Post-Traumatic Headache After TBI

BrainLine sat down with Dr. Nathan Zasler to talk about post-traumatic headache (PTHA), one of the most common complaints after traumatic head and brain injury (TBI). Dr. Zasler is an internationally respected neurorehabilitation physician who specializes in acquired brain injury and has a particular interest in post-traumatic pain disorders including headache.

BrainLine: What is post-traumatic headache, or PTHA?

Dr. Zasler: The term "post-traumatic headache" describes the most common complaint after brain injury: headaches. Unfortunately, PTHA is a "garbage-can" term — a catch-all phrase — because without a more specific diagnosis, PTHA simply states the obvious but doesn't tell you about the cause of the headache or how to treat it.

BrainLine: What types of headaches typically follow a TBI?

Dr. Zasler: There are several different types and causes of headache following a brain, head, or neck injury. The more you know about the various kinds of headache and their causes, the more informed you will be when talking with your doctor or specialist.

• Tension Headaches — Tension-type headaches often feel as if your head is being squeezed by a vice at your temples — the sensitive spots at the side of the head between your ears and eyes. A decrease in tolerance for stress, decreased thinking efficiency and reserve, and depression are often associated with tension headaches.
• Migraine or Neurovascular Headaches — Migraine headaches account for approximately 20 percent of PTHA (although many practitioners will debate this). Migraines are thought to be the result of changes in the blood flow inside the brain. The risk for migraines post-injury appears to be strongly genetically linked.
• Cervical/Cervicogenic Headaches — This kind of PTHA is common after a brain injury and is usually related to neck injury involving ligament, muscle, and/or joint (facet) injury.
• Musculoskeletal Headaches — Musculoskeletal headaches are often overlooked but are quite common after a TBI. Pain in the muscles or bones of the head, neck, shoulders, and/or jaw (see below) can be a source of head pain.
• Temporomandibular Joint Disfunction — TMJD sometimes occurs after trauma and involves injury to the "chewing" muscles around the jaw, or to the jaw joints themselves leading to headaches typically experienced on the side of the head in the temple region(s).
• Neuritic and Neuralgic Pain — Injury to the nerves in the scalp or larger nerves in the face (e.g. supra-orbital) and upper neck (e.g. greater occipital) from the trauma can result in head discomfort as well as headaches that may present with numbness, sensitivity, and/or shooting- or stabbing-type pains.

BrainLine: How common is PTHA after TBI? And when do these headaches start? Can there be a delay between the injury and the headaches?

Dr. Zasler: PTHA is one of the most common symptoms after a brain injury. In fact, approximately 70 percent of people who have had a mild TBI or concussion complain of PTHA. The catch is that PTHA is often not related to the brain injury itself, but rather to the other injuries sustained at the same time including trauma to the head, jaw, and/or neck. Most PTHA start within two weeks after the injury regardless of the cause of the headache pain; however, onset may be later with certain less common headache types.

BrainLine: How long does PTHA usually last after TBI?

Dr. Zasler: In medical circles, there is debate about this question. There is clearly evidence that PTHA can be chronic, especially if the headache types are tension or migraine headaches. However, it is very important to look at the cause of headache pain post-injury. Much of the literature on PTHA lump all the types of headaches together, which is a mistake since the more you know about the root cause of a headache post-trauma, the more effectively you can treat it.

BrainLine: What kind of information should you give your doctor to help him better understand your headaches?

Dr. Zasler: We all know that knowledge is power. And in this case, the more knowledge and information a doctor has about a person's injury and the nature of the PTHA, the more effective treatment he can offer. First of all, the doctor needs to understand the person's history. Make sure the doctor reviews your medical records including your imaging tests. Then he needs to take an adequate headache history, which should include among other inquiries questions expressed in the mnemonic COLDER:

Character — What the headache feels like
Onset — How the headache starts
Location — Where exactly the headache hurts
Duration — How long the headache lasts
Exacerbation — What makes the headache worse
Relief — What makes the headache less or better

The doctor will also want to ask when the PTHA started after the trauma; how severe and frequent the headaches are and whether the severity varies; what medicines have been effective, or not; and what the "functional consequences" of the headache are — meaning, can the person go to work or does he have to lie down and sleep in a dark room until the headache subsides?

BrainLine: What else should a doctor's evaluation entail?

Dr. Zasler: In addition to the medical and headache histories, the doctor will also want to perform appropriate neurological and musculoskeletal exams. This should include direct examinations of the face, head, neck, and upper spine and shoulder area. He may need to order further diagnostic tests. Finally, depending on the cause of the headache, the doctor may recommend any number of specialists, including a physiatrist (rehabilitation medicine physician), dentist or oromaxillofacial surgeon who specializes in TMJ problems, a neurologist, psychiatrist, physical therapist, and/or a pain management specialist.

You may also want to contact brain injury advocacy groups like the Brain Injury Association of America or one of its local state affiliates, which may have resources to help you find specialists in your area. Most importantly, when picking a specialist, make sure the specialist has experience with treating these types of headaches. Each person's headache disorder must be individually assessed and managed.

