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Post-traumatic headache: the most common and debilitating symptom of concussion
Post-traumatic headache: the most common and debilitating symptom of concussion
Post-traumatic headache (PTH) is a secondary headache disorder that develops after head or neck trauma, most commonly following a concussion or mild traumatic brain injury (mTBI).
Headache is the most common symptom after concussion and typically appears within hours to a day following the injury. In many patients the headache improves within weeks, but in some cases it can persist for months or longer and become a significant source of disability.
Post-traumatic headache often resembles other primary headache disorders, particularly migraine or tension-type headache. As a result, diagnosis and treatment often involve applying strategies used for these primary headache conditions.
At the Ottawa Headache Centre, we frequently evaluate patients with persistent headache following concussion or head injury and develop individualized treatment plans based on the headache phenotype and underlying mechanisms.
What are the symptoms of post-traumatic headache
What are the symptoms of post-traumatic headache
The symptoms of post-traumatic headache can vary widely between individuals. One of the largest studies evaluating the features of post-traumatic headache was led by Dr. Achelle Cortel-LeBlanc, highlighting that:
the majority of patients had most features of migraine
sensitivity to light and sound were present in the majority of patients
almost three-quarter of people had symptoms persist 4 weeks or more
almost 90% of people had normal brain imaging
In general, symptoms of post-traumatic headache can be migraine-like, tension-like, or cervicogenic-like.
Migraine-like PTH symptoms
Migraine-like PTH symptoms
Moderate to severe head pain
Throbbing or pulsating pain
Sensitivity to light or sound
Nausea or vomiting
Worsening with activity
Brain fog
Tension-type-like PTH symptoms
Tension-type-like PTH symptoms
Continuous dull pressure or tightness around the head
Mild to moderate pain
Neck tension
Cervicogenic-like symptoms
Cervicogenic-like symptoms
Neck pain and stiffness
Headache triggered by neck movement
Pain starting in the back of the head
Diagnosing post-traumatic headache at the Ottawa Headache Centre
Diagnosing post-traumatic headache at the Ottawa Headache Centre
Post-traumatic headache can have significant overlap with migraine and concussion or mild traumatic brain injury. Often, all three condition can co-exist. Consequently, many patients often received mixed information as to what their diagnosis is.
At the Ottawa Headache Centre, we use a structured and systematic approach to:
diagnose any pre-existing headache disorder
determine whether the current headache is attributed to the injury
distinguish between post-traumatic headache, migraine, and concussion
According to the International Classification of Headache Disorders (ICHD-3), post-traumatic headache is diagnosed when:
a new headache appears after an injury, or
a pre-existing headache is made significantly worse after an injury.
ICHD-3 criteria for post-traumatic headache
ICHD-3 criteria for post-traumatic headache
Trauma to the head and/or neck has occurred
Headache develops within 7 days after any of:
The injury
Regaining consciousness
Discontinuation of medications that impair the ability to sense headache
Headache is not better accounted for by another headache disorder
The majority of people with post-traumatic headache will have headache appear within 24 hours of injury.
If the headache persists longer than 3 months, it is classified as "persistent headache attributed to traumatic injury to the head" (persistent post-traumatic headache).
Why does post-traumatic headache occur
Why does post-traumatic headache occur
Many studies have been done to try to understand the cause of post-traumatic headache. It is complex and it remains poorly understood why some people develop significant headache after an injury whereas others do not.
Potential mechanisms in the persistence of post-traumatic headache include:
Brain injury and neuro-inflammation
Brain injury and neuro-inflammation
Traumatic brain injury may trigger:
Inflammatory changes
Alterations in brain signaling
Increased sensitivity of pain circuits
Disruption in CGRP-mediated pathways
Migraine activation
Migraine activation
Concussion and head injury can trigger migraine biology, particularly in people with a history of migraine.
For many people, especially when an injury was remote, migraine alone can often explain many of the persistent symptoms from a head injury.
Central sensitization
Central sensitization
Pain processing in the brain is amplified leading to hypersensitivity. This is also a key feature in the development of chronic migraine.
It develops after repeated activation of the brain's own pain pathways.
Managing post-traumatic headache in Ottawa
Managing post-traumatic headache in Ottawa
To effectively treat post-traumatic headache, an expert approach to recognizing the headache phenotype is needed (i.e., identifying "the type of headache"). At the Ottawa Headache Centre we focus on identifying:
The type of headache phenotype (migraine, tension-type, cervicogenic)
Associated symptoms
Potential secondary complications
Most patients do not require routine brain imaging if the clinical picture is consistent with post-traumatic headache or concussion.
Once the dominant headache type is identified, treatment is tailoured according to that headache disorder.
Typically, post-traumatic headache looks like migraine, and migraine therapies may be used.
Simple analgesics (acetaminophen or NSAIDs)
Migraine-specific medications (such as triptans or gepants)
Overuse of acute medications can worsen headache frequency, so careful use is important.
Non-specific oral preventives including blood-pressure medications, anti-depressants, or anticonvulsants are often trialed first.
Botox® can be an effective treatment PTH has evolved into chronic migraine.
Next steps
Next steps
Post-traumatic headache can be a debilitating condition. Thankfully, with expert evaluation and treatment most people recover well.
Out approach at the Ottawa Headache Centre includes:
identifying a precise headache-related diagnosis
neurology-driven assessment of the headache type
initiating evidence-base targeted treatment and coordinating with other disciplines when appropriate
Ask your doctor for a referral to the Ottawa Headache Centre to book an expert consultation.
Common questions about post-traumatic headache
Common questions about post-traumatic headache
Is post-traumatic headache the same as migraine?
Is post-traumatic headache the same as migraine?
Not exactly.
Post-traumatic headache is a secondary headache disorder caused by an injury, but it often resembles migraine in symptoms and may be treated similarly.
How long does post-traumatic headache last?
How long does post-traumatic headache last?
Most people with post-traumatic headache experience improvement of their headache within days to weeks. Some people develop persistent headache lasting more than three months. It doesn't mean that there is still ongoing injury, but rather that the brain has been sensitize to experience and promote pain.
Can concussion trigger chronic migraine?
Can concussion trigger chronic migraine?
Yes.
Head injury and concussion can trigger or worsen migraine biology, especially in individuals who already have migraine.
Do all people with post-traumatic headache require brain imaging?
Do all people with post-traumatic headache require brain imaging?
No.
The vast majority of people with concussion-related headache do not require imaging unless there are "red flags".
Can post-traumatic headache be treated?
Can post-traumatic headache be treated?
Yes.
Treatment of post-traumatic headache often includes migraine therapies, preventive medications, and rehabilitation strategies targeting neck injury, sleep problems, or other contributing factors.
Disclaimer
Disclaimer
This material is provided for educational purposes and does not replace independent clinical judgment or institutional protocols. Management decisions remain the responsibility of the treating clinician.
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