5.0: Headache associated with trauma

A variety of headache types occur after head trauma. The International Headache Society has divided post-traumatic headaches into two types: acute post-traumatic headache and chronic post-traumatic headache.

5.1: Acute post-traumatic headache

The nature, extent, and duration of post-traumatic headache in part depends upon the degree of head trauma. Assuming that it is closed head trauma, the initial headache is usually related to the degree of head injury. Headaches that last more than two weeks would fall into the chronic post-traumatic headache classification. There may be an initial headache for a number of days, but then a recrudescence or exacerbation of pre-existing migraine. This would then be a periodic disorder with increased frequency and intensity of vascular type headache. This differs significantly from the chronic post-concussion headaches described below.

5.2: Chronic post-traumatic headache

Headache that persists for more than 2 months occurs in 40-60 percent of patients hospitalized after closed head injury (Brenner et al., 1944). Although intensive post-traumatic symptoms may develop after major head injury, severe and protracted headache disorders also occur after apparently trivial head trauma. The development of headache does not correlate with the duration of unconsciousness or post-traumatic amnesia, with electroencephalographic abnormalities, with the presence of skull fractures, or with the finding of blood in the cerebrospinal fluid (Brenner et al., 1944; Kay et al., 1971).

Harold Wolff (1955) described three varieties of post-traumatic headache: (1) severe pain or circumscribed tenderness in a scar or site of impact; (2) a steady pressure sensation or aching pain in a circumscribed area or in a cap-like distribution; and (3) an episodic throbbing aching pain, usually unilateral and in the temporal or frontal region.

The first type occurs in patients who have tender areas in the scalp that persist sometimes for as long as 6 years after the trauma. Such tender spots are often related to visible scars and are often at or near the site of injury. Injection of the tender areas with isotonic saline accentuates the pain, while injection with procaine predictably eliminates it. Apparently such pain arises from stimulation of nerve endings in the locally damaged tissue.

A second type of pain results from sustained skeletal muscle contraction. Wolff (1955) demonstrated by electromyography that pain in any part of the head of such patients induces a sustained contraction of head and neck muscles sometimes remote from the original site of noxious stimulation, giving rise to steady pressure or aching pain in the head or neck. Often such sustained painful muscle contraction occurs without tender scars or circumscribed areas of tenderness and is associated with tension and apprehension. In some cases, these contractions represent unconscious protective immobilization of the head and neck. Such post-traumatic headaches may result from cervical injury, including ligamentous tears, and, occasionally, from dislocation or herniation of a cervical disc (Raney et al., 1949).

A third type of headache is caused by recurring episodes of distention of arterial walls. This pain is reduced by compression of the painful arteries and is eliminated by injection of ergotamine tartrate. Such pain is also associated with tension, anxiety, resentment, and fatigue.

Some patients have more than one type of headache after head injury. Often the principal cause of the pain is outside the head. Nearly all these patients harbor resentment related to the circumstances of their accident or fear that they have sustained permanent damage to their brain. Such emotional reactions and attitudes are intimately related to the pathophysiology of the post-traumatic headache.

Post-traumatic headache is usually present every day. The large majority of patients experience a dull, aching, constant, generalized discomfort, with exacerbations that may be polar, generalized, or unilateral, and usually persist for several hours. At such times, the pain is usually throbbing in quality (Symonds, 1974; Behrman, 1977). The headache is commonly worsened by effort, stooping, coughing, or rapid head movement and is alleviated by reclining and/or sleep. Vertigo is usually present from the start, but there is no nystagmus or other evidence of vestibular damage (Penfield, 1927).

Impaired concentration and memory, easy fatigability, and irritability occur with remarkable uniformity in most patients with other post-traumatic symptoms, occasionally in the absence of vertigo or headache. Many such patients are unable to process information at a normal rate (Gronwall and Wrightson, 1974; Mandelberg and Brooks, 1975; Schacter and Crovitz, 1977) and also manifest impaired visual reaction times (Van Zomeren and Deelman, 1978). The anxiety generated by these difficulties and aggravated by doubting or nonsupportive physicians may result in hypochondriasis, depression, obsessional trends, and conversion reactions (Merskey and Woodforde, 1972). These secondary psychologic reactions arise independent of pending claims for compensation and resolve over a time course that does not appear to be altered when a financial settlement is made (Merskey and Woodforde, 1972; Kelly, 1975). In fact, McKinlay et al. (1983) assessed symptoms and cognitive abilities in two groups of patients with post-traumatic syndromes. One group was comprised of patients seeking financial compensation for their injuries, while the second group included patients who were not involved in any financial or legal activity related to their injuries. McKinlay et al. (1983) found no substantial differences in either symptoms or cognitive performance between the two groups.

There may be an interval between the apparent recovery of the patient and the onset of the post-traumatic headaches as we have personally observed. The diagnosis of post-traumatic headache is made with some confidence when there is definite proof of trauma in the form of evidence of a fracture or the presence of focal signs, but in many cases there is no such evidence. It is always necessary to establish the onset of the headaches as occurring after the accident. In children, there is no idea of receiving compensation for the accident, but parents are likely to exaggerate the severity of the accident in their child. In adults, a desire for compensation must always be considered, and the general emotional state of the patient must be assessed. The diagnosis, therefore, is mainly one of exclusion.

Children who sustain head injuries and develop post-traumatic symptoms respond differently from adults. Hyperkinesia, poor anger control, impaired attention, and enuresis are the dominant symptoms, with actual headache being less severe and vertigo being rare (Dillon and Leopold, 1961; Black et al., 1969).

Post-traumatic headaches are a regular feature of the post-traumatic or post concussion syndrome which follows significant head injury. The syndrome is not necessarily associated with definable central nervous system injury and can occur whether or not unconsciousness occurred at the time of trauma (Raskin,1988). The syndrome is characterized by headache, vertigo, impairment of memory and concentration, and variable degrees of emotional impairment. Headache lasting more than two months occurs in up to 60 percent of patients hospitalized following head injury (Jakobsen et al.,1987). The degree of apparent disability may seem to outweigh the amount of objective evidence of central nervous system or musculoskeletal injury. Some believe that persistent symptoms relate to the patient's desire to seek compensation, but most believe that this occurs only in a small percent. There is evidence that an organic mechanism is operative in a large proportion of these patients (Raskin,1988; Leblanc 1987).
The headache in post-concussional states usually occurs within a day of the injury but may be delayed for weeks. It is characterized by a dull, aching, generalized discomfort with localized exacerbation in bifrontal, bioccipital or bitemporal locations which may last for hours. The headache tends to be on a daily basis, but may be periodic and throbbing, quite characteristic of migraine. The usual course is one of gradual improvement in all symptoms when there is not severe organic impairment, but the headache may persist for many months.

Both common and classic migraine may have a significant exacerbation following closed head injury; uncommonly typical migraine attacks may follow injury in a previously headache free individual. The incidence of post-traumatic migraine is higher in people with a strong family history of migraine headache.

 

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