Subcutaneous sumatriptan in the treatment of acute episodes of posttraumatic headache

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

Clinical Evaluation and Treatment of Patients with Postconcussion Syndrome

Postconcussion syndrome (PCS) is a complex set of symptoms occurring in a small percentage of patients following concussion. The condition is characterized by headaches, dizziness, cognitive difficulties, somatosensory issues, and a variety of other symptoms with varying durations. There is a lack of objective markers and standard treatment protocols. With the complexity created by premorbid conditions, psychosomatic issues, secondary gains, and litigations, providers often find themselves in a tough situation in the care of these patients. This article combines literature review and clinical insights with a focus on the underlying pathophysiology of PCS to provide a roadmap for evaluating and treating this condition.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Posttraumatic headache in pediatrics: an update and review

PURPOSE OF REVIEW

Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers.

RECENT FINDINGS

The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA.

SUMMARY

PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.

Mild Traumatic Brain Injury in a High School Football Player With Familial Hemiplegic Migraine: A Case Report

Mild traumatic brain injury is a major concern in young athletes, with an estimated 1.6-3.8 million reported concussions in the United States annually. Familial hemiplegic migraine is a rare autosomal-dominant condition characterized by sporadic episodes of transient unilateral motor weakness that may begin at any age. We present a case of a 17-year-old boy with a history of familial hemiplegic migraine who suffered prolonged symptoms after a mild traumatic brain injury during sports participation.

LEVEL OF EVIDENCE

V.

Pediatric Posttraumatic Headache: A Review

Head injuries are common in pediatrics, and headaches are the most common complaint following mild head trauma. Although moderate and severe traumatic brain injuries occur less frequently, headaches can complicate recovery. There is currently an intense spotlight on concussion and there has been a corresponding increase in the number of children seeking care for headache after mild traumatic brain injury or concussion. Understanding the natural history of, and recognition of factors that are associated with posttraumatic headache will help providers and families to limit disability and may prompt earlier intervention to address disabling headaches. While there are few studies on the treatment of posttraumatic headache, proper evaluation and management of posttraumatic headaches is essential to prevent further injury and to promote recovery. In this article, we will review the current definitions and epidemiology of pediatric posttraumatic headache and discuss current recommendations for the evaluation and management of this syndrome in children and adolescents.

Intravenous migraine therapy in children with posttraumatic headache in the ED

BACKGROUND

More than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are unclear.

OBJECTIVE

The objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response.

METHODS

This was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics.

RESULTS

A total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008).

CONCLUSIONS

Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.

Characteristics of posttraumatic headache following mild traumatic brain injury in military personnel in Iran

OBJECTIVES

The primary goal of this study was to evaluate the incidence and characteristics of posttraumatic headache attributed to mild brain injury in military personnel in Iran within a prospective and observational study design.

METHODS

A prospective observational descriptive study was conducted with a cohort of military personnel under military education during a 6-month period at the Military Education Center in Isfahan, Iran. 322 military personnel under education were selected randomly and were given a 13-item mild brain injury questionnaire accompanied with affective disorders and headache questionnaires and were reevaluated after a 3-month interval.

RESULTS

A total of 30 (9.3 %) of the 322 military personnel met criteria for a mild brain injury. Among them, 18 personnel (60 %) reported having headaches during the 3-month reevaluation. PTHs defined as headaches beginning within 1 week after a head trauma were present in 5.6 % of military personnel under study during 6 months. In total, 67 % of posttraumatic headaches (PTH) were classified as migrainous or possible migrainous features. Patients with affective disorders such as posttraumatic stress disorder and depression were at a higher risk for developing PTH following mild brain injury (p < 0.05). PTH did not relate to demographic factors such as age or type of trauma.

CONCLUSIONS

Posttraumatic headache attributed to mild brain injury is a common disorder in military personnel. Migrainous features are predominant among them in comparison with the general population. PTH is not related to a type of trauma, but has association with affective disorders.

Posttraumatic headaches in civilians, soldiers, and athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After mild head injury, more than 50% of people develop a postconcussion syndrome which has been controversial for more than 150 years. Headache is estimated as present in 30% to 90% of patients after mild head injury. Most headaches are of the tension type, although migraines can increase in frequency or occur acutely or chronically de novo. A review is provided of headaches in civilians, soldiers after blast trauma, athletes, and post-craniotomy including pathogenesis. The treatments are the same as for the primary phenotypes.

