Interventional Treatment for Post-traumatic Headache

Post-traumatic headache (migraine) is the most common symptom of concussion and traumatic brain injury. An expert opinion-based review along with a literature review (PubMed) was conducted looking at known interventional procedures for post-traumatic headache using the keywords post-traumatic headache, post-traumatic migraine headache, concussion, mild traumatic brain injury, and traumatic brain injury and the following categories: mechanism, pathophysiology, treatment, physical therapy, neurostimulation, Botox@/Onabotulinum toxin, and surgical intervention. The results returned a total of 181 articles of which 52 were selected. None of the articles included randomized placebo-controlled studies, and most were either prospective or retrospective case analysis and/or review articles or consensus opinion papers, with most studies yielding positive results. Despite a lack of hard evidence, interventional procedures, alone or in combination, appear to be an effective treatment for post-traumatic headaches.     

Sports-related concussion: the role of the headache specialist

Over the past few years, sports-related concussion has received significant media attention making it one of the most, if not highest profile neurological disorder. Thirty-one states now have passed sports concussion laws, with 14 states pending legislation. Most concussions are managed by primary care physicians, ie, family practice trained sports medicine physicians and pediatricians. Symptoms are usually short lived and do not require treatment. The one exception is headache, which is usually present from onset and is often the last symptom to resolve. Headache is the most common reason for referral to a specialist, and therefore it is imperative that the headache specialist have at least a basic understanding of all aspects of sports concussion as they are likely going to be called upon to evaluate these athletes, especially the more refractory cases.     

Subacute concussion-related symptoms in youth

Most athletes who experience a sports-related concussion recover from the acute effects within a few weeks. However, some children and adolescents with concussion experience symptoms for many weeks, or even months after the injury. Subacute and chronic symptoms related to concussion are particularly concerning in children, because cognitive deficits, headache or neck pain, sleep dysfunction, and emotional dysregulation can affect school performance and social function at a critical period of development and maturation. This article reviews the epidemiology of subacute symptoms after pediatric concussion and the current recommendations for the assessment and management of these symptoms in children and adolescents.     

Headaches After Concussion in US Soldiers Returning From Iraq or Afghanistan

(Headache 2010;50:1262‐1272) Objectives.— To determine the prevalence, characteristics, impact, and treatment patterns of headaches after concussion in US Army soldiers returning from a deployment to Iraq or Afghanistan. Methods.— A cross‐sectional study was conducted with a cohort of soldiers undergoing postdeployment evaluation during a 5‐month period at the Madigan Traumatic Brain Injury Program at Ft. Lewis, WA. All soldiers screening positive for a deployment‐related concussion were given a 13‐item headache questionnaire. Results.— A total of 1033 (19.6%) of 5270 returning soldiers met criteria for a deployment‐related concussion. Among those with a concussion, 957 (97.8%) reported having headaches during the final 3 months of deployment. Posttraumatic headaches, defined as headaches beginning within 1 week after a concussion, were present in 361 (37%) soldiers. In total, 58% of posttraumatic headaches were classified as migraine. Posttraumatic headaches had a higher attack frequency than nontraumatic headaches, averaging 10 days per month. Chronic daily headache was present in 27% of soldiers with posttraumatic headache compared with 14% of soldiers with nontraumatic headache. Posttraumatic headaches interfered with duty performance in 37% of cases and caused more sick call visits compared with nontraumatic headache. In total, 78% of soldiers with posttraumatic headache used abortive medications, predominantly over‐the‐counter analgesics, and most perceived medication as effective. Conclusions.— More than 1 in 3 returning military troops who have sustained a deployment‐related concussion have headaches that meet criteria for posttraumatic headache. Migraine is the predominant headache phenotype precipitated by a concussion during military deployment. Compared with headaches not directly attributable to head trauma, posttraumatic headaches are associated with a higher frequency of headache attacks and an increased prevalence of chronic daily headache.     

