Post-Traumatic Headache: Definition, Treatment, and More

Post-traumatic headache (PTH) is defined as the onset of persistent headaches within seven days of experiencing altered consciousness due to a blow or impact to the head. PTH is the most frequently reported complaint following a traumatic brain injury (TBI). The symptoms of PTH vary widely, though most people experience either migraine or tension headache type symptoms.

This condition is potentially disabling—especially when chronic. Treatment often consists of a combination of at-home approaches, medications, and other approaches. Here’s a quick overview of post-traumatic headache, including its causes, how it’s diagnosed, and treatment and management options.

Post-Traumatic Headache Symptoms

The symptoms of PTH generally arise within seven days of a traumatic brain injury (TBI), which is a significant injury to the head that often leads to a loss of consciousness.

Though this condition can take many forms, most people experience symptoms similar to either migraines or tension headaches. These are two types of primary headache disorders, headaches that arise in absence of other medical conditions.

When resembling tension headache, the symptoms include:

• Dull mild-to-moderate headache
• Squeezing headache
• Headache affecting both sides of the head
• Sensitivity to light or sound

PTH that resembles migraine causes:

• Throbbing, pulsing headache
• Moderate-to-severe in intensity
• Light, sound, and sensory stimuli sensitivity (a heightened reaction when exposed to certain stimuli)
• Nausea and vomiting

Additional symptoms of traumatic brain injury coexisting with PTH can include:

• Dizziness or vertigo
• Insomnia
• Trouble concentrating or remembering
• Fatigue
• Anxiety 
• Depression
• Worsening of symptoms with mental or physical activity

Causes

Most post-traumatic headaches are the direct result of traumatic brain injuries. These can range in severity from mild TBIs (concussions) to much more severe cases. Brain injuries can occur when the tissues of the brain strike the sides of the skull due to an impact or whiplash, for example. The most common causes of TBIs are:

• Falls
• Automobile accidents
• Sports injuries
• Impact on the head by an object
• Interpersonal violence or domestic abuse
• Blast injuries    

Currently, researchers don’t have a complete understanding of the physiology of post-traumatic headaches. As to the mechanism of PTH, evidence from neuroimaging and other kinds of studies suggest several potential explanations:

• Inflammation: Neurogenic (within the nervous system) inflammation occurs when there’s damage to the brain due to impact on the cranium (skull). The chemicals that are released spur a physiological response in the brain that causes rises in temperature, swelling, pain, and discomfort. This causes nerve cells associated with pain perception to be hyperexcited, which leads to recurrent headaches.
• Damage to the spine: TBIs are associated with damage to the spinothalamic pathways (the spinal cord that relays information back to the brain) and the thalamocortical pathways, which are nerves associated with pain and sensory signaling. As with inflammation, this impact makes these nerve pathways more sensitive, causing headaches.
• Dysfunction of pain inhibition: Another theory about the physiology of PTH is that it arises due to dysfunction and damage to the nervous system’s pain pathways. Specifically, the TBI limits the function of the nerves associated with easing and stopping pain, which increases the chances of headaches and other symptoms.

Diagnosis

A diagnosis of post-traumatic headache is considered when headaches start within seven days of a TBI. However, since there are many headache disorders—and since PTH can present in many different ways—it’s essential for healthcare providers to investigate the causes of the symptoms. Typically, this includes:

• Symptom assessment: Your healthcare provider, including a neurologist (a doctor specializing in conditions of the brain and nervous system), will evaluate your medical symptoms, take a health history, and perform assessments for signs of neurological symptoms. This is especially important within the first 72 hours of the TBI.
• Neuropsychological testing: Specialists may perform testing of cognitive and memory tasks. You may be asked to repeat items in given lists, perform reasoning problems, be screened for mood disorders, and have your speech patterns assessed, among others.
• Vestibular testing: This is an assessment of the causes of any dizziness, balance issues, or eye coordination problems you may experience as a result of the head trauma. A range of methods may be used, including electronystagmography (ENG) or rotary chair tests, which carefully measure eye movements, balance, and coordination.
• Neuro-ophthalmologic tests: These tests assess how well your eyes are working and if they’re able to move as needed. This may be paired with other neurological tests of coordination, movement, sensation, and strength.
• Imaging: Along with the above, imaging scans, such as magnetic resonance imaging (MRI) and computed tomography (CT), are often needed in more severe or prolonged cases. These let neurologists screen for bleeding in the brain, a medical emergency.

