for the child and their family to understand. However, some will develop symptoms that can persist for weeks or months, which can cause significant disability, loss of school time and loss of participation in sports and other extracurricular activities.
Red flags : Most children with concussion do not need neuroimaging or other tests. There are well established guidelines regarding when neuroimaging should be considered immediately following TBI, this includes those with some combination of the following risk factors:
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Age younger than 2 years
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Vomiting
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Loss of consciousness
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Severe mechanism of injury
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Severe or worsening headache
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Amnesia
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Nonfrontal scalp hematoma
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Glasgow Coma Scale score less than 15
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Clinical suspicion for skull fracture
In addition, providers may consider neuroimaging, with MRI or CT scan, or other testing, if the child has increasing headaches, new neurological symptoms, new severe headache greater than a week after injury, or symptoms of another disorder that could be causing headaches.
Pathophysiology of PTH
There is little that we understand definitively about the pathophysiology of PTH. Given the high proportion of patients with a migrainous phenotype to their PTH, as well as the efficacy of several medications used typically in migraine, it is likely that the trigeminovascular system is involved in the generation of PTH. The effect of a traumatic injury on the brain may be like the effect of cortical spreading depression (one of the mechanisms of migraine activation) on the brain. Both entities lead to ionic changes, excessive neurotransmitter/neuropeptide release, inflammatory cytokine release, cerebral metabolic changes and mismatch with neurovascular supply, and disruption of the blood brain barrier. It is unclear if TBI triggers cortical spreading depression or has similar effects on the brain, but the outcome seems to trigger the same final pathway. Functional imaging studies have shown changes in metabolism and cerebral blood flow that can persist for weeks and even months after concussive injury, so this may be another potential cause of PTH. In addition, the action of neuropeptides that are involved in migraine, like CGRP and PACAP, are altered after head injury in animal models. This offers exciting therapeutic targets for PTH given the recent approval of CGRP antibodies treatments and CGRP antagonists. The influence of the cervical nerve roots on the trigeminocervical complex may also contribute to the pathophysiology of PTH. Like migraine, there are many different pathways involved in the generation of PTH and hypothalamic/thalamic and higher cortical centers in pain amplification and maintenance, likely have a role.
Risk factors : Several factors have been associated with prolonged recovery from concussion, these include female sex, adolescent age, high number of symptoms immediately following concussion, migrainous symptoms following concussion, diagnosis of migraine or mental health problems prior to injury, and prior concussion with persistent symptoms. There are few studies of pediatric PTH specifically, but it appears that the risk factors for persistent PTH are similar to those for persistent symptoms following concussion overall. While it may seem that those with more severe brain injury would be at higher risk for prolonged or severe PTH, this does not appear to be true. In fact, those with moderate or severe TBI may have a lower risk of PTH than those with mild TBI, and neither loss of consciousness nor amnesia has been consistently associated with the risk of persistent symptoms or headache following TBI. Thus, for concussed individuals with PTH who have several of the risk factors noted above, one may consider early intervention for PTH following concussion to optimize headache management with little risk. This would include working on appropriate sleep, return to appropriate low-risk exercise, adequate hydration, and acute pain management (see Chapter 21, Chapter 22, Chapter 23 ), and then perhaps starting a low risk preventive treatment if headaches don’t improve after a few weeks of conservative management. Mental health problems should also be addressed as part of the treatment process.
Evaluation : The initial evaluation of a child with PTH should include assessment of headaches and other symptoms, including mental and physical health issues, which were present prior to injury. After assessing premorbid conditions, then proceed to the injury history to understand how the injury occurred, what symptoms and disabilities were present immediately following the concussion, and how symptoms have changed since the injury. It is also important to learn what the patient and their family are most worried about, as they may have concerns that are unanticipated, and if these are not discussed, it will be difficult to provide satisfactory treatment. The exam should include vital signs, (including orthostatic HR and BP if there are complaints of orthostatic intolerance), palpation and movement of the head and neck (looking for any focal tenderness or signs of neuropathic pain), fundoscopic exam, and a neurological exam, looking for evidence of asymmetry, abnormal eye movements, balance problems, or other new deficits. If there are new focal deficits, or if headaches are increasing over time, neuroimaging should be considered. If there are signs of other systemic illness that could be contributing to headaches, these potential diagnoses should be worked up as appropriate.
