Characteristics and Treatment of Headache After Traumatic Brain Injury

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

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects With Single Headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine ( n = 22), tension-type ( n = 33) or cervicogenic headache ( n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A dicriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

Repetitive Occipital Nerve Blockade for Cervicogenic Headache: Expanded Case Report of 47 Adults

PURPOSE

To evaluate the repetitive occipital nerve blocks using a nerve stimulator in the treatment of cervicogenic headache.

METHODS

This prospective noncomparative clinical interventional case-series study included 47 patients suffering from cervicogenic headache using a repetitive guided occipital nerve blockade.

RESULTS

Forty-one patients (87%) required more than one injection to achieve six-month pain-relief period. For every three years of headache history, the outcomes demonstrated that a patient needed one additional injection to the basic injection.

CONCLUSION

The repeated nerve stimulator-guided occipital nerve blockade is a treatment mode that may relieve cervicogenic headache with no recurrence for at least six months in addition to alleviation of associated symptoms.

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

BACKGROUND

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

NEW METHOD

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

RESULTS

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

COMPARISON WITH EXISTING METHODS

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

CONCLUSIONS

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

Post-traumatic headache: facts and doubts

The International Classification of Headache Disorders does not separate the moderate from severe/very severe traumatic brain injury (TBI), since they are all defined by Glasgow coma scale (GCS) < 13. The distinction between the severe and very severe TBI (GCS < 8) should be made upon coma duration that in the latter may be longer than 15 days up to months in the case of vegetative state. Post-traumatic amnesia duration may double the coma duration itself. Therefore, the 3-month parameter proposed to define the occurrence or resolution of post-traumatic headache (PTH) appears inadequate. Following TBI, neuropathic pain, central pain, thalamic pain, combined pain are all possible and they call for proper pharmacological approaches. One more reason for having difficulties in obtaining information about headache in the early phase after regaining consciousness is the presence of concomitant medications that may affect pain perception. Post-traumatic stress disorder (PTSD) develops days or weeks after stress and tends to improve or disappear within 3 months after exposure; interestingly, this spontaneous timing resembles that of PTH. In our experience the number of TBI patients with PTH at 1-year follow-up is lower in those with longer coma duration and more severe TBI. Cognitive functioning evaluated after at least 12 months from TBI, showed mild or no impairment in these patients with severe TBI and PTH, whereas they have psychopathological changes, namely anxiety and depression. The majority of patients with PTH after severe/very severe TBI had skull fractures or dural lacerations and paroxystic EEG abnormalities. The combination of psychological changes (depression and anxiety) and organic features (skull fractures, dural lacerations, epileptic EEG abnormalities) in PTH may be inversely correlated with the severity of TBI, with prevalence of psychological disturbances in mild TBI and of organic lesions in severe TBI. On the other hand, only in severe TBI patients with good cognitive recovery the influence of the psychopathological disorders may play a role. In fact, the affective pain perception is probably related to the integrity of cognitive functions as in mild TBI and in severe TBI with good cognitive outcome.

Responses of dural mast cells in concussive and blast models of mild traumatic brain injury in mice: Potential implications for post-traumatic headache

BACKGROUND

Chronic post-traumatic headache (PTH) is one of the most common symptoms of mild traumatic brain injury (mTBI) but its underlying mechanisms remain unknown. Inflammatory degranulation of dural mast cells (MCs) is thought to promote headache, and may play a role in PTH. Whether mTBI is associated with persistent degranulation of dural MCs is yet to be determined.

METHODS

Histochemistry was used to evaluate time course changes in dural MC density and degranulation level in concussive head trauma and blast mouse models of mTBI. The effects of sumatriptan and the MC stabilizer cromolyn sodium on concussion-evoked dural MC degranulation were also investigated.

RESULTS

Concussive head injury evoked persistent MC degranulation for at least 30 days. Blast trauma gave rise to a delayed MC degranulation response commencing at seven days that also persisted for at least 30 days. Neither sumatriptan nor cromolyn treatment reduced concussion-evoked persistent MC degranulation.

