Medical Procedures Often Required to Treat Brain Injuries

Medical Conditions Related to Brain Injury

Post-Traumatic Headache

By Nathan Zasler, MD

Last Updated:

Introduction

Headache and neck pain are the most common physical complaints following concussion (mild brain injury) and are experienced early after injury by up to 70 percent of persons with these types of injuries. Headache also occurs after more severe brain injury but not as often. Though post-traumatic headaches (also termed PTHA) may be quite persistent, they have not been found to relate to the severity of injury.

The majority of headaches following cerebral (brain) injury, as well as cranial and cervical trauma do not require surgery. However complications such as subdural and epidural hematomas (blood collecting between the brain and the skull) may occur, particularly after severe head injury. These may cause headache and require surgical intervention. Clinical examination and diagnostic tests may be needed to determine the seriousness of the condition and the appropriateness of surgery.

Sources of Head Pain

To better understand the injury, the doctor may ask questions about the mechanisms responsible for injury—for example types of restraints used and speed of the vehicles, if an auto accident. Any history of direct blows to the head or body or cervical whiplash is also important. Specifically, the doctor should inquire regarding clues to the presence of the 3 “Cs”:

Cerebral (brain) injury;
Cranial or cranial/adnexal trauma (damage to the head or structure in the head but outside the brain); and
Cervical acceleration/deceleration (CAD) insult (also called whiplash injury).

What Questions should be asked

The headache symptom profile is one of the major tools doctors use to discover the cause of headache. Pre-injury personal and family history of headache may also be important. The questions physicians usually ask are represented in the pneumonic “COLDER”: Character, Onset, Location, Duration, Exacerbation, and Relief. Doctors will also want to know the frequency and severity of pain, types and magnitude of associated symptoms, presence of aura, degree of functional disability associated with headache episodes, as well as, the time of day that the headaches come on.

The Physical Assessment

Adequate physical examination is paramount to an appropriate diagnosis and should include inspection, palpation, (to physically touch and examine) auscultation, (to listen with a stethoscope) and percussion (to tap against the structure as with a finger). The neurologic exam should be a centerpiece of this assessment; however, adequate examination of cranial and cervical structures including palpation of the head, neck and shoulders is often a crucial but often overlooked aspect of the exam.

Major Headache Subtypes

The major types of headaches seen following a trauma include:

Subdural and epidural hematoma
Musculoskeletal headache (e.g. myofascial referred pain, as well as,
TMJ disorder related pain)
Tension type headache
Neuroma/neuralgic (nerve) headache
Post-traumatic sympathetic nerve dysfunction (migraine-type headaches produced by injury to autonomic nerve in the neck)
Neurovascular (migraine) headache
Seizure disorder
Other uncommon causes

Pain Management Issues

Doctors use a variety of techniques in treating chronic headache pain. These may include medications, various physical modalities, injection techniques, psychological therapies, behavioral medicine techniques (e.g. biofeedback), pain adaptation counseling, and pain cope support groups. Persons with chronic pain often develop emotional difficulties such as depression, anxiety, difficulty thinking, and sleep problems all of which may further increase the perception of pain and level of distress. Education of the patient with PTHA is crucial to optimizing treatment success and decreasing distress and poor adaptation to pain, particularly when chronic. Some crucial components of education are making sure the patient understands the disease process, the expectations of treatment, how to take prescribed medication and the potential detrimental effects of non-compliance and/or over-use (e.g. drug induced headache and more importantly, rebound headache).

Conclusion

Multiple studies, some completed only in the last three to five years, demonstrate that ongoing lawsuits have little to no effect on the persistence of headache complaints. Specifically, studies have shown that individuals still continue to report significant symptoms even after litigation has ended. Only a very small population will develop intractable or persistent post-traumatic headache. When properly treated, most PTHA is not permanent and/or “totally disabling.” Once the appropriate diagnosis is made, treatment should be instituted in a holistic fashion taking into consideration:- benefit/risk ratio of any particular intervention - practicality of the prescribed treatment—can the patient follow through?

Nathan D. Zasler, MD is a Fellow of the American Academy of Physical Medicine and Rehabilitation with fellowship training in brain injury. He is a Diplomate of the American Academy of Pain Management, a fellow of the American Academy of Disability Evaluating Physicians, as well as, a Certified Independent Medical Examiner. He is Chief Executive Officer and Medical Director of the Concussion Care Centre of Virginia, Ltd., an outpatient assessment and treatment center for persons with ABI, as well as, Tree of Life, a community based living and rehabilitation program for persons with ABI. Dr. Zasler also serves as the medical consultant for Pinnacle Rehabilitation, an interdisciplinary general rehabilitation practice also located in Glen Allen, Virginia. He is internationally respected in the field of brain injury care and rehabilitation and has spoken and written extensively about neuromedical aspects of ABI.