Post-traumatic headache.

Abstract

The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to the International Headache Society (IHS) classification. The objective of this study was to evaluate the several forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39%) and 14 (34.1%) patients respectively. The time interval between HI and the onset of headache was less than seven days in 20 patients (48.7%) and longer than 30 days in 10 (24.3%) patients. The results suggest that PTC may arise after a period longer than is accepted at the present by the IHS.

Full text

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Arq Neuropsiquiatr 2009;67(1):43-45
43
Post-traumatic headache
Hugo André de Lima Martins1, Valdenilson Ribeiro Ribas2, Bianca Bastos Mazullo Martins3,
Renata de Melo Guerra Ribas4, Marcelo Moraes Valença5
Abstract – The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to
the International Headache Society (IHS) classification. The objective of this study was to evaluate the several
forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset
of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura
and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39%) and 14 (34.1%)
patients respectively. The time interval between HI and the onset of headache was less than seven days in 20
patients (48.7%) and longer than 30 days in 10 (24.3%) patients. The results suggest that PTC may arise after a
period longer than is accepted at the present by the IHS.
KEY WORDS: headache, post-traumatic headache.
cefaléia após traumatismo cranioencefálico
Resumo – O início da cefaléia pós-traumática (CPT) ocorre dentro de sete dias após o trauma, de acordo com
a classificação da Sociedade Internacional de Cefaléia (SIC). O objetivo deste estudo foi avaliar as diversas
formas de cefaléia que surgem após o traumatismo cranioencefálico (TCE) leve e o intervalo de tempo entre o
TCE e o início da dor. Foram avaliados 41 pacientes com diagnóstico de cefaléia pós-traumática leve segundo os
critérios da SIC. Migrânea sem aura e cefaléia do tipo tensional crônica foram os tipos de cefaléia mais comuns,
ocorrendo em 16 (39%) e 14 (34,1%) dos pacientes respectivamente. O intervalo de tempo entre o TCE e o início
da cefaléia foi menor que sete dias em 20 pacientes (48%) e maior que 30 dias em 10 (24,3%) pacientes. Estes
resultados sugerem que a CPT pode surgir após período maior do que é aceito atualmente pela SIC.
PALAVRAS-CHAVE: cefaléia, traumatismo cranioencefálico.
Pós Graduação em Neuropsiquiatria e Ciências do Comportamento, Universidade Federal de Pernambuco, Recife PE, Brazil (UFPE): 1Mestre em Neuro-
logia; 2Mestre em Neurociências; 3Graduada em Psicologia, Universidade Católica de Pernambuco; 4Graduanda em Nutrição, Pós Graduanda em Gestão
de Qualidade e Vigilância Sanitária em Alimentos; 5Doutor em Fisiologia Geral da Universidade de São Paulo, Professor Associado de Neurologia e
Neurocirurgia da UFPE.
Received 10 June 2008, received in final form 3 October 2008. Accepted 14 November 2008.
Dr. Valdenilson Ribeiro Ribas – Avenida Armindo Moura 581 / Quadra D / Bloco 02 / Ap 201 / Conjunto WXL - 51130-180 Recife PE - Brasil.
E-mail: ribaspsy@ufpe.br
Post-traumatic headache (PTH) is usually one of sev-
eral symptoms of the post-traumatic syndrome1-3. There-
fore, may be accompanied by somatic, psychological or
cognitive disturbances4-6. The etiology of these symptoms
in individuals with mild traumatic brain injury or whiplash
injury has been a subject of some controversy with expla-
nations ranging from neural damage to malingering7. The
PTH can resemble a tension-type headache, migrainous or
cervicogenic headaches7. The pathogenesis of PTH is still
not well-known but might share some common headache
pathways with primary headaches2. The problem, con-
versely, arises in PTH after a light trauma, since it is diffi-
cult to establish the cause-effect link8. There seems to be
an inverse relation between the severity of the head trau-
ma and the occurrence of a PTH, especially the chronic
type9. Psychological factors are believed to play a role in
the cause, maintenance and relief of chronic PTH.
The evaluation of the person with post-traumat-
ic headache remains a difficult clinical task10. Although
most cases of PTH are resolved within 6 to 12 months,
many patients have protracted or even permanent head-
ache11. Because PTH usually has no objective findings, it is
often controversial whether the symptom is “real,” “psy-
chogenic,” or “fabricated”11. Although the IHS criteria stip-
ulate that PTH should have an onset within one week of
the trauma, it has been observed that a headache linked
to the trauma can start later9.
The objective of this study is to characterize the head-
aches that arise after mild head injury (HI), and to evaluate
the time interval between the HI and the headache onset.