Initial management : Once the initial evaluation is complete and you have determined that your patient has PTH, rather than another primary or secondary headache syndrome, one can go forward with active headache management. Unfortunately, there is very little data on the ideal management of PTH for adults or children. The most typical approach to managing PTH is to use interventions appropriate to the “headache phenotype.” In addition, it has become clear that prolonged, complete rest following a simple concussion is not beneficial, and actually has been associated with prolonged recovery. Most individuals with PTH should begin “active recovery” or “subthreshold exercise,” low-level aerobic exercise that does not exacerbate symptoms, sometime in the first week or two following injury. In a formal subthreshold exercise program, patients complete a graded aerobic treadmill test to identify the level of exertion that provokes symptom worsening, and then they participate in a program that promotes exertion at 80% of the maximum heart rate achieved. Ideally, they will do this subthreshold exercise regime 5–7 days/week using a heart rate monitor, often supervised by a physical therapist who can help to advance exercise time and intensity as appropriate. In trials, after treatment for 3 weeks, patients reported improved symptoms as well as improvement in peak heart rate without symptom exacerbation. We hope that most communities would have a physical therapist or athletic trainer who is familiar with the subthreshold exercise techniques that are recommended after concussion, so they can work together with the patient, family, and primary care provider as a team to help return the youth with PTH back to school and then back to athletic activities.
We also recommend following the typical lifestyle management strategies for headache regarding appropriate sleep, meals, hydration, and stress management (see Chapter 21, Chapter 22, Chapter 23 ). This can be more complex when patients have significant sleep disruption or mood changes related to head injury, so one may consider active management of these problems with medications or other treatments. Dealing with these challenges is essential to move forward with headache control, as poor sleep, active anxiety, or depression will lead to exacerbation of headache.
School and PTH : Most pediatric patients are going to require adjustments to the school day after a concussion. For those with persistent PTH, concussion accommodations may be extended by developing a 504/IEP plan. These plans can help the student manage the school environment with the persisting pain, environmental stimuli exacerbation, and slowed processing/cognitive speeds. The goal is for kids with PTH to attend school as regularly as possible, as extended absence may also lengthen recovery time. It is important to discuss what types of activities/environments are worsening the headache to customize accommodations. General accommodations could include modified class schedule, ability to use sunglasses or tinted glasses, earplugs, the ability to skip noisy assemblies, have lunch with a friend in a quiet place, and extra time for assignments and tests. Patients may benefit from short rests in a quiet place if headache is worsening in class. Options to use a note taking services/audio recording instead of looking up and down at the board or screens can be helpful to reduce visually triggered headache. Sometimes it may be necessary to develop a plan that gradually increases school time and cognitive demands. The CDC “Heads Up” program provides a template for “return to school” letter for children with concussion, including those with PTH that lists several options for accommodations ( https://www.cdc.gov/traumaticbraininjury/pdf/pediatricmtbiguidelineeducationaltools/mTBI_ReturntoSchool_FactSheet-Pin.pdf ).
Medications : Abortive therapy should be considered to control acute headaches following concussion. Ibuprofen may be more effective than acetaminophen for the management of PTH, and ibuprofen or naproxen can be considered for acute management of headache once intracranial hemorrhage has been excluded by exam or imaging. There are case studies reporting that triptans can be effective for the management of PTH with migrainous features, so their use can be considered in appropriate circumstances (see Chapter 12 ). However, opiates should not be used for the treatment of persistent or acute PTH following mild TBI or concussion, and providers and families should avoid overusing any abortive therapy to prevent rebound or medication overuse headaches following TBI.