Posttraumatic headache

PURPOSE OF REVIEW

Posttraumatic headache (PTH) is a commonly occurring and potentially disabling consequence of concussion and mild traumatic brain injury (mTBI). This brief review highlights recent advances in the epidemiology, evaluation, and management of concussion, mTBI, and PTH.

RECENT FINDINGS

Current epidemiological studies suggest that previous estimates of concussion and mTBI incidence are grossly underestimated and have also helped to identify specific activities and demographic groups that might be more susceptible. Concussion results in profound metabolic derangements during which the brain is potentially vulnerable to repeat injury and permanent damage. Imaging studies such as magnetic resonance (MR) spectroscopy and diffusion tensor imaging have proven to be effective at identifying these abnormalities both acutely and also weeks after symptoms resolution. To date, there have been no randomized, placebo-controlled studies supporting the efficacy of any treatment for PTH and current therapeutic decisions are guided only by expert opinion and current evidence-based guidelines for the treatment of specific primary headache phenotypes, the most commonly occurring of which is migraine.

SUMMARY

Despite numerous advances in the awareness, pathophysiology, and diagnostic workup of concussion, mTBI, and PTH, there is a paucity of evidence-based guidance regarding treatment.

Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study

BACKGROUND

he effectiveness of medical therapies for chronic post-traumatic headaches (PTHs) attributable to mild head trauma in military troops has not been established.

OBJECTIVE

To determine the treatment outcomes of acute and prophylactic medical therapies prescribed for chronic PTHs after mild head trauma in US Army soldiers.

METHODS

A retrospective cohort study was conducted with 100 soldiers undergoing treatment for chronic PTH at a single US Army neurology clinic. Headache frequency and Migraine Disability Assessment (MIDAS) scores were determined at the initial clinic visit and then again by phone 3 months after starting headache prophylactic medication. Response rates of headache abortive medications were also determined. Treatment outcomes were compared between subjects with blast-related PTH and non-blast PTH.

RESULTS

Ninety-nine of 100 subjects were male. Seventy-seven of 100 subjects had blast PTH and 23/100 subjects had non-blast PTH. Headache characteristics were similar for blast PTH and non-blast PTH with 96% and 95%, respectively, resembling migraine. Headache frequency among all PTH subjects decreased from 17.1 days/month at baseline to 14.5 days/month at follow-up (P = .009). Headache frequency decreased by 41% among non-blast PTH compared to 9% among blast PTH. Fifty-seven percent of non-blast PTH subjects had a 50% or greater decline in headache frequency compared to 29% of blast PTH subjects (P =.023). A significant decline in headache frequency occurred in subjects treated with topiramate (n = 29, -23%, P = .02) but not among those treated with a low-dose tricyclic antidepressant (n = 48, -12%, P = .23). Seventy percent of PTH subjects who used a triptan class medication experienced reliable headache relief within 2 hours compared to 42% of subjects using other headache abortive medications (P = .01). Triptan medications were effective for both blast PTH and non-blast PTH (66% response rate vs 86% response rate, respectively; P = .20). Headache-related disability, as measured by mean MIDAS scores, declined by 57% among all PTH subjects with no significant difference between blast PTH (-56%) and non-blast PTH (-61%).

CONCLUSIONS

Triptan class medications are usually effective for aborting headaches in military troops with chronic PTH attributed to a concussion from a blast injury or non-blast injury. Topiramate appears to be an effective headache prophylactic therapy in military troops with chronic PTH, whereas low doses of tricyclic antidepressants appear to have little efficacy. Chronic PTH triggered by a blast injury may be less responsive to commonly prescribed headache prophylactic medications compared to non-blast PTH. These conclusions require validation by prospective, controlled clinical trials.

