The June 9, 1998 meeting of the East Bay Headache Support Group was held in the Ball Auditorium at John Muir Medical Center with 18 people in attendance. Jeffrey Klingman, M.D., head of the Neurology Department at Kaiser Permanente in Walnut Creek, spoke to the support group about headaches as a result of head injury.

Post-traumatic headache is the term used for a headache that is experienced after a head injury. It is a relatively common problem, and actually an enormous problem. 1.4 million people sustain a serious head injury each year, and 40 to 60 percent of those people suffer from persistent headaches for more than two months after the injury.

A concussion is a syndrome after head injury. It usually clears up on its own, but it can take awhile. 40 to 60% of people with concussions complain of headache, and it is very common to suffer from dizziness, irritability, and to experience difficulty in concentrating. Also, some report alcohol intolerance.

The headache component is more amenable to treatment than the other symptoms, such as difficulty concentrating and dizziness.

Remember, eventually the concussion improves on its own.

The post-concussion headache is seen more frequently in less severe head injuries. It usually begins within 24 hours, but in 5 to 7% of head injuries, the headache may take days or weeks to start.

The headache is usually (75% of the time) similar to tension-type headache.

45% are bi-frontal, bi-occipital, bi-temporal.

35% are generalized headaches (over the whole head).

20% are unilateral headaches (on one side of the head).

The cause of the post-concussion headache is unknown—perhaps it is caused by altered cerebral blood flow as one study suggested. Also, biochemical alterations may be similar to migraine.

The headache usually resolves (goes away) in 6 to 12 months. Statistics show:

• In 10% of those with post-concussion headache, the headache goes away in less than 30 days.

• In 70%, the headache goes away in less than 1 year.

• In 80%, the headache goes away in less than 2 years.

• In 85%, the headache goes away in less than 3 years.

However, that means that 15% of patients with post-concussion headache are still suffering with head pain more than 3 years after their injury.

Dr. Klingman said that most of the time a post-concussion headache will go away on its own.

About 75% of post-concussion headaches are described as tension-type headaches. They are chronic, nagging daily headaches. They often originate occipitally or bi-temporally, and the pain is worse with head movement. Dr. Klingman emphasized that a tension headache is not caused by emotional stress, but muscle tension.

Treatment options for tension-type headaches include:

Non-medication approaches:

• Massage

• Neck traction

• Neck pillow

• "Tincture of time"

Treatment with medication:

• Tricyclic antidepressants, such as Amitryptilene and Nortryptilene (Dr. Klingman prefers Nortryptilene)

• Propranolol

• Indomethacin (an anti-inflammatory)

• Valproate (Dr. Klingman said to use this medication with caution as it can cause rebound headaches).

Often when one experiences a head injury the neck is injured as well. Dr. Klingman said that it is good to have the neck x-rayed to look for possible injury. A neck injury is suspected when there is significant neck pain, cervical tenderness, or pain with neck range of motion.

Neck muscle spasm.

Generally a cervical MRI (magnetic resonance imaging) is not helpful in diagnosing a neck injury. The MRI is used to look for a pinched nerve.

Treatment options for cervicogenic headache:

• Medications:

Tricyclic antidepressants

Muscle relaxants

Anti-inflammatories

• Physical therapy

• "Tincture of time"

75% of post-concussion headaches have symptoms similar to tension-type headaches, but the rest are more like migraine. Patients generally exhibit migraines without aura, but migraine with aura may be present as well. Patients report throbbing, severe, and often unilateral pain, and nausea. Also, their migraine headaches may be more persistent than the tension-type headaches, i.e., they may continue to plague the patient longer than 6 to 12 months.

Treatment includes:

Medications—symptomatic or abortive (to relieve the pain):

• Triptans (Imitrex, etc.)

• Ergots (Cafergot)

• Isocom (Midrin)

• Butalbital (Fiorinal)

Medications—prophylaxis (to prevent the migraine)

• Beta blockers

• Tricyclic antidepressants

• Calcium channel blockers

• Valproate

• Methysergide

The intracerebral hemorrhage usually doesn’t produce a severe headache. Neurological symptoms are nearly always also present. When an intracerebral hemorrhage is accompanied by a headache, the pain is often worse when the patient is recumbent (lying down). The patient also suffers from nausea, and the headache is usually worse in the morning.

After Dr. Klingman’s presentation, the audience was asked if they they had any questions.

Questions and Answers

Donna Johnson made the statement that we hear about football concussion, but don’t hear football players complain of headaches. Dr. Klingman said football players must experience headaches, however.

Q. "What do you think about chiropractors who treat head injury headaches?"

A. "No treatment is completely benign." One way to look at an alternative therapy, such as chiropractic, is that it is another treatment, but the patient needs to ask himself, "Does it meet a reasonableness test?" "How expensive is it?" "Is it harmful?" Dr. Klingman said that vigorous chiropractic manipulation can cause harm. He went on to say that there is not much literature or scientific data about the effectiveness of chiropractic treatment, but there is lots of marketing. A controlled clinical trial to give us scientific data is needed.

He said there are studies about chiropractic treatments for low back pain, but not for headaches. Dr. Klingman also said that he knows little about this subject.

Q. "Can you define head trauma for us?"

A. Dr. Klingman said that if a person experiences a blow to the head that makes him momentarily dazed or confused, but doesn’t necessarily cause him to lose consciousness, he has a concussion. And it is a significant concussion if he is knocked out. A key indicator is how long the person doesn’t remember the incident (post-traumatic amnesia).

A second head injury probably doesn’t cause a higher incidence of headaches.

Muhammad Ali had repeated head trauma from all those years as a boxer, and repeated head trauma can lead to Parkinson’s Disease (as Ali has), and even Alzheimer’s Disease.

Q.: "What about biofeedback as a therapy for head injury headaches?"

A. A member of the audience said that he was referred to Ellen Place for biofeedback therapy after two years of headaches that began after receiving a head injury in a rear-end auto accident. Kaiser automatically refers its head injury patients to biofeedback therapy because they have discovered that it helps head injury patients (but not just for headaches).