If the child has persistent migrainous PTH, particularly if they have a strong personal or family history of migraine, one might consider using preventive treatments that are used for migraine management. As a primary care provider, start with safe, well-tolerated supplements such as magnesium, which has shown some benefits in experimental models of TBI, or melatonin for sleep induction. It is also important to recognize and treat anxiety and depression that co-occur with PTH. We let patients and families know that “stress” of all different kinds can make pain feel worse, and that addressing these issues is as important as any other therapy or testing. When PTH is disabling and persistent, it is reasonable to consider referral to a local headache or concussion specialist for further evaluation and treatment.
Information for the headache specialist
Comorbid conditions : In the evaluation of the headache patient who sustained head injury, it is important to understand some of the other physiological systems that may be affected in concussion, that can contribute to headaches including the vestibulo-ocular system, autonomic nervous system, and cervical paraspinal muscular system. It is helpful to know how to assess and address these systems to treat the patient appropriately. It is well known that concussion can cause vestibulo-ocular system dysfunction, and that this dysfunction can contribute to headaches. Concussion can disrupt the vestibular system function independently or when linked with ocular dysfunction. Vestibular dysfunction can cause movement induced headaches and motion sensitivity in addition to more typical vestibular signs like imbalance and vertigo. There are several balance screens that are easy to implement in an office setting, including the balance error scoring system (BESS) as well as more advanced technologies if desired. Typically, vestibular therapy is used to recalibrate the vestibular system. When vestibular dysfunction is identified, it is important to address these issues before starting aerobic physical therapy as the vestibular symptoms can prevent the patient from treadmill exercise.
Headaches that are worsened by visual tasks (reading/taking notes) or are accompanied by complaints of blurred vision or double vision should raise suspicion for visual dysfunction. Testing for ocular dysfunction should include an evaluation of smooth pursuits, saccadic movement, and convergence. There are several ways to do this. One quick standardized screen that can be used in the pediatric population is called the visual oculomotor screen (VOMS). The VOMS is easy to incorporate into your cranial nerve exam, and there are videos online demonstrating its use in concussion. If ocular symptoms and signs are uncovered during your history and exam, you should consider visual therapy for the patient. Some vestibular therapists are familiar with certain visual exercises such as convergence strengthening. If a patient is having symptoms of vestibular and visual dysfunction, it is reasonable to start with vestibular therapy, as vestibular therapy is much more readily available and typically covered by insurance. Visual therapy is often an out of pocket expense. However, if vestibular therapy is not enough, the child can try a course of visual therapy as well. Vision therapy can provide a significant benefit for those with abnormalities of oculomotor system function. A retrospective analysis of children with concussion who underwent vision therapy for oculomotor dysfunction found that 90% had complete or marked improvement in their primary symptoms. Subsequent small studies have found that visual therapy improved saccades, fixation, and simulated reading as well as improved convergence and accommodation. Improvements in these vision measures were all associated with improvement in reading-related symptoms, including headache.
Autonomic dysfunction, which has been associated with concussion, can lead to development of orthostatic dizziness and positional headaches (worse with standing). It can also lead to fatigue and exercise intolerance. Autonomic dysfunction can be identified on exam by noting a significant change in blood pressure or heart rate with change in position. Exercise, focusing on core and leg strengthening, is one of the best management techniques for autonomic dysfunction. In addition, ensuring proper electrolyte consumption, hydration, the use of compression stockings and medications to support blood pressure can be helpful. Liberating salt intake may improve headache in patients with autonomic dysfunction after concussion by increasing intravascular volume and making the patient thirsty.
Cervicogenic headaches can arise from whiplash injury that leads to muscle spasm as well as misalignment of the cervical spine, in addition to activating the trigeminocervical complex. If headaches are occipital, occurring with neck movement, or exacerbated by activities that require prolonged neck stabilization the neck may be playing a role. Of note, cervicogenic headaches are not worsened by physical activity. On exam there may be tenderness or reproduction of the headache with pressure over the occipital groove or neck and there may be reduced range of motion. Clinical tests that evaluate the upper cervical spine, like the cervical flexion rotation test (CFRT), have been shown to have the highest accuracy and may be useful in identifying those with cervicogenic component to their headache. For cervicogenic headache, therapeutic exercises and mobilization (a method of chiropractic treatment that does not involve quick high velocity movements) were equally effective. In addition, massage and acupuncture may provide benefit. A recent review concluded that the management of headaches associated with neck pain should include any or all these techniques to promote treatment of cervicogenic dysfunction Greater occipital nerve injections have also been shown to relieve pain in PTH in children. Blocks are typically well tolerated by patients, have low risk of systemic side effects, and can provide quick and lasting relief (see Chapter 16 ).
