The post-traumatic headache syndrome is a very common sequelae following injuries to the head or neck, and often occurs after rear-end auto accidents. The headaches are usually self-limited and resolve quickly, within days to several weeks. The vast majority of patients with post-traumatic headaches simply want their pain to be improved and their disrupted life back to normal. Surprisingly few are malingering or exaggerating their symptoms.
In many patients, particularly those with more severe trauma, headaches may be a problem for months, years, or a lifetime. If the headaches develop within 2 weeks of the event, and persist for more than several months, we would consider this to be the chronic phase of the post-traumatic headache syndrome. Very rarely, patients develop post-traumatic migraines months following the injury, but headaches usually begin within hours or days of the accident. The International Headache Society (IHS) has set 2 weeks as an arbitrary limit.
Predicting which patients will continue to suffer chronic, unremitting post-traumatic pain is a difficult undertaking. In general, patients with a preexisting headache or migraine problem are at increased risk. Women have a 1.9-fold increased risk. Patients with a strong family history of migraine may be at increased risk for developing chronic headaches. Severity of trauma may also aid in predicting outcome, but many patients endure months or years of severe headaches after trivial head trauma. Rear-end auto collisions, without head trauma, commonly produce severe headaches and cervical pain. Factors such as the angle of impact, where the patient was sitting in the car, and what happened to the brain within the skull are key elements in producing the headaches. The post-traumatic headaches occur more often with increasing age.
Many patients have associated neck and posterior occipital pain. The neck pain tends to be independent of the headaches, and the cervical pain and headaches may resolve at different times. Physical therapy is a key element in treating the associated neck pain and tenderness, and physical therapy may also decrease the headaches.
The headaches are usually of two types: (1) tension-type headache that may be daily or episodic, and (2) migraine headaches that are usually more severe. In some patients, the post-traumatic headaches are the major problem, with a periodic severe headache lasting hours to days. In other patients, the tension-type headache is the predominant problem. Many posttraumatic patients have mixed headaches, with both CDH and migraines. The occipital aching pain, so often associated with the neck pain, is usually considered to be of muscular origin. However, the occipital pain may respond to therapies for cervical pain, and at other times the occipital pain improves with the standard tension headache medications.
There are many other symptoms that often accompany the post-traumatic headache syndrome. These tend to be similar in most patients. They include some or all of the following: poor concentration, becoming easily angered, sensitivity to noise or bright lights, depression, dizziness or vertigo, tinnitus, memory problems, fatigue, insomnia, lack of motivation, decreased libido, nervousness, or anxiety, irritability, becoming easily frustrated, and decreased ability to comprehend complex issues. Neuropsychological testing is often abnormal early in the course of post-traumatic headache, but slowly returns to normal. Concentration and attention seem to be the first to return to normal, usually within 6 weeks. Analytic capacity, imagination, and visual memory take somewhat longer, but resolve by the end of 3 months. The last to recover are speed at which the patient processes information, cognitive selectivity, and verbal memory abstraction. While attention and concentration often improve over the first 4 to 6 weeks, memory and information processing speed may take considerably longer.
The presence of headaches, neck pain and the symptoms in the above paragraph often lead physicians, coworkers, and family members to conclude that the patient is exaggerating the complaints. However, in the vast majority of post-traumatic patients, every complaint is real, not exaggerated, and these people simply wish to to feel better. The post-traumatic headache syndrome ranges from mild to severe and is often disabling to a person’s life. Most patients have some degree of difficulty with their home or work life because of the headaches, anxiety, insomnia, and concentration difficulties. It then becomes a vicious cycle, with more psychological stress being placed on the patient because of the difficulties at work and at home. Unfortunately, our legal and insurance processes are not entirely fair to many of these patients, because objective testing does not reveal deficits in the vast majority of these injured patients. They are often unfairly viewed as functional or malingering. Studies are conflicted as to what percentage of patients are exaggerating or malingering. One study suggested that in countries where there are very few legal or insurance disability remedies, post-traumatic situations rarely exist at all. However, after secondary-gain issues (litigation, disability, worker’s compensation) have been settled, most patients continue having the same degree of post-traumatic symptoms.
As mentioned above, accompanying the post-traumatic headache problem is the very frequent neck pain. This is usually secondary to soft tissue damage to ligaments and muscles, but may involve disc damage and, occasionally, nerve root compression as well. Sensitivity over the occipital nerve area is very common and occipital neuralgia may accompany the post-traumatic headaches. We frequently find trigger points in the trapezius, posterior cervical, and occipital areas, with muscle spasm in these areas being very common. It is not infrequent to find such severe spasm that patients have almost zero range of motion of their cervical spine and the neck muscles feel extremely tight upon palpation.
Treatment of the post-traumatic syndrome involves one or several of the following: medication, physical therapy, psychological counseling, and relaxation training/biofeedback. Most patients do not need all of the modalities of therapy, and treatment programs need to be individualized. First and foremost, reassurance that this condition will improve is important, as in the vast majority of cases, the headaches and neck pain progressively lessen over time. While most patients do recover over time, a small (but important) percentage continue to suffer for months, years, or a lifetime.