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

Observations from a prospective small cohort study suggest that CGRP genes contribute to acute posttraumatic headache burden after concussion

Introduction

Post-traumatic headache (PTH) is commonly reported after concussion. Calcitonin gene-related peptide (CGRP) is implicated in the pathogenesis of migraine. We explored how single nucleotide polymorphisms (SNPs) from CGRP-alpha (CALCA) and the receptor activity modifying protein-1 (RAMP1) related to headache burden during the first week after concussion.

Methods

A prospective study was performed in 34 collegiate athletes who sustained a concussion. Participants completed the symptom evaluation checklist from the SCAT3 within 48 h of injury (V1), and again 4 (V2) and 7 (V3) days after injury. For each visit, the self-reported score (0–6) for headache, pressure in head, blurred vision, and sensitivity to light/noise were reported and summed to calculate the headache burden. A saliva sample was obtained and genotyped for CALCA (rs3781719) and RAMP1 (rs10185142). RAMP1 (TT, TC, CC) and CALCA (AA, AG, GG) were dichotomized (A+, A- and T+, T-, respectively), and concatenated (T+A+, T+A-, T-A+, T-A-) for analyses.

Results

Headache Burden at Visit 1 was greatest in T+A+ compared to T-A+, and trended toward a significant difference with T+A-. Repeated-measures ANOVA revealed the presence of significant visit main effects (p < 0.001, η2 = 0.404), but the group (p = 0.055) and interaction effects only trended (p = 0.094). Pearson's χ2-tests revealed that 88% of those with return-to play (RTP) exclusions ≥15 days had PTH with multi-sensory symptoms (PTH+SENS) as compared to 35% in those with RTP < 14 day.

Conclusion

Knowledge of RAMP1 and CALCA genotypes appear to improve an understanding the presenting features and magnitude of headache burden after concussion injury.

Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion

BACKGROUND

There is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury.

METHODS

Adults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI).

RESULTS

A total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness.

CONCLUSIONS

This study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Management of Pediatric Post-Concussion Headaches: National Survey of Abortive Therapies Used in the Emergency Department

Children frequently present to an Emergency Department (ED) after concussion, and headache is the most commonly associated symptom. Recent guidelines emphasize the importance of analgesia for post-concussion headache (PCH), yet evidence to inform treatment is lacking. We sought to characterize abortive therapies used to manage refractory PCH in the pediatric ED and factors associated with treatment. A scenario-based survey was distributed to ED physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding ED treatment of acute (48 h) and persistent (1 month) PCH refractory to appropriate doses of acetaminophen/ibuprofen. Logistic regression was used to assess factors associated with treatment. Response rate was 63% (137/219). Nearly all physicians (128/137, 93%) endorsed treatment in the ED for acute PCH of severe intensity, with most selecting intravenous treatments (116/137, 84.7%). Treatments were similar for acute and persistent PCH. The most common treatments were metoclopramide (72%), physiologic saline (47%), and nonsteroidal anti-inflammatory agents (NSAIDS; 35%). Second-line ED treatments were more variable. For acute PCH of moderate intensity, overall treatment was lower (102/137, 74%; p < 0.0001), and NSAIDS (48%) were most frequently selected. In multi-variable regression analyses, no physician- or ED-level factor was associated with receiving treatment, or treatment using metoclopramide specifically. Treatment for refractory PCH in the pediatric ED is highly variable. Importantly, patients with severe PCH are most likely to receive intravenous therapies, often with metoclopramide, despite a paucity of evidence supporting these choices. Further research is urgently needed to establish the comparative effectiveness of pharmacotherapeutic treatments for children with refractory PCH.

The Molecular Pathophysiology of Concussion

After a concussion, a series of complex, overlapping, and disruptive events occur within the brain, leading to symptoms and behavioral dysfunction. These events include ionic shifts, damaged neuronal architecture, higher concentrations of inflammatory chemicals, increased excitatory neurotransmitter release, and cerebral blood flow disruptions, leading to a neuronal crisis. This review summarizes the translational aspects of the pathophysiologic cascade of postconcussion events, focusing on the role of excitatory neurotransmitters and ionic fluxes, and their role in neuronal disruption. We review the relationship between physiologic disruption and behavioral alterations, and proposed treatments aimed to restore the balance of disrupted processes.