Collaborative care/wrap around care : For those with persistent PTH, one strategy that may be effective is “collaborative care intervention” providing the child with embedded cognitive-behavioral therapy, care management, and psychopharmacological consultation support. Although this model may be difficult to replicate outside of a structured program, it indicates that close follow up, socio-emotional support, school intervention and support, and consideration of medication management together will play a role in the management of PTH. Thus, assuming many won’t currently have access to this type of organized multidisciplinary care, it would be reasonable to consider at least one of these interventions when possible for those children with persistent PTH. Knowing community resources, one can create such a comprehensive plan while each member reports to the others.
Preventive medications : Medication may be used in children with PTH with the goal of decreasing headache frequency and severity and limiting disability. The timing of when to start preventive medication will vary depending on the patient, patient’s family, and the provider’s experience, as there is very little data on this topic. Children with significant disability, protracted symptoms, and a prior history of headache should be given the option of preventive medicine. It may be reasonable to consider earlier treatment for those with persistent headache and multiple risk factors for persistent symptoms following mild TBI. If the headache is migrainous it is very reasonable to follow the standard dosing and options used for migraine in children (see Chapter 15 ). A small retrospective study found that amitriptyline was helpful for 82% of those with PTH who were prescribed this treatment. A prospective cohort study in children found that 64% had positive response to prophylactic medication, which included amitriptyline, melatonin, nortriptyline, flunarizine (not available in the United States), and topiramate. Of note, the topiramate group had the lowest response, and another retrospective study evaluating topiramate in chronic postconcussive headache found that only 16% of patients had greater than 50% reduction in headache. It is important to consider that topiramate may worsen cognitive function, so in a child with significant cognitive complaints it may be best to avoid topiramate. Medication overuse should be considered as well. A retrospective review of adolescent patients with concussion referred to a pediatric headache clinic identified 77 with PTH. Of those, 70% met the criteria for probable MOH from simple analgesics. After discontinuing the overused medications 68% had resolution of headaches or improvements to the preconcussion headache rate.
Return to sport: One of the biggest challenges for those with posttraumatic headache is determining when it is okay to return to sport, particularly if the sport carries a high risk for concussion. There are no guidelines on retirement from contact sports following concussions. A physician guided family discussion should be held to discuss the ongoing risks of participating in the sport/activity with persisting headaches compared to the benefits the sport has on the child’s physical and emotional health. In general, if there is a history of longer recovery with each successive concussion, reduced force required to elicit concussion, or significant sustained disability from the headaches, the recommendation to consider transitioning to a noncontact sport or no sport is typically made. Information to share with the family includes: the knowledge that if you have prolonged recovery from a concussion you are more likely to have prolonged recovery from the next concussion. If you have a prior concussion you are more likely to have headache as part of your next concussion. If you have baseline migraine or prior concussion, you are at greater risk of more severe headaches after the next concussion as well as more disability overall. There is a very nice guide published recently to highlight some of the nuances of this conversation written by Davis-Hayes.
Also, for patients with preexisting migraine, it can be difficult to determine if they have sustained a concussion after an injury, if a head injury triggered status migrainosus, or they are simply at their baseline. For nonconcussed migraine patients, particularly those participating in high contact sports, keeping a diary of migraine frequency and treatments can be particularly helpful. In addition, we recommend doing a baseline assessment of balance, oculomotor function, as well as cognitive testing so you have baseline objective measures to use if they sustain a concussion in the future. There is some data to suggest that migraine patients may be at greater risk for sustaining a concussion so it may be helpful to share this information with patients, particularly athletes with migraine, so that they understand when making decisions about sports participation.
References
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