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

Management of Pain and Headache After Traumatic Brain Injury

This article will identify common causes of pain following traumatic brain injury (TBI), discuss current treatment strategies for these complaints, and help tailor treatments for both acute and chronic settings. We will also briefly discuss primary and secondary headache disorders, followed by common secondary pain disorders that may be related to trauma.

American Headache Society white paper on treatment of post-traumatic headache from concussion in youth

OBJECTIVE

To provide healthcare professionals guidance on youth at risk for prolonged recovery and post-traumatic headache (PTH), and on pharmacologic and non-pharmacologic management of PTH due to concussion and mild traumatic brain injury.

BACKGROUND

Headache is the most common persistent post-concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines.

METHODS

This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society.

RESULTS

Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair-to-poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro-modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective.

CONCLUSIONS

This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth.

Evaluating the Phenotypic Patterns of Post-Traumatic Headache: A Systematic Review of Military Personnel

INTRODUCTION

Mild traumatic brain injury (TBI) affects a significant number of military personnel, primarily because of physical impact, vehicle incidents, and blast exposure. Post-traumatic headache (PTH) is the most common symptom reported following mild TBI and can persist for several years. However, the current International Classification of Headache Disorders lacks phenotypic characterization for this specific headache disorder. It is important to appropriately classify the headache sub-phenotypes as it may enable more targeted management approaches. This systematic review seeks to identify the most common sub-phenotype of headaches in military personnel with PTH attributed to mild TBI.

METHODS

We conducted a systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines, focusing on the military population. PubMed, Web of Science, Cochrane, and Clinicaltrials.gov databases were searched. Abstracts and full texts were independently reviewed by two authors using predefined inclusion and exclusion criteria. Data extraction was performed using a standardized form. The risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Eight papers related to the military population were included in this review. Migraine was the most commonly reported headache sub-phenotype, with a prevalence ranging from 33 to 92%. Additionally, one military study identified tension-type headaches as the most prevalent headache phenotype. Although not the primary phenotype, one military cohort reported that approximately one-third of their cohort experienced trigeminal autonomic cephalalgias, which were associated with exposure to blast injuries and prior concussions.

CONCLUSION

This systematic review demonstrated that PTH in the military population frequently exhibit migraine-like features. Tension-type headache and trigeminal autonomic cephalalgias also occur, although less commonly reported. Sub-phenotyping PTH may be important for initiating effective treatment since different phenotypes may respond differently to medications. The study populations analyzed in this systematic review display heterogeneity, underscoring the necessity for additional research features, more stringent criteria and comprehensive recording of baseline characteristics. Characterizing headaches following injury is crucial for an accurate diagnosis to enable effective management and rehabilitation planning for our armed forces.

A Systematic Review of Chronic Pain Management Interventions Among Veterans of Recent Wars and Armed Conflicts

OBJECTIVES

To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

Key words "chronic pain," "veterans," and "injuries" were used to search for articles in the MEDLINE, CINAHL, APA PsycInfo, and Embase databases. Articles published in English between 2000 and 2023 were included.

REVIEW/ANALYSIS METHODS

A systematic literature search was conducted in June 2020, updated in April 2023, and managed using Covidence review software. Inclusion criteria focused on combat-injured veterans with chronic pain, excluding nonveterans and civilians treated for acute or chronic pain. Data from included studies were extracted, summarized, and critically appraised using the 2018 Mixed Methods Appraisal Tool. This review is registered with PROSPERO (CRD42020207435).

RESULTS

Fourteen studies met the inclusion criteria, with 10 of them supporting nonpharmacological approaches for managing chronic pain among veterans of armed conflicts and wars. Interventions included psychological/behavioral therapies, peer support, biofeedback training via telephone-based therapy, manual therapy, yoga, cognitive processing therapy, cognitive-behavioral therapy, and social and community integration to reduce pain intensity and enhance functional outcomes.

CONCLUSION

Nonpharmacological treatments for chronic pain have increased in recent years, a shift from earlier reliance on pharmacological treatments. More evidence from randomized controlled trials on the benefits of combined pain interventions could improve pain management of veterans with complex care needs.

Posttraumatic headache is a distinct headache type from migraine

PURPOSE OF REVIEW

Posttraumatic headache (PTH), a headache that develops within 7 days of a causative injury, is one of the most common secondary headaches, mostly attributed to mild traumatic brain injury (mTBI). Because presence of preinjury headache is a risk factor for developing PTH and PTH symptoms often resemble migraine or tension-type headache, the association between PTH and primary headaches has attracted attention from clinicians and scientists.

RECENT FINDINGS

Recent studies on epidemiological aspects, headache features, risk factors, imaging characteristics, and response to treatment, suggest overlapping features and distinct objective findings in PTH compared to migraine.

SUMMARY

We argue that PTH is distinct from migraine. Therefore, PTH epidemiology, pathophysiology, diagnosis, treatment, and prognosis should continue to be investigated separately from migraine.

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.

Treatment Options for Posttraumatic Headache: A Current Review of the Literature

PURPOSE OF REVIEW

We evaluate evidence-based treatments for posttraumatic headache (PTH), a secondary headache disorder resulting from traumatic brain injury (TBI), comprising nearly 4% of all symptomatic headache disorders. Utilizing recent publications, we aim to inform clinicians of current treatment methods.

RECENT FINDINGS

There is limited research on PTH treatment. A randomized controlled trial (RCT) of metoclopramide with diphenhydramine for acute PTH found that the treatment group (N = 81) experienced more significant pain improvement than placebo by 1.4 points. For persistent PTH, an open-label study of erenumab (N = 89) found that 28% of participants reported ≥ 50% reduction in moderate-to-severe headache days, but an RCT of fremanezumab showed a non-significant reduction in moderate-to-severe headache days. A randomized crossover study of 40 patients with persistent PTH found that onabotulinum toxin-A decreased cumulative number of headaches/week by 43.3% in the treatment group and increased by 35.1% among placebos. In a study of military veterans with severe posttraumatic stress disorder and persistent/delayed onset PTH (N = 193), patients who received Cognitive Behavioral Therapy reported significant improvements in headache-related disability compared to usual care (aggregate mean HIT-6, -3.4). A transcranial magnetic stimulation (N = 24) study found that 58% of participants with mild TBI-related headache experienced a 50% reduction in headache frequency. New studies indicate promise in improving clinically important outcomes of PTH. However, more research is necessary to determine the optimal treatment and whether combining pharmacologic and nonpharmacologic treatment versus a single modality is more effective.

