Posttraumatic headache is a distinct headache type from migraine.

PURPOSE OF REVIEW: Posttraumatic headache (PTH), a headache that develops within 7 days of a causative injury, is one of the most common secondary headaches, mostly attributed to mild traumatic brain injury (mTBI). Because presence of preinjury headache is a risk factor for developing PTH and PTH symptoms often resemble migraine or tension-type headache, the association between PTH and primary headaches has attracted attention from clinicians and scientists. RECENT FINDINGS: Recent studies on epidemiological aspects, headache features, risk factors, imaging characteristics, and response to treatment, suggest overlapping features and distinct objective findings in PTH compared to migraine. SUMMARY: We argue that PTH is distinct from migraine. Therefore, PTH epidemiology, pathophysiology, diagnosis, treatment, and prognosis should continue to be investigated separately from migraine.

Can Long-Term Outcomes of Posttraumatic Headache be Predicted?

PURPOSE OF REVIEW: Headache is one of the most common symptoms of traumatic brain injury, and it is more common in patients with mild, rather than moderate or severe, traumatic brain injury. Posttraumatic headache can be the most persistent symptom of traumatic brain injury. In this article, we review the current understanding of posttraumatic headache, summarize the current knowledge of its pathophysiology and treatment, and review the research regarding predictors of long-term outcomes. RECENT FINDINGS: To date, posttraumatic headache has been treated based on the semiology of the primary headache disorder that it most resembles, but the pathophysiology is likely to be different, and the long-term prognosis differs as well. No models exist to predict long-term outcomes, and few studies have highlighted risk factors for the development of acute and persistent posttraumatic headaches. Further research is needed to elucidate the pathophysiology and identify specific treatments for posttraumatic headache to be able to predict long-term outcomes. In addition, the effect of managing comorbid traumatic brain injury symptoms on posttraumatic headache management should be further studied. Posttraumatic headache can be a persistent symptom of traumatic brain injury, especially mild traumatic brain injury. It has traditionally been treated based on the semiology of the primary headache disorder it most closely resembles, but further research is needed to elucidate the pathophysiology of posttraumatic headache and determine risk factors to better predict long-term outcomes.

Comparison of continuous headache features in youth with migraine, new daily persistent headache, and persistent post-traumatic headache.

OBJECTIVE: To compare clinical features in youth with continuous headache from migraine, persistent post-traumatic headache, and new daily persistent headache to determine if they are similar, contrary to their distinction in the International Classification of Headache Disorders. METHODS: We pursued a single center age- and sex-matched observational study comparing the clinical characteristics of 150 youth (11 - 17 years old) with continuous headache from migraine, persistent post-traumatic headache, and new daily persistent headache. A diagnostic algorithm based on international classification of headache disorders criteria was used to identify those with migraine (headache features of migraine with gradual onset), and persistent post-traumatic headache and new daily persistent headache (based on the circumstances of headache onset regardless of headache features). Fifty participants each with migraine, persistent post-traumatic headache, and new daily persistent headache were matched by age and sex. Participant survey responses on headache characteristics were compared. RESULTS: Median usual headache severity was 6.0 [95%CI 6.0, 6.0] and was not different across diagnostic groups (H statistic = 1.2, p = 0.55). Headache exacerbation frequency, disability, associated symptoms, and most triggers were not significantly different across groups. The majority of persistent post-traumatic headache and new daily persistent headache had headache features consistent with a diagnose of migraine (72% and 62%, respectively). CONCLUSION: Our findings suggest that most persistent post-traumatic headache and new daily persistent headache may represent abrupt onset of migraine.

Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury.

OBJECTIVE: This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury. METHODS: Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site. RESULTS: PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, ß (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury. CONCLUSIONS: Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.

Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion.

BACKGROUND: There is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury. METHODS: Adults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI). RESULTS: A total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness. CONCLUSIONS: This study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.

Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints.

OBJECTIVES: The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine. METHODS: Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield. RESULTS: In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%. CONCLUSIONS: Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.