Post-traumatic headache

Post-traumatic headaches as well as post-traumatic syndrome can occur in patients after mild, moderate, or severe traumatic brain injury. Most of the patients' symptoms clear within the first 3 to 6 months; however, there are no precise criteria for predicting the clinical outcome. The diagnostic criteria for post-traumatic headaches were defined by the International Headache Society in 2004 and are helpful for classification. Evaluation must be done on an individual basis, and patients who do not clear their symptoms may need neuroimaging. The headaches fall into the category of chronic tension-type headache as well as headaches compatible with migraine and are treated in a similar fashion. There is a small group of people who do not respond and have long-term problems. These patients may benefit from a combination of pharmacologic, nonpharmacologic, and neuropsychiatric treatment. Long-term studies are needed to help clarify the history of these patients.     

Expert opinion and controversies in sports and musculoskeletal medicine: concussion in the young athlete

Concussion is a common injury in young athletes and can be very challenging for clinicians to diagnose and manage. Debate exists over not only the incidence of long-term risks of multiple concussions but also the potential for catastrophic outcomes after sports-related head injury. Decisions on returning athletes to competition can be difficult, and there are limited prospective data on which to make these decisions. This has resulted in the existence of a number of published guidelines and consensus statements on the management of concussion in athletes. Athletes sustaining a concussion need appropriate on-field care and structured follow-up. Baseline cognitive assessments can be helpful, but clinicians must be aware that head trauma may result in a wide array of clinical signs and symptoms. Delivery of care and decisions on return to play need to be based on an individual assessment of the affected athlete.     

Chronic daily headache in U.S. soldiers after concussion

(Headache 2012;52:732‐738) Objective.— To determine the prevalence and characteristics of, and factors associated with, chronic daily headache (CDH) in U.S. soldiers after a deployment‐related concussion. Methods.— A cross‐sectional, questionnaire‐based study was conducted with a cohort of 978 U.S. soldiers who screened positive for a deployment‐related concussion upon returning from Iraq or Afghanistan. All soldiers underwent a clinical evaluation at the Madigan Traumatic Brain Injury Program that included a history, physical examination, 13‐item self‐administered headache questionnaire, and a battery of cognitive and psychological assessments. Soldiers with CDH, defined as headaches occurring on 15 or more days per month for the previous 3 months, were compared to soldiers with episodic headaches occurring less than 15 days per month. Results.— One hundred ninety‐six of 978 soldiers (20%) with a history of deployment‐related concussion met criteria for CDH and 761 (78%) had episodic headache. Soldiers with CDH had a median of 27 headache days per month, and 46/196 (23%) reported headaches occurring every day. One hundred seven out of 196 (55%) soldiers with CDH had onset of headaches within 1 week of head trauma and thereby met the time criterion for posttraumatic headache (PTHA) compared to 253/761 (33%) soldiers with episodic headache. Ninety‐seven out of 196 (49%) soldiers with CDH used abortive medications to treat headache on 15 or more days per month for the previous 3 months. One hundred thirty out of 196 (66%) soldiers with CDH had headaches meeting criteria for migraine compared to 49% of soldiers with episodic headache. The number of concussions, blast exposures, and concussions with loss of consciousness was not significantly different between soldiers with and without CDH. Cognitive performance was also similar for soldiers with and without CDH. Soldiers with CDH had significantly higher average scores on the posttraumatic stress disorder (PTSD) checklist compared to soldiers with episodic headaches. Forty‐one percent of soldiers with CDH screened positive for PTSD compared to only 18% of soldiers with episodic headache. Conclusions.— The prevalence of CDH in returning U.S. soldiers after a deployment‐related concussion is 20%, or 4‐ to 5‐fold higher than that seen in the general U.S. population. CDH following a concussion usually resembles chronic migraine and is associated with onset of headaches within the first week after concussion. The mechanism and number of concussions are not specifically associated with CDH as compared to episodic headache. In contrast, PTSD symptoms are strongly associated with CDH, suggesting that traumatic stress may be an important mediator of headache chronification. These findings justify future studies examining strategies to prevent and treat CDH in military service members following a concussive injury.     

