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Mild Traumatic Brain Injury, Concussion, and Post-traumatic Headache

Bert B. Vargas, MD, FAHS

Mild traumatic brain injury (mTBI) – which includes concussion – is a significant public health concern that has become a hot-button issue and focus of attention for both the lay-public and the medical community. Significantly contributing to this increase in awareness are the countless high-profile individuals, including athletes and military service members, who have given names, faces, and legitimacy to the disabling symptoms frequently associated with concussion and mTBI.

Although millions of Americans suffer from mTBI every year from a number of mechanisms, the incidence reported by the CDC is likely a gross underestimate given the fact that many individuals never present to a healthcare provider because their symptoms are either mild and self-limited or go unrecognized altogether. Interestingly, the rate of TBI-related emergency department visits has climbed dramatically over the past decade, spiking sharply in 2008. Although the reason behind this increase is unclear, many argue that it is because of an increased public awareness of concussion and mTBI.

mTBI does not require direct contact to the head and may be secondary to indirect forces disrupting normal brain function through contact anywhere on the body. It has been described as the “signature injury” of the military conflicts in Iraq and Afghanistan (frequently secondary to blast injuries) and has been the inspiration behind countless rule changes and safety initiatives in professional and amateur sports. Currently, every state in the United States has some form of concussion legislation many of which require concussion education for youth athletes, coaches, and parents, mandate immediate removal from play for any suspected concussion, and require formal clearance by a healthcare provider who is an expert in the evaluation of concussion before returning to play.

Headache is the most common symptom of mTBI and is among the most disabling long-term sequelae in individuals who have a prolonged course of recovery. Headaches that present de novo and are temporally related to the traumatic injury are typically characterized as “headaches attributed to trauma or injury to the head and/or neck” based on ICHD3-b criteria. Although the most common headache phenotype is migraine, many other headache subtypes have been described in the literature including tension-type headache and various trigeminal autonomic cephalalgias.

Post-traumatic headache currently lacks well-established, evidence-based treatment guidelines. Most treatment recommendations are based on expert opinion and typically mirror the algorithms established for the headache subtype it most closely resembles.

Concussion and mTBI are of paramount importance and relevance to headache specialists as they are uniquely trained to differentiate post-traumatic headache from primary headache disorders, are able to direct appropriate investigations and treatment, and are able to establish reasonable expectations regarding outcomes for patients and their families.

Epidemiology, Pathophysiology, and Characteristics of Posttraumatic Headache

  1. Seifert T. Sports concussion and associated post-traumatic headache. Headache 2013;53:726-736.
  2. Theeler B, Lucas S, Riechers RG, Ruff RL. Post-traumatic headaches in civilians and military personnel: A comparative, clinical review. Headache 2013;53:881-900.
  3. Mayer CL, Huber BR, Peskind E. Traumatic brain injury, neuroinflammation, and post-traumatic headaches. Headache 2013;53:1523-1530.
  4. Finkel AG, Yerry J, Scher A, Choi YS. Headaches in soldiers with mild traumatic brain injury: findings and phenomelogic descriptions. Headache 2012;52:957-965.
  5. Theeler BJ, Fkynn FG, Erickson JC. Chronic daily headache in U.S. soldiers after concussion. Headache 2012;52:732-738.
  6. Theeler BJ, Erickson JC. Mild head trauma and chronic headaches in returning US soldiers. Headache 2009;49:529-534.
  7. Gfeller JD, Chibnall JT, Duckro PN. Postconcussion symptoms and cognitive functioning in posttraumatic patients. Headache 1994;34:503-507.
  8. Reik L. Cluster headache after head injury. Headache 1987;27:509-510.

Evaluation, Diagnosis and Treatment of posttraumatic headache

  1. Yerry JA, Kuehn D, Finkel AG. Onabotulinum Toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: a cohort study. Headache 2015; epub ahead of print.
  2. Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: A case series and patient satisfaction survey. Headache 2014;54:878-887.
  3. Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: An observational study. Headache 2011;51:932-934.
  4. Levin M. Resident and fellow section. Teaching case: Equine cephalalgia. Headache 2011;51:629-631.
  5. Sarmento E, Moreira P, Brito C, et al. Proton spectroscopy in patients with post-traumatic headache attributed to mild head injury. Headache 2009;49:1345-1352.
  6. Gladstone J. From psychoneurosis to ICHD-2: An overview of the state of the art in post-traumatic headache. Headache 2009;49:1097-1111.
  7. McBeath JG, Nanda A. Use of dihydroergotamine in patients with postconcussion syndrome. Headache 1994;34:148-151.

Notable Historical Perspectives and Commentary

  1. Robbins L, Conidi F. Stop football…save brains: A point counterpoint discussion. Headache 2013;53:817-823.
  2. Conidi FX. Sports-related concussion: The role of the headache specialist. Headache 2012;52;S1:15-21.
  3. Evans RW. Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: The evidence for a non-traumatic basis with an historical review. Headache 2010;50:716-724.
  4. Solomon S. Post-traumatic headache: Commentary: An overview. Headache 2009;49:1112-1115.
  5. Evans R. Post-traumatic headaches: Commentary: Clinical characteristics, comorbidity, and treatment. Headache 2009;49:1116-1119.

Patient Education

  1. Tepper D. Post-traumatic headache in veterans. Headache 2013;53:875-876.
  2. Tepper D. Headache after sports-related concussion. Headache 2013;53:1197-1198.

Bert B. Vargas, MD, FAHS is assistant professor of neurology at Mayo Clinic in Arizona in both the Headache and Sports Neurology and Concussion divisions. He previously served four years in the United States Air Force as a flight surgeon and is currently among the sideline neurotrauma consultants for Northern Arizona University and Arizona State University Athletics. He is chair of the Post-traumatic Headache Section of the American Headache Society and is a board member of the American Headache Society and the Headache Cooperative of the Pacific.

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