Navigating the Uncertainty of Posttraumatic Headache Recovery

Posttraumatic headache is an increasingly recognized secondary headache disorder. Posttraumatic headaches begin within 7 days of the causative injury and their characteristics most commonly resemble those of migraine or tension-type headache.

In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Todd Schwedt, MD, FAAN, author of the article “Posttraumatic Headache,” in the Continuum April 2024 Headache issue.

Dr. Berkowitz is a Continuum® Audio interviewer and a professor of clinical neurology at the University of California, San Francisco

Dr. Schwedt is a professor of neurology at Mayo Clinic in Phoenix, Arizona.

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Read the article: Posttraumatic Headache

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Host: @AaronLBerkowitz

Guest: @schwedtt

Full Transcript Available

Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.   

Dr Berkowitz: This is Dr Aaron Berkowitz, and today, I'm interviewing Dr. Todd Schwedt about his article on post-traumatic headache from the April 2024 Continuum issue on headache. Dr. Schwedt is a Professor of Neurology at Mayo Clinic in Phoenix, Arizona. Welcome to the podcast today, Dr. Schwedt.   

Dr Schwedt: Well, thanks so much. It's a real pleasure to be here.   

Dr Berkowitz: Thanks. We're very happy to have you. So, head trauma is common, and headache following head trauma is also very common. Let's say you're seeing an otherwise healthy young patient in your clinic who had a minor car accident a few weeks ago with some head strike and whiplash, presenting now for evaluation of headache again a few weeks out from the accident. Walk us through your approach to the history and exam here when you're seeing one of these patients.

Dr Schwedt: Yeah, absolutely. I'd be happy to do so. I'll start by saying, as you mentioned, this is such a common problem - patients that are coming in with post-traumatic headache). Of course, like almost everything in neurology, it's super important to get a detailed history to start with (so, doing the appropriate interview), and I usually like to start by getting some information about the injury itself - the mechanism of the injury, and the severity, and, of course, the symptoms that went along with the potential traumatic brain injury – so things we all know about. Then, of course, it's very important to understand how the patient felt prior to the injury because we know that, amongst people presenting with post-traumatic headache, oftentimes they might have had headaches even prior to their injury, and that's because having preinjury headaches is a risk factor for developing post-traumatic headache, as well as the persistence of that post-traumatic headache. If someone had headaches prior to their injury, then of course we want to know if that actually changed or not - is there a difference in the severity, or the frequency, or in the characteristics of the headaches they've been experiencing since their injury? Then, of course, you're going to ask about exactly what the symptoms are they're having now and what's concerning them the most, realizing that for a diagnosis of post-traumatic headache, it’s very important to understand the timing of the onset of these headaches in relation to the injury. By definition, post-traumatic headache should have onset within seven days of the inciting traumatic brain injury - so the diagnosis of PTH, I mean, really is dependent upon that timing -  so, using ICHD (which is International Classification of Headache Disorders) criteria, it's got to start (or be reported to have started) within seven days. It's important to realize there are no specific headache characteristics that help to actually rule in or rule out post-traumatic headaches; the criteria themselves just say “any headache,” as long as it was within that seven-day period. Having said that, though, the vast majority of people who come into the clinic for evaluation - their post-traumatic headache is going to be very similar to migraine. So, like, in other words, if they didn't tell you and you didn't ask about when the headache started and you just asked about symptoms, it would seem a lot like migraines – so, very common for the headache to be moderate and severe in intensity, be associated with light sensitivity and sound sensitivity and nausea, be worse with physical and mental exertion (very much the migraine-type characteristics). As far as diagnosis, it's also, of course, important to think about other sequelae of traumatic brain injury that could be causing the headache. For example, if you're under the impression it's a mild traumatic brain injury, but in fact, there's an intracranial hemorrhage - it wouldn't necessarily be mild any longer, but of course, that could cause headaches. We should be thinking about whether there could have been injuries to the cervical spine or the musculature of the neck that could be causing more of a muscular, cervicogenic-type headache. Think about rare possibilities, like if there was a cervical artery dissection, or if there's actually a spinal fluid leak, or, again, other things that after an injury could be causing headache. Most of the time, that's not going to be the case and you would move forward with your diagnosis of post-traumatic headache. 

