THECLINICAL SPECTRUM OF THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER CHRONIC PAIN SYNDROMES AFTER

TBITBI

Olli TenovuoOlli TenovuoMD, PhDMD, PhD

Department of NeurologyDepartment of NeurologyUniversity of Turku, FinlandUniversity of Turku, Finland

BackgroundBackground

• TBI has long been an underestimated area TBI has long been an underestimated area in clinical medicine, especially in regard to in clinical medicine, especially in regard to its significance for public health. its significance for public health.

• There are still major gaps in our knowledge There are still major gaps in our knowledge of some very central issues. One of these is of some very central issues. One of these is the co-occurrence of chronic pain and TBI. the co-occurrence of chronic pain and TBI.

BackgroundBackground

• The co-morbidity of chronic pain and TBI is The co-morbidity of chronic pain and TBI is highly complex highly complex →→ clear diagnostic and clear diagnostic and treatment guidelines, applicable at an treatment guidelines, applicable at an individual level, cannot be expected. individual level, cannot be expected.

• This should not hamper progression in This should not hamper progression in research and clinical care of these patients.research and clinical care of these patients.

The spectrumThe spectrum

Chronic pain syndromes after TBIChronic pain syndromes after TBI • chronic headachechronic headache• facial pain facial pain • neck pain neck pain • shoulder pain shoulder pain • pain in the extremities (painful hemisyndrome)pain in the extremities (painful hemisyndrome)• rare pain syndromes rare pain syndromes

Contents of the presentationContents of the presentation

A clinical and diagnostically oriented review A clinical and diagnostically oriented review of the most important pain problems after of the most important pain problems after TBI, especiallyTBI, especially– chronic headachechronic headache– chronic facial painchronic facial pain– chronic neck painchronic neck pain– central paincentral pain

ChronicChronic posttraumatic headache posttraumatic headache

The ICHD-II classification (2004):The ICHD-II classification (2004):1.1.Headache develops within 7 days after (mild Headache develops within 7 days after (mild

- severe) head injury- severe) head injury2.2.Headache persists > 3 months after the injuryHeadache persists > 3 months after the injury

5.2.2 Chronic posttraumatic headache attributed to 5.2.2 Chronic posttraumatic headache attributed to mild mild head injuryhead injury

• A. Headache, no typical characteristics known, A. Headache, no typical characteristics known, fulfilling criteria C and Dfulfilling criteria C and D

• B. Head trauma with at least one of the following:B. Head trauma with at least one of the following:• 1. Either no loss of consciousness or loss of 1. Either no loss of consciousness or loss of

consciousness for < 30 mins durationconsciousness for < 30 mins duration• 2. GCS 2. GCS ≥ ≥ 1313• 3. Symptoms and/or signs diagnostic of concussion3. Symptoms and/or signs diagnostic of concussion• C. Headache develops within 7 days after head C. Headache develops within 7 days after head

trauma or after regaining consciousness after head trauma or after regaining consciousness after head traumatrauma

• D. Headache persists for 3 months after head traumaD. Headache persists for 3 months after head trauma

The ICHD-II classificationThe ICHD-II classification

Problems in definitionProblems in definition

• The concepts of head injury and brain injury The concepts of head injury and brain injury have been mixedhave been mixed

• The definition of mild HI lacks the duration of The definition of mild HI lacks the duration of posttraumatic amnesia as a criteriaposttraumatic amnesia as a criteria

• ”” within 7 days or after regaining consciousness” within 7 days or after regaining consciousness” – in mild injury???– in mild injury???

• ““persists for 3 months” – but how often does it persists for 3 months” – but how often does it have to occur? have to occur?