Sports Concussion and Associated Post‐Traumatic Headache

Despite an incidence of approximately 3.8 million sports‐related concussions per year, the pathophysiological basis of this injury remains poorly understood. Associated post‐traumatic headache, both acute and chronic, can also provide a unique treatment challenge for medical personnel. The presence of new onset or persistent headache following injury often complicates return to play decisions. It is also now evident that recurrent head trauma may be associated with the development of some chronic neurodegenerative disorders. Although anecdotal reports and consensus guidelines are utilized in the management of sports concussion and associated post‐traumatic headache, further evidence‐based data are needed. Improved prevention and management of this injury will occur with ongoing educational and research efforts. As such advances are made, it is imperative the headache specialist have continued understanding of this evolving field.     

Combat-Related Headache and Traumatic Brain Injury

Post-traumatic headache is a commonly described complication of traumatic brain injury. Recent studies highlight differences between headache features of combat veterans who suffered traumatic brain injury compared to civilians. Not surprisingly, there is a higher rate of associated PTSD and sleep disturbances among veterans. Factors of lower socioeconomic status, rank, and multiple head injuries appear to have a similar effect on post-traumatic headache in combat-related traumatic brain injury. Areas of discordance in the literature include the effect of prolonged loss of consciousness and the prevalence of specific headache phenotypes following head trauma. To date, there have been no randomized trials of treatment for post-traumatic headache. This may be related to the variability of headache features and uncertainty of pathophysiologic mechanisms. Given this lack of data, many practitioners follow treatment guidelines for primary headaches. Additionally, because of mounting data linking PTSD to post-traumatic headache in combat veterans, it may be crucial to choose multimodal agents and take a multidisciplinary approach to combat-related headache.     

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.     

Sports-Related Shoulder Injuries Among Female Athletes

Purpose of ReviewThe objectives of this review are to explore the recent literature evaluating sports-related shoulder injuries among female athletes.Recent FindingsRecent literature has highlighted sex-related differences in injury trends and patterns among athletes. Increased participation of women in both recreational and professional sports has resulted in increased exposure to injury. While men experience greater rates of shoulder injury overall, women tend to experience more overuse-related injuries. Evidence also suggests women are more susceptible to shoulder laxity and rotator cuff tears. In comparison to their male counterparts, women note poorer function, increased pain, and decreased activity level following shoulder injuries. Women may also be more likely to experience worse outcomes following surgical intervention. Sex-related differences in injury patterns and outcomes results from a combination of molecular and environmental influences, including hormone pathways, shoulder morphology, and differing rates of participation in, and athletic regulations among, certain sports.SummarySex-related differences occur in how athletes sustain, experience, and recover from sports-related injuries. A comprehensive understanding of sex-related injuries enhances clinical decision making, treatment, and recovery. Further research is needed to clarify sex as an independent variable when evaluating sports-related shoulder injuries.     

Sports-related headache

Sports-related or sports-associated headaches are common. They can be benign as in primary exertional headache or may signal serious pathology as in headache associated with traumatic subdural hematoma. Specific sports activities are associated with unique headache conditions such as decompression sickness headache or high-altitude headache, which mountain climbers experience along with other symptoms of chronic mountain sickness. The management of sports-related headaches requires an adequate understanding of its underlying etiology with subsequent cause-directed treatment plan.     

Pediatric post-traumatic headache

Post-traumatic headache after craniocerebral trauma is not an uncommon occurrence in children and adolescents. It can occur after mild, moderate, or severe injury. The headache may have features of tension-type headache, migraine, or probable migraine and is rarely seen in isolation. It is often part of a syndrome encompassing a variety of somatic and psychobehavioral symptoms. In time, the headache and accompanying symptoms gradually resolve over a period of 8 to 12 weeks. However, sometimes it may become chronic, requiring a multidimensional management approach including pharmacologic intervention, physical rehabilitation, and cognitive-behavioral therapy as used in the adult population.     

Stop Football … Save Brains: A Point Counterpoint Discussion

In a recent Opinion Editorial posted on the Listserv of the Southern Headache Society ( http://www.SouthernHeadache.org ), Dr. Lawrence Robbins of the Robbins Headache Clinic, Northbrook, Illinois, explored how headaches resulting from trauma are sometimes difficult to treat and often remain refractory. Most neurologists likely encounter young athletes who have a moderate‐to‐severe post‐concussion syndrome. The following discussion, therefore, is relevant to the practice of headache medicine. In this Point Counterpoint, Dr. Robbins has repurposed his OpEd once more for Headache, followed by a response from Dr. Frank Conidi of the Florida Center for Headache and Sports Neurology, and Team Neurologist for the Florida Panthers of the National Hockey League. The discussion concludes with a retort from Dr. Robbins.     