From psychoneurosis to ICHD-2: an overview of the state of the art in post-traumatic headache

Post-traumatic headache (PTH) is an important public health issue - head injuries are common, headache is the most common sequelae of head injuries, and PTH can be particularly disabling. Fortunately, for most individuals with PTH, the headache gradually dissipates over a period of several days, weeks, or months either spontaneously or aided by non-pharmacologic and/or pharmacologic management. Regrettably, for a minority of head-injured individuals, the PTH is intractable and disabling despite aggressive and comprehensive treatment. Unfortunately, there are many prejudices against individuals with PTH. Frequently, the presence or absence of litigation and/or the mechanism of head injury (sports-related trauma, slip-and-fall injury, motor vehicle accident, or military service-related injury) biases physicians' views on the legitimacy of the patient's PTH. Accordingly, this review attempts to summarize the state of the art of our understanding of PTH. This clinical review highlights: (a) views on PTH throughout the last few centuries, (b) the ICHD-2 classification of PTH, (c) the epidemiology of head injuries and PTH, (d) the clinical characteristics of PTH, (e) PTH related postconcussive symptoms, (f) pathophysiology of PTH, (g) evaluation of PTH, and (h) management of PTH.

Subcutaneous sumatriptan in an adolescent with acute posttraumatic headache

Acute posttraumatic headache is common and can evolve into chronic posttraumatic headache, which is associated with medication overuse and disability. However, there are few studies to guide treatment management of acute posttraumatic headache. We describe an adolescent with acute posttraumatic headache that did not respond to several initial medications but had rapid and sustained improvement in headache and associated migrainous features with subcutaneous sumatriptan.

Post-traumatic headache

Post-traumatic headaches as well as post-traumatic syndrome can occur in patients after mild, moderate, or severe traumatic brain injury. Most of the patients' symptoms clear within the first 3 to 6 months; however, there are no precise criteria for predicting the clinical outcome. The diagnostic criteria for post-traumatic headaches were defined by the International Headache Society in 2004 and are helpful for classification. Evaluation must be done on an individual basis, and patients who do not clear their symptoms may need neuroimaging. The headaches fall into the category of chronic tension-type headache as well as headaches compatible with migraine and are treated in a similar fashion. There is a small group of people who do not respond and have long-term problems. These patients may benefit from a combination of pharmacologic, nonpharmacologic, and neuropsychiatric treatment. Long-term studies are needed to help clarify the history of these patients.

Pediatric post-traumatic headache

Post-traumatic headache after craniocerebral trauma is not an uncommon occurrence in children and adolescents. It can occur after mild, moderate, or severe injury. The headache may have features of tension-type headache, migraine, or probable migraine and is rarely seen in isolation. It is often part of a syndrome encompassing a variety of somatic and psychobehavioral symptoms. In time, the headache and accompanying symptoms gradually resolve over a period of 8 to 12 weeks. However, sometimes it may become chronic, requiring a multidimensional management approach including pharmacologic intervention, physical rehabilitation, and cognitive-behavioral therapy as used in the adult population.

Characteristics and Treatment of Headache After Traumatic Brain Injury

Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH). Although most PTH resolves within 6-12 mos after injury, approximately 18-33% of PTH persists beyond 1 yr. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Although there is no universally accepted protocol for treating PTH, many clinicians treat PTH as if they were managing primary headache. As a result of the heterogeneity in the terminology and paucity in prospective, well-controlled studies in this field, there is a definite need for conducting double-blind, placebo-controlled treatment trials in patients with PTH.

Posttraumatic headache

Posttraumatic headache (PTH) is divided into acute and chronic groups whose management and prognosis are clearly different. Although IHS criteria stipulate that PTH should have an onset within 2 weeks of the trauma, it has been observed that a headache linked to the trauma can start later. PTH can be clinically divided into the following groups: migraine-like headache, tension-type-like headache, cluster-like headache, cervicogenic-like headache, and others. Based on these clinical distinctions, therapy can be administered accordingly. However, the distinction is relative and numerous clinical features may be common to all. There seems to be a weak inverse relationship between the severity of the head trauma and the occurrence of a PTH, especially chronic. A holistic approach is not only useful but it is necessary for a therapeutic success. Early and aggressive treatment and empathy are essential to the patient's improvement. Prompt recognition and treatment of laceration, peripheral nociceptive sources such as cervical joint displacement, vascular factors, may diminish chronicity. Neuromodulation of pain with prophylactic agents is recommended early. Although it is less necessary for the acute PTH, it will be crucial for the chronic form and should be initiated no later than 2 months cut-off time between acute and chronic PTH. Recognition and treatment of psychiatric factors such as depression and anxiety will lessen the risk of chronicity. Analgesic rebound-withdrawal headache commonly is seen in chronic PTH. This must be corrected rapidly because it can protract the headache and render other inappropriate therapeutic measures inefficient.