CONCLUSIONS

mTBI evoked by closed head injury or blast exposure is associated with persistent dural MC degranulation. Such a response in mTBI patients may contribute to PTH. Amelioration of PTH by sumatriptan may not involve inhibition of dural MC degranulation. If persistent dural MC degranulation contributes to PTH, then cromolyn treatment may not be effective.

Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients

Since many years we routinely use diagnostic selective nerve root blocks (SNRB) at our department when evaluating patients with cervical radiculopathy. Frequently patients who also presented with headache reported that the headache disappeared when the nerve root responsible for the radicular pain was blocked with local anaesthetics. Headache has been described as a companioning symptom related to cervical radiculopathy but has never before been evaluated with SNRB performed in the lower cervical spine. For this reason we added to our routine an evaluation of the response from the SNRB on headache in patients with cervical radiculopathy. The aim was to describe the frequency of headache in patients with cervical radiculopathy and its response to a selective nerve root block of the nerve root/roots responsible for the radiculopathy. Can nerve root compression in the lower cervical spine produce headache? In this consecutive series of 275 patients with cervical radiculopathy, 161 patients reported that they also suffered from daily or recurrent headache located most often unilaterally on the same side as the radiculopathy. All patients underwent a careful clinical examination by a neurosurgeon and a MRI of the cervical spine. The significantly compressed root/roots, according to the MRI, underwent SNRB with a local anaesthetic. The effect of the nerve root block on the radiculopathy and the headache was carefully noted and evaluated by a physiotherapist using visual analogue scales (VAS) before and after the SNRB. All patients with headache had tender points in the neck/shoulder region on the affected side. Patients with headache graded significantly more limitations in daily activities and higher pain intensity in the neck/shoulder/arm than patients without headache. After selective nerve root block, 59% of the patients with headache reported 50% or more reduction of headache and of these 69% reported total relief. A significant correlation was seen between reduced headache intensity and reduced pain in the neck, shoulder and arm. The result indicates that cervical root compression from degenerative disease in the lower cervical spine producing radiculopathy might also induce headache.

Prevalent musculoskeletal pain as a correlate of previous exposure to torture

Aim: To research possible associations between previous exposure to specific torture techniques and prevalent pain in the head and face, back, and feet. Methods: 221 refugees, 193 males and 28 females, previously exposed to torture in their home country, were subject to a clinical interview at a rehabilitation clinic for torture victims. The interview focused on exposure to torture and somatic symptoms prevalent at examination. Results: The mean number of times imprisoned was 2.3; the mean number of months imprisoned was 19.7; the mean duration from initial imprisonment to final release was 3.7 years; and the mean duration from final release to preliminary interview was 8.4 years. The most frequent physical torture method reported was beating (92.3%) and the main mental torture method was deprivation (84.6%). Pain in the head and face was found to be strongly associated with torture against head and face (OR 3.89, 95% CI 1.49—10.20) and with the cumulative number of physical torture methods exposed to. Pain in the back was associated with sexual torture (OR 2.75, 95% CI 1.07—7.12). Besides beating of the lower extremities (OR 5.98, 95% CI 2.47—14.48), the strongest predictor for pain in the feet was general abuse of the whole body (OR 5.64, 95% CI 1.93—16.45). Conclusion: In spite of many factors being potentially co-responsible for prevalent pain, years after the torture took place it presents itself as strongly associated with specific loci of pain, with generalized effects, and with somatizing.

Percutaneous endoscopic cervical discectomy for discogenic cervical headache due to soft disc herniation

A discogenic cervical headache is a subtype of cervicogenic headache (CEH) that arises from a degenerative cervical disc abnormality. The purpose of this study was to evaluate the clinical outcome of percutaneous endoscopic cervical discectomy (PECD) for patients with chronic cervical headache due to soft cervical disc herniation. Seventeen patients underwent PECD for intractable headache. The inclusion criteria were soft disc herniation without segmental instability, proven by both local anesthesia and provocative discography for headache unresponsive to conservative treatment. The mean follow-up period was 37.6 months. Fifteen of the 17 patients (88.2%) showed successful outcomes based on the Macnab criteria. Pain scores on a visual analog scale (VAS) improved from a preoperative mean of 8.35 +/- 0.79 to 2.12 +/- 1.17, postoperatively (P < 0.01). The mean disc height decreased from 6.81 +/- 1.08 to 5.98 +/- 1.07 mm (P < 0.01). There was no newly developed segmental instability or spontaneous fusion on follow-up radiography. In conclusion, PECD appears to be effective for chronic severe discogenic cervical headache under strict inclusion criteria.