Equity and Disparities in Diagnosis, Management, and Research of Post-Traumatic Headache.

PURPOSE OF REVIEW: There are notable health disparities and inequities in individuals with traumatic brain injury (TBI) and concussion by race, ethnicity, gender, socioeconomic status, and geography. This review will evaluate these disparities and inequities and assess the social determinants of health that drive outcomes for post-traumatic headache. Interventions for achieving this are also discussed. RECENT FINDINGS: Significant disparities and inequities exist in TBI and concussion among people of different races, socioeconomic status, and geographic locations. Migraine is a common symptom post-concussion, for which disparities and social determinants of health are also discussed. Overall, multi-level interventions to reduce these disparities and inequities are reviewed for post-traumatic headache but require further investigation. Interventions are needed to reduce disparities and inequities including public health initiatives, improvements in clinical care, diversity/inclusion training, and research efforts. As literature expands, we can form guidance to identify solutions for eliminating disparities in care of diverse populations.

Post-traumatic headache after mild traumatic brain injury in a one-year follow up study - risk factors and return to work.

BACKGROUND: Post-traumatic headache (PTH) is a common symptom following mild traumatic brain injury (mTBI). Patients at risk to develop acute PTH (aPTH) and further persistent PTH (pPTH) need to be recognized. METHODS: This is a one-year follow-up of 127 patients with mTBI, aged 18 to 68, referred to outpatient clinic in the Helsinki University Hospital. Symptoms were assessed at the emergency department (ED), with structured interview at outpatient clinic visit and with Rivermead post-concussion symptom questionnaire at one, three, and 12 months after injury. Psychiatric disorders were assessed with Structured Clinical Interview for DSM-IV Axis I disorders at 3-4 months and return to work (RTW) from patient records. RESULTS: At one month, 77/127 patients (61%) had aPTH. According to multiple logistic regression analysis, risk factors for aPTH were headache at the emergency department (ED) (OR 5.43), other pain (OR 3.19), insomnia (OR 3.23), and vertigo (OR 5.98). At three months, 17 patients (22% of aPTH patients) had developed pPTH, and at one year, 4 patients (24% of pPTH patients) still presented with pPTH. Risk factors for pPTH at three months were older age (OR 1.06) and current insomnia (OR 12.3). The frequency of psychiatric disorders did not differ between the groups. pPTH patients performed worse on their RTW. CONCLUSIONS: Risk factors for aPTH were insomnia, headache at ED, other pain, and vertigo and for pPTH, insomnia and older age. RTW rate was lower among pPTH patients.

Headache complexity (number of symptom features) differentiates post-traumatic from non-traumatic headaches.

BACKGROUND: Post-traumatic headaches are a common sequela of mild traumatic brain injury (concussion). It is unclear whether or how these headaches differ phenotypically from primary headaches. OBJECTIVE: Determine whether there is an overarching unobserved latent trait that drives the expression of observed features of post-traumatic headache and other headaches. METHODS: Data from this post-hoc analysis come from the Warrior Strong Cohort Study conducted from 2010 through 2015. Approximately 25,000 soldiers were screened for concussion history at routine post-deployment health assessments. A random sample was invited to participate, enrolling 1567. Twelve observed headache phenotypic features were used to measure "headache complexity", the latent trait of clinical interest, using single factor confirmatory factor analysis. We compared headache complexity between groups and determined whether headache complexity predicted accessing medical care for headache. RESULTS: Of 1094 soldiers with headaches, 198 were classified as having post-traumatic headache. These headaches were compared to those in the other soldiers (647 without concussion history and 249 with concussion history). Soldiers with post-traumatic headache had greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The confirmatory factor analysis showed good model fit (χ2 (51) = 95.59, p = 0.0002, RMSEA = 0.03, comparative fit index = 0.99, and Tucker-Lewis index = 0.99), providing empirical support for the headache complexity construct. Soldier groups differed in their mean headache complexity level (p < 0.001) such that post-traumatic headache soldiers had greater headache complexity compared to non-concussed soldiers (standardized mean difference = 0.91, 95% confidence interval: 0.72-1.09, p < 0.001 and to concussed soldiers with coincidental headaches standardized mean difference = 0.75, 95% confidence interval: 0.53-0.96, p < 0.001). Increasing headache complexity predicted medical encounters for headache (odds ratio = 1.87, 95% confidence interval: 1.49-2.35, p < 0.001) and migraine (odds ratio = 3.74, 95% confidence interval: 2.33-5.98, p < 0.001) during the year following deployment.Conclusions and relevance: The current study provided support for a single latent trait, characterized by observed headache symptoms, that differentiates between concussive and non-concussive headaches and predicts use of medical care for headache. The single trait confirmatory factor analysis suggests that post-traumatic headaches differ from non-concussive headaches by severity more than kind, based on the symptoms assessed.ClinicalTrials.gov identifier NCT01847040.