The ICHD-II classificationThe ICHD-II classification5.2.1 Chronic posttraumatic headache attributed to 5.2.1 Chronic posttraumatic headache attributed to

moderate or severe head injurymoderate or severe head injury• A. Headache, no typical characteristics known, fulfilling A. Headache, no typical characteristics known, fulfilling

criteria C and Dcriteria C and D• B. Head trauma with at least one of the following:B. Head trauma with at least one of the following:• 1. Loss of consciousness for > 30 mins1. Loss of consciousness for > 30 mins• 2. GCS < 132. GCS < 13• 3. Posttraumatic amnesia for > 48 hrs3. Posttraumatic amnesia for > 48 hrs• 4. Imaging demonstration of a traumatic brain lesion 4. Imaging demonstration of a traumatic brain lesion

(cerebral hematoma, intracerebral and/or(cerebral hematoma, intracerebral and/or• subarachnoid hemorrhage, brain contusion, and/or subarachnoid hemorrhage, brain contusion, and/or

skull fracture)skull fracture)• C. Headache develops within 7 days after head trauma C. Headache develops within 7 days after head trauma

or after regaining consciousness after head traumaor after regaining consciousness after head trauma• D. Headache persists for 3 months after head traumaD. Headache persists for 3 months after head trauma

Problems in definitionProblems in definition

• The concepts of head injury and brain injury The concepts of head injury and brain injury have been mixedhave been mixed

• PTA > 48 hrs – why this limit??PTA > 48 hrs – why this limit??• ””Imaging demonstration of a traumatic brain Imaging demonstration of a traumatic brain

lesion” – Is skull fracture a brain lesion? Axonal lesion” – Is skull fracture a brain lesion? Axonal injury or oedema are not brain lesions?injury or oedema are not brain lesions?

• ””Within 7 days…” – what about PTA > 7 days?Within 7 days…” – what about PTA > 7 days?• ””Persists for 3 months” – at which frequency?Persists for 3 months” – at which frequency?

And further critique…And further critique…• Why should the TBI severity be included in the Why should the TBI severity be included in the

criteria?criteria?• The time limits are artificial and do not base on The time limits are artificial and do not base on

any evidenceany evidence• The role of frequent extracerebral causes The role of frequent extracerebral causes

(especially concomitant neck injury) has been (especially concomitant neck injury) has been neglectedneglected

- should the research of posttraumatic headache - should the research of posttraumatic headache really be based on these criteria?really be based on these criteria?

An alternative definitionAn alternative definition

Chronic posttraumatic headache Chronic posttraumatic headache = Headache that usually develops within 3 months = Headache that usually develops within 3 months

after an injury to the head or neck and is not after an injury to the head or neck and is not better explained with non-traumatic causes better explained with non-traumatic causes after a thorough clinical history and after a thorough clinical history and examination, including appropriate imaging and examination, including appropriate imaging and laboratory studies. After developing, the laboratory studies. After developing, the headache should occur at least weekly for at headache should occur at least weekly for at least 6 months.least 6 months.

A new official definition for clinical and research A new official definition for clinical and research purposes should be made urgently, including purposes should be made urgently, including

the definition for various subtypes.the definition for various subtypes.

How common is chronic How common is chronic posttraumatic headache?posttraumatic headache?

• The figures have been very variable, depending The figures have been very variable, depending on the study population, protocol and headache on the study population, protocol and headache criteriacriteria

• The available data suggest that headache The available data suggest that headache follows head injury in 50 to 80% of patients follows head injury in 50 to 80% of patients acutely and continues in 20 to 30% 1 to 2 years acutely and continues in 20 to 30% 1 to 2 years later later (Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury (Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury increases the risk of chronic daily headache. A population-based study. increases the risk of chronic daily headache. A population-based study. Neurology® 2007;69:1169–1177)

Subacutely…Subacutely…• 100 sequential admissions with mild TBI (as 100 sequential admissions with mild TBI (as

defined by American Congress of Rehabilitation defined by American Congress of Rehabilitation Medicine, 1993), and 100 matched minor injury Medicine, 1993), and 100 matched minor injury controls with nondeceleration injuries controls with nondeceleration injuries