Posttraumatic Headache

OBJECTIVE

This article provides an overview of the epidemiology, diagnosis, clinical presentation, pathophysiology, prognosis, and treatment of posttraumatic headache attributed to mild traumatic brain injury (mTBI).

LATEST DEVELOPMENTS

The International Classification of Headache Disorders, Third Edition requires that posttraumatic headache begin within 7 days of the inciting trauma. Although posttraumatic headache characteristics and associated symptoms vary, most commonly there is substantial overlap with symptoms of migraine or tension-type headache. New insights into posttraumatic headache pathophysiology suggest roles for neuroinflammation, altered pain processing and modulation, and changes in brain structure and function. Although the majority of posttraumatic headache resolves during the acute phase, about one-third of individuals have posttraumatic headache that persists for at least several months. Additional work is needed to identify predictors and early markers of posttraumatic headache persistence, but several potential predictors have been identified such as having migraine prior to the mTBI, the total number of TBIs ever experienced, and the severity of initial symptoms following the mTBI. Few data are available regarding posttraumatic headache treatment; studies investigating different treatments and the optimal timing for initiating posttraumatic headache treatment are needed.

ESSENTIAL POINTS

Posttraumatic headache begins within 7 days of the causative injury. The characteristics of posttraumatic headache most commonly resemble those of migraine or tension-type headache. Posttraumatic headache persists for 3 months or longer in about one-third of individuals. Additional studies investigating posttraumatic headache treatment are needed.

Strain in the Midbrain: Impact of Traumatic Brain Injury on the Central Serotonin System

Traumatic brain injury (TBI) is a pervasive public health crisis that severely impacts the quality of life of affected individuals. Like peripheral forms of trauma, TBI results from extraordinarily heterogeneous environmental forces being imparted on the cranial space, resulting in heterogeneous disease pathologies. This has made therapies for TBI notoriously difficult to develop, and currently, there are no FDA-approved pharmacotherapies specifically for the acute or chronic treatment of TBI. TBI is associated with changes in cognition and can precipitate the onset of debilitating psychiatric disorders like major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Complicating these effects of TBI, FDA-approved pharmacotherapies utilized to treat these disorders often fail to reach the desired level of efficacy in the context of neurotrauma. Although a complicated association, decades of work have linked central serotonin (5-HT) neurotransmission as being involved in the etiology of a myriad of neuropsychiatric disorders, including MDD and GAD. 5-HT is a biogenic monoamine neurotransmitter that is highly conserved across scales of biology. Though the majority of 5-HT is isolated to peripheral sites such as the gastrointestinal (GI) tract, 5-HT neurotransmission within the CNS exerts exquisite control over diverse biological functions, including sleep, appetite and respiration, while simultaneously establishing normal mood, perception, and attention. Although several key studies have begun to elucidate how various forms of neurotrauma impact central 5-HT neurotransmission, a full determination of precisely how TBI disrupts the highly regulated dynamics of 5-HT neuron function and/or 5-HT neurotransmission has yet to be conceptually or experimentally resolved. The purpose of the current review is, therefore, to integrate the disparate bodies of 5-HT and TBI research and synthesize insight into how new combinatorial research regarding 5-HT neurotransmission and TBI may offer an informed perspective into the nature of TBI-induced neuropsychiatric complications.

Sensory hypersensitivities are associated with post-traumatic headache-related disability

OBJECTIVE

To examine whether sensory hypersensitivity contributes to headache-related disability in a secondary analysis of patients with post-traumatic headache.

BACKGROUND

Up to one-third of individuals with traumatic brain injuries report persistent headache 3 months post-injury. High rates of allodynia and photophobia have been observed in clinical studies and animal models of post-traumatic headache, but we do not fully understand how sensory amplifications impact post-traumatic headache-related disability.

METHODS

We identified a cross-sectional sample of patients from the American Registry for Migraine Research database with new or worsening headaches post-head injury from 2016 to 2020 and performed a secondary analysis of those data. We modeled the relationship between sensory sensitivity and Migraine Disability Assessment scores using questionnaires. Candidate variables included data collection features (study site and year), headache-related and general clinical features (headache frequency, migraine diagnosis, abuse history, sex, age, cognitive and affective symptom scores), and sensory symptoms (related to light, sound, and touch sensitivity).

RESULTS

The final sample included 193 patients (median age 46, IQR 22; 161/193, 83.4% female). Migraine Disability Assessment scores ranged from 0 to 260 (median 47, IQR 87). The final model included allodynia, hyperacusis, photosensitivity, headache days per month, abuse history, anxiety and depression, cognitive dysfunction, and age (R2  = 0.43). An increase of one point in allodynia score corresponded to a 3% increase in headache disability (95% CI: 0%-7%; p = 0.027), an increase of one-tenth of a point in the photosensitivity score corresponded to a 12% increase (95% CI: 3%-25%; p = 0.002), and an increase of one point in the hyperacusis score corresponded to a 2% increase (95% CI: 0%-4%; p = 0.016).

CONCLUSIONS

Increased photosensitivity, allodynia, and hyperacusis were associated with increased headache-related disability in this sample of patients with post-traumatic headache. Symptoms of sensory amplification likely contribute to post-traumatic headache-related disability and merit an ongoing investigation into their potential as disease markers and treatment targets.

Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies

Post-traumatic headache (PTH) is a common and debilitating consequence of mild traumatic brain injury (mTBI) that can occur over one year after the head impact event. Thus, better understanding of the underlying pathophysiology and risk factors could facilitate early identification and management of PTH. There are several factors that could influence the reporting of PTH prevalence, including the definition of concussion and PTH. The main risk factors for PTHs include a history of migraines or headaches, female gender, younger age, greater severity of the head injury, and co-occurring psychological symptoms, such as anxiety and depression. PTH clinical profiles vary based on onset, duration, and severity: tension-type headache, migraine headaches, cervicogenic headache, occipital neuralgia, and new daily persistent headache. Pharmacological treatments often consist of analgesics and non-steroidal anti-inflammatory drugs, tricyclic antidepressants, or antiepileptic medication. Cognitive behavioral therapy, relaxation techniques, biofeedback, and physical therapy could also be used for PTH treatment. Our work highlighted the need for more rigorous studies to better describe the importance of identifying risk factors and patient-centered treatments and to evaluate the effectiveness of the existing treatment options. Clinicians should consider a multidisciplinary approach to managing PTH, including pharmacotherapy, cognitive behavioral therapy, and lifestyle changes.