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Arq Neuropsiquiatr 2009;67(1)
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Post-traumatic headache
Martins et al.
method
This was a prospective study of patients seen in the Head-
ache Clinic of Pernambuco Federal University from 2004 to
2006. Ninety-five patients after mild HI were assessed. Fifty-four
of these patients were excluded due to the presence of head-
ache prior to the HI, inadequate information related to the onset
of headache or absence of headache complaint after HI. Of the
remaining 41 patients, 22 men and 19 women all met the criteria
to the mild HI according to the International Headache Society
(IHS) guidelines: HI with loss of consciousness less than 30 min-
utes or its absence, and the Glasgow scale superior to 13.
All patients presented the neurological exam normal and no
complementary exam was realized.
It was performed an initial assessment of all patients, in
which it was questioned the main features of headache like: lo-
cation of pain, duration, precipitant factors, installation way and
associated symptoms, being included in the group of migraine,
tension-type headache or cluster headache.
After the first interview, each patient included in this study
was assessed once for each thirty days, during six months, to
appreciate the headache’s evolution. It was also researched the
time interval between the HI and the headache onset, being
all patients divided into four groups according to the following
criterion: headache beginning up to 7 days, 7 to 14 days, 14 to
28 days, and over 30 days after the HI. The study was aproved
by the Local Ethics Committee and all patients signed an in-
formed consent.
resuLts
Forty-one patients with mild HI who had attended the
neurology clinic from 2004 to 2006 were assessed. Fig-
ure 1 demonstrates the distribution of data for each type
of headache after the HI. The migraine without aura and
the chronic tension-type headache were the most prev-
alent groups, occurring in 16 (39%) and 14 (34.1%) patients
respectively, whereas the episodic cluster headache oc-
curred in only one patient (2.4%).
The interval of time between the HI and the onset of
headache is shown in Figure 2.
The onset of PTH occurred in the first seven days after
the HI in 20 (48.7%) patients, whereas 10 (24.3%) patients
presented the onset of headache beyond thirty days of HI.
discussioN
Post-traumatic headache is a general term for pain lo-
calized in the head or neck, occurring after head trauma
and varied etiology and pathogenesis12,15. In many cases
one only finds a time-dependent relation to trauma, but
no causal one. There is no uniform, typical “post-traumat-
ic headache”. The headaches are commonly caused by in-
jury to scalp, cervical spine and intracranial structures15-18.
It is usually difficult to decide whether the post-traumatic
headache is exclusively caused by organic or psychogenic
factors. Probably both factors are involved to an individu-
ally different degree12,19,20.
In the some authors view, genuine chronic PTH exists
only in very rare cases and is always associated with con-
siderable organic intracranial lesions13.
There has been relatively little information dealing
with the characteristics of the headache in the post-trau-
ma syndrome14. The data suggested that the majority of
Fig 1. Characteristics of post-traumatic headache.

