Post-traumatic Headaches, Migraines, and Sleep Disorders
Of the post-concussion symptoms that can occur after a traumatic brain injury (TBI), headaches and sleep disorders are among the most common early features. Studies demonstrate a very high proportion of both symptoms and these require treatment to help combat the persistent disability. What is not often recognized is that the headaches often have migrainous features or are brand-new or reactivated migraine headaches. Treatment has very often simply not been offered to the patient by their physician. Similarly, sleep disorders—including initiation or maintenance of a normal sleep pattern—are quite prominent after TBI. Unfortunately, these, too, are ignored and often untreated—even years after the TBI.
Despite a high incidence per year of so-called “minor” or “mild” TBI—estimates vary but a figure of 5 million occurrences is not far-fetched—there is very little literature to document the high prevalence of headaches and sleep disorders as prominent post-concussion symptoms. In my practice—which deals primarily with headache, pain management, sleep disorders, and TBI—I have evaluated and treated over two thousand patients with post-TBI symptoms. We have found that the majority of patients complaining of these symptoms is quite in concordance with published data on post-TBI regarding headaches and sleep disorders.1-12 The total available data pool, however, is rather meager, despite the high incidence of mild TBI. Based on first-hand clinical experience, I will present anecdotal information along with recommendations for treatments of both post-traumatic headaches (PTHA) and sleep disorders using modern state-of-the-art pharmacologic strategies.
It was recently published1 that 41 out of 109 (38%) of a group of VA patients with moderate or severe traumatic brain injury had acute post-traumatic headache. Of those, 20 of 41 (49%) experienced it in a frontal location, and 31 out of 41 (76%) experienced it at a daily frequency. Post-hospitalization, PTHA symptom severity declined and better individual improvement was associated with less anxiety and depression at 6-month follow-up. Almost all subjects with PTHA symptoms that persisted into the 6-month follow-up (21 of 22; 95%) continued to report symptoms at 12-month follow-up. In another recent publication2 from Spain, post-traumatic headache is one of several symptoms of the post-traumatic syndrome and therefore may be accompanied by somatic, psychological, or cognitive disturbances. PTHA can resemble a tension-type, migrainous, or cervicogenic headaches. Post-whiplash headache habitually is a pain radiating from the neck to the forehead, with moderate intensity and a benign but prolonged course. The pathogenesis of PTHA is still not well-known but might share some common headache pathways with primary headaches.
The relationship of PTHA to cognitive dysfunction after sports-related concussion is poorly understood. As shown in a recent publication, high school athletes reporting headache approximately one week after injury have significantly more of the other concussion symptoms and will perform more poorly on neuropsychological tests than athletes not experiencing headache.3 One hundred nine athletes who had sustained concussion were divided into two groups: those reporting headache seven days after injury and those reporting no headaches. The two groups were compared regarding on-field markers of concussion severity at the time of injury and symptoms and neurocognitive test results collected via ImPACT, a computerized neuropsychological test battery and post-concussion symptom scale, at a mean of 6.8 days after injury. Those reporting PTHA had significantly worse performance on reaction time and memory as measure by ImPACT neurocognitive composite scores. They also reported significantly more symptoms besides headache and were more likely to have demonstrated on-field anterograde amnesia. The authors concluded that any degree of post-concussion headache in athletes after brain injury (seven days after injury) is likely to be associated with an incomplete recovery after concussion.3
An even more recent report in 2005 from the same authors,4 studied a larger cohort of high school and college-aged athletes who had sustained concussive injuries—with and without headaches (HA) and post-traumatic migraine (PTM). In this study, 261 high-school and collegiate athletes with a mean age of 16.36 +/- 2.6 years were divided into three groups: the PTM group (74 athletes with a mean age of 16.39 +/- 3.06 years), the HA group (124 athletes with a mean age of 16.44 +/- 2.51 years), and the non-HA group (63 patients with a mean age of 16.14 +/- 2.18 years). Symptom scores were collected using ImPACT to assess sports-related concussion. Significant differences existed among the three groups for all outcome measures. The PTM group demonstrated, once again, significantly greater neurocognitive deficits when compared with the HA and non-HA groups. The authors concluded that athletes suffering a concussion accompanied by PTM should be examined in a setting that includes symptom status and neurocognitive testing to address their recovery more fully. Given the increased impairments observed in the PTM group, parents and schools should exercise increased caution in decisions about when the athlete should be allowed to return to play.
A Finnish study evaluated patients with mild head injury (MHI) in a series of 172 consecutive MHI patients admitted into the emergency room of a general hospital and who developed post-concussion symptoms (PCSs). A modified Rivermead Post-Concussion Symptoms Questionnaire was used to identify the patients with and without PCSs one month after injury. They identified 37 patients with MHI who developed PCSs (22%). Risk factors for PCSs in the MHI patients were skull fracture (OR 8.0, 95% CI 2.6-24.6), serum protein S-100B > 0.50 microg/l (OR 5.5, 95% CI 1.6-18.6), dizziness (OR 3.1, 95% CI 1.2-8.0), and headache (OR 2.6, 95% CI 1.0-6.5). Serum protein S-100B proved to be a specific, but not a sensitive predictor of PCSs. The presence of skull fracture, elevated serum protein S-100B, dizziness, and headache may help the emergency room physician to identify patients at risk of PCSs and refer them for further examination and follow-up.5
A study published in Germany in 19976 suggested that head trauma (HT) and whiplash injury (WI) is followed by a post-traumatic headache (PH) in approximately 90% of patients. The PH due to common WI is located occipitally (67%), is of dull-pressing or dragging character (77%), and lasts three weeks on average. Tension-type headache is the most frequent type of PH (85%). Besides post-traumatic cervicogenic headache, migraine- or cluster-like headache may be observed in rare cases.
Chronic Post-traumatic Headaches
Within six months, 80% of patients with post-traumatic headache following head trauma show remission, but chronic PH—lasting at least four years occurs in 20%. Unfavorable prognostic factors included age more than 40 years; a low intellectual, educational, and socio-economic level; previous HT; or history of alcohol abuse. A prolonged PH due to WI, lasting years and with an extensive decrease of mobility of the cervical spine and other associated risk factors, can be expected in patients with initially severe headache.