Post-Traumatic Headache After TBI

Post-Traumatic Headache After TBI: BrainLine Talks with Dr. Nathan Zasler

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.

BrainLine: What questions should a person with headaches after a TBI ask the doctor?

Dr. Zasler: People experiencing headaches after a TBI should not settle for PTHA as their diagnosis. As mentioned above, PTHA is a catch-all phrase that doesn't give any particular clues about the headache's cause or how to treat it. If a doctor cannot give the person a more specific diagnosis based on the nature of the injury, the headache history, and the exam, then the person should keep seeking specialists who can be more specific about diagnosis and treatment.

BrainLine: How does a history of headaches before injury influence PTHA after TBI?

Dr. Zasler: A person's history prior to a brain injury can play a significant role. People who have a personal or family history of migraine or tension headaches, in particular, tend to experience even worse headaches after injury. Also, if a person has a genetic predisposition to headaches even if he has never experienced them, he would be at greater risk of having PTHA after trauma. Another risk factor for PTHA would be someone who had neck problems, like herniated disks or arthritis, prior to a brain injury.

BrainLine: What types of treatments are effective for PTHA?

Dr. Zasler: A person's PTHA treatment depends on what headache sub-type or headache combination he or she has. There are many available treatments or treatment combinations. They run the gamut from manual therapy work with a physical therapist or osteopath, to stress management intervention, to modalities like ultrasound or injection therapies such as nerve blocks, facet blocks, and trigger-point injections.

But again, each headache type or combination should be treated differently based on the cause of pain. For example, if you have damage to the nerves on your scalp (neuritic and neuralgic pain), treatment might include local nerve blocks that stop nerve cells from sending pain messages to the brain, electrical stimulation, treating muscle spasms, or acupuncture. A tension-type headache, on the other hand, would most likely be treated by medication or by non-medication approaches like cognitive behavioral therapies, relaxation therapy, or EMG biofeedback*.

* Biofeedback is a form of alternative medicine that involves measuring a person's bodily functions such as blood pressure, heart rate, skin temperature and conveying the information to the patient in real-time. This knowledge raises the patient's awareness and conscious control of their unconscious physiological activities.

BrainLine: How does stress come into play with PTHA?

Dr. Zasler: As we all know, stress can negatively affect any facet of our lives. With PTHA, stress is like throwing fuel on an open fire. Therefore, stress management is crucial, especially for migraine and tension-type headaches. Some stress management therapies include stress inoculation training, relaxation therapy, and biofeedback. In fact, studies have shown that biofeedback is one of the most effective ways to treat certain types of headaches, though it can be labor-intensive and expensive.

BrainLine: What other symptoms may be related to PTHA?

Dr. Zasler: In addition to stress, other related symptoms of PTHA can include irritability, cognitive impairment, and difficulty sleeping.

BrainLine: What new research is being done to help people with PTHA?

Dr. Zasler: The good news is that there are a significant number of research studies being conducted on different headache types after TBI. I believe that in the next five to 10 years, we'll learn a good deal more about the different types of PTHA and will then be able to develop more targeted treatments. But above all else, treatment must always be individualized for each person.

BrainLine: Can you explain why making sure you get a specific or accurate diagnosis is so important?

Dr. Zasler: The issue — and danger — of mislabeling people should not be understated. Over the years, I have seen a lot of people who have been given the general label of PTHA. If they had been given a more specific diagnosis, they may have gotten the right treatment — and relief — sooner. I remember giving a talk about PTHA and describing a post-traumatic headache disorder called occipital neuralgia. I mentioned that with this kind of headache, a person might experience sharp, lightening-like pain and also pain behind one or both eyes. A woman in the audience spoke up saying that I had described exactly the kind of headache pain she continued to have even many years post-injury. She'd been diagnosed with chronic post-traumatic headache and had been treated unsuccessfully with a variety of migraine medications over the years. I examined her head and neck and applied pressure over the greater occipital nerve on the right side of her craniocervical junction. I knew from her headache description as well as from her reaction to my exam that she likely did not suffer from migraines, but from greater occipital neuralgia. Apparently, no one had ever asked her the right questions or done an appropriate exam. Had she been correctly diagnosed, she might have gotten relief sooner.

Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CBIST, is an internationally respected physician specialist in brain injury care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with brain injury in Glen Allen, Virginia.

He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury. Dr. Zasler is a Clinical Professor of PM&R at VCU in Richmond, Virginia, as well as a Clinical Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He also serves as a consultant in neurorehabilitation to the Northeast Center for Special Care in New York. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomate of the American Academy of Pain Management. His main areas of clinical and research interest include neuromedical issues in acquired brain injury (particularly mild TBI, neuropsychopharmacology and low level neurologic states), differential diagnosis in acquired brain injury community-based care issues, as well as chronic pain rehabilitation including headache.

Dr. Zasler is a practicing clinician who is involved with community-based neurorehabilitation and neuromedical assessment and management of persons with brain injury, neurodisabililty, as well as chronic pain. www.tree-of-life.com.

Posted on BrainLine March 2, 2009. Reviewed July 27, 2018.

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Comments (71)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

3.5 cm minengioma removed 9.5 mnths ago and then 4 weeks ago, hit my head really hard. Im told, dont hit your head again until it goes away. Im still having point tenderness where I hit. Is this normal.?

Im a 49 or old woman and on September 21, 2014 I was in a motorcycle accident most of the impact was my upper body and right side of my head. When I came to, after the accident my brain was shaking back and forth inside my scalp. The catscan came back normal but now I suffer everyday with a headache, my Chiropractor says my neck is sprained. These headaches ate constant, I wake up with one everyday. Im not sure what to do.

I know what it's like to live every day with headaches. I suffered a temporal bone fracture and jaw dislocation from a fall at work. I fell into some steel structure, hitting the right side of my head and fracturing my temporal bone. Neurosurgeon said that there was no trauma to the lobe that they could see and that the bone being pushed in and slightly rubbing on my temporal lobe would be of no consequence. I beg to differ. My fall was March 22 2013. Since then I have had jaw surgery to realign my right jaw. But I've noticed a constant headache and pressure behind my right eye, plus my vision has blurred a bit. Now it seems the only way they want to "fix" my headache problem is inject Botox in the affected area. Of course it doesn't take care of the blurry vision or the pressure behind my right eye. I've also noticed that my left eye has began to get red more often. No burning, no itching, no discharge other than watering at times. It's all strange to me. Also I can relate to the irritability, sleeplessness and loss of cognitive thinking.

My ex-boyfriend ,kept repeatedly hitting me in the same spot as well as others,but it's behind right ear that seems to have suffered more than I initially thought. my scalp is tender and is in constant pain ...it feels like a baby's "soft spot" if you will...in lots of pain ...can't ignore it!

I hit my head when I was about 10. I was sitting in a tyre leaning up against a wall, rocking back and forth, letting the tyre hit they wall. That last time I did it I hit my head, I was that dizzy I could not walk, my friends had to help me home as I could not see. I had to go hospital and they gave me an injection, I assume it was to stop me going dizzy. 

I hit my head again, the day I turned 18. Was stupidly drunk, ran down the stairs, blacked out and fell like a pencil 6-7ft straight to the corner of a table. I hit the left part of my head, where my hairline is. I lost hair there, I hear a clicking noise when I walk, still get pains to this day and it will be 5 years in 3 months. 

I was born with a squint, which I have had 6 operations, 3 on each. My eyes have gotten worse, vision in my right eye also. Have to wear glasses. I am seeing a neurologist soon, and also have been referred back to the eye doctor to get my squint checked out as they thinks its not my vision that is causing it, the lenses in my glasses are fine, so they think its from where I hit my head.

