Ontario Neurotrauma Foundation

Guideline For Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms

3rd Edition, for Adults over 18 years of age

Ontario Neurotrauma Foundation

Post-Traumatic Headache

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Headache is the most common and among the most prevalent persistent symptoms following mTBI.1-4 Studies to date have documented that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache.2,5 Interestingly, several researchers have reported that post-traumatic headache is more common after concussion/mTBI than after severe TBI.5-17 Notably, post-traumatic headache is associated with a high degree of disability1 and is more chronic and persistent than previously thought.18 The vast majority of people with post-traumatic headache improve within days or weeks; however, for some individuals, headaches may persist beyond this time frame up to months or years. The International Classification of Headache Disorders (ICHD-III)19 includes diagnostic criteria for both acute (see Appendix 6.1) and persistent post-traumatic headache following mTBI (see Appendix 6.2).

Unfortunately, the management of persistent post-traumatic headache is often difficult and there is a paucity of research in the area and no evidence-based treatment guidelines available to guide management. Post-traumatic headache is classified as a secondary rather than primary headache subtype. Headache subtypes are then based upon clinical characteristics that best fit primary headache categories (i.e. migraine- or tension-type headaches).13 Comorbid conditions and psychological disorders such as post-traumatic stress disorder (PTSD) contribute to the complexity of managing post-traumatic headache.13,20,21 Accordingly, post-traumatic headache should not be treated as an isolated condition15 and the management of symptoms is based upon clinical experience and expert opinion.19

In line with this, diagnostic criteria for the common phenotypes of post-traumatic headache are provided in Appendix 6.3, and individual treatment pathways for these classes of primary headaches can be found in Algorithm 6.1. Clinical studies to date have been conflicting regarding the type of headache that most commonly occurs in post-traumatic headache. Some studies have suggested that the headaches most commonly resemble migraine headaches, whereas other studies have suggested that headaches more commonly resemble tension-type headache.3,8,14,16,22-27

Unfortunately, too frequent use of analgesics is a significant problem in many individuals suffering from persistent posttraumatic headaches.8,16 It is well known that too frequent use of analgesics/acute headache medications can, in some, perpetuate and lead to chronification of headaches via the phenomenon of medication overuse (“rebound”) headache. Accordingly, it is important to provide clear instructions on the maximal allowable daily dosing and the maximum allowable monthly frequency of medication consumption - combination analgesics, narcotic analgesics, ergotamines, triptans, and diclofenac potassium oral solution can be utilized no more than 10 days per month to avoid medication overuse (rebound) headache. It is also important to accurately ascertain the frequency and quantity of the patient’s acute headache medication use. Ideally, a blank monthly calendar should be utilized to maintain an accurate headache and medication calendar (Headache Diary-Appendix 6.4). For example, advise the patients to put the calendar in their bedroom or beside their toothbrush and fill out nightly, or utilize a notebook to record the information and then transfer to their monthly calendar.

It can be very challenging to determine whether an individual’s persistent post-traumatic headaches are secondary to the severity of their post-traumatic headache disorder or whether they are secondary to medication overuse (rebound) headache. In order to try to determine whether the individual’s headaches may, in fact, be perpetuated by the medication overuse (rebound), it is important to withdraw the individual from the offending medication(s) for a washout period of at least 6-8 weeks.1 The ICHD-III criteria for Medication Overuse in Headache is presented in Appendix 6.5. Prolonged passive treatment (i.e., many months) is generally not required.

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Assessment of Post-Traumatic Headache

New Key Section Level of evidence A B C Updated Evidence

6.1 icon recommendation B icon

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 icon

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).

Non-Pharmacological Treatment of Post-Traumatic Headache

New Key Section Level of evidence A B C Updated Evidence

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).

Pharmacological Treatment of Post-Traumatic Headache

New Key Section Level of evidence A B C Updated Evidence

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 icon

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.

Appendix 6.1

International Classification of Headache Disorders (ICHD-III) Beta:

Acute Headache Attributed to Mild Traumatic Injury to the Head

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Appendix 6.2

International Classification of Headache Disorders (ICHD-III) Beta:

Persistent Headache Attributed to Mild Traumatic Injury to the Head

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Appendix 6.3

Diagnostic Criteria for Selected Primary Headache Types from the International Classification of Headache Disorders (ICHD-III) Beta

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Appendix 6.4

Headache Diary

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Appendix 6.5

International Classification of Headache Disorders (ICHD-III) Beta: Medication-Overuse Headache

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Appendix 3.4

Important Components to Include in the Neurological and Musculoskeletal Exam

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Appendix 6.6

Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence

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Appendix 6.7

Prophylactic Therapy

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Appendix F

Other Links/Resources to consider

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Table 6.1

Important Components to Include in the Focused Headache History

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Algorithm 6.1

Assessment and Management of Post-Traumatic Headache following mTBI

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Kennedy E, Quinn D, Tumilty S, Chapple CM. Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskelet Sci Pract. 2017;29:91-98.
Country: New Zealand
Design: Retrospective Cohort
Quality Rating:DOWNS & BLACK: 16/32 *5 of the sections were not applicable

Sawyer K, Bell KR, Ehde DM, et al. Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms. Arch Phys Med Rehabil. 2015;96(11):2000-2006.
Country: USA
Design: Longitudinal Perspective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable

Defrin R, Riabinin M, Feingold Y, Schreiber S, Pick CG. Deficient pain modulatory systems in patients with mild traumatic brain and chronic post-traumatic headache: implications for its mechanism. J Neurotrauma. 2015;32(1):28-37.
Country: Israel
Design: Case-Control
Quality Rating: DOWNS & BLACK: 13/32 *6 of the sections were not applicable

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