Persistent post-traumatic headache: a migrainous loop or not? The clinical evidence

BACKGROUND

Headache is a common complication of traumatic brain injury. The International Headache Society defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following trauma. Acute post-traumatic headache resolves after 3 months, but persistent post-traumatic headache usually lasts much longer and accounts for 4% of all secondary headache disorders.

MAIN BODY

The clinical features of post-traumatic headache after traumatic brain injury resemble various types of primary headaches and the most frequent are migraine-like or tension-type-like phenotypes. The neuroimaging studies that have compared persistent post-traumatic headache and migraine found different structural and functional brain changes, although migraine and post-traumatic headache may be clinically similar. Therapy of various clinical phenotypes of post-traumatic headache almost entirely mirrors the therapy of the corresponding primary headache and are currently based on expert opinion rather than scientific evidence. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, especially impaired sleep and post-traumatic disorder. There are also effective options for non-pharmacologic therapy of post-traumatic headache, including cognitive-behavioral approaches, onabotulinum toxin injections, life-style considerations, etc. CONCLUSION: Notwithstanding some phenotypic similarities, persistent post-traumatic headache after traumatic brain injury, is considered a separate phenomenon from migraine but available data is inconclusive. High-quality studies are further required to investigate the pathophysiological mechanisms of this secondary headache, in order to identify new targets for treatment and to prevent disability.

Can Anything Good Ever Come From Bearing Migraine Attacks? Suggestions for a Comprehensive Concept of Gain in Migraine

PURPOSE OF REVIEW

The purpose of this review is to summarise the current state of knowledge concerning known types of gain, the reasons why patients might seek it, as well as implications for headache disorders.

RECENT FINDINGS

Even though the subject has been studied in the past, it received less attention in recent years. There is no doubt that migraine is a highly disabling disorder. However, attacks sometimes may be beneficial for the migraine brain as a time-out from the daily routine. On the other hand, patients are often stigmatised as trying to satisfy other needs through their disease. These "other needs" may be the exaggerated seeking for attention and affection or an undue official sickness certificate and were named secondary gain. Striving for secondary gain denotes a behaviour that aims at benefiting from a disease in a way that is seen as inappropriate by others. The fact that the term has persisted in doctors' vocabulary for decades probably indicates that it designates a concept considered relevant by many. However, its usage is complicated by its usually imprecise definition. We found in a literature search that the strive for secondary gain is not limited to neurosis, might both occur consciously and unconsciously, sometimes may aim at financial gain and sometimes at social gain, and can either be potentially expected or readily obtained. This behaviour mainly seems to aim at shaping one's interactions with the environment. Its causes have not been elucidated completely, though, but "unrequited demands for love, attention and affection" have been postulated. The desire for social gain can be influenced by approaches based upon behavioural psychology. Broaching the issue of secondary gain may be beneficial in the daily clinical routine.

Treatment of Persistent Post-Traumatic Headache and Post-Concussion Symptoms Using Repetitive Transcranial Magnetic Stimulation: A Pilot, Double-Blind, Randomized Controlled Trial