Treating Post-Traumatic Headache

There’s no set therapy for PTH, and the condition tends to be treated based on how it presents. Migraine-like PTH is treated as migraines, and tension headache PTH is treated as headaches would be treated for that condition. Since individual cases vary so much, treatment and management plans need to be customized, mixing and matching strategies to manage the issue.

Acute Medications

There are two types of medications for headache disorders: acute and preventive. Acute medications manage pain and other symptoms after PTH has set on. Several classes of acute drugs are recommended over the counter (OTC) or prescribed, though overuse may lead to problems:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Available as OTCs and in prescription strength, NSAIDs have both painkilling and inflammation-reducing effects. Aleve (naproxen) and Motrin and Advil (ibuprofen) are common OTC options. Prescription options include Celebrex (celecoxib) and DayPro (oxaprozin).
• Acetaminophen: Like NSAIDs, Tylenol (acetaminophen) works to ease pain, however, it’s not effective for inflammation. These drugs are available OTC and in prescription strength.  
• Combination drugs: Additional medications, such as Excedrin, Cafergot, and Midrin, blend aspirin, caffeine, and acetaminophen to provide relief from tension, migraine, and post-traumatic headaches.
• Opioids: Opioid drugs, such as Percocet (oxycodone/paracetamol), Vicodin (hydrocodone/acetaminophen), and Oxycontin (oxycodone), are very strong, prescription painkillers. However, they have many side effects and can be addictive, so their use is carefully monitored and limited. Generally, other options are explored first.
• Triptans: Often prescribed for migraines, triptans like Imitrex (sumatriptan) and Zomig (zolmitriptan) are another option to take on attacks. This class of drug stimulates two kinds of receptors for serotonin, a brain chemical involved in mood and feelings of wellbeing.

Preventive Medications

In chronic post-traumatic headache cases—in which the headaches return and recur even after two months—medications may also be prescribed to prevent them. Classes of these drugs usually prescribed for migraines include:

• Tricyclic antidepressants: A class of drugs also used to treat depression and other mood disorders, tricyclic antidepressants include Elavil (amitriptyline) and Pamelor (nortriptyline). Low to moderate doses are often effective for PTH, while higher doses have historically been used for treatment of mood disorders.
• Anticonvulsants: These medications, such as Neurontin (gabapentin), Lyrica (pregabalin), Topamax (topiramate), and valproic acid, are primarily prescribed for epilepsy; however, they also are effective in preventing migraine attacks. As such, they’re prescribed for migraines as well as chronic PTH.   
• Beta-blockers: Inderal (propranolol), Levatol (penbutolol), and many others can help prevent chronic headaches. These drugs can take on a range of heart and blood circulation problems as well.

Counseling and Therapy

Several therapeutic methods have been shown to be effective in taking on chronic pain problems, such as chronic PTH. Common among these approaches is cognitive behavioral therapy (CBT), which works to increase the patient’s conscious control of pain responses. A mental health professional can help you with strategies for easing tension, relaxation, and coping with pain.  

Biofeedback and Relaxation Training

Another approach to chronic headaches, such as persistent PTH, is the use of biofeedback and relaxation techniques. Basically, a wearable device will track physiological signs of stress—such as muscle tension and body temperature—which can set off attacks or worsen pain. With that information, users can begin to sense issues arising and work to prevent them.  

Patients can learn relaxation strategies, such as breathing exercises, through these techniques. This has been shown to reduce the frequency and intensity of headaches.