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.

Post-traumatic headaches correlate with migraine symptoms in youth with concussion

OBJECTIVE

The term "post-traumatic migraine" (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion.

METHODS

Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache.

RESULTS

The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster.

CONCLUSIONS

PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients.

Pharmacologic Therapies for Pediatric Concussions

Context:

Pediatric concussions are common, and emphasis on correct diagnosis and management is stressed in consensus guidelines. Medications may have a role in management of concussion, but no consensus exists regarding appropriate pharmacologic therapy.

Evidence Acquisition:

Nonsystematic review.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

There is limited evidence for hypertonic saline to improve posttraumatic headache in the emergency department setting. There is essentially no evidence for the use of any other medication in management of pediatric sport-related concussion.

Conclusion:

Further research is necessary to determine whether there is benefit to the use of any pharmacotherapy in the management of pediatric-aged athletes with concussions.

From blast to bench: A translational mini-review of posttraumatic headache

Current events within the military and professional sports have resulted in an increased recognition of the long-term and debilitating consequences of traumatic brain injury. Mild traumatic brain injury accounts for the majority of head injuries, and posttraumatic headache is the most common adverse effect. It is estimated that between 30% to 90% of traumatic brain injuries result in posttraumatic headache, and for a significant number of people this headache disorder can continue for up to and over a year post injury. Often, the most severe and chronic posttraumatic headache has a migraine-like phenotype and is difficult to resolve. In this review we discuss the preclinical findings from animal models of posttraumatic headache. We also describe potential mechanisms by which traumatic brain injury leads to chronic posttraumatic headache, including neuroinflammatory mediators and migraine-associated neuropeptides. There are surprisingly few preclinical studies that have investigated overlapping mechanisms between posttraumatic headache and migraine, especially considering the prevalence and debilitating nature of posttraumatic headache. Given this context, posttraumatic headache is a field with many emerging opportunities for growth. The frequency of posttraumatic headache in the general and military population is rising, and further preclinical research is required to understand, ameliorate, and treat this disabling disorder. © 2017 Wiley Periodicals, Inc.

Headache in patients with neck-shoulder-arm pain of cervical radicular origin

In a series of 81 patients with chronic cervicobrachialgia, 54 (67%) reported that they also suffered from recurrent headache. Forty-four (81%) of these patients were classified as having cervical headache, 5 as having migraine, 2 with tension-type headache, and 3 patients were not classifiable according to the diagnostic system of the International Headache Society (IHS). Patients with headache presented significantly higher tenderness scores and pain intensity in the neck-shoulder-arm region than patients without headaches. Twenty-three (52%) of the 44 patients with cervical headache reported that their headache had improved after treatments directed towards their cervicobrachialgia. The IHS classification system of cervical headache is discussed.

Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks

OBJECTIVES

Neck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern's validity has not been tested against the 'gold standard' of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain.

DESIGN

Prospective concurrent validity study that employed a diagnostic model building approach to analysis.

SETTING

Hospital-based multidisciplinary outpatient clinic in Joliet, Illinois.

PARTICIPANTS

A convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis.

OUTCOME MEASURES

Participants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3-C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants' responses to diagnostic blocks.

RESULTS

Ten of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants' responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses.

CONCLUSIONS

This study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.