Randomized controlled pilot trial of prazosin for prophylaxis of posttraumatic headaches in active-duty service members and veterans

OBJECTIVE

Evaluate the efficacy and tolerability of prazosin for prophylaxis of headaches following mild traumatic brain injury in active-duty service members and military veterans.

BACKGROUND

Prazosin is an alpha-1 adrenoreceptor antagonist that reduces noradrenergic signaling. An open-label trial in which prazosin reduced headache frequency in veterans following mild traumatic brain injury provided the rationale for this pilot study.

METHODS

A 22-week parallel-group randomized controlled trial  which included 48 military veterans and active-duty service members with mild traumatic brain injury-related headaches was performed. The study design was based on International Headache Society consensus guidelines for randomized controlled trials for chronic migraine. Following a pre-treatment baseline phase, participants with at least eight qualifying headache days per 4 weeks were randomized 2:1 to prazosin or placebo. After a 5-week titration to a maximum possible dose of 5 mg (morning) and 20 mg (evening), participants were maintained on the achieved dose for 12 weeks. Outcome measures were evaluated in 4-week blocks during the maintenance dose phase. The primary outcome measure was change in 4-week frequency of qualifying headache days. Secondary outcome measures were percent participants achieving at least 50% reduction in qualifying headache days and change in Headache Impact Test-6 scores.

RESULTS

Intent-to-treat analysis of randomized study participants (prazosin N = 32; placebo N = 16) demonstrated greater benefit over time in the prazosin group for all three outcome measures. In prazosin versus placebo participants, reductions from baseline to the final rating period for 4-week headache frequency were -11.9 ± 1.0 (mean ± standard error) versus -6.7 ± 1.5, a prazosin minus placebo difference of -5.2 (-8.8, -1.6 [95% confidence interval]), p = 0.005 and for Headache Impact Test-6 scores were -6.0 ± 1.3 versus +0.6 ± 1.8, a difference of -6.6 (-11.0, -2.2), p = 0.004. The mean predicted percent of participants at 12 weeks with ≥50% reduction in headache days/4 weeks, baseline to final rating, was 70 ± 8% for prazosin (21/30) versus 29 ± 12% for placebo (4/14), odds ratio 5.8 (1.44, 23.6), p = 0.013. The trial completion rate of 94% in the prazosin group (30/32) and 88% in the placebo group (14/16) indicated that prazosin was generally well tolerated at the administered dose regimen. Morning drowsiness/lethargy was the only adverse effect that differed significantly between groups, affecting 69% of the prazosin group (22/32) versus 19% of the placebo group (3/16), p = 0.002.

CONCLUSIONS

This pilot study provides a clinically meaningful efficacy signal for prazosin prophylaxis of posttraumatic headaches. A larger randomized controlled trial is needed to confirm and extend these promising results.

The value of brain MRI functional connectivity data in a machine learning classifier for distinguishing migraine from persistent post-traumatic headache

Background

Post-traumatic headache (PTH) and migraine often have similar phenotypes. The objective of this exploratory study was to develop classification models to differentiate persistent PTH (PPTH) from migraine using clinical data and magnetic resonance imaging (MRI) measures of brain structure and functional connectivity (fc).

Methods

Thirty-four individuals with migraine and 48 individuals with PPTH attributed to mild TBI were included. All individuals completed questionnaires assessing headache characteristics, mood, sensory hypersensitivities, and cognitive function and underwent brain structural and functional imaging during the same study visit. Clinical features, structural and functional resting-state measures were included as potential variables. Classifiers using ridge logistic regression of principal components were fit on the data. Average accuracy was calculated using leave-one-out cross-validation. Models were fit with and without fc data. The importance of specific variables to the classifier were examined.

Results

With internal variable selection and principal components creation the average accuracy was 72% with fc data and 63.4% without fc data. This classifier with fc data identified individuals with PPTH and individuals with migraine with equal accuracy.

Conclusion

Multivariate models based on clinical characteristics, fc, and brain structural data accurately classify and differentiate PPTH vs. migraine suggesting differences in the neuromechanism and clinical features underlying both headache disorders.

Headache classification and automatic biomarker extraction from structural MRIs using deep learning

Data-driven machine-learning methods on neuroimaging (e.g. MRI) are of great interest for the investigation and classification of neurological diseases. However, traditional machine learning requires domain knowledge to delineate the brain regions first, followed by feature extraction from the regions. Compared with this semi-automated approach, recently developed deep learning methods have advantages since they do not require such prior knowledge; instead, deep learning methods can automatically find features that differentiate MRIs from different cohorts. In the present study, we developed a deep learning-based classification pipeline distinguishing brain MRIs of individuals with one of three types of headaches [migraine (n = 95), acute post-traumatic headache (n = 48) and persistent post-traumatic headache (n = 49)] from those of healthy controls (n = 532) and identified the brain regions that most contributed to each classification task. Our pipeline included: (i) data preprocessing; (ii) binary classification of healthy controls versus headache type using a 3D ResNet-18; and (iii) biomarker extraction from the trained 3D ResNet-18. During the classification at the second step of our pipeline, we resolved two common issues in deep learning methods, limited training data and imbalanced samples from different categories, by incorporating a large public data set and resampling among the headache cohorts. Our method achieved the following classification accuracies when tested on independent test sets: (i) migraine versus healthy controls-75% accuracy, 66.7% sensitivity and 83.3% specificity; (2) acute post-traumatic headache versus healthy controls-75% accuracy, 66.7% sensitivity and 83.3% specificity; and (3) persistent post-traumatic headache versus healthy controls-91.7% accuracy, 100% sensitivity and 83.3% specificity. The most significant biomarkers identified by the classifier for migraine were caudate, caudal anterior cingulate, superior frontal, thalamus and ventral diencephalon. For acute post-traumatic headache, lateral occipital, cuneus, lingual, pericalcarine and superior parietal regions were identified as most significant biomarkers. Finally, for persistent post-traumatic headache, the most significant biomarkers were cerebellum, middle temporal, inferior temporal, inferior parietal and superior parietal. In conclusion, our study shows that the deep learning methods can automatically detect aberrations in the brain regions associated with different headache types. It does not require any human knowledge as input which significantly reduces human effort. It uncovers the great potential of deep learning methods for classification and automatic extraction of brain imaging-based biomarkers for these headache types.

