Headache Management in Concussion and Mild Traumatic Brain Injury

Headache after traumatic brain injury: a national survey of clinical practices and treatment approaches

BACKGROUND

Individuals with headache after traumatic brain injury (TBI) receive care in a wide variety of clinical locations by physicians trained in multiple specialties.

OBJECTIVE

To understand current practice patterns and perceptions of treatment issues among clinicians managing headache after TBI.

DESIGN

National survey of current clinical practice using a 20-item questionnaire developed by the authors.

PARTICIPANTS

Survey respondents were members of the Central Nervous System Council list survey of the American Academy of Physical Medicine and Rehabilitation (N = 1782) and the American Headache Society membership (N = 1260).

METHODS

The survey was sent electronically to potential participants and was followed by 2 biweekly reminders. The survey queried the physicians' clinical setting; their use of headache classification systems, headache diaries, checklists, and diagnostic procedures; the pharmacologic and nonpharmacologic treatments prescribed; and headache chronicity and associated symptoms and disorders among their patients with TBI.

RESULTS

Completed surveys were received from 193 respondents. The use of standardized classification systems and checklists was commonly reported. Respondents used nonpharmacologic and pharmacologic treatment approaches with similar frequency and modest perceived success rates. A high frequency of headache-associated new sleep and mood disorders was reported. When response differences occurred between practice settings, they reflected a focus on headache diagnosis, classification, and pharmacologic treatment among neurology and specialty headache clinics, whereas a nonpharmacologic approach to management among TBI specialty and general rehabilitation clinicians was more commonly reported.

CONCLUSION

Management strategies for treating headache after TBI vary widely among general and specialty clinical practices. This suggests that additional research is needed that would lead to an increase in the use of established headache classification and the development of standardized management approaches so that all practitioners who care for patients after TBI can provide consistent effective care.

Mechanical allodynia induced by traumatic brain injury is independent of restraint stress

BACKGROUND

This study identifies the relationship between a test for post-traumatic headache and a marker for acute stress in rodent models of traumatic brain injury.

NEW METHOD

C57BL/6 mice and Sprague Dawley rats were divided into Controlled Cortical Impact (CCI) injury, craniotomy (CR), and incision groups. Periorbital and paw allodynia were evaluated using the von Frey test prior to injury and up to four weeks post-operatively. Serum corticosterone was evaluated in groups with and without mild restraint.

RESULTS

Periorbital and forepaw thresholds, but not hindpaw thresholds, were reduced in CCI and CR mice compared to incision (p<0.0001 and p<0.01). In contrast to mice, reduced periorbital and forepaw periorbital thresholds were found in CCI rats but not CR rats compared to incision (p<0.0001). Right periorbital thresholds were reduced compared to left thresholds for both rat and mouse at one week (p<0.01), but there were no side differences for forepaw thresholds. Hindpaw thresholds did not change from baseline values for any groups of mice or rats. In mice serum corticosterone levels were increased at one, two and four weeks post-CCI and CR, while the levels for rats were not different from incision (p<0.0001). Corticosterone levels were not different in mice subjected to restraint compared to no restraint.

COMPARISON WITH EXISTING METHODS

This study presents novel data for allodynia in a rat model of TBI, and differences among mouse and rat species.

CONCLUSIONS

Mechanical allodynia occurs independent of evoked restraint stress, while hypothalamic pituitary adrenal axis activity is dependent on head trauma and species.

Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion

BACKGROUND

Although previous research has demonstrated that patients with posttraumatic migraine (PTM) after concussion report more symptoms and cognitive deficits after injury than do those without PTM, it is not known whether these effects persist beyond the first week of injury or whether PTM predicts recovery time.

PURPOSE

To determine whether PTM during the first week after injury predicts (1) cognitive impairment and symptoms in the second week after injury and (2) overall recovery time.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Participants were 138 male high school football players with a mean age of 15.96 years (SD, 1.18 years; range, 13-19 years). They were classified into 3 groups: PTM (headache, nausea, and photosensitivity or phonosensitivity), headache (headache without the other PTM symptoms), or no headache (no headache or PTM symptoms). The Immediate Post-concussion Assessment and Cognitive Test (ImPACT) was used to assess cognitive performance and symptoms at baseline, postinjury days 1-7, and postinjury days 8-14. Recovery time data were collected from medical records.

RESULTS

The PTM group performed worse on verbal memory than did the headache group at 8-14 days after injury. The PTM group performed worse on visual memory, reaction time, and symptoms than did the other groups at 1-7 days and 8-14 days after injury. The PTM group was 7.3 times (95% confidence interval, 1.80-29.91) more likely to have protracted recovery (>20 days) than the no headache group and 2.6 times (95% confidence interval, 1.10-6.54) more likely than the headache group.

CONCLUSION

Results suggest that PTM is associated with cognitive impairments and protracted recovery and that headache alone is not a good predictor of recovery.

A Case for Mental and Physical Rest in Youth Sports Concussion: It's Never too Late

Over the past decade, there has been a considerable increase in research on, and media attention to, sports-related concussion. However, despite accurate diagnosis, effective treatment and management of sports-related concussion have remained a challenge. There are approximately 1.8 million traumatic brain injuries in the United States annually (Faul et al., 2010) and emergency department pediatric visits for suspected concussion have doubled in the past decade (Bakhos et al., 2010). However, health care providers and medical researchers have yet to offer an effective, reliable evidence-based treatment for concussive brain injury. The Zurich 2008 Consensus Statement on Concussion in Sport codified the prescription for cognitive and physical rest immediately following a concussion based on clinical acumen and common sense (McCrory et al., 2009). Currently, rest is the considered the best immediate treatment for concussion. Other supportive and anecdotal treatments are often applied throughout the post-concussive recovery process to address persistent symptoms. The need for empirical research to translate current guidelines for rest into evidence-based treatment protocols is essential. A recent study evaluated the efficacy of comprehensive rest and concluded that such rest may be helpful whether applied soon after a concussion or weeks to months later (Moser et al., 2012). Here, we present a case illustrating the effectiveness of rest in a youth athlete, commenced after experiencing 13 months of post-concussion symptoms. There appears to be value in applying a specific period of cognitive and physical rest following concussion, whether immediately or later in the recovery phase.

In situ free-floating craniectomy: an unusual cause of chronic post-traumatic cephalalgia

We describe a case of post-traumatic cephalalgia in a 54-year-old man with chronic right parieto-occipital headache 3 years posthead injury. At the initial presentation, his Glasgow Coma Scale (GCS) was 13/15 and CT brain revealed an acute subdural haematoma with fronto-temporal contusions. After 24 h his GCS dropped to 8/15 and subsequently he underwent a right-sided craniotomy and evacuation of the subdural haematoma and contusionectomy and intracranial pressure monitoring. To manage the cerebral oedema, the cranial bone flap was left in situ free-floating and was managed in an intensive care setting. He made good clinical recovery and 3 months postoperatively he complained of right-sided headache not relieved with medication and occipital nerve block. Three years later he underwent an exploration of the previous craniotomy scalp wound and the free-floating bone flap under the scalp was immobilised. The headache completely resolved following the procedure and is currently asymptomatic.

The young brain and concussion: imaging as a biomarker for diagnosis and prognosis

Concussion (mild traumatic brain injury (mTBI)) is a significant pediatric public health concern. Despite increased awareness, a comprehensive understanding of the acute and chronic effects of concussion on central nervous system structure and function remains incomplete. Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.