Managing and treating headache of cervicogenic origin

CGH is a common entity that has been assessed historically in various medical disciplines. Currently, CGH is a controversial topic whose existence has supporters and naysayers. The difficulty evaluating CGH is caused by a lack of objective findings on imaging and biologic tests. Patients present with pain but often with a lack of hard, concrete physical findings. Other clinical diagnoses may confound the clinical presentation of patients. The concomitant presence of ON and migraine headaches has been noted in the literature. Positive analgesia after interventional techniques remains the major way to consider the diagnosis in potential patients with headaches. Although the IHS has acknowledged CGH as a secondary headache in its diagnostic schema, more research, specifically randomized double-blinded evaluations of patients with CGH, are required. These data would be deemed as objective gold-standard evidence to lead us from controversy to collaborative agreement regarding the fate of CGH. What is certain regarding CGH is that a cooperative effort should be considered in the treatment of the patients between evaluating physicians, interventional pain physicians, surgeons, and physical therapy providers. This multidisciplinary effort can lead to the effective management of CGH.

Prevalence of and Risk Factors for Post-traumatic Headache in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study

OBJECTIVE

To ascertain the prevalence of and risk factors for post-traumatic headache (PTH) attributed to mild traumatic brain injury (mTBI).

PATIENTS AND METHODS

A prospective, longitudinal, multicenter cohort study of patients with mTBI and orthopedic trauma controls who were enrolled from February 26, 2014, to August 8, 2018. The baseline assessment was conducted as soon as possible following evaluation at the emergency department. Follow-ups were scheduled at 2 weeks, 3 months, 6 months, and 12 months postinjury. Eligible patients with mTBI included those 18 years of age or older who presented to the emergency department within 24 hours of head injury warranting evaluation by noncontrast head computed tomography scan. Acute PTH was considered present when a patient reported a headache score of greater than or equal to 2 on the Rivermead Post-concussion Questionnaire at 2 weeks postinjury (ie, headache is at least a mild problem compared with pre-injury). Persistent PTH was defined when a patient with acute PTH reported a Rivermead Post-concussion Questionnaire headache score of greater than or equal to 2 at the scheduled follow-up examinations.

RESULTS

Acute PTH was reported by 963 (60.4%) of 1594 patients with mTBI at 2 weeks postinjury. Among those with acute PTH, 439 (52.4%) of 837 patients reported persistent PTH at 3 months postinjury. This figure decreased over time and 278 (37.5%) of 742 patients continued to report persistent PTH at 6 months, whereas 187 (28.9%) of 646 patients did so as well at 12 months postinjury. Risk factors for acute PTH included younger age, female sex, fewer years of formal education, computed tomography-positive scans, alteration of consciousness, psychiatric history, and history of migraine. Risk factors for persistent PTH included female sex, fewer years of formal education, and history of migraine.

CONCLUSION

Post-traumatic headache is a prevalent sequela of mTBI that persists for at least 12 months in a considerable proportion of affected individuals. The attributable burden necessitates better patient follow-up, disease characterization, improved awareness of PTH in clinical practice, and identification of effective therapies.

Post-traumatic Headache: Pharmacologic Management and Targeting CGRP Signaling

PURPOSE OF REVIEW

Post-traumatic headache is a common sequela of injury to the head and/or neck. Here, we review the current approach to pharmacologic management of post-traumatic headache and explore the therapeutic promise of targeting calcitonin gene-related peptide signaling to address unmet treatment needs.

RECENT FINDINGS

The scarcity of data from controlled trials has left clinicians to rely on mainly expert opinion for the pharmacologic management of post-traumatic headache. The current view is that a phenotype-guided approach should be used, in which patients are treated according to the primary headache phenotype that their clinical features resemble the most (e.g. migraine, tension-type headache). Moreover, incremental advances are being made in the field that aim to identify possible cellular and molecular drivers of headache persistence. Calcitonin gene-related peptide has emerged as a key drug target which, in turn, has prompted novel insights on the potential importance of early initiation of pharmacologic treatment following the onset of post-traumatic headache. This, in turn, might prevent subsequent persistence and chronification of headache.