BrainLine: What questions should a person with headaches after a TBI ask the doctor?

Dr. Zasler: People experiencing headaches after a TBI should not settle for PTHA as their diagnosis. As mentioned above, PTHA is a catch-all phrase that doesn't give any particular clues about the headache's cause or how to treat it. If a doctor cannot give the person a more specific diagnosis based on the nature of the injury, the headache history, and the exam, then the person should keep seeking specialists who can be more specific about diagnosis and treatment.

BrainLine: How does a history of headaches before injury influence PTHA after TBI?

Dr. Zasler: A person's history prior to a brain injury can play a significant role. People who have a personal or family history of migraine or tension headaches, in particular, tend to experience even worse headaches after injury. Also, if a person has a genetic predisposition to headaches even if he has never experienced them, he would be at greater risk of having PTHA after trauma. Another risk factor for PTHA would be someone who had neck problems, like herniated disks or arthritis, prior to a brain injury.

BrainLine: What types of treatments are effective for PTHA?

Dr. Zasler: A person's PTHA treatment depends on what headache sub-type or headache combination he or she has. There are many available treatments or treatment combinations. They run the gamut from manual therapy work with a physical therapist or osteopath, to stress management intervention, to modalities like ultrasound or injection therapies such as nerve blocks, facet blocks, and trigger-point injections.

But again, each headache type or combination should be treated differently based on the cause of pain. For example, if you have damage to the nerves on your scalp (neuritic and neuralgic pain), treatment might include local nerve blocks that stop nerve cells from sending pain messages to the brain, electrical stimulation, treating muscle spasms, or acupuncture. A tension-type headache, on the other hand, would most likely be treated by medication or by non-medication approaches like cognitive behavioral therapies, relaxation therapy, or EMG biofeedback*.

* Biofeedback is a form of alternative medicine that involves measuring a person's bodily functions such as blood pressure, heart rate, skin temperature and conveying the information to the patient in real-time. This knowledge raises the patient's awareness and conscious control of their unconscious physiological activities.

BrainLine: How does stress come into play with PTHA?

Dr. Zasler: As we all know, stress can negatively affect any facet of our lives. With PTHA, stress is like throwing fuel on an open fire. Therefore, stress management is crucial, especially for migraine and tension-type headaches. Some stress management therapies include stress inoculation training, relaxation therapy, and biofeedback. In fact, studies have shown that biofeedback is one of the most effective ways to treat certain types of headaches, though it can be labor-intensive and expensive.

BrainLine: What other symptoms may be related to PTHA?

Dr. Zasler: In addition to stress, other related symptoms of PTHA can include irritability, cognitive impairment, and difficulty sleeping.

BrainLine: What new research is being done to help people with PTHA?

Dr. Zasler: The good news is that there are a significant number of research studies being conducted on different headache types after TBI. I believe that in the next five to 10 years, we'll learn a good deal more about the different types of PTHA and will then be able to develop more targeted treatments. But above all else, treatment must always be individualized for each person.

BrainLine: Can you explain why making sure you get a specific or accurate diagnosis is so important?

Dr. Zasler: The issue — and danger — of mislabeling people should not be understated. Over the years, I have seen a lot of people who have been given the general label of PTHA. If they had been given a more specific diagnosis, they may have gotten the right treatment — and relief — sooner. I remember giving a talk about PTHA and describing a post-traumatic headache disorder called occipital neuralgia. I mentioned that with this kind of headache, a person might experience sharp, lightening-like pain and also pain behind one or both eyes. A woman in the audience spoke up saying that I had described exactly the kind of headache pain she continued to have even many years post-injury. She'd been diagnosed with chronic post-traumatic headache and had been treated unsuccessfully with a variety of migraine medications over the years. I examined her head and neck and applied pressure over the greater occipital nerve on the right side of her craniocervical junction. I knew from her headache description as well as from her reaction to my exam that she likely did not suffer from migraines, but from greater occipital neuralgia. Apparently, no one had ever asked her the right questions or done an appropriate exam. Had she been correctly diagnosed, she might have gotten relief sooner.

Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CBIST, is an internationally respected physician specialist in brain injury care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with brain injury in Glen Allen, Virginia.

He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury. Dr. Zasler is a Clinical Professor of PM&R at VCU in Richmond, Virginia, as well as a Clinical Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He also serves as a consultant in neurorehabilitation to the Northeast Center for Special Care in New York. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomate of the American Academy of Pain Management. His main areas of clinical and research interest include neuromedical issues in acquired brain injury (particularly mild TBI, neuropsychopharmacology and low level neurologic states), differential diagnosis in acquired brain injury community-based care issues, as well as chronic pain rehabilitation including headache.

Dr. Zasler is a practicing clinician who is involved with community-based neurorehabilitation and neuromedical assessment and management of persons with brain injury, neurodisabililty, as well as chronic pain. www.tree-of-life.com.