Can Posttraumatic Headache Characteristics Inform Prognosis and Treatment?

OJAI, CA—Soldiers with posttraumatic headaches are “complicated patients,” said Alan G. Finkel, MD, Director of the Carolina Headache Institute in Chapel Hill, North Carolina. No drugs are approved for the treatment of posttraumatic complications, and persistent posttraumatic headaches may interfere with return to military service.

Alan G. Finkel, MD

Characteristics of posttraumatic headaches—such as whether they are continuous, nummular, or holocephalic—may provide prognostic clues and suggest possible therapies, Dr. Finkel said at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific. In addition, neurologists can address sleep, mood, and concussion symptoms when managing patients with posttraumatic headache.

Occupational Outcomes

Posttraumatic headaches most commonly are classified as migraine. Other classifications include tension-type headache and trigeminal autonomic cephalalgia. A patient may report multiple types of headache. Dr. Finkel and his research colleagues hypothesized that among patients with posttraumatic headache, the headache diagnosis may not be sufficient to predict occupational outcomes and that other headache characteristics might be more important.

To assess associations between headache characteristics and the outcome of leaving military service for medical reasons, Dr. Finkel and colleagues analyzed data from a retrospective cohort study. The cohort included 95 patients who were referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center, Fort Bragg, North Carolina, between August 2008 and December 2009. The study was published online ahead of print February 27 in Headache.

About 14% of the patients had a history of headache, and about 40% had a prior history of concussion. The most common injury cited was blast injury (53.7%).

People were able to report as many as three headaches (ie, one continuous and two noncontinuous). The 95 patients reported 166 headaches. About 75% of the patients reported a continuous headache. Approximately 72% of patients reported a headache of a migraine type. The most clinically important headache was migraine for 61% of patients, tension-type headache for 4%, and trigeminal autonomic cephalalgias, including hemicrania continua, for 24%.

“The presence of a continuous headache was very likely to predict leaving service, and the headache diagnosis or the presence of a migraine diagnosis did not,” Dr. Finkel said.

Patients with continuous headache were approximately four times more likely to leave military service, compared with patients without continuous headache. Prior history of regular headache also appeared to predict the probability of discharge. Among patients with prior history of headache, continuous holocephalic headache, as well as the tendency to medicate and stay active with the most clinically important headache (as opposed to lying down or continuing activities without medication), also increased the likelihood of severance.

The study’s limitations included its retrospective design, the possibility of recall bias, and the lack of controls, Dr. Finkel noted.

Assessment Tools

When evaluating patients, instruments such as the Neurobehavioral Symptom Inventory and concussion checklists can be useful. “Get some tested baselines that you can then compare longitudinally,” he said.

The Balance Error Scoring System and the King–Devick test can assess concussion symptoms. “While you are making an assessment for persistent posttraumatic headache, make some comments in your chart about … whether or not they have concussive symptoms,” Dr. Finkel said. Neurologists also can assess problems with emotions and mood, which may be treatable. A combination of dextromethorphan hydrobromide and quinidine sulfate is approved for the treatment of emotional incontinence, which is associated with traumatic brain injury. Dr. Finkel uses the Pain Catastrophizing Scale and Posttraumatic Stress Disorder (PTSD) Checklist to evaluate pain-related anxiety. Neurologists also can ask patients about sleep, which may play an important role in patients’ recovery.

Treatment Options

In a clinic-based sample of 100 soldiers with chronic posttraumatic headache after mild head trauma, topiramate appeared to be an effective prophylactic.

Investigators plan to conduct a placebo-controlled trial of prazosin in patients with chronic postconcussive headache. Prazosin, an alpha one antagonist, may be prescribed to improve sleep and reduce nightmares. It may be a treatment option if a patient with chronic headache is hypervigilant and has insomnia, said Dr. Finkel. When prescribing prazosin, it is important to tell patients about the risk of fainting on the first night after taking the drug.

Defense Recommendation

The Department of Defense in February 2016 published a clinical recommendation for the primary care management of headache following concussion or mild traumatic brain injury. The recommendation describes red flags, establishes four categories into which symptoms might fall (ie, migraine, tension-type, cervicogenic, and neuropathic), and provides treatment guidance for each headache category.

If therapy alleviates holocephalic headaches, but focal pain persists, neurologists can try injecting onabotulinum toxin to treat the focal pain, Dr. Finkel said. In a case series of 64 patients with concussion-related headaches who were treated with onabotulinum toxin, 64% reported feeling better. The presence of PTSD did not appear to affect treatment outcomes, Dr. Finkel said.

Exercise and Expectation

Cardinal symptoms of concussion, including headache and PTSD, can improve with exercise, Dr. Finkel said. Evaluating patients on a treadmill can determine whether postconcussive symptoms recur at elevated heart rates. Patients can progressively increase the intensity of exercise until they are ready to resume activity.

When posttraumatic headache persists, neurologists should consider patients’ expectations. Research suggests that the language used to convey a diagnosis (eg, mild head injury, mild traumatic brain injury, or concussion) can affect what symptoms people anticipate. And patients’ perceptions of the illness may play a role in the persistence of postconcussion symptoms. Telling patients that they have a traumatic brain injury or expressing uncertainty about the diagnosis or prognosis is doing them a disservice, he said. “Tell them they are going to get better,” Dr. Finkel said.

—Jake Remaly

Suggested Reading

Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932-944.

Finkel AG, Ivins BJ, Yerry JA, et al. Which matters more? A retrospective cohort study of headache characteristics and diagnosis type in soldiers with mTBI/concussion. Headache. 2017 Feb 27 [Epub ahead of print].

Finkel AG, Yerry JA, Klaric JS, et al. Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification. Cephalalgia. 2016 May 20 [Epub ahead of print].

Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. 2007;78(6):644-646.

Yerry JA, Kuehn D, Finkel AG. Onabotulinum toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: a cohort study. Headache. 2015;55(3):395-406.