Hypersensitivity to PACAP-38 in post-traumatic headache: a randomized clinical trial

Pituitary adenylate cyclase-activating polypeptide-38 (PACAP-38), known for its role in migraine pathogenesis, has been identified as a novel drug target. Given the clinical parallels between post-traumatic headache (PTH) and migraine, we explored the possible role of PACAP-38 in the pathogenesis of PTH. To this end, we conducted a randomized, double-blind, placebo-controlled, two-way crossover trial involving adult participants diagnosed with persistent PTH resulting from mild traumatic brain injury. Participants were randomly assigned to receive a 20-min continuous intravenous infusion of either PACAP-38 (10 pmol/kg/min) or placebo (isotonic saline) on two separate experimental days, with a 1-week washout period in between. The primary outcome was the difference in incidence of migraine-like headache between PACAP-38 and placebo during a 12-h observational period post-infusion. The secondary outcome was the difference in the area under the curve (AUC) for baseline-corrected median headache intensity scores during the same 12-h observational period. Of 49 individuals assessed for eligibility, 21 were enrolled and completed the trial. The participants had a mean age of 35.2 years, and 16 (76%) were female. Most [19 of 21 (90%)] had a migraine-like phenotype. During the 12-h observational period, 20 of 21 (95%) participants developed migraine-like headache after intravenous infusion of PACAP-38, compared with two (10%) participants after placebo (P < 0.001). Furthermore, the baseline-corrected AUC values for median headache intensity scores during the 12-h observational period was higher after PACAP-38 than placebo (P < 0.001). These compelling results demonstrate that PACAP-38 is potent inducer of migraine-like headache in people with persistent PTH. Thus, targeting PACAP-38 signalling might be a promising avenue for the treatment of PTH.

Posttraumatic Headache

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61-e68.].

Hypersensitivity to opening of ATP-sensitive potassium channels in post-traumatic headache

OBJECTIVE

To investigate whether levcromakalim (a KATP channel opener) induces migraine-like headache in people with persistent post-traumatic headache who had no known history of migraine.

METHODS

In a randomized, double-blind, placebo-controlled, 2-way crossover trial, participants were randomly assigned to receive a 20-minute continuous intravenous infusion of levcromakalim (50 µg/mL) or placebo (isotonic saline) on two separate experimental days with a 1-week wash-out period in between. The primary endpoint was the difference in incidence of migraine-like headache between levcromakalim and placebo during a 12-hour observational period after infusion start. The secondary endpoint was the difference in area under the curve for baseline-corrected median headache intensity scores between levcromakalim and placebo during the 12-hour observational period.

RESULTS

A total of 21 participants with persistent post-traumatic headache were randomized and completed the trial. During the 12-hour observational period, 12 (57%) of 21 participants reported experiencing migraine-like headache following the levcromakalim infusion, compared with three after placebo (P = 0.013). Moreover, the baseline-corrected median headache intensity scores were higher following the levcromakalim infusion than after placebo (P = 0.003).

CONCLUSION

Our findings suggest that KATP channels play an important role in the pathogenesis of migraine-like headache in people with persistent post-traumatic headache. This implies that KATP channel blockers might represent a promising avenue for drug development. Further research is warranted to explore the potential therapeutic benefits of KATP channel blockers in managing post-traumatic headache.Trial Registration: ClinicalTrials.gov Identifier: NCT05243953.

Serum calcitonin gene-related peptide in patients with persistent post-concussion symptoms, including headache: a cohort study

BACKGROUND

Calcitonin gene-related peptide (CGRP) plays an important role in migraine pathophysiology, and post-traumatic headache (PTH) frequently presents with migraine-like features. Despite several clinical similarities, few studies have explored CGRP in PTH and concussion. This study investigates serum CGRP levels in patients with persistent post-concussion symptoms (PPCS), including PTH.

METHODS

This cohort study was based on serum samples from individuals aged 18-30 years with PPCS who participated in a previously published randomized controlled trial of a non-pharmacological intervention. The primary outcome was serum CGRP concentrations, determined at baseline before randomization and at follow-up 7 months later, using an enzyme-linked immunosorbent assay (ELISA). CGRP levels at baseline were compared with healthy anonymous blood donors in the same age group.