Targeted dietary interventions to reduce pain in persistent post-traumatic headache among service members: Protocol for a randomized, controlled parallel-group trial

INTRODUCTION

Post-traumatic headache (PTH) is common after traumatic brain injury (TBI), especially among active-duty service members (SMs), affecting up to 35% of patients with chronic TBI. Persistent PTH is disabling and frequently unresponsive to treatment and is often migrainous. Here, we describe a trial assessing whether dietary modifications to increase n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and reduce n-6 linoleic acid (LA), will alter nociceptive lipid mediators and result in clinical improvements in persistent PTH.

METHODS

This prospective, randomized, controlled trial tests the efficacy, safety, and biochemical effects of targeted, controlled alterations in dietary n-3 and n-6 fatty acids in 122 adult SMs and military healthcare beneficiaries with diagnosed TBI associated with actively managed persistent frequent (>8 /month) PTH with migraine. Following a 4-week baseline, participants are randomized to one of two equally intensive dietary regimens for 12 additional weeks: 1) increased n-3 EPA + DHA with low n-6 LA (H3L6); 2) usual US dietary content of n-3 and n-6 fatty acids (Control). During the intervention, participants receive diet arm-specific study oils and foods sufficient for 75% of caloric needs and comprehensive dietary counseling. Participants complete daily headache diaries throughout the intervention. Clinical outcomes, including the Headache Impact Test (HIT-6), headache hours per day, circulating blood fatty acid levels, and bioactive metabolites, are measured pre-randomization and at 6 and 12 weeks. Planned primary analyses include pre-post comparisons of treatment groups on clinical measures using ANCOVA and mixed-effects models. Similar approaches to explore biochemical and exploratory clinical outcomes are planned.

CLINICALTRIALS

gov registration: NCT03272399.

An update on pathophysiology and treatment of sports-mediated brain injury

Traumatic brain injury (TBI) is a neurological disorder which represents a major health issue worldwide. It causes mortality and disability among all group ages, caused by external force, sports-related events or violence and road traffic accidents. In the USA, approximately one-third people die annually due to injury and 1.7 million people suffer from traumatic brain injury. Every year in India around 1.6 million individuals suffer from sustain brain injury with 200,000 deaths and approximately one million person needed recovery treatment at any stage of time. Sports-related head impact and trauma has become an extremely controversial public health and medico-legal problem that accounts for 20% of all brain injury (including concussion). It is difficult to reverse the primary injury but the secondary injury can be minimized by using proper pharmacological intervention during the initial hours of injury. This article highlights the pathophysiology and types of TBI along with treatment therapies. Till date, there is no single medication that can decrease the progression of the disease so that symptomatic treatment is given to the patient by determining proper pathology. Recently various herbal medicine therapies and traditional supplements have been developed for TBI. Nutritional supplementation and nutraceuticals have exposed potential in the treatment of TBI when used before and after TBI. The compiled data will enable the readers to know the pathophysiology as well as the allopathic and natural remedies to treat the TBI.

Characterization of persistent post-traumatic headache and management strategies in adolescents and young adults following mild traumatic brain injury

Characteristics of persistent post-traumatic headache (PTH) in young individuals are poorly known leading to diagnostic problems and diverse management. We aimed to describe headache phenotypes and self-reported management strategies in young individuals with PTH following mild traumatic brain injury (mTBI). A comprehensive structured questionnaire was used to evaluate headache phenotypes/characteristics and management strategies to relieve headache in 107, 15–30-year-old individuals with PTH. Around 4 months post-injury, migraine-like headache in combination with tension-type like headache (40%) was the most commonly encountered headache phenotype followed by migraine-like headache (36%). Around 50% reported aura-like symptoms before/during the headache attack. Medication-overuse headache was diagnosed in 10%. Stress, sleep disturbances, and bright lights were the most common trigger factors. More than 80% reported that their headache was worsened by work-related activity and alleviated by rest/lying down. Simple analgesics were commonly used (88%) whereas prophylactic drugs were rarely used (5%). Bedrest and physiotherapy were also commonly used as management strategies by 56% and 34% of the participants, respectively. In conclusion, most young individuals with PTH after mTBI presented with combined migraine-like and tension-type-like headache followed by migraine-like headache, only. Preventive headache medication was rarely used, while simple analgesics and bedrest were commonly used for short-term headache relief.

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter

OBJECTIVE

To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning.

BACKGROUND

Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments.

METHODS

This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively.

RESULTS

Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms.

CONCLUSION

The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Scoping Review of Opioid Use After Traumatic Brain Injury

OBJECTIVE

To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI).

DATA SOURCES

The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings.

RESULTS

Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder.

CONCLUSIONS

Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

Altered speech patterns in subjects with post-traumatic headache due to mild traumatic brain injury

Background/objective

Changes in speech can be detected objectively before and during migraine attacks. The goal of this study was to interrogate whether speech changes can be detected in subjects with post-traumatic headache (PTH) attributed to mild traumatic brain injury (mTBI) and whether there are within-subject changes in speech during headaches compared to the headache-free state.

Methods

Using a series of speech elicitation tasks uploaded via a mobile application, PTH subjects and healthy controls (HC) provided speech samples once every 3 days, over a period of 12 weeks. The following speech parameters were assessed: vowel space area, vowel articulation precision, consonant articulation precision, average pitch, pitch variance, speaking rate and pause rate. Speech samples of subjects with PTH were compared to HC. To assess speech changes associated with PTH, speech samples of subjects during headache were compared to speech samples when subjects were headache-free. All analyses were conducted using a mixed-effect model design.

Results

Longitudinal speech samples were collected from nineteen subjects with PTH (mean age = 42.5, SD = 13.7) who were an average of 14 days (SD = 32.2) from their mTBI at the time of enrollment and thirty-one HC (mean age = 38.7, SD = 12.5). Regardless of headache presence or absence, PTH subjects had longer pause rates and reductions in vowel and consonant articulation precision relative to HC. On days when speech was collected during a headache, there were longer pause rates, slower sentence speaking rates and less precise consonant articulation compared to the speech production of HC. During headache, PTH subjects had slower speaking rates yet more precise vowel articulation compared to when they were headache-free.

Conclusions

Compared to HC, subjects with acute PTH demonstrate altered speech as measured by objective features of speech production. For individuals with PTH, speech production may have been more effortful resulting in slower speaking rates and more precise vowel articulation during headache vs. when they were headache-free, suggesting that speech alterations were related to PTH and not solely due to the underlying mTBI.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Distinguishing persistent post-traumatic headache from migraine: Classification based on clinical symptoms and brain structural MRI data

BACKGROUND

Persistent post-traumatic headache most commonly has symptoms that overlap those of migraine. In some cases, it can be clinically difficult to differentiate persistent post-traumatic headache with a migraine phenotype from migraine. The objective of this study was to develop a classification model based on questionnaire data and structural neuroimaging data that distinguishes individuals with migraine from those with persistent post-traumatic headache.