I also hit my head again the next year, june/july. I again was stupidly drunk, was ill for 4-5 days. I fell out of a bed and hit the door frame, and kept hitting my head. The same place I hit before. 

I still get pains to this day. I feel my blood pressure go up and I get a pain where I hit my head, it pulsates with my heart beat, and it makes me like put my head into my shoulders from where it hurts, I also get what I believe is de ja vu. Where I feel I have been there, but I get it where it makes me heave. When I am in or starting a de ja vu, I know the ways I am going to try to get out of it, which makes it worse, the feeling is horrible, it is much like being put to sleep for an op, if anyone knows that feeling. 

Like said above when I walk I hear a click in my neck or head. 

My focusing and concentration is worse. My speech is even gotten bad. I slur my words, get mixed up, feel like I am getting stupid. 

I will be talking about something, then all of a sudden forget what I am saying, and struggle to remember, sometimes I just give up because I cannot remember. Just sit there going...errm, errmm...swear I am going to become mentally retarted. I don't know if its anything, all connected or anything, just fed up now. 

went to spec savers again today as my new glasses I got last week are not doing what they should, seem worse. She asked about if I have hit my head, I told her about above. She wondered why I never mentioned this before. Also she shone a light into my eyes, I had to follow it. Every time I had to look up I would get a pain in my head. Kept having to squint cause it hurt. 

Hopefully once I have seen neurologist and eye doctor they can explain what this is. Believe my doctor recommended in my referral that I have a head scan. Hopefully that can show if its anything or nothing. 

I  suffered a mild concussion on January 28,2014 and to date I still suffer from pain in the occipital lobe on my head although that is  not where was injured and my left ear and upper jaw still hurts constantly. I now have migraine which I never had before and reading this article has given some relief that it is possible I will not  have to live with this forever. Thanks.

I was hit on my head 2 months ago by a heavy 10ft long aluminum beam that in cases a large security storage door. I've been dealing with many symptoms over the past couple months. I'm getting really aggravated by the slow healing process. Where I was struck I've been feeling a tingling burning pain on my scalp. My CT scan and Xray were normal and I'm waiting on results of my MRI. Could I possibly have nerve damage from the injury and would that show up on my MRI?

