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Expert commentary

by Nada Hindiyeh, MD

Through the Toronto Concussion Study, Dr. Langer and colleagues provide some helpful insights on a topic in headache medicine that has often been difficult to study. As they mentioned, few studies have been conducted on a heterogenous post-concussion population that can be easily generalized to the public as we mainly see athletes and military populations most commonly  studied.

Although there has been evidence to show that people with a history of migraine are at increased risk for post-concussive headache, the specifics of these risk factors have not been fully elucidated. This study helps us recognize that even a history of 1 migraine a month can increase the risk of persistent headaches post-concussion.

The most important first step for this population is education about these risk factors. Helping our patients with migraine understand that concussion could put them at a greater risk for increasing or persistent headaches not only empowers patients, but helps them recognize times when seeking medical care is prudent.

When it comes to treatment options post-traumatic headache lacks well established, evidence based  guidelines. Thus, most treatment recommendations are based on expert opinion focused on treating the headache phenotype it most closely resembles. Most commonly in this patient population these headaches will resemble migraine.

The cornerstone of migraine treatment, as well as post traumatic or post-concussive headache is lifestyle modification with a focus on daily aerobic exercise, a routine sleep schedule and routine meals. It is important to maintain these habits both pre and post injury.

Certainly, lifestyle modifications may not always be enough, especially if there has been a significant increase in headache frequency post concussion and patients are more debilitated.  Patients may experience not only an increase in frequency, but also severity and duration of headaches. This can leave people susceptible to  the development of medication overuse headache as many try to treat with the acute medications they already have.

Patients may require the addition of a migraine preventive medication as well as optimization of their acute medication during this period with reassessment every few months to monitor progress.

When it comes to recovery times, the good news is, most people recover and are back to baseline within 12 weeks. However, it is important for people with a history of more frequent migraine to understand they might not fit this timeframe. Their headaches may take a longer time to control, and may require more vigilant attention to treatment.

 

References

  1. Yilmaz T, et al. Risk factors and outcomes associated with posttraumatic headache after mild traumatic brain injury. Emerg Med J 2017;34:800–805. doi:10.1136/emermed-2015-205429
  2. Brigid Dwyer, MD. Posttraumatic Headache. Semin Neurol 2018;38:619–626.
  3. Lucas, S et al. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia 2014, Vol 34(2) 93–102
  4. Kamins, J, Charles, A. Posttraumatic Headache: Basic Mechanisms and Therapeutic Targets. Headache 2018;58:811-826




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