METHODS

Questionnaires assessing headache characteristics, sensory hypersensitivities, cognitive functioning, and mood, as well as T1-weighted magnetic resonance imaging and diffusion tensor data from 34 patients with migraine and 48 patients with persistent post-traumatic headache attributed to mild traumatic brain injury were included for analysis. The majority of patients with persistent post-traumatic headache had a migraine/probable migraine phenotype (77%). A machine-learning leave-one-out cross-validation algorithm determined the average accuracy for distinguishing individual migraine patients from individual patients with persistent post-traumatic headache.

RESULTS

Based on questionnaire data alone, the average classification accuracy for determining whether an individual person had migraine or persistent post-traumatic headache was 71.9%. Adding imaging data features to the model improved the classification accuracy to 78%, including an average accuracy of 97.1% for identifying individual migraine patients and an average accuracy of 64.6% for identifying individual patients with persistent post-traumatic headache. The most important clinical features that contributed to the classification accuracy included questions related to anxiety and decision making. Cortical brain features and fibertract data from the following regions or tracts most contributed to the classification accuracy: Bilateral superior temporal, inferior parietal and posterior cingulate; right lateral occipital, uncinate, and superior longitudinal fasciculus. A post-hoc analysis showed that compared to incorrectly classified persistent post-traumatic headache patients, those who were correctly classified as having persistent post-traumatic headache had more severe physical, autonomic, anxiety and depression symptoms, were more likely to have post-traumatic stress disorder, and were more likely to have had mild traumatic brain injury attributed to blasts.

DISCUSSION

A classification model that included a combination of questionnaire data and structural imaging parameters classified individual patients as having migraine versus persistent post-traumatic headache with good accuracy. The most important clinical measures that contributed to the classification accuracy included questions on mood. Regional brain structures and fibertracts that play roles in pain processing and pain integration were important brain features that contributed to the classification accuracy. The lower classification accuracy for patients with persistent post-traumatic headache compared to migraine may be related to greater heterogeneity of patients in the persistent post-traumatic headache cohort regarding their traumatic brain injury mechanisms, and physical, emotional, and cognitive symptoms.

Headache Characteristics and Psychological Factors Associated with Functional Impairment in Individuals with Persistent Posttraumatic Headache

OBJECTIVE

Persistent posttraumatic headache (PPTH), one of the most common symptoms following mild traumatic brain injury, is often associated with substantial functional disability. The objective of this study was to assess the contribution of demographics, headache characteristics, and psychological symptoms to disability associated with PPTH.

METHODS

Participants completed the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory (BDI), the Pain Catastrophizing Scale (PCS), and the Migraine Disability Assessment (MIDAS) questionnaire. Two linear regression models were formulated to interrogate the relationships between 1) demographics and headache characteristics with the MIDAS questionnaire and 2) demographics, headache characteristics, and psychological symptoms with the MIDAS questionnaire. A two-way stepwise regression using the Akaike information criterion was performed to find a parsimonious model describing the relationships between demographics, headache characteristics, and psychological measures with the MIDAS questionnaire.

RESULTS

Participants included 58 patients with PPTH and 39 healthy controls (HCs). The median MIDAS score among those with PPTH was 48.0 (first quartile [1Q] = 20.0, third quartile [3Q] = 92.0), indicative of severe disability. Compared with the HCs, those with PPTH had higher scores on the BDI, STAI, and PCS. Older age predicted lower MIDAS scores (age: B=-0.11, P<0.01), whereas higher headache frequency, greater headache intensity, and higher trait anxiety scores predicted higher MIDAS scores in individuals with PPTH (headache frequency: B=0.07, P<0.001; headache intensity: B=0.51, P=0.04; trait anxiety score: B=1.11, P=0.01).

CONCLUSIONS

Individuals with PPTH had substantial psychological symptoms and headache-related disability. Disability was partially explained by age, headache frequency and intensity, and trait anxiety. Holistic management of patients with PPTH to address headaches and psychological symptoms might reduce headache-associated disability.

Medical Therapies for Concussion

The medications used in postconcussion syndrome are typically used to help manage or minimize disruptive symptoms while recovery proceeds. These medications are not routinely used in most concussions that recover within days to weeks. However, it is beneficial to be aware of medication options that may be used in athletes with prolonged concussion symptoms or for those that have symptom burdens that preclude entry into basic concussion protocols. Medications and supplements remain a small part of the concussion treatment plan, which may include temporary academic adjustments, physical therapy, vestibular and ocular therapy, psychological support, and graded noncontact exercise.

Characteristics and Impact of U.S. Military Blast-Related Mild Traumatic Brain Injury: A Systematic Review

As a result of armed conflict, head trauma from exposure to blasts is an increasing critical health issue, particularly among military service members. Whilst numerous studies examined the burden of blast-related brain injuries on service members', few systematic reviews have been published. This work provides a comprehensive summary of the evidence on blast-related mild traumatic brain injury (mTBI) burden in active U.S. military service members and inactive Veterans, describing characteristics and outcomes. Records published up to April 2017 were identified through a search of PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane Library. Records-based and original research reporting on U.S. military service members and Veterans with mild blast TBI were included. Data on subject characteristics, exposure, diagnostic criterion, and outcomes were extracted from included studies using a standardized extraction form and were presented narratively. Of the 2,290 references identified by the search, 106 studies with a total of 37,515 participants met inclusion criteria for blast-related mTBI. All but nine studies were based out of military or Veteran medical facilities. Unsurprisingly, men were over-represented (75–100%). The criteria used to define blast-related mTBI were consistent; however, the methodology used to ascertain whether individuals met those criteria for diagnosis were inconsistent. The diagnosis, most prevalent among the Army, heavily relied on self-reported histories. Commonly reported adverse outcomes included hearing disturbances and headaches. The most frequently associated comorbidities were post-traumatic stress disorder, depression, anxiety, sleep disorders, attention disorders, and cognitive disorders. The primary objective of this review was to provide a summary of descriptive data on blast-related mTBI in a U.S. military population. Low standardization of the methods for reaching diagnosis and problems in the study reporting emphasize the importance to collect high-quality data to fill knowledge gaps pertaining to blast-related mTBI.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Addressing chronic persistent headaches after MTBI as a neuropathic pain state