Persistent post-traumatic headache (PTH) after mild traumatic brain injury is one of the most prominent and highly reported persistent post-concussion symptoms (PPCS). Non-pharmacological treatments, including non-invasive neurostimulation technologies, have been proposed for use. Our objective was to evaluate headache characteristics at 1 month after repetitive transcranial magnetic stimulation (rTMS) treatment in participants with PTH and PPCS. A double-blind, randomized, sham-controlled, pilot clinical trial was performed on 20 participants (18-65 years) with persistent PTH (International Classification of Headache Disorders, 3rd edition) and PPCS (International Classification of Diseases, Tenth Revision). Ten sessions of rTMS therapy (10 Hz, 600 pulses, 70% resting motor threshold amplitude) were delivered to the left dorsolateral pre-frontal cortex. The primary outcome was a change in headache frequency or severity at 1 month post-rTMS. Two-week-long daily headache diaries and clinical questionnaires assessing function, PPCS, cognition, quality of life, and mood were completed at baseline, post-treatment, and at 1, 3, and 6 months post-rTMS. A two-way (treatment × time) mixed analyisis of variance indicated a significant overall time effect for average headache severity (F_(3,54) = 3.214; p = 0.03) and a reduction in headache frequency at 1 month post-treatment (#/2 weeks, REAL -5.2 [standard deviation {SD} = 5.8]; SHAM, -3.3 [SD = 7.7]). Secondary outcomes revealed an overall time interaction for headache impact, depression, post-concussion symptoms, and quality of life. There was a significant reduction in depression rating in the REAL group between baseline and 1 month post-treatment, with no change in the SHAM group (Personal Health Questionnaire-9; REAL, -4.3 [SD = 3.7[ p = 0.020]; SHAM, -0.7 [SD = 4.7; p = 1.0]; Bonferroni corrected). In the REAL group, 60% returned to work whereas only 10% returned in the SHAM group (p = 0.027). This pilot study demonstrates an overall time effect on headache severity, functional impact, depression, PPCS, and quality of life after rTMS treatment in participants with persistent PTH; however, findings were below clinical significance thresholds. There was a 100% response rate, no dropouts, and minimal adverse effects, warranting a larger phase II study. Clinicaltrials.gov: NCT03691272.

An Approach to Identifying Headache Patients That Require Neuroimaging

Headache is one of the most common clinical scenarios faced by a neurologist or neurologist in training. However, the decision process on when to complete neuroimaging can be difficult in clinical practice. This article focuses on a well-organized and evidence-based approach to identify patients with headache that require neuroimaging and will lend confidence to the clinician faced with these scenarios in clinical practice. The approach includes neuroimaging in episodic migraine, chronic migraine, identifying secondary headache disorders in clinic and the emergency department, and discusses pitfalls to over imaging. The article concludes with a flowchart to summarize an overall clinical approach.

Impact of Body Mass Index on Postconcussion Symptoms in Teenagers Aged 13 to 18 Years

CONTEXT

Adolescent obesity and sports-related concussion are rising in prevalence, yet there is minimal research exploring the relationship between these two conditions.

OBJECTIVE

To assess the impact of body mass index (BMI) percentile on duration of recovery and reported symptoms after sports-related concussion in adolescents.

DESIGN

Retrospective chart review at a regional concussion program located at an academic medical center. Medical records of all patients aged 13 to 18 years treated from March 2006 through January 2012 were reviewed. Two hundred fifty-two patients met the inclusion criteria of sports-related concussion and having BMI data.

MAIN OUTCOME MEASURES

Outcome variables included reported emotional symptoms, sleep-related symptoms, physical symptoms (headache), and time to recovery after a concussion. Explanatory variables in this analysis were BMI percentile and sex.

RESULTS

More male patients were obese and overweight than were females (42% vs 27%, p = 0.02). There was no statistically significant difference in recovery time between obese and overweight patients and others. Obese and overweight patients were more likely than healthy-weight patients to report symptoms of irritability (p = 0.05) and impulsivity (p = 0.01), and less likely to report headache (p = 0.03).

CONCLUSION

After concussion, irritability and impulsivity may be more likely than headaches in overweight and obese patients. There was no difference in recovery time between obese and healthy-weight teens. These findings may have importance in the evaluation, treatment, and anticipatory guidance of patients with concussions.

Disability from posttraumatic headache is compounded by coexisting posttraumatic stress disorder

BACKGROUND

Posttraumatic headache (PTH) occurs in up to 82% of patients with traumatic brain injury (TBI). Posttraumatic stress disorder (PTSD) occurs in 39% of those with PTH. This study evaluates whether PTSD affects PTH disability.