Post-Traumatic Headache: Commentary: An Overview

The history of post-traumatic headache begins in the middle of the 19th century, and its latest iteration has been defined in the International Headache Classification of 2004. Contrary to the latter, there are instances when mild head injury without symptoms or signs of concussion may evoke the pathophysiological changes of migraine. The mechanisms of chronic post-traumatic headache and the associated syndrome are complex and include pathophysiological, psychological, and socioeconomic factors. Treatment of these headaches is similar to that of the primary headaches with particular attention to nonpharmacological measures.     

Psychogenic Headache

SYNOPSIS
An attempt has been made to identify what is commonly referred to as "psychogenic headache" and to differentiate between the most frequently encountered psychiatric disorders where headache is the main symptom. These disorders include anxiety reactions, conversion reactions and depressive reactions. While it is recognized that psychogenic factors often play a major part in migraine headaches and vascular headaches⁸ and possibly cluster headaches, this topic has not been discussed here as the literature on these types of headache is already extensive.This article attempts to review the causes, types, location and duration of psychogenic headaches and the types of premorbid personality encountered in the sufferer. It suggests how the diagnosis of psychogenic headache may be made and notes that effective treatment will depend upon establishing the correct diagnosis and include not only treatment of the symptom, i.e., the headache, but treatment of the underlying psychiatric disorder also.     

Chronic post-traumatic headache: Associations with mild traumatic brain injury,concussion, and post-concussive disorder

Chronic post-traumatic headache (PTH) always arises from some sort of head injury such as mild traumatic brain injury or concussion. The terminology and definitions for these injuries remain controversial and continue to evolve. This article reviews and updates current terminology and definitions for these head injuries, along with current concepts of pathophysiology. The second portion of this article considers the persistence of the other symptoms associated with chronic PTH, which constitute the post-concussive disorder. PTH is the most common symptom after a head injury, but post-concussive symptoms often complicate the clinical picture and must be considered in the overall management of the chronic PTH patient.     

The role of pre-season health characteristics as injury risk factors in female adolescent soccer players

[Purpose] Determine if female adolescent soccer players with a history of concussion, impaired K-D scores, and pre-season subjective complaints of neck pain, dizziness, and headache were predisposed to additional risk of musculoskeletal or concussive injury during 10-weeks of competitive play. [Participants and Methods] Twenty-three female high school soccer athletes provided concussion history and reported pre-season subjective complaints. K-D testing was performed pre and postseason. During the 10-week season, all injuries, preventing participation in practice or game, were recorded. [Results] Six reported a history of concussion. Of those six, three injuries were reported, including two concussions and a hamstring strain. Baseline K-D scores were worse in athletes that had two or more pre-season subjective factors compared to those that did not have any. Moderate positive correlations were found between a history of concussion and the number of injuries and a history of concussion and K-D post-test scores. [Conclusion] Findings indicate that pre-season subjective factors of neck pain, dizziness and headache, history of concussion, and K-D potentially increased injury risk. Combining pre-season metrics both at baseline and during the course of the season may assist in better injury risk screening in-season or indicate suboptimal function due to cumulative effects.Key words: Concussion, Female, Soccer     

Review of sports-related concussion: Potential for application in military settings

This article reviews current issues and practices in the assessment and clinical management of sports-related concussion. An estimated 300,000 sports-related concussions occur annually in the United States. Much of what has been learned about concussion in the sports arena can be applied to the diagnosis and management of concussion in military settings. Current military guidelines for assessing and managing concussion in war zones incorporate information and methods developed through sports-concussion research. We discuss the incidence, definition, and diagnosis of concussion; concussion grading scales; sideline evaluation tools; neuropsychological assessment; return-to-action criteria; and complications of concussion.