I am a Chiari patient and had brain decompression suffer in 2004. Following surgery I developed severe occipital neuralgia and migraines triggered by the surgery. I underwent a trial of neuro stimulation which was amazing. In 2007 I hand a neuro simulator implanted along my left occipital nerves and have been almost pain free since.
"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." I was told by a medical doctor that he did not have the time to review all the medical records of his patients and relies on families to tell him about the history. Some doctors do not practice what they preach!
I am a survior of domestic violence. Around August 2012 i started getting headaches and they are just getting worse and worse everyday. I am aslo having weird side effects: signifagant weight loss (30 pounds) um forgetfullness about things happing now i can remember years ago but not a few hours ago if i eat or drink i voimit or dry heve for hours um i use foul language without any control i studder when i talk i can be awake for days without any sleep. my behavior is erriact. i am constentally being accused of doing drugs. sometimes i cant remember how to write or spell or even talk walk.
I hit my head twice on a cement floor and over the following week my brain swelled tearing a nerve from my ear to my brain, thereby leaking fluid through my ear and nose. Loss of brain fluid creates terrible headaches, I suffered for at least eight months with debilitating headaches. Not to mention stretching the ligamnets in my neck. All of this can be pretty hard to sort out so close to the injury.
I just wanted to say thank you for such an informative evaluate on the different types of headaches and stating the things I should know before speaking to my doctor. This is well written and easy to understand, even for a person like myself who had suffered cognitive effects from my head injury.
hello sir, m 21 yrs old boy and m suffering for migraine but now a days i am having pain at a particular point in my head apart form migraine headache....and in my childhood i had a injury at that point...so is there any serious issues about this pain or it is the part of my migraine headache..please suggest..!!
Prolotherpy/prolozone is addressing my headaches that started with a 2008 rear-end collision. The prolotherapy (injections) treats ligament damage (stretched/lax) in head/neck/shoulders/upper back, facet joint damage, etc. This treatment has been around since the 1930s in one fashion or another. I had to learn about it on my own by researching my symptoms+whiplash (acceleration/deceleration injury). Otherwise I wouldn't have known about it or Barre-Lieou Syndrome. Warning, you will be scoffed at. I did not want to live on OTC anti-inflammatories or narcotic remedies. Mary (finally recovering)
As a chiropractor who suffered a TBI in 1985, I would like to point out that a significant number of headaches are related to the neurologic tension generated in the brain stem by these injuries. There are a group of Chiropractors specifically trained to manage these distressing consequences. This group IS NOT WELL-KNOWN by other Chiropractors or conventional medicine; they are Upper Cervical Chiropractors: www.upcspine.com/links1.htm
I\'m 3 yrs post TBI and having intractable migraine HA, along with vestibular disorder, neurogenic bladder, memory loss, depression, and some aphasia. I think this whole ordeal really sucks! Not a lot of hope for the future and nearly daily, unbearable, torturous pain with the migraines. Please encourage the neuro community to research better treatment options quickly because I see no value in continuing my life with this hell in my head. It is the invisable disorder because everyone questions why I am at home, in bed, with a home health nurse. If some of my neurologists could only walk 10 minutes with my migraine pain, I think they would be much more empathetic to relieve that pain! I understand, no one likes a migraine patient... we\'re very irritable and always asking for narcotics to relieve the pain, but we\'re still human beings and deserve to be treated with dignity, not like a drug-seeker. If I wanted to get high, it would be much easier to score drugs on a corner in the neighborhood than to sit for hours in an ER, only to listen to the doctor lecture me about narcotic use. Sorry, but I am irritable and angry about the ignorance of the medical community with regards to TBI. Thanks for letting me vent.
I suffered a TBI in 2002 to my frontal lobe. Since, I have had many changes to who I was and who I am today. One of the largest complaints aside from memory and what not are the headaches I recieve. I sometimes get very severe migraines that can last for days if I dont take medication immediately upon onset. More recently, I have started having "ice pick" headaches. They are short, almost thirty seconds or so, intense headaches that feel as though someone is carving at my brain. My eyes squint and tears flow. Before the motorcycle accident of 02', I have never experienced anything so excrutiating in my life. This article is very helpful and allows me to understand more why the headaches continue. And thank you to my mom for sending me the article.
I suffered TBI in 2003. Only had one severe headache to where I ended up in the hospital. That was post concussion. Now I have started getting intense headaches the last week now twice. Had a catscan and it came back negative. I am afraid now on top of my dizzy issues I am going to have these headaches off and on now. Today the headache was brought on after I went into a store with bright lights. Have been sensitive to bright lights after the initial injury, but never like this. Now I hope with this info to help get some relief. Good luck to those who are suffering from the same thing.
this article has been very useful, I am 10 yrs post TBI and have been having these stabbing pain like headaches for the last 2+ years. Most doctor's don't really know what to do, but this article has opened up some other avenues that I plan on looking into. Thanks again. Karin (Washington DC)
Interesting article. I have been diagnosed with migraines for several years and cervic-genic head for one year (10 years post TBI). They are chronic and get worse during the work day. This is valuable information that I will share with my pain doc. I have kept a variety of logs, but no one really bothered to look at them, maybe with this information, they will!
Thank you so much for this article. I have been suffering from chronic daily headaches ever since my serous concussion 35 years ago. My doctor kept telling me "it's just who you are" every time I brought the subject up, but she hadn't even asked any questions about them or looked into where they were coming from. I have just changed doctors because of this (I finally got fed up!), and he is willing to look into the headaches. This article has confirmed my decision to change doctors, as I find it hard to believe my headaches are not connected to the concussion, as they started shortly after the accident. Thank you again! Arlene Vancouver, BC

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