METHODS

Eighty-six patients with TBI were prospectively evaluated in a secondary care trauma center. Headache disability was assessed using the Headache Impact Test version 6 and signs indicative of PTSD using the PTSD Check List Civilian version.

RESULTS

Increased PTSD-type symptoms were significantly associated with increased headache disability (p<0.001), as were employment status and loss of consciousness (p=0.049 and 0.016, respectively). Age was negatively correlated with headache disability (Spearman's correlation rho=0.361, p=0.001).

CONCLUSION

Increased severity of PTSD-type symptoms is significantly associated with increased headache disability in patients with chronic PTH. Managing PTSD symptoms in patients with chronic PTH may facilitate headache management.

Staying in service with posttraumatic headache

Objective:

To predict the probability of a military outcome (medical discharge/retirement) in patients with mild traumatic brain injury from a clinical analysis of predetermined patient and headache characteristics.

Methods:

This retrospective cohort study sampled all new patients referred for headache evaluation at the Brain Injury Clinic of the Womack Army Medical Center, Ft. Bragg, NC (August 2008–January 2010). Headache characteristics were extracted and analyzed. Multivariable binary logistic regressions were conducted to predict probability of medical discharge/retirement.

Results:

Ninety-five soldiers (age 31.3 ± 7.4 years, male 93.7%) reported 166 headaches. The most common injury cited was a blast (53.7%). Patients with a continuous headache have almost 4 times the odds of a medically related discharge/retirement compared to patients without such a headache (continuous headache regression coefficient estimate: p < 0.042, odds ratio 3.98, 95% Wald confidence interval 1.05–15.07). Results suggest that, compared to service members who did not have a continuous headache, patients with headache histories with severe holocephalic pain who medicate to keep functioning had the highest probability of medical discharge/retirement.

Conclusions:

Certain headache characteristics may be predictive of military outcomes after mild traumatic brain injury, and we propose a profile that may be useful in that prediction. These data could be useful in future attempts to assess and treat patients with posttraumatic headache and to advise longer-term planning for return to duty or discharge.

Concussion

Concussion has been recognized as a clinical entity for more than 1000 years. Throughout the 20th century it was studied extensively in boxers, but it did not pique the interest of the general population because it is the accepted goal of the boxer to inflict such an injury on their opponent. In 2002, however, the possibility that repetitive concussions could result in chronic brain damage and a progressive neurologic disorder was raised by a postmortem evaluation of a retired player in the most popular sports institution in the United States, the National Football League. Since that time concussion has been a frequent topic of conversation in homes, schools, and on television and has become a major focus of sports programs in communities and schools at all levels. Now all 50 states, the District of Columbia, and the National Collegiate Athletic Association have enacted laws and rules to protect the athlete.

Rest and treatment/rehabilitation following sport-related concussion: a systematic review

AIM OR OBJECTIVE

The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded.

RESULTS

Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care.

SUMMARY/CONCLUSIONS

A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039570.

Sports Neurology in Clinical Practice: Case Studies

With regard to persistent posttraumatic headache, there is legitimate concern that duration of symptoms may have an impact on the efficacy of future treatment attempts. Without neuropathologic confirmation, a clinical diagnosis of chronic traumatic encephalopathy cannot be made with a high degree of confidence. Sport-related headaches are challenging in a return-to-play context, because it is often unclear whether an athlete has an exacerbation of a primary headache disorder, has new-onset headache unrelated to trauma, or is in the recovery phase after concussion. Regular physical exercise may prove beneficial to multiple neurologic disease states.

Demographics and treatment of adolescent posttraumatic headache in a regional concussion clinic

OBJECTIVE

Mild traumatic brain injury affects over one million pediatric patients annually. Minimal data and no guidelines exist regarding treatment of posttraumatic headache (PTH). The current study investigated treatment and outcomes in patients with posttraumatic headache.

