Chronic Post-traumatic Headache - Understanding the Complexities and Treatment Options
Chronic Post-traumatic Headache - Understanding the Complexities and Treatment Options
US Neurology, 2010;6(1):78–81
Abstract
As there are few or no objective signs of disease and standard laboratory tests and imaging studies often appear normal, chronic post-traumatic headache (CPTH) is frequently disrespected. Confusion about its legitimacy began with its initial recognition in the mid-19th century, followed by modern attempts to establish its criteria in the International Classification of Headache Disorders (ICHD). There are no distinct clinical features of CPTH. Most resemble tension-type headache, but symptoms of migraine and, rarely, of other primary headaches may occur. CPTH is often associated with the post-concussion/post-traumatic stress syndrome. Anatomic, physiologic, psychologic, socioeconomic, and cultural factors may contribute to the development of CPTH. Changes in diffusion tensor imaging, a refinement of magnetic resonance imaging (MRI), have been correlated with subtle cognitive abnormalities in neuropsychologic tests of patients after mild traumatic brain injury. These studies and others may prove to be biologic markers for headache and other symptoms of the post-concussion syndrome. The therapy of CPTH is similar to that of the phenotypically primary headaches. Avoidance of analgesic overuse, prophylactic medications, and, in particular, non-pharmacologic modalities are the basic elements. Active participation by patients in headache management and an empathetic physician are essential.
Keywords
Post-concussion syndrome, diffusion tensor imaging, tension-type headache, post-traumatic stress disorder, behavioral medicine
Disclosure: The author has no conflicts of interest to declare.
Received: May 6, 2010 Accepted: June 29, 2010 Citation: US Neurology, 2010;6(1):78–81
Correspondence: Seymour Solomon, MD, Montefiore Headache Center, 1575 Blondell Avenue, Bronx, NY 10461. E: solsy@optonline.net
History
The complexities of chronic post-traumatic headache (CPTH) date back to its initial recognition. By the mid-1800s the persistence of headache after head injury was acknowledged as a manifestation of brain injury or ‘molecular derangement.’ However, with the advent of financial compensation for these injuries, the psychologic aspects were thought to be predominant, hence such terms as ‘compensation neurosis.’ The latter concept persisted into the early decades of the 20th century with more sophisticated terms as ‘somatization’ and ‘conversion disorder’. However, by the late 1800s ‘post-concussion syndrome’ was considered to be a legitimate ailment comprising the triad of headache, dizziness, and alcohol intolerance. In recent decades, post-traumatic headache has been recognized as having an organic or pathophysiologic basis as well as associated psychologic factors.
Terminology and Criteria
The term CPTH implies an underlying cerebral trauma that is part of the post-concussion syndrome. The International Classification of Headache Disorders, 2nd edition (IHCD) divides criteria for CPTH into pain attributed to moderate or severe head injury and pain attributed to mild head injury.1 The term ‘concussion’ in Table 1 is not defined, but would include symptoms such as dazed, confused, memory impairment, and dizziness, in addition to headache or brief loss of consciousness, or both. However,mild head injury without concussion or any other of the IHCD criteria can trigger headache. Examples are migraine with aura evoked by heading a ball during soccer or hemiplegic migraine provoked by trivial head trauma. In addition head trauma need not be direct, such as during blast or whiplash injuries. Trauma may be psychologic, as in chronic post-traumatic stress disorder (PTSD). The time limits indicated in the IHCD criteria have been disputed. Many agree that CPTH may develop more than seven days after trauma, but there is evidence that headache beginning more than three months after concussion is a primary headache (migraine or tension-type) rather than due to brain trauma.2 Until there are biologic markers for the condition, seven days is a logical limit. Similarly, the classification of ‘chronic’ if the headache lasts for more than three months has been disputed as being too short. Criteria of other illnesses define chronic as having a duration of more than six months. The numbers in the classification criteria are arbitrary but necessary operational criteria for research purposes.
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Post-concussion syndrome, diffusion tensor imaging, tension-type headache, post-traumatic stress disorder, behavioral medicine