Dr Berkowitz: Fantastic. That's very helpful to hear your approach. You just mentioned, as you said, most patients who've had minor head trauma and are presenting with headache, fortunately, have not suffered a cervical artery dissection or CSF leak or have an evolving subdural. But when you're in this early stage (just a few weeks after the initial injury) and there is headache, what features of the history or exam would clue you into thinking that this patient does need neuroimaging to look for some of these less common, but obviously very serious, sequelae of head trauma? 

Dr Schwedt: So, it's things that, as neurologists, we all know about, right? But certainly, if you're concerned about a spinal fluid leak, then really someone who has a prominent orthostatic component to their headache (so, you know, much worse when they sit up or stand up, compared to lying down) could be concerning. With a cervical artery dissection, almost always you're going to have focal neurologic deficits in addition to the headaches. With intracranial hemorrhage - again, usually it's going to be fairly obvious, in that the symptoms that someone's presenting with are much more diffuse and more severe, and maybe they're actually having progression of symptoms over time rather than stability or even early improvement. Then, as we would always say, the exam is essential, right? I mean, certainly someone who's had a mild traumatic brain injury might have very subtle deficits in things like their cognition and memory of events around the injury itself - and perhaps some ocular motor deficits and some vestibular dysfunction - but they should be relatively minor compared to somebody who has one of these other etiologies for a postinjury headache. We'll point out, of course, not everyone requires imaging, again, as there's all these decision rules out there about who needs CT, for example, after an injury (and certainly not everyone does). But, you know, if people have red flags, then of course it makes sense to initially get a CT of the head, and then if symptoms persist, perhaps an MRI.

Dr Berkowitz: So, once you're confident that this is a primary headache disorder - and presuming again (as in the example I gave to start us off here) that we're just a few weeks out from the initial trauma - and the patient’s presenting to you for evaluation of their headache, how do you approach treatment in these patients?

Dr Schwedt: Yeah, so the specificity of your question, I think, is actually quite important - so considering the timing of when you're seeing that patient really is essential. So, if we're a couple weeks out or a few weeks out and the person is still having symptoms, that tells us something to start. The majority of people who have postconcussion symptoms are going to have resolution within a few days, or a week or two, so if someone's still having symptoms at, let's say, two weeks, three weeks, four weeks, well, then that’s an indicator that, unfortunately, they're likely to continue to have symptoms for some time - when we want to be a little more aggressive, if you will, with the diagnostics and management of that patient. So, like, very early on - let's say within the first few days, or even the first week or two - some patients won't require any treatment. So, if they're having mild headaches, and maybe they take something over the counter every once in a while as it gets a little more severe, that's oftentimes fine, actually. If someone's having much more severe problems with headache (even in that very acute setting), then maybe we would give them a prescription medicine just to take for their more severe headaches. But then as symptoms progress and persist, then we should of course be thinking about other ways to - in more of a preventive approach of how to - help the patient, because, unfortunately, we don't have high-quality evidence for how to treat both acute and persistent post-traumatic headaches. The recommendation for many years (and it continues to be) is that you determine the other headache type that the PTH most resembles and you treat it like that. For example, if someone has PTH and a lot of migraine symptoms, well, then you would treat it like migraine. That might mean actually giving people specific acute migraine medications. It might mean, perhaps, putting them on migraine-preventive medications. Certainly, using other forms of therapy besides medications - maybe physical therapy is needed if someone has a lot of muscular involvement of the neck. And if they're having vestibular dysfunction from the injury, maybe they need vestibular rehab. Cognitive behavioral therapies - there's some evidence, at least, to suggest that can be helpful after an injury - so, kind of the multimodal approach. We need to make sure that people are getting good sleep, or doing what we can for that to occur (we know that sleep problems, including insomnia, are quite common after a concussion, for example), and really making sure that we're treating the whole patient. The person who is still having headaches at multiple weeks after their injury - likely they're still having other symptoms, too (some of which I just named, but other symptoms as well), like symptoms of autonomic dysfunction are quite common (like orthostatic problems; autonomic type of orthostatic problems) after an injury, cognitive problems, emotional issues - people probably are anxious and not feeling well. A lot of these folks are quite healthy prior to their injury, and all of a sudden, they have, really, a significant problem, and maybe they’re missing work and missing school, and so we really have to treat the patient as a whole, of course.