An increasing number of patients with chronic persistent post-traumatic headache (PPTH) after mild traumatic brain injury (MTBI) are being referred to headache or pain specialists as conventional treatment options for primary headache disorders have not been able to adequately alleviate their debilitating headache symptoms. Evolving clinical and mechanistic evidences support the notation that chronic persistent MTBI related headaches (MTBI-HA) carry the hallmark characteristics of neuropathic pain. Thus, in addition to conventional treatment options applicable to non-traumatic primary headache disorders, other available treatment modalities for neuropathic pain should be considered. In this comprehensive review article, the author reveals the prevalence of MTBI-HA and its clinical manifestation, discusses existing clinical and mechanistic evidence supporting the classification of chronic persistent MTBI-HA as a neuropathic pain state, and explores current available treatment options and future directions of therapeutic research related to MTBI-HA.

Efficacy, tolerability, and safety of erenumab for the preventive treatment of persistent post-traumatic headache attributed to mild traumatic brain injury: an open-label study

BACKGROUND

Calcitonin gene-related peptide (CGRP) has recently been implicated in the pathogenesis of post-traumatic headache (PTH), which raises the prospect for therapeutic use of monoclonal antibodies targeting CGRP or its receptor. Therefore, we decided to assess the efficacy, tolerability, and safety of erenumab for prevention of persistent PTH attributed to mild traumatic brain injury.

METHODS

A single-center, non-randomized, single-arm, open-label study of erenumab for adults aged 18-65 years with persistent PTH. Patients were assigned to receive 140-mg erenumab monthly by two subcutaneous 1-mL injections, given every 4 weeks for 12 weeks. The primary outcome measure was the mean change in number of monthly headache days of moderate to severe intensity from baseline (4-week pretreatment period) to week 9 through 12. Tolerability and safety endpoints were adverse events (i.e. number and type).

RESULTS

Eighty-nine of 100 patients completed the open-label trial. At baseline, the mean monthly number of headache days of moderate to severe intensity was 15.7. By week 9 through 12, the number was reduced by 2.8 days. The most common adverse events were constipation (n = 30) and injection-site reactions (n = 15). Of 100 patients who received at least one dose of erenumab, two patients discontinued the treatment regimen due to adverse events.

CONCLUSIONS

Among patients with persistent PTH, erenumab resulted in a lower frequency of moderate to severe headache days in this 12-week open-label trial. In addition, erenumab was well-tolerated as discontinuations due to adverse events were low. Placebo-controlled randomized clinical trials are needed to adequately evaluate the efficacy and safety of erenumab in patients with persistent PTH.

TRIAL REGISTRATION

ClinicalTrials.Gov, NCT03974360. Registered on April 17, 2019 - Retrospectively registered.

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.

Posttraumatic headache: recent progress

PURPOSE OF REVIEW

Posttraumatic headache (PTH) attributed to mild traumatic brain injury is common and debilitating. In up to one-half of those with acute PTH, the PTH becomes persistent (PTH), enduring for longer than 3 months. The high incidence and persistence of PTH necessitate research into PTH pathophysiology and treatment. In this review, recent developments regarding the diagnostic criteria for PTH, the pathophysiology of PTH, and PTH treatment are discussed.

RECENT FINDINGS

International Classification of Headache Disorders 3 diagnostic criteria for PTH attributed to head trauma require that 'a headache of any type' starts within 7 days of a head injury. PTH is considered 'persistent' when it endures for more than 3 months. Preclinical and human PTH research suggest multiple pathophysiologic mechanisms including genetic influences, neuroinflammation, increased release and inadequate clearance of neuropeptides and neurotransmitters, mast cell degranulation, and brain structural and functional remodeling. Even when it has a phenotype similar to a primary headache, data suggest that PTH is distinct from primary headaches. There is a lack of high-quality evidence for the acute or preventive treatment of PTH. However, results from published studies of conventional headache therapies and newer therapies, such as calcitonin gene-related peptide mAbs and transcranial magnetic stimulation, justify the current and future randomized controlled trials.

SUMMARY

Evidence points towards a complex pathophysiology for PTH that is at least partially distinct from the primary headaches. Although properly conducted clinical trials of PTH treatment are needed, existing work has provided important data that help to plan these clinical trials. Current and future investigations will help to identify PTH mechanisms, predictors for PTH persistence, therapeutic targets, and evidence-based treatment options.

Persistent Post-Traumatic Headache and Migraine: Pre-Clinical Comparisons

Background: Oftentimes, persistent post traumatic headache (PPTH) and migraine are phenotypically similar and the only clinical feature that differentiate them is the presence of a mild or moderate traumatic brain injury (mTBI). The aim of this study is to describe the differences in brain area and in biochemical cascade after concussion and to define the efficacy and safety of treatments in use. Methods: Sources were chosen in according to the International Classification of Headache Disorder (ICHD) criteria. Results: The articles demonstrated a significant difference between PPTH and migraine regarding static functional connectivity (sFC) and dynamic functional connectivity (dFC) in brain structure that could be used for exploring the pathophysiological mechanisms in PPTH. Many studies described a cascade of neuro-metabolic changes that occur after traumatic brain injury. These variations are associated to the mechanism occurring when developing a PPTH. Conclusions: The state of art of this important topic show how although the mechanisms underlying the development of the two different diseases are different, the treatment of common migraine is efficacious in patients that have developed a post traumatic form.

Acute and preventive pharmacological treatment of post-traumatic headache: a systematic review

Background

Post-traumatic headache (PTH) is associated with considerable disability and reduced health-related quality of life. Despite the very high prevalence of PTH, there are no evidence-based guidelines for PTH treatment. Thus, we found it timely to provide a systematic review of the current literature on acute and preventive pharmacological treatment of PTH using PubMed and Embase databases.

Findings

Included studies involved acute and preventive pharmacological treatment of headache attributed to traumatic injury to the head in adherence to the International Classification of Headache Disorders (ICHD) criteria. Of 1424 potentially relevant articles identified, 63 were retrieved for detailed evaluation and seven studies (one prospective and six retrospective) met the inclusion criteria. None of the seven included studies were randomized clinical trials (RCTs) or used a placebo-controlled study design.

Conclusion

We found that there is a lack of high-quality evidence-based studies on the pharmacological treatment of PTH. Future studies are highly needed and must emphasize open-label studies with rigorous methodology or RCTs with a placebo-controlled design.