• 15.34% of those with minor head injury 15.34% of those with minor head injury continued to complain of persistent continued to complain of persistent posttraumatic headache at 3 months compared posttraumatic headache at 3 months compared to 2.2% of the minor injury controlsto 2.2% of the minor injury controls

(Faux S, Sheedy J. (Faux S, Sheedy J. A Prospective Controlled Study in the Prevalence of Posttraumatic Headache Following Mild Traumatic Brain Injury. Pain Med 2008, Epub ahead of print)

And in the long run…And in the long run…• A Norwegian study compared the prevalence A Norwegian study compared the prevalence of of

headache in a cohort with previous hospitalization for headache in a cohort with previous hospitalization for head injury (22 yrs earlier) and matched controlshead injury (22 yrs earlier) and matched controls

• In multivariate In multivariate conditional regression analysis among conditional regression analysis among 192 responding case/control pairs, there was no 192 responding case/control pairs, there was no evidence of higher odds of headache > 1 day per month evidence of higher odds of headache > 1 day per month (odds ratio, OR 1.04, 95% CI 0.56–1.92, p = 0.90) (odds ratio, OR 1.04, 95% CI 0.56–1.92, p = 0.90) compared with controls.compared with controls.

(Nestvold K, Staven M. Headache 22 Years after Hospitalization for Head Injury (Nestvold K, Staven M. Headache 22 Years after Hospitalization for Head Injury Compared with Matched Compared with Matched Community Controls. Neuroepidemiology 2007;Community Controls. Neuroepidemiology 2007; 29:113–120)29:113–120)

Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics Characteristics and treatment of headache after traumatic brain and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.

The type of posttraumatic headacheThe type of posttraumatic headache

We performed a systematic literature review We performed a systematic literature review on this topic and found that many patients on this topic and found that many patients

with PTH had clinical presentations very with PTH had clinical presentations very similar to tension-type headache (37% of all similar to tension-type headache (37% of all

PTH) and migraine (29% of all PTH).PTH) and migraine (29% of all PTH).

Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics Characteristics and treatment of headache after traumatic brain and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–injury: A focused review. Am J Phys Med Rehabil 2006;85:619–

627.627.

Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics Characteristics and treatment of headache after traumatic and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.2006;85:619–627.

The profile of posttraumatic headacheThe profile of posttraumatic headache

Chronic Chronic posttraumatic posttraumatic

headacheheadache

Periodic Periodic / daily/ daily

EpisodicEpisodicContinuousContinuous

Cervical / Cervical / occipitaloccipital

Frontal, Frontal, frontotemporal, frontotemporal,

ribbon-like, variableribbon-like, variable

Without Without cervical cervical

signssigns

With With cervical cervical

signssigns

Neck-derived Neck-derived headacheheadache

PsychogenicPsychogenic

IdiopathicIdiopathic

Analgetics Analgetics ≥ ≥ 3 3 days / weekdays / week

Medication Medication overuse overuse

headacheheadache

YesYes

NoNoOrofacial Orofacial

dysfunctiondysfunction

Visual Visual dysfunctiondysfunction

Hormonal Hormonal insufficiencyinsufficiency

Chronic episodic posttraumatic Chronic episodic posttraumatic headacheheadache

• Migrainous (with migrainous characteristics)Migrainous (with migrainous characteristics)

• Neuritic (with neuralgic signs and localization)Neuritic (with neuralgic signs and localization)

Chronic periodic posttraumatic Chronic periodic posttraumatic headacheheadache

• Muscular source (with muscular signs and Muscular source (with muscular signs and localization)localization)

• Migrainous (with characteristics of prolonged Migrainous (with characteristics of prolonged migraine)migraine)

• Cervical (with cervical signs, precipitating Cervical (with cervical signs, precipitating factors, cervical / frontal localization)factors, cervical / frontal localization)

Some important notes…Some important notes…

• The spectrum of acute and subacute The spectrum of acute and subacute posttraumatic headaches is much widerposttraumatic headaches is much wider

• In a minor but significant portion of patients, In a minor but significant portion of patients, the clinical history, examination and the clinical history, examination and consultations reveal no clear causes for the consultations reveal no clear causes for the persisting headache. persisting headache.