Photophobia and allodynia in persistent post-traumatic headache are associated with higher disease burden.

OBJECTIVE: To assess photophobia and allodynia in subjects with post-traumatic headache and examine how these sensory hypersensitivities associate with clinical measures of disease burden. BACKGROUND: Post-traumatic headache is the most frequent and disabling long-term consequence of mild traumatic brain injury. There is evidence of sensory dysfunction in acute post-traumatic headache, and it is known from other headache conditions that sensory amplifications correlate with more severe disease. However, systematic studies in post-traumatic headache are surprisingly scarce. METHODS: We tested light and tactile sensitivity, along with measures of disease burden, in 30 persistent post-traumatic headache subjects and 35 controls. RESULTS: In all, 79% of post-traumatic headache subjects exhibited sensory hypersensitivity based on psychophysical assessment. Of those exhibiting hypersensitivity, 54% exhibited both light and tactile sensitivity. Finally, sensory thresholds were correlated across modalities, as well as with headache attack frequency. CONCLUSIONS: In this study, post-traumatic headache subjects with both light and tactile sensitivity had significantly higher headache frequencies and lower sensitivity thresholds to both modalities, compared to those with single or no sensory hypersensitivity. This pattern suggests that hypersensitivity across multiple modalities may be functionally synergistic, reflect a higher disease burden, and may serve as candidate markers of disease.

Post-traumatic Headache and Mild Traumatic Brain Injury: Brain Networks and Connectivity.

PURPOSE OF REVIEW: Post-traumatic headache (PTH) consequent to mild traumatic brain injury (mTBI) is a complex, multidimensional, chronic neurological disorder. The purpose of this review is to evaluate the current neuroimaging studies on mTBI and PTH with a specific focus on brain networks and connectivity patterns. RECENT FINDINGS: We present findings on PTH incidence and prevalence, as well as the latest neuroimaging research findings on mTBI and PTH. Additionally, we propose a new strategy in studying PTH following mTBI. The diversity and heterogeneity of pathophysiological mechanisms underlying mild traumatic brain injury pose unique challenges on how we interpret neuroimaging findings in PTH. Evaluating alterations in the intrinsic brain network connectivity patterns using novel imaging and analytical techniques may provide additional insights into PTH disease state and therefore inform effective treatment strategies.

Clinical profile and short-term course of post-traumatic headache in children with mild traumatic brain injury: a prospective cohort study.

OBJECTIVE: To study the clinical profile and factors associated with post-traumatic headache (PTH) in children with mild traumatic brain injury (mTBI) attending an urban public hospital. METHODS: We enrolled 130 consecutive children aged 6-12 years with mTBI (as per the International Classification of Headache Disorders-III criteria), and followed them up for 7 days. Those who developed PTH were further followed up monthly for 3 months. RESULTS: Thirty (23.1%) children developed PTH; 25 (19.2%) children had acute PTH (duration 7 days to 3 months) and the remaining 5 (3.8%) developed persistent PTH (> 3 months). Majority (50%) had bilateral headache and squeezing quality (50%). Forty percent of those with PTH met the criteria for migraine. Obesity (P = 0.84), female gender (P = 0.26), family history of headache (P = 0.93), and prior history of concussion (P = 0.70) were not associated with risk of PTH. Children who developed PTH had higher rate of nausea (RR (95% CI) = 2.42 (1.06, 5.5); P = 0.03) and vomiting (RR (95% CI) = 3.76 (1.64, 8.5); P = 0.001) after mTBI. Headache resolved within 1 month in 63.3% of children. CONCLUSION: PTH was found to be common after mTBI in children. Protocolized follow-up and directed history taking for PTH in all children with mTBI, who are frequently discharge from the emergency department after first aid, will lead to appropriate diagnosis and management of this problem.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis.

