LOS ANGELES—Headaches are common after traumatic brain injury (TBI) and, perhaps counterintuitively, they are more common after mild TBI than after moderate to severe TBI. At the 54th Annual Scientific Meeting of the American Headache Society, Sylvia Lucas, MD, PhD, reported that she and her research collaborators found a higher prevalence of headache among a cohort of patients with mild TBI than among patients with moderate to severe TBI.
The prevalence of headache at all levels of severity of TBI remained high over one year postinjury, and the majority of those headaches met International Classification of Headache Disorders, Second Edition (ICHD-2), criteria for migraine or probable migraine.
Persons with a history of headache prior to injury and women had a higher risk for developing post-traumatic headache.
“These findings should caution us not to underestimate seemingly milder head injuries and to take all brain trauma seriously,” Dr. Lucas said.
Mild Versus Moderate to Severe TBI
Dr. Lucas, who is a Clinical Professor of Neurology at the University of Washington in Seattle, and colleagues enrolled two cohorts of patients with TBI and prospectively studied them for one year. The group with mild TBI included 220 individuals who were enrolled from a single site within one week of injury. The group with moderate to severe TBI included 378 individuals who were enrolled from seven TBI Model System Centers and were admitted for inpatient rehabilitation. Both cohorts were evaluated at three, six, and 12 months postinjury.
The two groups had similar demographics. They were primarily male (76% in the mild TBI group and 71% in the moderate to severe TBI group), white (75% in both groups), with similar average ages (44 versus 43 years). Injury was primarily due to motor vehicle accidents (60% versus 56%). In both groups 17% of individuals reported preinjury headaches.
In the mild TBI group, new or worse headache prevalence increased postinjury and remained high for one year, with 56% reporting headache soon after injury, 63% at three months, 69% at six months, and 58% at 12 months. In the moderate to severe TBI group, 37% reported headache at three months, 33% at six months, and 34% at 12 months. For those headaches that were ICHD-2 classifiable, migraine or probable migraine was the most common phenotype at all time points over one year in both groups.
Improving Treatment Is the Goal
In the civilian population, post-traumatic headache is common following a motor vehicle accident. It is also the salient physical symptom after blast exposure in the military population.
“We feel that the ICHD-2 criteria in both the civilian and military population really don’t help contribute to treatment planning, and they also don’t account for the latency of post-traumatic headache following trauma,” Dr. Lucas said. “Using symptom-based criteria for headache after TBI may hopefully serve as the framework to provide evidence-based treatment.”
—Glenn S. Williams
Hoffman JM, Lucas S, Dikmen S, et al. Natural history of headache after traumatic brain injury. J Neurotrauma. 2011;28(9):1719-1725.
Lucas S, Hoffman JM, Bell KR, et al. Characterization of headache after traumatic brain injury. Cephalalgia. 2012;32(8):600-606.
Patil VK, St Andre JR, Crisan E, et al. Prevalence and treatment of headaches in veterans with mild traumatic brain injury. Headache. 2011;51(7):1112-1121.