Challenging or difficult headache patients

This article addresses interesting and enigmatic presentations of headache from a diagnostic and treatment perspective. The emphasis is on migraineurs and other headache patients who represent a significant burden for the primary care provider. In particular, the author focuses on undiagnosed migraine, menstrual migraine, migraine in pregnancy, intractable migraine and status migrainosus,transformed migraine, hemiplegic migraine, basilar migraine, "triptan syndrome," sudden onset of severe headache, post-traumatic headache, and headache in elderly patients.

Headache and the cervical spine: a critical review

Headache related to the cervical spine is often misdiagnosed and treated inadequately because of confusing and varying terminology. Primary headaches such as tension-type headache and migraine are incorrectly categorized as "cervicogenic" merely because of their occipital localization. Cervicogenic headache as described by Sjaastad presents as a unilateral headache of fluctuating intensity increased by movement of the head and typically radiates from occipital to frontal regions. Definition, pathophysiology; differential diagnoses and therapy of cervicogenic headache are demonstrated. Ipsilateral blockades of the C2 root and/or greater occipital nerve allow a differentiation between cervicogenic headache and primary headache syndromes such as migraine or tension-type headache. Neither pharmacological nor surgical or chiropractic procedures lead to a significant improvement or remission of cervicogenic headache. Pains of various anatomical regions possibly join into a common anatomical pathway, then present as cervicogenic headache, which should therefore be understood as a homogeneous but also unspecific pattern of reaction.

Sumatriptan. A reappraisal of its pharmacology and therapeutic efficacy in the acute treatment of migraine and cluster headache

Sumatriptan is a potent and selective agonist at a vascular serotonin1 (5-hydroxytryptamine1; 5-HT1) receptor subtype (similar to 5-HT1D) and is used in acute treatment of migraine and cluster headache. Following administration of sumatriptan 100mg orally, relief of migraine headache (at 2 hours) was achieved in 50 to 67% of patients compared with 10 to 31% with placebo in controlled clinical trials. In a comparative study, oral administration of sumatriptan 100mg consistently achieved significantly greater response rates than a fixed combination of ergotamine 2mg plus caffeine 200mg during 3 consecutive migraine attacks (66 vs 48% for first attack). Oral sumatriptan 100mg was also more effective than aspirin 900mg plus metoclopramide 10mg orally in a similar study. In the majority of controlled clinical trials, headache relief (at 1 hour after administration) was achieved in 70 to 80% of patients with migraine receiving sumatriptan 6mg subcutaneously compared with 18 to 26% of placebo recipients. Approximately 40% of patients who initially responded to oral or subcutaneous sumatriptan experienced recurrence of their headache, usually within 24 hours, but the majority of these patients responded well to a further dose of sumatriptan. Patients with cluster headache were treated for acute attacks with sumatriptan 6mg subcutaneously or placebo in 2 crossover trials. Headache relief was achieved within 15 minutes in 74 and 75% of patients receiving sumatriptan in these studies compared with 26 and 35%, respectively, with placebo. Patients receiving sumatriptan 12mg had a similar response rate as those receiving 6mg, but the higher dose was associated with an increased incidence of adverse events. Based on extensive safety data pooled from controlled clinical trials, sumatriptan is generally well tolerated and most adverse events are transient. The most frequently reported adverse events following oral administration include nausea, vomiting, malaise, fatigue and dizziness. Injection site reactions (minor pain and redness of brief duration) occur in approximately 40% of patients receiving subcutaneous sumatriptan, although the incidence appears to be markedly reduced when patients self-administer the drug with an auto-injector. Chest symptoms (mainly tightness and pressure) occur in 3 to 5% of sumatriptan recipients, but have not been associated with myocardial ischaemia except in a few isolated cases. Sumatriptan is contraindicated in patients with ischaemic heart disease, angina pectoris including Prinzmetal (variant) angina, previous myocardial infarction and uncontrolled hypertension, but is not contraindicated in patients with migraine and asthma. Data from long term studies in acute treatment of migraine and cluster headache suggest that sumatriptan remains effective and well tolerated over several months.(ABSTRACT TRUNCATED AT 400 WORDS)