BACKGROUND: Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals. METHODS: The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed. RESULTS: From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm2], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N]. CONCLUSION: The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings. STUDY REGISTRATION: Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Effectiveness of Mulligan manual therapy over exercise on headache frequency, intensity and disability for patients with migraine, tension-type headache and cervicogenic headache - a protocol of a pragmatic randomized controlled trial.

BACKGROUND: Non - pharmacological management of migraine, tension-type headache (TTH), and cervicogenic headache (CGH) may include spinal manual therapy and exercise. Mulligan Manual Therapy (MMT) utilizes a protocol of headache elimination procedures to manage headache parameters and associated disability, but has only been evaluated in CGH. There is little evidence for its effectiveness in migraine and TTH. This study aims to determine the effectiveness of MMT and exercise over exercise and placebo in the management of migraine, TTH, and CGH. METHODS: This pragmatic trial is designed as a prospective, three-armed randomised controlled trial in a clinical setting provided at a general hospital physiotherapy department. Two hundred ninety-seven participants with a diagnosis of migraine, TTH or CGH based on published headache classification guidelines will be included. An assessor blind to group allocation will measure outcomes pre-and post-intervention as well as 3 and 6 months after commencement of treatment. Participants will be allocated to one of the three groups: MMT and exercise; placebo and exercise; and exercise alone. The primary outcome measure is headache frequency. Secondary outcome measures are headache duration and intensity, medication intake, pressure pain threshold (PPT), range of motion recorded with the flexion rotation test, and headache disability recorded with Headache Activities of Daily Living Index (HADLI). The intention-to-treat principle will be followed for statistical analysis. Between groups differences for all outcome measures at baseline and at reassessment points and 95% confidence intervals will be calculated using a mixed model ANOVA. Post hoc tests will be conducted to identify any significant difference between groups and over time. DISCUSSION: This pragmatic study will provide evidence for the effectiveness of MMT when compared with a placebo intervention and exercise on headache frequency, intensity, and disability. Limitations are that baseline evaluation of headache parameters may be affected by recall bias. External validity will be limited to the population with a minimum 1-year history of headache. The HADLI is not yet extensively evaluated for its psychometric properties and association between PPT and headache parameters is lacking. Performance bias is inevitable as a single therapist will be delivering all interventions. TRIAL REGISTRATION: The trial was registered prospectively under the Clinical Trial Registry India (Registration number: CTRI/2019/06/019506 , dated on 03/06/2019). .

POST-TRAUMATIC HEADACHE. CURRENT VIEWS ON PATHOPHYSIOLOGICAL MECHANISMS OF DEVELOPMENT AND CLINICAL SPECIFICS (REVIEW).

