10/19/12
1
Post-Traumatic Headache
Professor and Interim Chair, Department of PM&R Wayne State University School of Medicine Detroit, MI Medical Director Neuroscience Rehabilitation Institute of Michigan Detroit, MI
Lawrence J. Horn, MD
● Speakers Bureau: Allergan, Inc.
Disclosures
10/19/12
2
Learning Objective
Review the clinical presentations of various post-traumatic headaches.
Post-Traumatic Headache
● Most common physical complaint in patients who have had a traumatic brain injury (TBI)
● Present in mild TBI/concussion and severe TBI ● International Headache Society (IHS)
classification has shortcomings ● There is no one type of post-traumatic
headache (PTH) ● Limited repertoire of headache responses,
regardless of nociceptor ● Treatment should be multifaceted
Lucas S, et al. Cephalalgia. 2012;32(8):600-606. PMID: 22623761.
IHS Definition: Headache Attributed to Head and/or Neck Trauma ● 5.1 Acute PTH ● 5.1.1 Acute PTH attributed to moderate or
severe head injury ● 5.1.2 Acute PTH attributed to mild head
injury ● 5.2 Chronic PTH (> 3 months) And the list goes on….
International Headache Society (IHS). IHS Classification ICHS-II. 2006. http://ihs-classification.org/en/02_klassifikation 03_teil2/05.02.02_necktrauma.html.
10/19/12
3
Epidemiology of PTH: Civilian
● Of all people with TBI ● 30%-90% develop PTH ● Most show improvement in first 3-6 months ● Most do not convert from acute to chronic headache
● Of those with moderate to severe TBI ● More likely to develop chronic PTH ● 40%-50% have headache at 12 months
● Dominant phenotype now appears to be “migraine” ● Risk Factors ● Women ● Premorbid history of headache
Lucas S, et al. Cephalalgia. 2012;32(8):600-606. PMID: 22623761.
Epidemiology: Military
● 20% deployment-related concussion ● 1/3 meet criteria for PTH ● 58% of these have post-traumatic migraine (PTM)
● Associated with post-traumatic stress disorder (PTSD) ● Health complaints ↑ in PTSD ● PTH more likely with mild TBI
● Associated with blast or blast-induced neurotrauma ● Type of headache not well defined ● Neurovascular and structural elements
Lucas S, et al. Cephalalgia. 2012;32(8):600-606. PMID: 22623761.
Sources of Head Pain
● Dura and venous sinuses ● Skin, nerves, muscles, periosteum and
cranial cavities of head and neck ● Cervical joints ● Cervical muscles
Gladstone J. Headache. 2009;49(7):1097-1111. PMID: 19583599.
10/19/12
4
Interconnectivity between the spinal nucleus and tract of cranial nerve V
Zasler N, et al. Brain Injury Medicine: Principles and Practice. 2006.
Schematic representation of interconnectivity between the spinal nucleus and tract of cranial nerve V upper three cervical roots and the occipital branch of the fifth cranial nerve through the Gasserian ganglion.
Theorized Mechanisms of Central Sensitization
Zasler N, et al. Brain Injury Medicine: Principles and Practice. 2006:
Immediate Late
Clinical Evaluation of PTH
● History: Mechanism of injury ● Whiplash ● Blast ● Neurosurgery
● Severity ● Associated symptoms: aura, vomiting ● Degree of functional disability ● Presence of pending litigation ● Psychiatric history ● History of headache
Gladstone J. Headache. 2009;49(7):1097-1111. PMID: 19583599. Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1):22-33. PMID: 9949244.
10/19/12
5
Clinical Evaluation of PTH
● Character: Dull, throbbing, sharp… ● Onset: Precipitants, menses, time of day, time
after injury ● Location: Unilateral, bilateral, occipital, at a scar ● Duration and frequency ● Exacerbation: Physical activity, touch, sleep,
noise ● Relief: Medications (how much/often), rest
Gladstone J. Headache. 2009;49(7):1097-1111. PMID: 19583599. Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1):22-33. PMID: 9949244.
Physical Examination of Patient with PTH
● Observation: scars, craniectomy ● Neurologic exam ● Palpation of head and neck ● Include “clicking” in temporomandibular joint ● Myofascial trigger points
● Auscultation for bruits
Gladstone J. Headache. 2009;49(7):1097-1111. PMID: 19583599. Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1):22-33. PMID: 9949244.
IHS Classification: Primary Headaches
● Migraine ● Migraine without aura ● Migraine with aura
● Tension-type headaches ● Episodic tension-type headache (TTH) ● Chronic TTH ● Associated with disorder of pericranial muscles ● Unassociated with disorder of pericranial muscles
● Cluster headache and chronic paroxysmal hemicrania ● Miscellaneous headaches unassociated with structural
lesion International Headache Society (IHS). IHS Classification ICHS-II. 2006. http://ihs-classification.org/en/02_klassifikation/03_teil2/05.02.02_necktrauma.html.