RESULTS

Baseline serum samples were collected from 86 participants with PPCS. The participants were most often female (78%) and migraine-like headache was the most frequent headache phenotype (74%). Serum CGRP levels were higher in participants with PPCS than in 120 healthy individuals (median: 158.5 pg/mL vs. 76.3 pg/mL, p = 0.050). A stratified analysis revealed that females with PPCS had a fivefold higher median than healthy females (166.3 pg/mL vs. 32.1 pg/mL, p = 0.0006), while no differences were observed in males (p = 0.83). At follow-up, CGRP levels decreased with a median change of  - 1.3 pg/mL (95% confidence interval:  - 17.6-0, p = 0.024).

DISCUSSION

Elevated serum levels of CGRP in patients with PPCS and a decrease over time suggest an involvement of CGRP in PTH/PPCS. If confirmed in other studies, it could pave the way for CGRP-targeted therapies, which could have clinical significance.

The prevalence of persistent post-traumatic headache in adult civilian traumatic brain injury: a systematic review and meta-analysis on the past 14 years

ABSTRACT

The most recent prevalence estimate of post-traumatic headache (PTH) after traumatic brain injury (TBI) in veterans and civilians dates back to 2008. The prevalence was found to be 57.8%, with surprising higher rates (75.3%) in mild TBI when compared with those with moderate/severe TBI (32.1%). However, the revision of mild TBI diagnostic criteria and an historic peak of TBI in the elderly individuals attributed to the ageing population may lead to different results. Thus, we conducted a systematic review and meta-analysis to assess the updated prevalence of PTH during the past 14 years only in civilians. A literature search was conducted following PRISMA guidelines guided by a librarian. Screening, full-text assessment, data extraction, and risk of bias assessment were performed blindly by 2 raters. Meta-analysis of proportions using the Freeman and Tukey double arcsine method of transformation was conducted. Heterogeneity, sensitivity analysis, and meta-regressions were performed with the predictors: year of publication, mean age, sex, TBI severity, and study design. Sixteen studies were selected for the qualitative analysis and 10 for the meta-analysis. The overall prevalence estimate of PTH was 47.1%, (confidence interval = 34.6, 59.8, prediction intervals = 10.8, 85.4), being similar at different time points (3, 6, 12, and 36+ months). Heterogeneity was high, and none of the meta-regressions were significant. The overall prevalence of PTH after TBI over the past 14 years remains high even if assessed only in civilians. However, the prevalence rates attributed to mild and moderate/severe TBI were similar, differing significantly from previous reports. Efforts are needed to improve TBI outcomes.

Update on the prevalence of persistent post-traumatic headache in adult civilian traumatic brain injury: protocol for a systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) is a major public health concern. Persistent post-traumatic headache (PTH) is a common consequence of TBI affecting productivity and quality of life. The only review providing information about headache prevalence after TBI was published in 2008, combined data from civilian and military TBI, and was strictly derived from Medline database. Due to recent changes in TBI diagnosis and trauma epidemiology, the aim of the current study is to perform a systematic review and meta-analysis to derive updated prevalence estimates of persistent PTH in adult civilian TBI.

METHODS AND ANALYSIS

The methods have been defined following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published from 2008 to 2019 will be identified searching the electronic databases Medline, Embase, Cochrane, Google Scholar, Directory of Open Access Journals and Web of Science. Retrieved records will be independently screened by two authors and relevant data will be extracted from studies reporting data on persistent PTH prevalence among civilian TBI individuals (≥16 years). The pooled prevalence estimates of any form of headache will be computed applying random-effects meta-analysis. Heterogeneity will be assessed using the I2 statistic and explored through subgroup analyses considering TBI severity (mild vs moderate/severe). Estimations of risk of bias will be performed using the Risk of Bias Tool for Prevalence Studies.

ETHICS AND DISSEMINATION

The result of this systematic review will be published in a peer-reviewed journal and disseminated at relevant conferences presentations. Formal ethical approval is not required because we will search and evaluate only existing sources of literature. By focusing on studies conducted in the last decade, this review will provide the most up-to-date information about the global prevalence of persistent PTH after TBI. Considering the economical and social burden of persistent PTH after TBI, accurate estimates of this problematic disorder is of utmost importance for planning, implementing and evaluating prevention interventions.

PROSPERO REGISTRATION NUMBER

CRD42018094138.