METHODS

Medical records of all patients (age 13-18 years of age) seen at a regional concussion program from 2006 to 2011 were reviewed. Statistical analysis using SAS 9.2 was conducted to determine the effectiveness of treatment as well as the association of gender, concussion history, and football participation on the duration of posttraumatic headache.

RESULTS

Four hundred subjects met the inclusion criteria. Females were more likely to report posttraumatic headache than males (90% vs. 79%, P = 0.004), more likely to be prescribed amitriptyline (24% vs. 13%, P = 0.004), and had a significantly longer recovery time (median, 80 days versus 34 days, P < 0.001). Seventeen percent of subjects were prescribed amitriptyline for treatment of posttraumatic headache, of which 82% reported a beneficial effect. There was no difference in the percentage of posttraumatic headache or recovery time in football players versus other male athletes from other sport mechanisms.

CONCLUSION

Females are more likely to report posttraumatic headache than males and also take longer to recover. Amitriptyline appears to be well-tolerated and an effective treatment strategy for patients with posttraumatic headache. Among pediatric patients evaluated in a concussion clinic, there is no difference in the proportion of football players reporting headaches compared with male players of other sports.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.

Chronic daily headache

Chronic daily headache (CDH) is a challenging condition to treat. CDH is often accompanied by significant comorbidities, such as chronic fatigue, depression, anxiety, and insomnia, which further complicate treatment. Unrealistic expectations of treatment goals can lead to patient frustration, and, as a result, decrease treatment adherence. Patients often desire headache-free status, but this outcome is not realistic for many patients with CDH. By contrast, an effective treatment goal starts with establishing the correct diagnosis and creating a multimodal treatment plan to improve function and well-being. With proper comprehensive treatment, the condition improves in most patients.

Cognitive behavioural treatment for the chronic post-traumatic headache patient: a randomized controlled trial

BACKGROUND

Chronic post-traumatic headache (CPTH) after mild head injury can be difficult to manage. Research is scarce and successful interventions are lacking.To evaluate the effect of a group-based Cognitive Behavioural Therapy (CBT) intervention in relation to headache, pain perception, psychological symptoms and quality of life in patients with CPTH.

METHODS

Ninety patients with CPTH according to ICHD-2 criteria were enrolled from the Danish Headache Center into a randomized, controlled trial. Patients were randomly assigned to either a waiting list group or to a nine-week CBT group intervention. At baseline and after 26 weeks all patients completed the Rivermead Post Concussion Symptoms Questionnaire, SF-36, SCL-90-R and a headache diary.

RESULTS

The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms. The waiting-list group experienced no change in headache but, opposed to the treatment group, a significant decrease in somatic and cognitive symptoms indicating a spontaneous remission over time.

CONCLUSIONS

Our primarily negative findings confirm that management of patients with CPTH still remains a considerable challenge. Psychological group therapy with CBT might be effective in an earlier stage of CPTH and in less severely affected patients but our findings strongly underline the need for randomized controlled studies to test the efficacy of psychological therapy.

Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients?

BACKGROUND

The causes of persistent headache following concussion are poorly understood. The objective of this study is to explore analgesic overuse as a potential cause of chronic post-traumatic headache among adolescents referred to a headache clinic following concussion.

METHODS

A retrospective chart review was conducted of all adolescent concussion patients referred to our pediatric headache clinic over the 16-month period between August 1, 2011, and November 30, 2012. Those patients with chronic post-traumatic headaches of 3-12 months' duration who also met International Headache Society criteria for probable medication-overuse headache were identified. Demographic data, concussion symptoms, and headache features were characterized from the initial evaluation and from follow-up visits.

RESULTS

Of 104 adolescent concussion patients referred during the study period, 77 had chronic post-traumatic headache of 3-12 months' duration. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache. Only simple analgesics were overused. Thirty-seven patients (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics; seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up.

CONCLUSION

Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents. Management of patients with chronic post-traumatic headache should include analgesic detoxification when medication overuse is suspected.