10/19/12
6
Clinical Classification System PTH 1
● Musculoskeletal PTH ● TTH (tension-type headache) ● Myofascial ● Cervicogenic PTH ● Craniomandibular PTH
● PTM/probable migraine ● Neuralgias/neuritic ● Certain cranial neuralgias
Theeler BJ, et al. Cephalalgia. 2012;32(8):589-591. PMID: 22623763.
Clinical Classification System PTH 2
● PTH from intracranial abnormalities ● ↑ Intracranial pressure (ICP), including
tension pneumocephalus ● ↓ ICP ● Syndrome of the trephined
(postcraniectomy headache) ● Carotid cavernous fistula ● Cavernous sinus or intracranial sinus
thrombosis ● Carotid dissection
Theeler BJ, et al. Cephalalgia. 2012;32(8):589-591. PMID: 22623763.
Clinical Classification System PTH 2
● Other ● Medication overuse headache (MOH) ● Dysautonomic ● Blast ● Sinus
Theeler BJ, et al. Cephalalgia. 2012;32(8):589-591. PMID: 22623763.
10/19/12
7
Musculoskeletal Headache
● Classic tension headache (?) ● Myofascial-pain–related
headache ● Cervicogenic headache ● Craniomandibular syndrome
Jull G, et al. Cephalalgia. 2007;27(7):793-802. PMID: 17598761.
Tension Headache
● Bilateral head pain ● Pressing quality (like a tight hat) ● Mild to moderate intensity ● May have peri-cranial tenderness ● Not associated with: ● Nausea/vomiting ● Aura ● Sensitivity to light or sound ● Exacerbation by physical activity
● May be confused with ● Migraine without aura ● Medication overuse headache
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-412. PMID: 22035683.
Pathophysiology of TTH
● Pericranial and cervical Injury produces peripheral activation of nociceptors
● Peripheral and central sensitization (chronic TTH) ● Antidromic release of pain mediators ● Substance P ● Bradykinin ● CGRP
● Heightened pain sensitivity peripherally ● Neutral stimuli perceived as painful ● Development of trigger points
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-412. PMID: 22035683.
TTH=tension-type headache
10/19/12
8
Central Sensitization
● Overlap of receptive fields from C1 – C4 muscles and trigeminal nucleus caudalis ● Trapezius ● Suboccipital ● Sternocleidomastoid ● Temporalis ● Masseter
Jensen R. Cephalagia. 2001;21(7):786-789. PMID: 11595014.
Myofascial Pain: Part of TTH?
● Commonly injured muscles of head and neck
● Trigger points (with associated increased allogenic substances)
● Radiation of pain in characteristic distribution ● Autonomic dysfunction ● May cause unilateral or bilateral headache
Jensen R. Cephalagia. 2001;21(7):786-789. PMID: 11595014. TTH=tension-type headache
Muscular Reaction to “Whiplash” Injury
Center, Sternocleidomastoid muscle, (SCM) extension to upper half of cervical spine and flexor to lower half. Right, Hyperextension, the SCM is completely an extension and shorter than in neutral. Left, In flexion, the SCM is completely flexor and shorter than in neutral and hyperextension. This rapid movement overstretches muscle and causes a reflex inhibition and muscle strain.
Cailliet R. Neck and Arm Pain. 2nd ed. 1981.
10/19/12
9
Referred Pain Patterns Sternocleidomastoid Muscle
Travell JG, Simons DG. Sternocleidomastoid muscle. In: Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. 1998.
Sternal (superficial) division Clavicular (deep) division
Referred Pain Patterns Splenius Capitis and Splenius Cervicis Muscles
Travell JG, e. Splenius capitis and splenius cervicis muscles. In: Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. 1998.
Referred Pain Patterns
● Referred pain pattern and location (Xs) of trigger point 1 in the upper trapezius muscle. Solid red shows the essential referred pain zone; stippling maps the spillover zone.
Trapezius muscle
Travell JG, Simons DG. Trapezius muscle. In: Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. 1998.
10/19/12
10
Treatment of TTH
● Nonsteroidal anti-inflammatory drugs (NSAIDs) ● Prophylaxis ● Tricyclic antidepressant (TCA)* ● Topiramate?* ● Botulinum toxin?* ● Acupuncture? ● Behavioral strategies ● Biofeedback ● Correct sleep disturbances
Prevent Conversion of Acute → Chronic
*This is not an FDA-approved use for this agent
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-S412. PMID: 22035683.
Treatment of Myofascial Pain
● Apply cold and stretch ● Apply moist heat and stretch ● Perform needling: dry or with local
anesthetic agent ● Conduct strengthening program ● Avoid certain postures
Borg-Stein J, et al. Arch Phys Med Rehabil 2002;83(3 Suppl 1):S40-47, S48-49. PMID: 11973695.
