Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > P. Pain and Headaches

P. Pain and Headaches

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Persons with traumatic brain injury (TBI) can suffer from pain and headaches immediately following their injury and throughout the period of recovery. Pain has a negative effect on cognitive recovery, sleep, mood, anxiety and can precipitate challenging behaviours. Some individuals can be managed with non-pharmacological strategies like cognitive behavioural counselling and biofeedback. Some individuals have pain related to the nerve injury (neuropathic pain) which requires treatments with different types of analgesic medications.

Clinicians should develop competency in comprehensive assessment of pain. Patients should be routinely asked about the nature and severity of pain. Ideally, brain injury services should have easy access to specialists in pain management. 


Indicators exemples

  • Proportion of individuals with TBI who benefitted from a pain management protocol.

  • Proportion of individuals with TBI and post-traumatic headaches who received cognitive behavioural therapy (CBT).


The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

Patient and Family Resource:

Other Resources:

Persons with TBI can suffer from pain and headaches immediately following their injury and throughout the period of recovery.  Moreover delay in cognitive recovery, sleep disorders and fatigue, elevated levels of anxiety and depression and post-traumatic stress disorder are issues associated with pain (Dobscha et al., 2009; Hoffman et al., 2007). A lack of recognition or diagnosis of pain can lead to an increase in aggression and agitation, or an inability to participate or benefit from rehabilitation (Ivanhoe & Hartman, 2004; Sherman, Goldberg, & Bell, 2006); therefore, early detection and management of pain is important to minimize the use of maladaptive coping strategies and maximize an individual’s recovery. Several treatments have shown to be effective such as cognitive behavioral therapy, biofeedback and medication. Biofeedback, relaxation, meditation and cognitive behavioural therapy are often considered the standard of behavioural treatments for pain (Branca & Lake, 2004).
Biofeedback (thermal and EMG) as an intervention for post-traumatic headaches was studied by Tatrow, Blanchard, and Silverman (2003) in combination with progressive muscle relaxation. Improvements in post-traumatic headaches were seen for the majority of participants; four participants had a clinically significant improvement in headache activity, six had some improvement, two had minor improvement and two worsened (Tatrow et al., 2003). Cognitive behavioural therapy has also been shown to be effective in reducing post-traumatic headaches. In a pre-post study, Gurr and Coetzer (2005) investigated 20 participants with a mild to severe TBI. Following cognitive behavioural therapy, headache intensity and headache frequency significantly decreased (p=0.004). Headache disability also decreased as measured by the Headache Disability Inventory (p=0.001) and the Headaches Needs Assessment (p=0.02)  (Gurr & Coetzer, 2005). 


Branca, B., & Lake, A. E. (2004). Psychological and neuropsychological integration in multidisciplinary pain management after TBI. J Head Trauma Rehabil, 19(1), 40-57.

Dobscha, S. K., Clark, M. E., Morasco, B. J., Freeman, M., Campbell, R., & Helfand, M. (2009). Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain Med, 10(7), 1200-1217.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.

Gurr, B., & Coetzer, B. R. (2005). The effectiveness of cognitive-behavioural therapy for post-traumatic headaches. Brain Inj, 19(7), 481-491.

Hoffman, J. M., Pagulayan, K. F., Zawaideh, N., Dikmen, S., Temkin, N., & Bell, K. R. (2007). Understanding pain after traumatic brain injury: impact on community participation. Am J Phys Med Rehabil, 86(12), 962-969.

Ivanhoe, C. B., & Hartman, E. T. (2004). Clinical caveats on medical assessment and treatment of pain after TBI. J Head Trauma Rehabil, 19(1), 29-39.

Sherman, K. B., Goldberg, M., & Bell, K. R. (2006). Traumatic brain injury and pain. Phys Med Rehabil Clin N Am, 17(2), 473-490, viii.

Tatrow, K., Blanchard, E. B., & Silverman, D. J. (2003). Posttraumatic headache: an exploratory treatment study. Appl Psychophysiol Biofeedback, 28(4), 267-278.

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P Priority F Fundamental New Level of evidence A B C

P 1.1 C

Pain should always be considered if a person with traumatic brain injury presents agitation or has cognitive/communication issues, non-verbal psychomotor restlessness or worsening spasticity, with particular attention paid to non-verbal signs of pain (e.g., grimacing).

(ABIKUS 2007, G73, p. 27)

Suggested tool: Algorithm for Agitation and Aggression

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C

P 2.1 P C

Rehabilitation programs for individuals with traumatic brain injury should have pain management protocols in place, which include:

  • Regular review and adjustment mechanisms

  • Handling, support and pain relief modalities appropriate to the person’s needs

  • Education of healthcare professionals and caregivers about appropriate handling of paretic upper limbs during transfers, hypersensitivity and neurogenic pain

(Adapted from ABIKUS 2007, G74, p. 27)

P 2.2 P icon B

Cognitive behaviour therapy (CBT) can be considered to reduce pain symptoms in individuals with post-traumatic headaches.

(INESSS-ONF, 2015)


- ERABI Module 4-Motor & Sensory Impairment Remediation -

P 2.3 icon B

Biofeedback can be considered to reduce pain symptoms in individuals with post-traumatic headaches.

(INESSS-ONF, 2015)


- ERABI Module 4-Motor & Sensory Impairment Remediation -

P 2.4 P icon C

Pregabalin may be considered for reducing central neuropathic pain caused by injuries to the brain or spinal column.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use


- ERABI Module 4-Motor & Sensory Impairment Remediation -

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