6.1 B

The primary care provider should take a focused headache history (see Table 6.1) in order to identify the headache subtype(s) that most closely resemble(s) the patient’s symptoms. To aid in determining the specific phenotype of headache disorder present, refer to the ICHD-III Beta classification criteria in Appendix 6.3. It should be noted that some post-traumatic headaches are currently unclassifiable.

6.2 C

Delayed brain imaging (Brain CT or MRI) should be considered when neurologic signs or symptoms are suggestive of possible intracranial pathology, progressive/worsening symptoms without any indications of other cause.

6.3 C

Establish the degree of headache-related disability (i.e. missed work/school, decreased productivity, missed social/recreational activities, bedridden) to assist in stratifying a treatment approach. Markedly limiting or atypical symptoms should be considered for referral to an interdisciplinary concussion clinic, neurologist or headache clinic.

6.4 B

Primary care providers and healthcare professionals treating patient’s headaches should perform a neurologic and musculoskeletal exam including cervical spine and vestibular examination (see Appendix 3.4).

6.5 C

Education should be provided on lifestyle strategies and simple, self-regulated intervention strategies that may minimize headache occurrence and/or decrease the impact of headaches when they occur. For more details on lifestyle management (see Appendix 6.6).

6.6 C

The treatment of headaches should be individualized and tailored to the clinical features and patient preferences. The treatment may include:

• Headache education including topics such as stimulus control, use of caffeine/tobacco/ alcohol and other stimulants
• Non-pharmacologic interventions such as sleep hygiene education, dietary modification, manual therapy and exercise, relaxation and modification of the environment.
• Pharmacologic interventions as appropriate both for acute pain and prevention of headache attacks.

^{Taken from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2016).}

6.7 C

All patients with frequent headaches should be strongly encouraged to maintain an accurate headache diary (see Appendix 6.5), medication calendar and activity log in order to accurately gauge symptoms and guide management.

6.8 C

Based upon the patient’s headache characteristics, consideration may be given to using acute headache medications, limited to less than 15 days per month, including:

1. Over-the-counter or prescription analgesics (e.g., acetaminophen, ibuprofen, Naproxen, acetylsalicylic acid (ASA))
2. Less than 10 days per month for combination analgesics (with codeine or caffeine)
3. Triptan class medications (less than 10 days per month)

6.9 B

For patients with post-traumatic headaches that are migrainous in nature, the use of migrainespecific abortants including diclofenac potassium oral solution and triptan class medications (i.e., Almotriptan, Eletriptan, Sumatriptan, Rizatriptan, Zolmitriptan, etc.) may be used if effective, but should be limited to fewer than 10 days per month due to risk of developing medication-induced headaches with more frequent use.

6.10 C

Narcotic analgesics should be avoided or restricted solely to “rescue therapy” for acute attacks when other first- and second-line therapies fail or are contraindicated.

6.11 B

Prophylactic therapy should be considered if headaches are occurring too frequently, are too disabling, or if acute headache medications are contraindicated or poorly tolerated or are being used too frequently (see Appendix 6.7).

6.12 C

Post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to a neurologist, pain management specialist, or interdisciplinary concussion clinic is recommended.