Military & VeteransHeadache is the most common and complex complaint after a concussion/mTBI. You have multiple treatment options before referring your patient to specialty care.
Recommendations:
- Encourage your patient to maintain a headache diary and present it at appointments. The patient should detail:
- The time and duration of headaches
- Intensity (on a 1-10 scale)
- Where in the cranium the pain was experienced
- Other symptoms
- Aggravating and alleviating factors (for example, is the headache better or worse after a meal or a workout?)
- What the patient was doing when the episode occurred (resting, taking medications, turning off the lights, and so on)
With this information you can better characterize the headaches (e.g., tension, cluster, or migraine) and refine your treatment plan. This chart from the Defense Centers of Excellence Case Studies Series can also help. Please note: It includes the two most common types of headaches following concussion/mTBI, but there are other types that occur (cluster, occipital neuralgia, etc.).
Headache Type: Headache Feature Tension-like Migraine-Like Pain Intensity Mild-moderate Often severe/debilitating Pain Character Dull, aching, or pressure. Can be sharp but that is not predominant Throbbing/pulsatile, can be sharp/stabbing or electric-like Duration Usually less than 4 hours Can be longer than 4 hours Phono- or photo-phobia One but not both may be present One or both usually present Able to carry out routine activities/work Usually Usually not or decreases ability to participate Location Bilateral frontal, retro-orbital, temporal, cervical and occipital or holocephalic Usually unilateral & may vary in location among episodes Nausea/malaise Not present Usually present Palpable muscle tenderness/contraction Pericranial muscles (temporalis, masseter, pterygoid, posterior neck, sternocleidomastoid, splenius, or trapezius Local muscle tenderness not typical but can be present with long duration headaches - Be aware that excessive use of — and withdrawal from — caffeine and nicotine can trigger headaches.
- If your patient's headaches are mild, you can advise over-the-counter analgesics that don't contain caffeine.
- You should avoid prescribing narcotics, prescription medications containing caffeine, and benzodiazepines because of the risk of rebound headaches and addiction.
- For acute headache episodes, consider the following: NSAIDs, Triptans, rest, and applications of heat.
- Consider referring your patient to specialists for alternative care such as biofeedback, massage, stress management, and acupuncture.
- For prophylactic measures, refer your patient to specialty care where abortive agents such as tricyclic antidepressants, anticonvulsants, or beta-blockers can be used and monitored. Some of these medications are contraindicated with certain co-morbidities, so the specialist must first review the patient's complete medical history.