Migraine: Trigemino-Neurovascular Headache
10/19/12
11
Migraine Clinical Presentation
● Episodic attacks of headaches ● Throbbing (lasts 4-72 hours) ● Unilateral (up to 40% become bilateral) ● Worse with coughing, bending, physical exertion ● Photophobia, phonophobia
● Associated autonomic disturbances ● Nausea, vomiting, anorexia
● With or without an aura ● Usually visual
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-412. PMID: 22035683.
Migraine Treatment
Migraine treatment
Prophylaxis
Beta-blockers
Ca Channel Blockers
Tricyclic Antidepressants
Anticonvulsants
Acute Episodes
Nonspecific Treatments
NSAIDs Antiemetics
Specific Treatments
Triptans Dihydroergotamine
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-412. PMID: 22035683.
Other PTM Treatments
● Sphenopalatine block ● Used in past for cluster headache ● Parasympathetics to face and meninges
● Therapy to musculoskeletal component ● Heat, stretch, massage
● Naturopathic ● Butterbar ● Feverfew
Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-412. PMID: 22035683.
10/19/12
12
Neuralgia/Neuroma
● Neuroma ● Injury to skin, muscle, or periosteum ● Small nerve trapped in scar
● Greater (GON) or lessor occipital nerve (LON) injury ● May radiate to ipsilateral eye
● Supraorbital nerve injury ● Pain ● Sharp, tingling ● Localized (neuroma) or territory of major scalp nerve ● Can be elicited on palpation
Ducic I, et al. Plast Reconstruct Surg. 2008;121(6):1943-1948. PMID: 18520879. Schankin CJ, et al. Cephalalgia. 2009;29(7):760-771. PMID: 19239675.
Neuralgia/Neuroma
Panskey B, House EL. Review of Gross Anatomy. Second Edition.1969
Dermatomal Distribution of Occipital Nerves
Cailliet R. Neck and Arm Pain. 2nd ed. 1981.
10/19/12
13
Treatment: Neuroma
● Modalities: cold ● Topical anesthetic agents ● NSAID ● Tricyclic antidepressant agent* ● Serotonin norepinephrine reuptake inhibitor* ● Gabapentin* or pregabalin* ● Injection with local anesthetic ± steroid ● Surgery
*This is not an FDA-approved use for this agent
Schankin CJ, et al. Cephalalgia. 2009;29(7):760-771. PMID: 19239675.
Treatment: Neuralgia (GON, LON)
● Myofascial release of associated muscles and upper cervical segment
● Topical anesthetic agents ● NSAID ● Tricyclic antidepressant agent* ● Selective norepinephrine reuptake inhibitor* ● Gabapentin* or pregabalin* ● Injection with local anesthetic agent ± steroid ● Cryo- or radiofrequency ablation ● Neuromodulation: occipital nerve stimulator
*This is not an FDA-approved use for this agent GON = greater occipital nerve; LON = lesser occipital nerve
Ducic I, Larson EE. Plast Reconstruct Surg. 2008;121(6):1943-1948. PMID: 18520879.
PTH with Intracranial Pathology
● Intracranial pressure (ICP) abnormalities ● ↑ ICP ● Hydrocephalus ● Tension pneumocephalus
● ↓ ICP ● Cerebrospinal fluid (CSF) leak ● Syndrome of the trephined
● Carotid-cavernous fistula ● Cavernous sinus thrombosis ● Carotid artery dissection ● Meningitis
Ramirez-Lassepas M, et al. Arch Neurol. 1997;54(12):1506-1509. PMID: 9400360.
10/19/12
14
Syndrome of the Trephined
● Etiology ● Complication of craniotomy ● Impaired cerebral blood flow
● Symptoms ● Apathy ● Cognitive dysfunction ● Gait abnormality ● Headaches ● Hemiparesis ● Midbrain syndrome ● ± Orthostatic component ● Tremor
● Treatment ● Cranioplasty
Joseph V, et al. J Neurosurg. 2009;111(4):650-652. PMID: 19361266.
Controversies in PTH: Prognosis
● Tied to resolution of post-concussive syndrome in mild TBI ● Of patients with moderate to severe TBI,
40%-50% have persistent headaches ● Mixed evidence for an effect of litigation
on persistence ● PTSD? ● Pre-injury history or genetic predisposition ● Psychological and social factors
Gladstone J. Headache. 2009;49(7):1097-1111. PMID: 19583599.
Clinical Connections
● Most common headache is migraine or migraine-like ● Need to treat musculoskeletal or
tension headache component regarding of clinical classification ● Remember to palpate the head
and neck, you find what you look for
10/19/12
15
Co-sponsored by
Save the Date!
6th Annual Chair Summit September 26-28, 2013 Westin Tampa Harbour Island Tampa, Florida Check out www.cmeoutfitters.com for the most recent information on Chair Summit 2013. Registration will be open soon. See you in Tampa!