Headache after craniocerebral injury is an urgent problem due to its frequent occurrence, tendency towards chronization, and strong patient disadaptation effect. Despite the significant incidence of post-traumatic headache (the PTHA) and related socioeconomic factors, many fundamental aspects of this problem have not been considered adequately. Therefore, the aim of our review is to highlight key points regarding the pathogenetic mechanisms of development, key clinical features, and strategies for optimal management of PTHA. A literature review was performed using the Pubmed database by selecting articles about post-traumatic headache (PTHA) over 10 years (from 2010 to 2020).The search was performed in English, Russian, and Ukrainian using the following key words and terms: post-traumatic headache, post-traumatic cephalalgia, headache after brain injury, and post-concussion syndrome. All articles with information on etiology, pathogenesis, clinic, diagnosis, differential diagnosis, neuroimaging, pathomorphological evaluation, and treatment strategies for this pathology were included in the analysis. After identifying all the articles that met the inclusion criteria and deleting duplicate data, 46 literature sources on PTHA were selected. According to the International Headache Classification, PTHA is a secondary cephalalgia associated with head and/or neck injury, which develops within 7 days of a craniocerebral injury. A distinction is made between acute and persistent PTHA associated with mild, moderate, and severe injury. To diagnose persistent PTHA, it is sufficient to establish a causal link between the fact of head injury and the duration of pain for 3+ months. It is interestingly that individuals with mild craniocerebral injury have both higher incidence and higher duration and intensity of PTHA compared to those with severe injury. Despite the absence of specific characteristics, several clinical phenotypes of PTHA are distinguished, the most common of which are migraine-like and tensor types. The pathogenetic mechanisms of PTHA development are complex and diverse. Since recently, special attention has been paid to activation of the trigemino-vasculo-thalamic system, central sensitization, and GCRP-associated mechanisms that probably play an important role in the PTHA pathogenesis. Modern neuroimaging methods using diffusion-tensor and functional MRI are important in the PTHA diagnosis and differential diagnosis. PTHA treatment requires a multidisciplinary approach and includes a combination of drug and drug-free methods. Despite a long history of PTHA research, the issues concerning diagnostic criteria, pathogenetic mechanisms, clinical features, and strategies, in particular in patients who suffered severe craniocerebral injury, have not been considered properly. The above data indicate the need to clarify many aspects of the studied problem.

Clinical features and sex differences in pediatric post-traumatic headache: A retrospective chart review at a Boston area concussion clinic.

BACKGROUND: Often concussion/mTBI triggers a chronic headache syndrome called persistent post-traumatic headache (P-PTH) that can last from months to years post-injury, and produce significant disruption of childhood education, social interaction and development. Although prevalent and highly disabling, P-PTH is underrepresented in headache and pain research and lacks clear definition and pathophysiology. Clinical presentation of P-PTH frequently resembles that of other headache disorders, like migraine, yet the pathophysiological mechanisms are distinct and not fully understood, making the disorder difficult to treat in the clinical setting. METHODS: In a retrospective analysis of 1506 pediatric patients attending Boston Children's Hospital clinics, demographic trends, symptom features, and the influence of sex on clinical presentation of PTH are presented. We compare clinical characteristics of P-PTH with a published cohort of migraine patients to evaluate the clinical features that are unique to P-PTH. RESULTS: Findings show that despite equivalent representation of sex in the clinic, P-PTH is expressed more in females than males and is weighted towards somatic symptoms. Relative to migraine, PTH is less associated with a family history of headache. CONCLUSIONS: The ability to identify persons with PTH can help manage risk factors and identify persons likely to develop persistent post-concussion symptoms.

Risk Factors for the Development of Post-Traumatic Headache Attributed to Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To systematically identify risk factors for the development of post-traumatic headache (PTH) attributed to traumatic brain injury (TBI) as defined in the International Classification of Headache Disorders (ICHD). BACKGROUND: PTH is a common sequela of TBI and a leading cause of injury-related disability worldwide. However, little is known about risk factors for the development of PTH attributed to TBI. METHODS: We searched PubMed and Embase for literature on risk factors for the development of acute and/or persistent PTH attributed to TBI in accordance with any version of the ICHD. Original studies published in English and of prospective, cross-sectional or retrospective design were considered for the review. Data extraction was performed independently by 2 investigators. RESULTS: Of 1993 potentially relevant articles identified, 3 articles met the inclusion criteria. The following risk factors were assessed for the development of acute PTH: age, sex, type of injury, loss of consciousness, previous TBIs, history of primary headache disorders, history of chronic pain condition other than headache, current treatment for depression/anxiety, attention or learning disorders, body mass index, and other diseases (not further specified). None of the included studies assessed risk factors for the development of persistent PTH. CONCLUSIONS: We found that there is little evidence for any risk factors involved in the development of acute PTH, whereas no study had assessed risk factors for the development of persistent PTH. Further studies are warranted and should be powered to examine possible risk factors for the development of PTH. Rigorous methodology and standardized monitoring should be prioritized to support high-quality research and validate potential findings.