Treatment of posttraumatic headache migraine phenotype with erenumab – An observational study

Objective

To report the observed effect of erenumab in mild posttraumatic headache migraine phenotype with and without aura.

Background

There is no clinical algorithm of pharmacotherapy for migraine following posttraumatic headache. Most migraine preventatives that are typically used are either ineffective or not tolerated.

Methods

Seven patients who met the clinical criteria for migraine with or without aura following posttraumatic headache who failed or were intolerant of conventional migraine preventatives were treated with erenumab 140 mg subcutaneously. Most had no history of migraine. In those patients with a history of migraine, the posttraumatic headache migraine headaches were different than the past migraine experience. Descriptive headache intensity or disability using the Head Impact Test-6 and monthly headache days were recorded before and after treatment. All patients were debilitated on presentation and demonstrated no signs of spontaneous resolution.

Results

Patients responded with a 95% (SD 1.22, p < .001) reduction in headache days. All Head Impact Test-6 scores went from disabling to non-disabling without adverse effects. Most required only one dose of erenumab with no migraine recurrence. Onset of efficacy often became apparent within days to four weeks. Extended follow-up six months after treatment revealed no relapses.

Conclusions

Erenumab is effective in the treatment of posttraumatic headache with migraine phenotype in this small cohort. Large-scale studies are urgently required for this highly prevalent, disabling, condition which has no effective established treatment.

Practice Current: How do you diagnose and treat post-concussive headache?

A common complaint after concussion is the development of new or worsening headaches which can make it difficult or even impossible for patients to work or function in their day-to-day lives. Uncertainties associated with the complaints and a wide variety of approaches exist regarding the appropriate work-up and management of these patients. Areas of ongoing debate include the need for neuroimaging; optimal, acute, and preventative treatment; and proper counseling and expectation management. Given the wide variety of potential approaches and the lack of consensus, we sought expert opinion from around the globe on how to evaluate and manage patients with headache following concussion. Similar questions were posed to the rest of our readership in an online survey (links.lww.com/CPJ/A96), the results of which are also presented.

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.

Differences in fibertract profiles between patients with migraine and those with persistent post-traumatic headache

Objectives

Often, persistent post-traumatic headache and migraine are phenotypically similar. However, the similarities and differences in the neuropathological underpinnings of persistent post-traumatic headache and migraine require further understanding. We used diffusion tensor imaging (DTI) and a novel method for detecting subtle changes in fibertract integrity by measuring node-by-node parameters along each tract to compare fibertract profiles between those with migraine and those with persistent post-traumatic headache, and compared both cohorts to a group of controls.

Methods

Eighteen fibertracts were reconstructed for 131 subjects, including 49 patients with persistent post-traumatic headache attributed to mild traumatic brain injury, 41 with migraine, and 41 controls. Node-by-node diffusion parameters of mean diffusivity and radial diffusivity were calculated along each tract. Mean diffusivity and radial diffusivity measurements were averaged along quartiles of each tract for statistical interpretation and group comparison. Using a post-hoc analysis, correlations between tract quartile measurements and headache frequency were calculated.

Results

There were significant differences between migraine and persistent post-traumatic headache cohorts for quartile measurements of mean diffusivity or radial diffusivity in the bilateral anterior thalamic radiations, cingulum (angular bundles and cingulate gyri), inferior longitudinal fasciculi, and uncinate fasciculi, the left corticospinal tract, and the right superior longitudinal fasciculi-parietal portion. For migraine patients, there was a significant positive correlation between headache frequency and forceps major mean diffusivity, whereas for persistent post-traumatic headache there was a positive correlation between headache frequency and cingulum angular bundle mean diffusivity and radial diffusivity.

Conclusions

Quartile measurements of radial diffusivity and mean diffusivity indicate unique differences in fibertract profiles between those with migraine vs. persistent post-traumatic headache. Although for both migraine and persistent post-traumatic headache there was a positive relationship between fibertract alterations and headache frequency, there were disease-specific differences between headache frequency and fibertract injury patterns. These findings might suggest potential differences in the neuropathological mechanisms underlying migraine and persistent post-traumatic headache.

The development of a mouse model of mTBI-induced post-traumatic migraine, and identification of the delta opioid receptor as a novel therapeutic target

BACKGROUND

Post-traumatic headache is the most common and long-lasting impairment observed following mild traumatic brain injury, and frequently has migraine-like characteristics. The mechanisms underlying progression from mild traumatic brain injury to post-traumatic headache are not fully understood. The aim of this study was to develop a mouse model of post-traumatic headache and identify mechanisms and novel targets associated with this disorder.

METHODS

We combined the closed head weight-drop method and the nitroglycerin chronic migraine model. To induce mild traumatic brain injury, a weight was dropped onto intact crania of mildly anesthetized mice, and mechanical responses to chronic-intermittent administration of nitroglycerin, a human migraine trigger, were determined at multiple time points post-injury.

RESULTS

Low dose nitroglycerin (0.1 mg/kg) evoked acute periorbital and hind paw allodynia in both mild traumatic brain injury and sham animals. However, only mild traumatic brain injury mice developed chronic hypersensitivity to low dose nitroglycerin. Migraine medications, sumatriptan and topiramate, inhibited post-traumatic headache-associated allodynia. In addition, the delta opioid receptor agonist, SNC80, also blocked post-traumatic headache-associated allodynia. Finally, we examined the expression of calcitonin gene-related peptide within this model and found that it was increased in trigeminal ganglia two weeks post-mild traumatic brain injury.

CONCLUSIONS

Overall, we have established a mouse model of post-traumatic headache and identified the delta opioid receptor as a novel therapeutic target for this disorder.

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.

Blast-induced brain injury in rats leads to transient vestibulomotor deficits and persistent orofacial pain

Blast-induced traumatic brain injury (blast-TBI) is associated with vestibulomotor dysfunction, persistent post-traumatic headaches and post-traumatic stress disorder, requiring extensive treatments and reducing quality-of-life. Treatment and prevention of these devastating outcomes require an understanding of their underlying pathophysiology through studies that take advantage of animal models. Here, we report that cranium-directed blast-TBI in rats results in signs of pain that last at least 8 weeks after injury. These occur without significantly elevated behavioural markers of anxiety-like conditions and are not associated with glial up-regulation in sensory thalamic nuclei. These injuries also produce transient vestibulomotor abnormalities that resolve within 3 weeks of injury. Thus, blast-TBI in rats recapitulates aspects of the human condition.