Dr Berkowitz: Along those same lines, I was wondering - at this early stage - the patient has had still relatively recent head trauma (they are a few weeks out from this initial injury) but still having symptoms which, as you importantly highlighted, can go well beyond headache and a number of other neurologic symptoms they might have. Very common for the patient to ask, “How long is this going to last? How long am I going to feel like this?” How do you counsel patients? Obviously, the outcomes are very variable. How do you counsel patients as an expert here,  based on seeing so many of these patients a few weeks out - as you said, an otherwise healthy patient, minor head trauma, having headache, and potentially even other concussion symptoms as you mentioned - how do you counsel them on what to expect? 

Dr Schwedt: I'll start by saying that this is an area of really high interest to me and my research team, as well as my clinical team - so we're not good enough yet in being able to actually predict recovery and the timing of that recovery - but this is an absolutely essential point, and for multiple reasons. The main reason is based on the question you just asked. Of course, our patients want to know, “When am I going to get better? How long is it going to take? When can I get back to my normal life (whether that be work, or playing sports, or military, or other scenarios)?” – so, that's the most important reason. And it's important as well, because from the clinician’s standpoint, if you know (or if you think you know) based on prediction that someone's highly likely to continue to have symptoms – well, again, that might help you make the decision about how (you know, I'll use the word aggressive) to be with their treatment and how closely to have them follow up, and this type of thing. It’s also important for research. I already mentioned that, unfortunately, there really isn't decent quality evidence (for example, for what treatments to use for post-traumatic headache), and part of that reason for that is that there have been attempts at large clinical trials, and they've failed in a sense, and I think part of the reason for that is because there is, fortunately, such a high rate of natural resolution of symptoms that if you end up enrolling those patients into these prospective clinical trials, it makes it difficult to actually study any difference you might see between a treatment and your placebo. So, if we can have and develop good, clinically useful predictive models, that would really help in each of those domains. So what do I do now? I mean, basically, it's a little bit of a cop-out answer, but what I do is, I try to look at the trajectory that the patient has had thus far (and so, you know, this is all just logical and obvious), but if a patient is already having some degree of improvement - even if they still have symptoms, but they're having some improvement over those first three weeks - well, you would more or less consider the slope of that recovery to persist more or less at the same level. On the flip side, though, if someone's there and it's been multiple weeks - and they've just had absolutely no recovery and maybe they're even feeling worse - then I'm more concerned that this might be a longer-term issue.

Dr Berkowitz: That's helpful to understand both your approach and the challenges in making a firm statement on counseling our patients and using (as has been a theme in many of your helpful responses today) just, sort of, the clinical trajectory and what information that patient's giving you to try to help with the prognosis (however ambiguous it may be) and just needing time to see how the patient does.

Dr Schwedt: I might just add as well, though, that there are studies that have suggested there are certain risk factors for prolonged recovery from post-traumatic headache (and there's some limitations to these studies, so, really, validation is needed), but for post-traumatic headaches specifically, I mean, probably the biggest risk factor for persistence of the post-traumatic headache is having headaches prior to the injury. So, for example, people who have migraine before TBI that then are having an exacerbation or a new headache after the injury - unfortunately, they're less likely to have resolution during the acute phase. Other factors include the severity of the injury itself - so there are certain features of the injury that if, you know, it is seemingly more severe, maybe their likelihood for resolution in the acute phase is lower. And then there are multiple other factors that have been suggested as well, including the patient's own expectations for recovery, which I find to be quite an interesting one. 

Dr Berkowitz: Yeah - very important points. So, let's say that, unfortunately, the patient does continue to have headache now several months out after the trauma; how do you approach these patients with respect to treatment?