Lifestyle Modifications

Alongside pharmaceutical management, making certain lifestyle changes can make a big difference when it comes to chronic PTH. Frequently recommended strategies include:

• Getting enough sleep
• Going to bed and getting up at consistent times
• Staying hydrated and eating regular, healthy meals
• Getting exercise 
• Taking an immediate rest from mental or physical exertion if they trigger TBI symptoms, including PTH

Other Approaches

Very difficult to manage (refractory) cases, of chronic headache may also be treated with a range of other medical approaches, including:

• Botox injections: Injections of the botulinum toxin A (Botox) into specific areas of the temple, neck, and head prevent chronic headaches in some people. Botox temporarily halts the activity of nerves associated with pain management.
• Nerve block: Nerve blocks are among the most common treatments for PTH. Injections of anesthetic into nerves associated with pain can stop their functioning and prevent headaches.
• Trigger-point injections: Used for some other kinds of headaches, such as TMJ (temporomandibular joint) headache, trigger-point injections target specific points of tension on the face or neck. Though evidence is mixed, this may be a helpful preventive measure.
• Transcranial stimulation: Magnetic or electronic waves are targeted at specific regions of the brain via wearable devices. This essentially scrambles the pain messaging, easing or even resolving headache attacks.
• Decompression surgery: Often the last resort in only the toughest PTH cases, decompression surgery aims to relieve pressure on the peripheral nerves of the head associated with headache. Via very small incisions in the head, neck, or temples, tissue and bone matter surrounding these nerves is removed.  
• Physical activity: Sessions with a physical therapist, massage therapy, and acupuncturist have all been shown effective for chronic headaches and migraines. These may be considered along with other treatments and have been shown to reduce medication use.

Prognosis

Post-traumatic headache is very common among those who experience TBI. However, in cases of concussion or mild TBI, the vast majority of cases resolve within days to weeks.

While many cases resolve within three months, chronic cases prove particularly challenging. As with other headache disorders, prolonged PTH can cause or worsen depression and anxiety, and affect sleep quality. Sleep problems can, in turn, make headache problems even worse.

Coping With Post-Traumatic Headache

There’s no doubt that headache disorders can be difficult to live with, especially in more severe cases. This is why psychiatric evaluation and therapy are often important aspects of treatment for PTH. But what else can you do to cope with this difficult condition? According to the American Psychological Association (APA), there are several steps you can take, including:

• Take on stress: Manage your stress by ensuring you are getting enough sleep and maintaining good fitness and dietary habits. Take part in activities that promote relaxation, such as yoga, gardening, or walks.
• Stay connected: Social isolation and feelings of being alone are common among chronic pain sufferers. Studies have shown that those who are more socially connected and have support have better outcomes. Try to find ways to get involved with your community and reach out to family and friends.
• Find social support: Sharing experiences and finding emotional support from others with chronic pain can also be instrumental. Ask your medical team about support groups, both in person and online. Social media groups can also be great resources, as can advocacy organizations for chronic pain or headaches.
• Talk to a mental health professional: Your doctor will likely recommend therapy as a means of taking on the emotional and mental health burden of PTH. This can be crucial, providing you with strategies for healthily managing these feelings.

Summary

Post-traumatic headache (PTH) is frequently defined as a headache arising within seven days of a traumatic brain injury. Its presentation can vary, with some experiencing milder, tension headache symptoms, while others have symptoms like those of migraines or rare headache syndromes.

Treatments for this condition involve everything from medications to lifestyle adjustments to biofeedback and relaxation techniques. More difficult cases may require transcranial stimulation or decompression surgery.

If headache characteristically worsens with activity, it is important to take note your capacity for activity and gradually make adjustments. This is often done with guidance from a neurologist and/or physical therapist.

Although PTH after mild TBI usually resolves within weeks, chronic PTH can be very challenging, and, especially when persistent, may significantly impact mental health and morale. Stress management, finding support from family, friends, and fellow chronic pain sufferers, or counseling can all help you cope.

A Word From Verywell

Among the many impacts of traumatic brain injury, post-traumatic headache is the most common, and it can be very debilitating. It’s hard to live with unpredictable pain. But while there’s more that doctors need to learn about this condition, the good news is that our understanding of PTH is continuing to grow.

New therapies will be added to the extensive list of approaches to this disorder, making outcomes even better for sufferers. It helps to stay informed about your condition, work on strategies to manage it, and not hold back in asking for help when you need it.