Pharmacotherapy for Persistent Posttraumatic Headaches in Children and Adolescents: A Brief Review of the Literature

Concussion, now most often referred to as mild traumatic brain injury in recent literature, is common in pediatrics, and headache is often the most common complaint post-injury. Although most children and adolescents recover within 1-2 weeks, some develop frequent and debilitating headaches that can last for months or longer. Most clinicians would agree on the importance of managing both acute and persistent posttraumatic headaches appropriately to speed recovery, minimize disability, maximize function, and improve quality of life, but there are no well-established guidelines to instruct physicians in doing so. As this continues to be a developing field, there is much we still need to learn about concussion and the appropriate strategies to prevent and treat these injuries and their sequelae. This review is intended to help providers understand the current evidence, and sometimes the lack thereof, and ultimately to lead to improved care for children with headaches after mild traumatic brain injury.

Imaging Post-Traumatic Headache

PURPOSE OF REVIEW

Headache is a frequent and debilitating symptom after mild traumatic brain injury, yet little is known about its pathophysiology and most effective treatments. The goal of this review is to summarize findings from imaging studies used during the clinical evaluation and research investigation of post-traumatic headache (PTH).

RECENT FINDINGS

There are no published recommendations or guidelines for when to acquire imaging studies of the head or neck in patients with PTH. Clinical acumen is required to determine if imaging is needed to assess for a secondary cause of headache which may have been precipitated or unmasked by the trauma. Several guidelines for when to image the patient with mild traumatic brain injury (mTBI) in the emergency setting consider headache among the deciding factors. In the research arena, imaging techniques including proton spectroscopy magnetic resonance imaging, diffusion tensor imaging, magnetic resonance morphometry, and functional neck x-rays have been employed with the goal of identifying diagnostic and prognostic factors for PTH and to help understand its underlying pathophysiologic mechanisms. Results indicate that changes in regional cortical thickness and damage to specific white matter tracts warrant further research. Future research should interrogate whether these imaging findings contribute to the classification and prognosis of PTH. Current research provides evidence that imaging findings associated with PTH may be distinct from those attributable to mTBI. A variety of imaging techniques have potential to further our understanding of the pathophysiologic processes underlying PTH as well as to provide diagnostic and prognostic indicators. However, considerable work must be undertaken for this to be realized.

Posttraumatic Headache: Classification by Symptom-Based Clinical Profiles

There are currently no accepted therapies for posttraumatic headache (PTH). In order to meet the urgent need for effective therapies for PTH, we must continue to address fundamental gaps in our understanding of the clinical course and impact of PTH. Here we examine the existing schema used to characterize the clinical characteristics of PTH, including the International Classification of Headache Disorders (ICHD). There remain unresolved questions about whether to classify patients based on the extent of brain injury or on clinical symptom profiles. There also remain problematic issues of definition such as continuous headache, and chronic daily headache with features of "embedded" migraine-type within these headaches, which will need to be studied further. We make the case that a symptom-based classification is needed to begin an examination of these unresolved questions, and to establish clinically relevant endpoints for research and clinical trials for effective therapies.

Intranasal Oxytocin Attenuates Reactive and Ongoing, Chronic Pain in a Model of Mild Traumatic Brain Injury

BACKGROUND

Approximately 1.7 million Americans sustain a traumatic brain injury (TBI) each year and chronic pain is a common complication.

OBJECTIVE

We studied the effects of intranasally administered oxytocin as a potential treatment for chronic pain in an animal model of mild TBI.

METHODS

The lateral fluid percussion model of mild TBI was chosen for this purpose and after exposure to mild TBI the rats (n = 12) developed hind paw and facial allodynia compared to sham animals (n = 6). Oxytocin or a vehicle was afterwards administered intranasally and reactive pain was assessed by hind paw and facial von Frey testing. Some animals received the oxytocin receptor antagonist, atosiban, in addition to oxytocin/vehicle treatment (n = 12). The effect of oxytocin on ongoing and spontaneous pain was examined through conditioned place preference testing. To determine whether the effects of intranasal oxytocin could be attributed to delivery via the peripheral blood stream, some TBI animals received an intravenous injection of the same oxytocin dose that was given intranasally. ELISA immunoassays were carried out (n = 6) to measure concentrations of oxytocin in the trigeminal ganglia, pons, spinal cord, and olfactory bulb after intranasal administration and evaluate the most likely route of entry.

RESULTS

These studies confirmed that the fluid percussion model can be used to study post-TBI facial allodynia. Oxytocin attenuated both reactive and spontaneous, ongoing non-reactive pain following mild TBI for at least 3-4 hours after intranasal administration by binding to OT or VA1-receptors most likely by a peri-trigeminal nerve mediated uptake.

CONCLUSIONS

Intranasal oxytocin attenuates measures of reactive and non-reactive pain in a model of mild TBI and may represent a novel treatment for chronic pain in TBI patients.

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.

Preliminary evidence of reduced brain network activation in patients with post-traumatic migraine following concussion

Post-traumatic migraine (PTM) (i.e., headache, nausea, light and/or noise sensitivity) is an emerging risk factor for prolonged recovery following concussion. Concussions and migraine share similar pathophysiology characterized by specific ionic imbalances in the brain. Given these similarities, patients with PTM following concussion may exhibit distinct electrophysiological patterns, although researchers have yet to examine the electrophysiological brain activation in patients with PTM following concussion. A novel approach that may help differentiate brain activation in patients with and without PTM is brain network activation (BNA) analysis. BNA involves an algorithmic analysis applied to multichannel EEG-ERP data that provides a network map of cortical activity and quantitative data during specific tasks. A prospective, repeated measures design was used to evaluate BNA (during Go/NoGo task), EEG-ERP, cognitive performance, and concussion related symptoms at 1, 2, 3, and 4 weeks post-injury intervals among athletes with a medically diagnosed concussion with PTM (n = 15) and without (NO-PTM) (n = 22); and age, sex, and concussion history matched controls without concussion (CONTROL) (n = 20). Participants with PTM had significantly reduced BNA compared to NO-PTM and CONTROLS for Go and NoGo components at 3 weeks and for NoGo component at 4 weeks post-injury. The PTM group also demonstrated a more prominent deviation of network activity compared to the other two groups over a longer period of time. The composite BNA algorithm may be a more sensitive measure of electrophysiological change in the brain that can augment established cognitive assessment tools for detecting impairment in individuals with PTM.