Pediatric Post-Traumatic Headache and Implications for Return to Sport: A Narrative Review.

BACKGROUND: Headache attributed to mild traumatic injury of the head (aka: mild traumatic brain injury, mTBI), frequently abbreviated to Post-Traumatic Headache (PTH), is one of the most common and disabling symptoms after a head injury. PTH often phenotypes to migraine. Evidence for treating PTH in the pediatric population is limited. Widely accepted guidelines do not exist to aid the clinician and there are currently no placebo-controlled trials for the pharmacologic management of PTH in this age group. Recommendations for when to return a child or adolescent to sport if they develop and/or are being treated for persistent PTH (PPTH) are lacking. The objective of this narrative review is to review the implications of returning an adolescent with PPTH to sport. METHODS: Pediatric neurologists with special qualification in headache collaborated on this narrative review. Literature was searched up until Oct 2019 for articles pertaining to PTH, concussion, mTBI, and the return of a pediatric athlete to sport after mTBI. Article inclusion was at the discretion of the authors. There was author consensus regarding all recommendations made. CONCLUSION: The authors recommend that strict adherence to the guidelines that return to sport cannot occur until a child is symptom free at rest, off any medication, may be unreasonable in certain situations. Symptom stability is the proposed new concept for return to sport.

Post-Traumatic Headache in Children and Adolescents: a Narrative Review with a Focus on Management.

PURPOSE OF REVIEW: Although common, post-traumatic headache (PTH) in the pediatric population is a niche group with a paucity of published evidence on the diagnosis, most appropriate acute and preventative management, and prognosis. This article aims to review pediatric PTH, its epidemiology and pathophysiology with a focus on management and future directions. RECENT FINDINGS: Using MEDLINE, EMBASE, 52 articles on PTH in children and adolescents from 2016 to 2020 were identified. Over the last 4 years, our understanding of traumatic brain injury pathophysiology has grown, expanding the potential for more therapeutic targets. Despite this achievement, and recently published consensus guidelines, the review demonstrated a lack of published controlled trials to help guide management of pediatric PTH. The last 4 years have provided new insights into the potential pathophysiological mechanisms through laboratory research and advanced MR imaging; however, there continues to be a translational gap to clinical practice.

Profiling the Extent and Location of Pain in Migraine and Cervicogenic Headache: A Cross-sectional Single-Site Observational Study.

OBJECTIVES: The primary aim was to quantify and compare the location and extent of pain in people with either episodic migraine, chronic migraine, or cervicogenic headache. A secondary aim was to examine the associations between pain extent and headache features, quality of life, and psychological distress for each headache type. DESIGN: A cross-sectional, single-site, observational study. SETTING: Headache outpatient clinic. SUBJECTS: From a sample of 390 patients, 114 patients with migraine or cervicogenic headache (48 episodic migraine, 30 chronic migraine, 36 cervicogenic headache) were eligible for the study. METHODS: Pain location and extent were determined using a novel approach for digital pain drawing acquisition and analysis. Headache features included intensity and history duration. Quality of life was measured using the SF-36 and psychological distress using the Hospital Anxiety and Depression Scale. RESULTS: Overall, pain was most frequently reported in the frontal and temporal regions in patients with either episodic or chronic migraine, whereas pain was most frequent in the suboccipital region in patients with cervicogenic headache. A larger pain extent was moderately correlated with higher headache intensity (rs = 0.53, P = 0.003) and poorer quality of life (rs ranged from -0.36 to -0.40, P < 0.05) in patients with chronic migraine, whereas pain extent was associated with longer headache duration in those with cervicogenic headache (rs = 0.35, P = 0.04). No correlation was found between pain extent and psychological features for any headache type (P > 0.05). CONCLUSIONS: Despite some differences, there was a large symptomatic overlap between headache types, highlighting the limitations of using pain location in the differential diagnosis of headache.