BrainLine sat down with Dr. Nathan Zasler to talk about post-traumatic headache (PTHA), one of the most common complaints after traumatic head and brain injury (TBI). Dr. Zasler is an internationally respected neurorehabilitation physician who specializes in acquired brain injury and has a particular interest in post-traumatic pain disorders including headache.
BrainLine: What is post-traumatic headache, or PTHA?
Dr. Zasler: The term "post-traumatic headache" describes the most common complaint after brain injury: headaches. Unfortunately, PTHA is a "garbage-can" term — a catch-all phrase — because without a more specific diagnosis, PTHA simply states the obvious but doesn't tell you about the cause of the headache or how to treat it.
BrainLine: What types of headaches typically follow a TBI?
Dr. Zasler: There are several different types and causes of headache following a brain, head, or neck injury. The more you know about the various kinds of headache and their causes, the more informed you will be when talking with your doctor or specialist.
- Tension Headaches — Tension-type headaches often feel as if your head is being squeezed by a vice at your temples — the sensitive spots at the side of the head between your ears and eyes. A decrease in tolerance for stress, decreased thinking efficiency and reserve, and depression are often associated with tension headaches.
- Migraine or Neurovascular Headaches — Migraine headaches account for approximately 20 percent of PTHA (although many practitioners will debate this). Migraines are thought to be the result of changes in the blood flow inside the brain. The risk for migraines post-injury appears to be strongly genetically linked.
- Cervical/Cervicogenic Headaches — This kind of PTHA is common after a brain injury and is usually related to neck injury involving ligament, muscle, and/or joint (facet) injury.
- Musculoskeletal Headaches — Musculoskeletal headaches are often overlooked but are quite common after a TBI. Pain in the muscles or bones of the head, neck, shoulders, and/or jaw (see below) can be a source of head pain.
- Temporomandibular Joint Disfunction — TMJD sometimes occurs after trauma and involves injury to the "chewing" muscles around the jaw, or to the jaw joints themselves leading to headaches typically experienced on the side of the head in the temple region(s).
- Neuritic and Neuralgic Pain — Injury to the nerves in the scalp or larger nerves in the face (e.g. supra-orbital) and upper neck (e.g. greater occipital) from the trauma can result in head discomfort as well as headaches that may present with numbness, sensitivity, and/or shooting- or stabbing-type pains.
BrainLine: How common is PTHA after TBI? And when do these headaches start? Can there be a delay between the injury and the headaches?
Dr. Zasler: PTHA is one of the most common symptoms after a brain injury. In fact, approximately 70 percent of people who have had a mild TBI or concussion complain of PTHA. The catch is that PTHA is often not related to the brain injury itself, but rather to the other injuries sustained at the same time including trauma to the head, jaw, and/or neck. Most PTHA start within two weeks after the injury regardless of the cause of the headache pain; however, onset may be later with certain less common headache types.
BrainLine: How long does PTHA usually last after TBI?
Dr. Zasler: In medical circles, there is debate about this question. There is clearly evidence that PTHA can be chronic, especially if the headache types are tension or migraine headaches. However, it is very important to look at the cause of headache pain post-injury. Much of the literature on PTHA lump all the types of headaches together, which is a mistake since the more you know about the root cause of a headache post-trauma, the more effectively you can treat it.
BrainLine: What kind of information should you give your doctor to help him better understand your headaches?
Dr. Zasler: We all know that knowledge is power. And in this case, the more knowledge and information a doctor has about a person's injury and the nature of the PTHA, the more effective treatment he can offer. First of all, the doctor needs to understand the person's history. Make sure the doctor reviews your medical records including your imaging tests. Then he needs to take an adequate headache history, which should include among other inquiries questions expressed in the mnemonic COLDER:
Character — What the headache feels like
Onset — How the headache starts
Location — Where exactly the headache hurts
Duration — How long the headache lasts
Exacerbation — What makes the headache worse
Relief — What makes the headache less or better
The doctor will also want to ask when the PTHA started after the trauma; how severe and frequent the headaches are and whether the severity varies; what medicines have been effective, or not; and what the "functional consequences" of the headache are — meaning, can the person go to work or does he have to lie down and sleep in a dark room until the headache subsides?
BrainLine: What else should a doctor's evaluation entail?
Dr. Zasler: In addition to the medical and headache histories, the doctor will also want to perform appropriate neurological and musculoskeletal exams. This should include direct examinations of the face, head, neck, and upper spine and shoulder area. He may need to order further diagnostic tests. Finally, depending on the cause of the headache, the doctor may recommend any number of specialists, including a physiatrist (rehabilitation medicine physician), dentist or oromaxillofacial surgeon who specializes in TMJ problems, a neurologist, psychiatrist, physical therapist, and/or a pain management specialist.
You may also want to contact brain injury advocacy groups like the Brain Injury Association of America or one of its local state affiliates, which may have resources to help you find specialists in your area. Most importantly, when picking a specialist, make sure the specialist has experience with treating these types of headaches. Each person's headache disorder must be individually assessed and managed.
Nathan D. Zasler, MD, Nathan Zasler, MD is CEO and medical director for Concussion Care Centre of Virginia, Ltd. as well as CEO and medical director for Tree of Life Services, Inc. He is board certified in physical medicine and rehabilitation and fellowship trained in brain injury.
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