Chapter 20-8: Headaches Associated with Head Trauma

TEXTBOOK PRESENTATION

A common presentation of a posttraumatic headache would be a middle-aged person who recently suffered head trauma, usually without detectable cranial or neurologic injury, with a headache similar in quality to tension headaches. The headaches are often associated with symptoms such as irritability or anxiety.

DISEASE HIGHLIGHTS

1. Head trauma can cause serious cranial or neurologic injury including subdural, epidural or parenchymal hematoma, SAH, cerebral contusion, or depressed skull fracture.

2. More commonly, head trauma can cause new headaches or worsen preexisting headache syndromes.

3. Trauma-related headaches might occur after minor or major trauma. The IHS has distinct criteria for what qualifies as major and minor trauma.

4. A headache associated with head trauma develops within 3 days of head injury (or becoming able to report headache after head trauma) and resolves after 3 months.

EVIDENCE-BASED DIAGNOSIS

1. Acute evaluation of head trauma

   1. In a patient with head trauma or a headache seemingly associated with head trauma, the first goal is to identify important and potentially treatable injury.

   2. The initial test is usually a head CT scan. A difficult question is who can be clinically cleared without a CT scan.

      1. Two clinical decision rules (The Canadian Head CT Rule and the Nexus II).

      2. Nexus II says that if none of the following signs are present, the patient does not need a head CT: Evidence of significant skull fracture, scalp hematoma, neurologic deficit, altered level of alertness, abnormal behavior, coagulopathy, persistent vomiting, age > 65.

      3. The Canadian Head CT Rule is referenced at the end of the chapter.

      4. Both rules have nearly 100% sensitivity for clinically important brain injuries and injuries requiring neurosurgical intervention.

2. Diagnosis of headache as part of a mild traumatic brain injury (concussion)

   1. Headache is a common symptom of postconcussion syndrome.

   2. Headache develops in about 25% of patients following minor trauma.

      1. These headaches are most likely to be chronic.

      2. They are also most likely to meet criteria for tension-type headaches.

TREATMENT

1. Any patient with concern for a concussion should undergo cognitive rest immediately following the injury. This may involve time away from work/school and be advised to avoid computer, television, and phone screens.

2. Initially, NSAIDs and acetaminophen are helpful to treat postconcussion headache. For patients in whom chronic headaches develop, amitriptyline or topiramate can be helpful.