Post Traumatic Headache (PTH)

Timothy C. Hain, MD • Page last modified: August 20, 2020

You may also be interested in our many pages on headache on this site (migraine is the biggest cause of headache).

Definition: Post-traumatic headache means that the head hurts after "trauma", which means an injury. This is vague. We will here use a tighter definition where the "trauma" has to be directly to the head.

PTH is generally managed similarly to migraine. Lane et al (2019) suggested that PTH was generally a trauma induced migraine. Shaw et al. suggested that the pattern in children and adolescents also fit migraine (2018)

Treatment of PTH:

Conditi reviewed the treatment of PTH. In 2017, he stated that "no large placebo-controlled studies on the treatment of PTH exist". He also stated that "most PTH meets the International Headache Society criteria for migraine or probable migraine". Thus conventional migraine treatment is generally attempted. Obvious exceptions might be headaches due to TMJ injury, or injuries to the occipital nerve resulting in occipital neuralgia.

He stated that small studies of "abortives" have documented various treatments including ergots, sumatriptan, topical ketoprofen, and indomethacin have all been shown to be successful. Some of these drugs are narrow migraine drugs (e.g. sumatriptan). According to Conditi (2017), NSAID type medications such as indocmethacin should not be taken in the first 3 days, because of the risk of delayed bleeds. Friedman et al (2018) suggested that "IV metoclopramide 20mg+diphenhydramine 25mg is an effective and well-tolerated medication regimen for patients presenting to the ED with acute post-traumatic headache, though 1/3 of patients report headache relapse after ED discharge and 1/4 of patients report persistent headaches one week later."

Preventative drugs that were reviewed, include valproic acid, amitriptyline, propranolol, topiramate. These again are all migraine drugs. Again, there was somewhat variable results, with topiramate doing well. Conditi opines (2017) that the best option may be tricyclic antidepressants, although he mentions that amitriptyline should be avoided because of anticholinergic effects that can worsen cognitive symptoms. He also suggested that antiepileptic medications (e.g. topiramate, depakote, others), should generally be avoided because of sedation and worsening of cognition. He felt that topirimate in particular should be avoided. He suggested that zonisimide was the best option.

Nerve blocks may be considered of the occipital nerves, various other nerves in the head, and sphenopalatine ganglion. In our opinion, only occipital nerve blocks are reasonable. Steroids should not be used in the forehead blocks because of the danager of cosmetic side effects. Nerve blocks are usually not covered by insurance.

Botulinum toxin may be appropriate treatment for those who have chronic PTH. This is again following along the lines of migraine treatment.

Concerning psychotherapy, according to Fraser et al, (2017), "Therefore, future research, which considers the noted biopsychosocial factors, is needed in the field to determine if these interventions reduce PTH.". It seems that the proof is not there that these help. Kjeldgaard stated "The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms." Again, does not seem very effective.

Concerning physical therapy for PTH, it does not appear to be better than "standard therapy" (Obermann et al, 2015).

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