Chronic post-traumatic headache after mild head injury: a descriptive study

BACKGROUND

The aetiology behind chronic post-traumatic headache (CPTH) after mild head injury is unclear and management is complicated. In order to optimize treatment strategies we aimed to characterize a CPTH population.

METHODS

Ninety patients with CPTH and 45 patients with chronic primary headaches were enrolled from the Danish Headache Center. All patients were interviewed about demographic and headache data. They completed the Harvard Trauma Questionnaire (HTQ), Rivermead Post Concussion Symptoms Questionnaire, SF-36 and a headache diary.

RESULTS

The CPTH group experienced more cognitive ( P < 0.001) and somatic symptoms ( P = 0.048) and rated their self-perceived health as more affected in terms of physical function ( P = 0.036), physical role function ( P = 0.012) and social function ( P = 0.012) than the control group. Surprisingly, 31% of the CPTH group had a score equal to or above the cut-off score for having post-traumatic stress disorder (PTSD) according to the HTQ. In terms of demographics and headache, the groups were comparable except the CPTH group were more often without affiliation to the labour market ( P < 0.001).

CONCLUSIONS

The loss of work capacity and high levels of disability for the CPTH patients suggests directions for further research into what important factors are embedded in the patients' PTSD symptoms and might explain their prolonged illness.

Neuroimaging biomarkers in mild traumatic brain injury (mTBI)

Reviewed herein are contemporary neuroimaging methods that detect abnormalities associated with mild traumatic brain injury (mTBI). Despite advances in demonstrating underlying neuropathology in a subset of individuals who sustain mTBI, considerable disagreement persists in neuropsychology about mTBI outcome and metrics for evaluation. This review outlines a thesis for the select use of sensitive neuroimaging methods as potential biomarkers of brain injury recognizing that the majority of individuals who sustain an mTBI recover without neuroimaging signs or neuropsychological sequelae detected with methods currently applied. Magnetic resonance imaging (MRI) provides several measures that could serve as mTBI biomarkers including the detection of hemosiderin and white matter abnormalities, assessment of white matter integrity derived from diffusion tensor imaging (DTI), and quantitative measures that directly assess neuroanatomy. Improved prediction of neuropsychological outcomes in mTBI may be achieved with the use of targeted neuroimaging markers.

Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort

AIM

Post-traumatic headaches (PTHs) following mild traumatic brain injury (mTBI) are common; however, few studies have examined the characteristics of PTHs or their response to treatment. The aims of this study were (1) to describe the clinical characteristics of PTH in a prospective cohort of children presenting to a paediatric emergency department with mTBI, and (2) to evaluate the response of PTH to treatment.

METHOD

The emergency department cohort was obtained from a prospective longitudinal cohort study of symptoms following mTBI (n=670; 385 males, 285 females) and a comparison group of children with extracranial injury (n=120; 61 males, 59 females). A retrospective chart review of a separate cohort of children from a brain injury clinic (the treatment cohort) treated for PTH was performed (n=44; 29 females, 15 males; mean age 14 y 1 mo, SD 3 y 1 mo). The median time since injury was 6.9 months (range 1-29 mo). The mean follow-up interval after treatment started was 5.5 weeks (SD 4.3 wks).

RESULTS

Among the emergency department cohort (n=39; 20 males, 19 females; mean age 11 y 1 mo, SD 4 y 3 mo) 11% of children were symptomatic with PTHs at a mean of 15.8 days (SD 11.6d) post injury. Three months post injury, 7.8% of children complained of headaches; of those, 56% had pre-existing headaches and 18% had experienced migraine before the injury. Although headache type varied, 55% met the criteria for migraine. A family or past medical history of migraine was present in 82% of cases. Among the treatment cohort, medications included amitriptyline, flunarizine, topiramate, and melatonin, with an overall response rate of 64%.

CONCLUSION

This is the first prospective cohort study to describe the clinical characteristics of PTHs following mTBI in children. Migraine was the most common headache type seen; other headaches included tension-type, cervicogenic, and occipital neuralgias, and 64% responded to treatment. Referral to a headache specialist should be considered, especially when the features are not typical of one of the primary headache disorders.