• In many of these, the headache clearly In many of these, the headache clearly accompanies tiredness or fatigue. Treating a accompanies tiredness or fatigue. Treating a sleep problem or fatigue may offer a relief. sleep problem or fatigue may offer a relief.

Some important notes…Some important notes… continued continued

• The often underdiagnosed post-traumatic The often underdiagnosed post-traumatic hormonal insufficiency may also cause hormonal insufficiency may also cause headache, and must be kept in mind as a headache, and must be kept in mind as a treatable cause. treatable cause.

• Cervicogenic headaches are underdiagnosed – Cervicogenic headaches are underdiagnosed – suggestive features:suggestive features:– rotatory injury mechanismrotatory injury mechanism– acute neck pain and restricted movementsacute neck pain and restricted movements– weakness, numbness or pain in the extremitiesweakness, numbness or pain in the extremities– cervical pain and impaired mobility persist for weeks cervical pain and impaired mobility persist for weeks

after the injuryafter the injury

Some important notes…Some important notes… continued continued

Clinical signs of cervicogenic headache:Clinical signs of cervicogenic headache:• asymmetrically impaired cervical mobilityasymmetrically impaired cervical mobility• pain or tingling produced by rotation or flexion – pain or tingling produced by rotation or flexion –

extensionextension• local tenderness in palpation of the C I-II local tenderness in palpation of the C I-II

vertebrae vertebrae

Further evaluation should preferably happen with Further evaluation should preferably happen with functional cervical MRI, which is able to show functional cervical MRI, which is able to show eventual disruptions of the alar or transverse eventual disruptions of the alar or transverse

ligamentsligaments

Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and impact direction in whiplash injuries: associations with MRI-impact direction in whiplash injuries: associations with MRI-verified lesions of ligaments and membranes in the upper cervical verified lesions of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005 Nov;22(11):1294-302spine. J Neurotrauma. 2005 Nov;22(11):1294-302

Chronic neck pain after TBIChronic neck pain after TBI

• Is usually accompanied by headache, at least Is usually accompanied by headache, at least intermittentlyintermittently

• May stem from bony or soft tissue injuriesMay stem from bony or soft tissue injuries

• The clinical assessment should include The clinical assessment should include detailed injury reconstruction, skilled detailed injury reconstruction, skilled examination of the cervical function and examination of the cervical function and neurological examination of the cranial neurological examination of the cranial nerves and upper extremitiesnerves and upper extremities

Chronic neck pain after TBIChronic neck pain after TBI

• Sensory disturbances in the upper extremities or Sensory disturbances in the upper extremities or C I-II region should raise a suspicion of nerve C I-II region should raise a suspicion of nerve root injury or posttraumatic syringomyeliaroot injury or posttraumatic syringomyelia

• Imaging of traumatic lesions in the cervical spine Imaging of traumatic lesions in the cervical spine requires expertise and normal results do not requires expertise and normal results do not necessarily mean normal anatomynecessarily mean normal anatomy

• An experienced physiotherapist or specialist in An experienced physiotherapist or specialist in physical medicine is invaluablephysical medicine is invaluable

Chronic facial pain after TBIChronic facial pain after TBI

May have multiple aetiologies, such as:May have multiple aetiologies, such as:• Trigeminal injuryTrigeminal injury• Orofacial dysfunctionOrofacial dysfunction• Sinus disturbanceSinus disturbance• Upper cervical lesionsUpper cervical lesions• Orbital lesionsOrbital lesions• Atypical facial painAtypical facial pain

Irritation to structures innervated Irritation to structures innervated by the by the cervical sensory nerves can activate the cervical sensory nerves can activate the

trigeminal nucleus along with the trigeminal nucleus along with the trigeminovascular system and result in trigeminovascular system and result in

referred pain to the anterior or frontal aspect referred pain to the anterior or frontal aspect of of the headthe head