Most patients with mild traumatic brain injury (TBI) recover quickly and have few sequelae. Headache is common during the first few hours or days. But some patients experience significant and sometimes unrelenting headaches after their injury. How should we treat them? Are they the same as other common headaches?

There are several common types of headaches that are not related to brain injury, but many of these can begin after TBI. These include tension headaches from muscle tension or spasm, cervicogenic headaches from strains, sprains or more significant injury to the neck and cervical spine, musculoskeletal headaches from pain in bone or muscle in the head or neck, and headaches related to the TMJ and jaw.

But many patients experience significant headaches without any of these factors. Why? Sometimes it is due to blood in or around the brain, irritating the meninges. But often, there is nothing that we can detect using our current diagnostic technology. However, even if we can’t find a reason, the headache is very real and very concerning to the patient.

I’ve seen practitioners treat post-TBI headaches with a variety of drugs ranging from acetominophen and NSAIDs to anti-seizure and psychotropic drugs. Unfortunately, there is little literature support for any of them. A review article published in 2012 found only one article with Class II data that showed no lasting effect from manipulation therapy.

So what do we do? Here is an algorithm suggested by the review article:

• Consider a workup to rule out intracranial pathology as a source of the headache
• Categorize the headache. If it is one of the non-TBI types listed above, treat appropriately.
• If the headache severely limits function, consider time-release opioids
• For milder headache, consider adetominophen or NSAIDs
• Treat any comorbidities that may contribute to headache
• If the headache has migraine-type properties, treat as such
• If the headache is associated with cervical spine pain, mobilize the neck as appropriate

Bottom line: There is very little guidance for treatment of headache purely associated with TBI. Time-honored drugs like opioids for severe pain and acetominophen and NSAIDs for mild to moderate pain help, but generally do not entirely relieve the pain. Only tincture of time will make things better. And it’s probably best to stay away from prescription drugs other than opioids recommended for the pain. They have not been shown to work, and there are plenty of side effects to worry about.

Related post:

• Prescription drugs and side effects

Reference: Systematic review of interventions for post-traumatic headache. PM&R. 4(2):129-140, 2012.