Subacute concussion-related symptoms and postconcussion syndrome in pediatrics

PURPOSE OF REVIEW

Millions of youth sustain concussion each year; although most fully recover following an isolated concussion, a significant minority develop prolonged symptoms and disability following concussion. This article reviews recent data regarding the epidemiology of postconcussion syndrome (PCS) and recommendations for the evaluation and management of postconcussive symptoms in pediatrics.

RECENT FINDINGS

PCS is a constellation of symptoms related to head injury including somatic symptoms, sleep dysregulation, cognitive deficits and emotional disturbance. Postconcussive symptoms affect 1.5-11% of concussed youth for more than 1 month after injury, depending on the population studied. Girls have a higher risk of postconcussive headache but it is not clear if cognitive recovery differs between the sexes. Advanced neuroimaging techniques demonstrate a correlation between postconcussive symptoms and functional neurological changes. However, pre-existing and psychosocial factors also affect risk for prolonged PCS. Current treatment strategies are based mainly on expert opinion and studies of related syndromes.

SUMMARY

Although a minority of concussed youth develop prolonged PCS, those who are affected can develop significant disability. Prolonged postconcussive symptoms are likely due to interactions between the biological injury, pre-existing risk factors and psychosocial issues. Further research is essential to improve outcomes for this vulnerable population.

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.

Headaches in soldiers with mild traumatic brain injury: findings and phenomenologic descriptions

OBJECTIVE

The primary goal of this study was to use headache criteria-based classification for headache types described by service members.

BACKGROUND

Headache is common in soldiers returning from the wars in Afghanistan and Iraq. To date, few papers have provided detailed descriptions of these headaches.

METHODS

The first 25 patients seen by a certified headache specialist at the Traumatic Brain Injury Center at Womack Army Medical Center, Fort Bragg, NC, between August 2008 and December 2009 are reported.

RESULTS

Service members described a total of 55 headaches. Most, but not all, headaches began within 1 week after injury. Migraine type was most common. Aura occurred in 5 soldiers. Continuous headaches were described in 88%. Uncommon headache types including cluster type were diagnosed. Additional symptoms and service outcomes are described.

CONCLUSIONS

We conclude that headaches occurring after various types of head injury, including explosions, can be assigned primary and secondary headache diagnoses using standard classifications not necessarily available to larger survey-based studies.

Life quality, depression and anxiety symptoms in chronic post-traumatic headache after mild brain injury

Post-traumatic headache (PTH) is the most common symptom found in the post-traumatic syndrome, whose onset occurs within seven days of the trauma. The condition is characterized as acute when it persists for up to 3 months. PTH beyond this period is considered chronic.

OBJECTIVES

The objective of this study was to determine the clinical features of chronic post-traumatic headache (cPTH) and its association with depression, anxiety and quality of life.

METHODS

A total of 73 female subjects were evaluated. Patients were divided into three groups: (a) group without headache, CONTROL, n=25; (b) cPTH group, n=19; and (c) MIGRAINE, n=29, with all subjects in the 11-84 year age group. Symptoms of anxiety and depression were evaluated by the Beck inventories of anxiety and depression, and quality of life assessed by the Lipp and Rocha quality of life inventory. Qualitative variables were analyzed using the Chi-square or Fisher's exact tests and expressed as percentages whereas quantitative variables were analyzed by ANOVA, Mann-Whitney or Kruskal-Wallis tests with data expressed as mean±standard deviation, p<0.05.

RESULTS

Subjects with cPTH presented with headache manifesting similar features to those found in migraine. The cPTH group was associated with similar levels of anxiety and depression to the migraine group and higher than the CONTROL (p<0.001). Quality of life of individuals with cPTH was similar to that of subjects with migraine and lower than CONTROL subjects (p<0.05).

CONCLUSIONS

cPTH presents similar clinical characteristics to migraine. Subjects with cPTH had high levels of anxiety and depression symptoms and reduced quality of life.