Dr Schwedt: Yeah. Once someone's gotten to that point, they probably really are going to need more in the way of preventive measures (and, you know, I did mention some of these). So, if someone's having migraine-like PTH, well, then I'm probably going to end up putting them on medicines that I would use for prevention of migraine. You know, you do have to be especially careful, though, in these individuals who have had TBIs, because you want to make sure that the treatments you're starting aren't going to actually exacerbate their other symptoms, right? So, of course we know some of our migraine preventives can cause things like hypotension, or, you know, cause things like insomnia or cognitive problems, as side effects, and if people are already having those issues from their TBI, then we could actually make them overall feel worse even if we make some progress for their headaches. So, you know of course, we're always careful when thinking about side effects from these medications, but especially so, perhaps, in the patient with a concussion who's having some of these symptoms anyway. And then again - just to highlight, it's not all about medication - that's one small aspect here (one important, but perhaps small, aspect here). So, really, trying to get at lifestyle measures that can be helpful - so, again, sleep, and trying to help people to moderate their stress levels, and making sure that they have an environment that's going to facilitate the recovery (meaning, if they're having a lot of light sensitivity and sound sensitivity and these types of things, you know, doing what we can to help these individuals to be in environments that will allow them to recover).

Dr Berkowitz: Yeah, all very important points - medication being just one part of treatment for these patients, as you said. But to just ask another question about medication so our listeners can learn from your expertise - I'm a general neurologist, and my experience with patients with post-traumatic headache and migraine and otherwise is that it's hard to predict who will respond to which medication (and some patients who failed many pharmaceutical medications will have an amazing response to riboflavin and vice versa) - in your experience (acknowledging that we are very limited in terms of data here), are there any migraine prophylactic agents that you feel, anecdotally, have been particularly helpful in patients with post-traumatic headaches or similar to the general migraine/tension headache population? It's very hard to predict, and it's trial and error and picking the right medication and finding the right dose (just depends on the patient). It requires the patient’s patience - and our patience as well - as we sort of go through some trial and error.

Dr Schwedt: Yeah, I guess. You can hardly even imagine how much I want to answer this question by saying, "Yes, with my experience, I've found that it's these two classes of medications that really work the best for folks with acute or persistent post-traumatic headache,” - but that would be disingenuous. It's so much like it is in migraine, where there is some trial and error, and, you know, again, as you say, it's so difficult to predict exactly which one is going to be the right pharmacologic agent for which patient. If access was no issue, I would go to medications that have the least side effects (which tend to be some of the newer medicines that we have for migraine), but we all know the realities of practice, and oftentimes, that's not a possibility due to access issues. Almost all of our patients that have significant postconcussion symptoms are also being managed by our neuropsychologists - and so, again, they're getting things like cognitive behavioral therapy and getting things like cognitive rehab, and they also are very helpful when it comes to workplace or school-place recommendations and accommodations. Many of our patients are being seen by our vestibular audiologists, as well, to work on their vestibular dysfunction, and vestibular rehab with physical therapy and occupational therapy. And so, you know, as you say, once you get out to multiple months, this is really a multidisciplinary, comprehensive type of treatment approach. 

Dr Berkowitz: Let's say the patient has now gone one to two years out from their initial injury and you had started them on a prophylactic agent (or found the one that works for them maybe after a few trials), and they're doing great (no headaches for several months; otherwise young, healthy person), and they ask you, “Well, do you think I can just go ahead and try coming off these medications now? My injury is a long time ago. While those first few months were awful - thank you for helping me to get these headaches under control - do you think if I go off this medicine, that my headaches will come back, or am I sort of in the clear now?” How do you think about tapering patients off of preventive medications when they've had a good response at a year or so out?

Dr Schwedt: That's so important, right? I mean, I think we all see patients that we inherit that end up kind of being left on medications that perhaps aren't even needed anymore, and it's certainly a mistake we wouldn't want to make. Post-traumatic headache - unlike primary headaches like migraine that tend to be present for decades - they can go away; they can resolve, and they usually do. I mean, we can't lose sight of that, right? Usually, it's going to go away on its own (as I mentioned, you know, within the first few days or weeks), and even after it's become persistent, if you can get a good treatment response, then, absolutely, after several months of that good treatment response, we should be tapering people off. Just like with any headache patient who's on a preventive, I would recommend tapering off of the effective treatment slowly, so if that's a medication, I'm usually very slowly just reducing the dose over several weeks or months (depends on how long they've been on it), usually not because I'm concerned about side effects of withdrawing the medication, but you're just testing it to make sure that the headaches aren't starting to creep back as you reduce the dose of that medication. So, it's a test, and if headaches do start to come back as you're lowering the dose, well, then, presumably you can more quickly get control of it again by elevating the dose back to where it was previously effective. For medications and treatments that don't really have dosing, the other way of doing it - so, you know, some of our medicines, of course, are given at one dose but given at intervals (like, let's say, each month or every three months) where you can't really reduce the dose - you can increase the interval between treatments. So, if you're supposed to have a treatment every month, well, if someone's doing really well, then maybe you say, “You know what? Give it an extra week.” Maybe do it in five weeks instead of four or six weeks. In that same way, you're kind of testing whether or not the medication is still really needed.

