Symptoms Following MTBI: Part II

Post-traumatic Headaches (PTHA)

Post-traumatic headaches are probably the most common pain symptom in MTBI. Headaches usually occur within the first 14 days of an MTBI. The source of most headaches following MTBI originate from structures external to the brain and skull such as the muscles and ligaments attached to the skull, spine, and shoulder.

Fear of movement (kinesophobia) is an unreasonable fear of pain or re-injury upon movement. A neuropsychologist can quickly screen for kinesophobia using the K-scale on the Multiaxial Pain Inventory (MPI). Cogniphobia, the fear that thinking will produce pain can also be assessed using the MPI C-scale.

Types of Headaches

Tension headaches are felt as a dull aching pain, which can be either chronic or episodic. Emotional tension and stress are contributors. A common combination of tension and muscular, or migraine-type, headaches may occur. Treatment should involve physical therapy and relaxation techniques.

Post-traumatic migraine headaches may come from a genetic predisposition that is triggered by the MTBI. The majority of migraine-type headaches are dramatically reduced with medications such as propanolol, amitriptyline, or verapamil.

TMJ Syndrome can originate from stretched and/or torn ligament structures of the jaw joint. The mastoid and the temporalis muscles are typically tender and painful, producing a clicking or popping sound of the jaw when the mouth is opened. Dental management is recommended with possible treatment by a physical therapist.

Whiplash injuries involve neck hyperflexion and extension and often a rotational injury. Most whiplash-related headaches are tension-type pain, associated with cervical muscle injury, occipital neuralgia, or TMJ syndrome. Whiplash can also be the cause of diffuse axonal injury (DAI) without the head ever being struck. Treatment should include physical therapy and relaxation techniques.

Occipital neuralgia is pain along the occipital nerves at the back of the head. Compression of these nerves may cause a continuous ache and throbbing pain in suboccipital region and over parts of the scalp. Injecting an occipital block may temporarily ease the pain or headache.

Analgesic rebound headaches are caused by overuse of narcotics, simple analgesics, or migraine-specific agents (e.g., ergotamines, narcotics, and a combination of analgesics with barbiturates, sedatives, and/or caffeine)--many of which are sold over-the-counter. Post-trauma headaches can lead to chronic headaches when the individual becomes dependent upon medication aimed at the symptoms rather than the cause of the headache. Chronic use of medication can also cause headaches to be resistant to drugs.

Assessment

Assessment of post-traumatic headaches should include information about (a) onset, (b) location of pain, (c) how often and how long the headache pain occurs, and (d) what factors make it worse or better. An examination for muscle tension should be performed on the head and neck.

Estimates indicate that persistence of post-trauma headache for six months are as high as 44%. Chronic headache pain poses a liability to overall post-injury recovery. These headaches are frequently associated with decreases in, or avoidance of, activity, preventing a return to normal functioning. This can produce a self-perpetuating disability by reinforcing avoidance and inactivity.

Treatment

Post-traumatic headaches have typically been found to be resistant to traditional headache treatment with medication alone. Certain pain-coping strategies must be addressed with this type of headache. Treatment should target not only the physical pain but also the person's reaction to pain in daily life. Supportive treatment should include short-term use of medication, conventional physical therapy, and psychotherapy for the development of coping techniques. This approach is usually quite beneficial.

Counseling sessions should include gradual exposure to the cause of the anxiety, cognitive reinterpretation, and systematic desensitization. "Habit reversal" involves detection, interruption, and reversal of maladaptive habits. These include jaw clenching/tension, head posture, and negative cognition or thinking. Awareness training and deep breathing exercises are also beneficial.

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