Wednesday, January 9, 2019

Wisdom Wednesday: Headaches Attributed to Trauma to the Head or Neck

Headache attributed to trauma or injury to the head and/or neck are among the most common secondary headache disorders. During the first 3 months from onset they are considered acute; if they continue beyond that period they are designated persistent. This time period is consistent with ICHD-II diagnostic criteria, although the term persistent has been adopted in place of chronic.

There are no specific headache features known to distinguish the Headache attributed to trauma or injury to the head and/or neck from other headache disorders; most often these resemble Tension-type headache or Migraine. Consequently their diagnosis is largely dependent upon the close temporal relation between the trauma or injury and headache onset. Consistently the diagnostic criteria of ICHD-3 for all types of Headache attributed to trauma or injury to the head and/or neck require that headache must be reported to have developed within 7 days following trauma or injury, or within 7 days after regaining consciousness and/or within 7 days after recovering the ability to sense and report pain. Although this 7-day interval is somewhat arbitrary, and some experts argue that headache may develop after a longer interval in a minority of patients, there is not enough evidence at this time to change this requirement.

Headache may occur as an isolated symptom following trauma or injury or as one of a constellation of symptoms, commonly including dizziness, fatigue, reduced ability to concentrate, psychomotor slowing, mild memory problems, insomnia, anxiety, personality changes and irritability. When several of these symptoms follow head injury, the patient may be considered to have a post-concussion syndrome.

The pathogenesis of Headache attributed to trauma or injury to the head and/or neck is often unclear. Numerous factors that may contribute to its development include, but are not limited to, axonal injury, alterations in cerebral metabolism, neuroinflammation, alterations in cerebral haemodynamics, underlying genetic predisposition, psychopathology and a patient’s expectations of developing headache after head injury. Recent research, using advanced neuroimaging modalities, suggests a potential for detecting brain structural, functional and metabolic abnormalities following minor trauma that are not detectable through conventional diagnostic tests. Post-traumatic sleep disturbances, mood disturbances and psychosocial and other stressors can plausibly influence the development and perpetuation of headache. The overuse of abortive headache medications may contribute to the persistence of headache after head injury through the development of Medication-overuse headache. Clinicians must consider this possibility whenever a post-traumatic headache persists beyond the initial post-trauma phase.

Risk factors for the development of Headache attributed to trauma or injury to the head and/or neck may include a previous history of headache, less severe injury, female gender and the presence of comorbid psychiatric disorders. The association between repetitive head trauma and the development of headache should be investigated further. The degree to which a patient’s expectation of headache following head injury and litigation regarding such headache promote its development and persistence is still widely debated. The majority of evidence suggests that malingering is a factor in only a small minority of patients.

It is recognized that some patients develop headache following very minor trauma to the head – so minor that it does not meet criteria even for mild traumatic brain injury. These headaches may begin after a single trauma or following repetitive minor head impacts (eg, in players of American football or rugby). However, headache due to very minor head trauma has not been adequately studied, so there are insufficient data to support its recognition and inclusion in ICHD-3.

My Take:
Automobile accidents are the most common cause of these headaches. Often the headaches do not begin until after the acute inflammation in the neck has subsided. So I expand that 7 day criteria to a maximum of 14 days.

I prefer not to treat auto accident cases as the level of fraud is so high, especially here in South Florida. However, if one of my patients is involved in a motor vehicle accident, I will treat them.

Bottom Line:
If you suffer head or neck trauma you should be evaluated at a hospital emergency room as soon as possible. If you develop headaches following the trauma, consult with a chiropractor that practices functional neurology. Untreated, you could develop chronic pain syndrome, the topic of next weeks’ Wisdom Wednesday.

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