Dr Berkowitz: Yeah, that makes sense as an approach here. In addition to your clinical expertise, Dr Schwedt, you're also a researcher in this area. Tell us, what's on the horizon for the future of diagnosis and treatment of patients with post-traumatic headache? 

Dr Schwedt: There's a lot of exciting things on the horizon. It's really encouraging that despite, for example, the lack of evidence currently that we have for treatment, and perhaps not as much preclinical and clinical research into post-traumatic headache as we need, the exciting part is that there's a lot going on. Fortunately, the funding environment for such research has been decent over the past so many years, and so, again, there's almost certainly going to be meaningful breakthroughs here in the near future. Some of our own work - for example, we do a lot of neuroimaging research of post-traumatic headache. One of the main areas of controversy in the headache field is whether or not post-traumatic headache and migraine are really the same thing or are they truly distinct headache disorders? And so, like, a lot of our work has gone towards addressing that - both through neuroimaging, as well as just examining outcomes and symptoms and whatnot - to see where there are similarities and differences. And I'm absolutely biased when it comes to addressing this, but I feel strongly that they really are distinct headache disorders. And that's important, because that means that we need to continue to study them as distinct disorders and we can't just fall back to the idea of saying, “Well, PTH of a migraine phenotype is migraine, and we already have migraine therapy, so let's just use those,” because I think all of us that see patients with PTH in clinical practice realize that our migraine treatments don't work as well for PTH as they do for migraine. So, we really need to continue down the path of understanding the mechanisms underlying PTH, the mechanisms of what makes PTH persist (you know, why it persists in some people and not others), and then what we can do to intervene. I think a major topic, I believe, in determining best treatment approaches is also kind of related to the way you were asking me these questions - it's related to the timing of the intervention. Much of what's been done in studying treatment of PTH is done after it's already persistent, and so in some of these studies, including ours (I mean, it's not a criticism; including ours) - sometimes, these people have had post-traumatic headache for five years or ten years at the time that you enroll them into a study. And, you know, at that point, that's probably a very different population as far as mechanisms and who might respond to which treatments (compared to if you were studying those folks, let's say, in the first few weeks or in the first couple months). There's preclinical evidence (from rodent models of mild traumatic brain injury and post-traumatic headache) that the earlier you intervene, the more effective that intervention is going to be in treating that headache and preventing its persistence, and I would think we could logically presume that's probably the case in people as well. But, of course, we don't want to expose everybody early on to treatments if they don't need it (I mean, if they're going to have natural resolution, then that would actually be inappropriate [to expose them to treatments]). And that's where the prediction comes in. If we had good predictive models of - oh, you know, even though they're only a week into their headache, based on their pre-TBI factors and other characteristics, that they're very likely to have persistence - well, maybe that's the patient where they should have an earlier intervention, and, you know, in another patient, maybe not. 

Dr Berkowitz: It's great to hear about your work and the work of others to help us understand this very, very common condition (and that’s been a theme in many of our questions), one in which we do our best, but are often limited by, our scientific understanding and the data on how to best manage these patients’ headaches. I've learned a lot from our discussion - both clinically, and I’m excited to have learned more about your work and what's on the horizon to help us take care of these patients. Thank you very much, Dr Schwedt, for joining me on Continuum Audio today. Again, for our listeners, I've been interviewing Dr Todd Schwedt, whose article on posttraumatic headache appears in the most recent issue of Continuum on headache. Be sure to check out other Continuum Audio podcasts from this and other issues. Thank you so much to our listeners for joining today. 

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