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Arq Neuropsiquiatr 2009;67(1)
45
Post-traumatic headache
Martins et al.
patients in the present study had headaches that could be
classified by the IHS criteria as episodic or chronic ten-
sion-type headache or intermittent migraine.
In this paper, the most common PTH, were migraine
without aura and chronic tension-type headache. In a study
that assessed 27 patients relating mild HI and chronic head-
ache, these types of headaches were more prevalent too15.
By definition, the headache that develops within one
week after head trauma (or within one week after regain-
ing consciousness) is referred to as PTH16. In the first edi-
tion of the IHS classification, the time interval between
trauma and headache beginning was 14 days, reducing to
one week in the last edition. In this paper, a quarter of the
patients had symptoms only after thirty days of HI.
Although sensitive fibers imprisonment in lesion point
and anomalous regeneration is common in local head-
ache, it may be a part of the explanation for the later
beginning of other types of headache like migraine and
tension type headache.
Some authors believe that PTH is a brain dysfunction
manifestation aggravated by muscle skeletal injury. Acute
headache may be provoked by lesion of the scalp tissue.
Stimulus in muscle skeletal tissue may provoke neuroplas-
tic alteration in the neuron of caudalis trigeminal nucleus,
promoting wind up and sensibilization phenomenon. With
continuous stimulus, there is an increased sensitiveness
of dorsal corner neuron, provoking an increase of spon-
taneous activity, reduced threshold of pain and altered
processing of afferent stimulus which can explain in part
the source and maintenance of PTH12,17.
Trauma event and headache start, must be correlate in
time, but as the exact mechanism of start and maintenance
of PTH is not known, this time interval must be continuous-
ly discussed with the aim of framing the largest number of
patients in these criteria, allowing a reasonable treatment.
reFereNces
1. O’Bryant SE, Marcus DA, Rains JC, Penzien DB. The neuropsychology
of recurrent headache. Headache 2006; 46:1364-1376.
2. Pascual-Lozano AM, Salvador-Aliaga A, Lainez-Andres JM. [Posttrau-
matic headache. Pathophysiology, clinical, diagnostic and therapeutic
aspects]. Neurologia 2005; 20:133-142.
3. Martelli MF, Grayson RL, Zasler ND. Posttraumatic headache: neu-
ropsychological and psychological effects and treatment implications.
J Head Trauma Rehabil 1999; 14:49-69.
4. Goldstein J. Posttraumatic headache and the postconcussion syndrome.
Med Clin N Am 1991; 75:641-651.
5. Packard RC, Weaver R, Ham LP. Cognitive symptoms in patients with
posttraumatic headache. Headache 1993; 33:365-368.
?6.? Lyczak?P,?Lyczak-Rucińska?M.?Chronic?post-traumatic?headache?and?
brain perfusion changes assessed using magnetic resonance imaging.
Neurol Neurochir Pol 2005; 39:49-54.
7. Gurr B, Coetzer BR. The effectiveness of cognitive-behavioural thera-
py for post-traumatic headaches. Brain Inj 2005; 19:481-491.
8. Moscato D, Peracchi MI, Mazzotta G, Savi L, Battistella PA.Post-trau-
matic headache from moderate head injury. J Headache Pain 2005;
6:284-286.
9. Lenaerts ME, Couch JR. Posttraumatic headache. Curr Treat Options
Neurol 2004;6:507-517.
10. Zafonte RD, Horn LJ. Clinical assessment of posttraumatic headaches.
J Head Trauma Rehabil 1999;14:22-23.
11. Packard RC. Posttraumatic headache. Semin Neurol 1994;14:40-45.
12. Wessely PHF. On the problem of post-traumatic headache. Wien Klin
Wochenschr 1987; 99:549-554.
13. Scherzer EB. [On the so-called posttraumatic headache (author’s
transl)]. Fortschr Neurol Psychiatr Grenzgeb 1975; 43:271-283.
14. Couch J. Chronic Daily headache in the posttrauma syndrome: relation
to extent of head injury. Headache 2001; 41:559-564.
15. Souza JA, Moreira PF, Jevoux CC. Cefaléia pós-traumática crônica em trau-
matismos crânio-encefálicos leves. Arq Neuropsiquiatr 1999;57:243-248.
16. Lew PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and
treatment of headache after traumatic brain injury: a focused review.
Am J Phys Med Rehabil 2006; 85:619-627.
17. Speciali JG, Farias da Silva W. Cefaléias. São Paulo: Lemos Ed; 2002.
18. Marcus DA. Disability and chronic posttraumatic headache. Headache
2003; 43:117-121.
19. Tatrow K, Blanchard EB, Hickling EJ, Silverman DJ. Posttraumatic head-
ache: biopsychosocial comparisons with multiple control groups. Head-
ache 2003; 43:755-766.
20. Solomon SMD. Chronic post-traumatic neck and head pain. Headache
2005;45:53-67.
Fig 2. Time interval between trauma and headache onset.