Post-Traumatic Headache

What post-traumatic headache is

Under the International Classification of Headache Disorders (ICHD-3), a headache is classed as post-traumatic when it begins within 7 days of:

• the head injury, or
• regaining consciousness, or
• stopping medicines that prevented the person from feeling or reporting pain

It is called acute if it resolves within 3 months, and persistent if it lasts longer. Paradoxically, post-traumatic headache is more common and often longer-lasting after mild injuries than severe ones.

Symptoms and patterns

Post-traumatic headache does not have a single pattern. Common types:

Other concussion symptoms often occur alongside: dizziness, fatigue, poor concentration, memory problems, sleep disturbance, irritability and light sensitivity. When these persist, they are called post-concussion syndrome.

Causes and risk factors

After a concussion, chemical and blood flow changes in the brain, inflammation, and stretched nerve fibers can trigger headache pathways. Neck injury from whiplash adds a muscle and joint component.

Risk factors for longer-lasting headache:

• previous migraine or other headache disorders
• female sex
• previous concussions
• anxiety, depression or PTSD
• poor sleep after injury
• overuse of pain relievers

Red flags: bleeding in the brain

A headache after head injury can rarely be the first sign of bleeding, such as a subdural hemorrhage, which can develop hours to weeks after even a minor injury, especially in older adults and people on blood thinners. Seek emergency care for any red flag symptom in the triage box above. A CT scan is used to check for bleeding.

Diagnosis

Diagnosis is based on the history: a headache that began within 7 days of the injury. Your doctor will:

• examine your nervous system and neck
• review medicines and how often you take pain relievers
• check sleep, mood and other concussion symptoms
• order a CT or MRI if there are red flags, worsening symptoms or unusual features

Treatment

In the first days

• rest for 24 to 48 hours, then gradually return to normal activities as tolerated; total rest for longer slows recovery
• light aerobic exercise, such as walking, once symptoms allow, as advised by your clinician
• limit screens if they worsen symptoms, but avoid complete isolation
• regular sleep schedule, hydration and meals

Pain relief

• acetaminophen (paracetamol) or ibuprofen, following the label dose
• avoid aspirin and NSAIDs immediately after a significant head injury until bleeding is ruled out, as advised by a clinician
• limit simple pain relievers to fewer than 15 days a month, and triptans or combination medicines to fewer than 10 days a month, to prevent medication-overuse headache

Treating by headache type

• migraine-like: triptans and other migraine acute treatments; see migraine
• tension-type: see tension headache
• neck-related: physical therapy, posture and neck exercises
• occipital neuralgia: nerve blocks

Prevention of frequent headaches

For headaches on many days or lasting beyond a few weeks:

• preventive medicines such as amitriptyline, nortriptyline, propranolol or topiramate
• CGRP-targeting treatments in some migraine-like cases
• treat insomnia, anxiety and depression
• cognitive behavioral therapy and biofeedback
• graded return to work, school and sport

Outlook

Most post-traumatic headaches improve within days to weeks, and the majority resolve within 3 months. A minority become persistent, especially in people with prior migraine or medication overuse. Even persistent headaches often improve with a combined treatment plan.

Frequently asked questions

How long does a post-traumatic headache last?

Most post-traumatic headaches improve within a few weeks, and the majority resolve within 3 months. Headaches lasting more than 3 months are called persistent post-traumatic headache and benefit from specialist treatment.

When should I worry about a headache after hitting my head?

Seek emergency care if the headache keeps getting worse, or comes with repeated vomiting, confusion, drowsiness, slurred speech, weakness, a seizure, unequal pupils or clear fluid from the nose or ears. These can signal bleeding in the brain.

What helps post-concussion headaches?

Short rest followed by gradual return to activity, regular sleep, hydration and limited use of acetaminophen or ibuprofen help. Migraine-type headaches may respond to migraine medicines. Physical therapy helps neck-related headaches. Preventive medicines are used for frequent headaches.

Can taking too many painkillers make post-traumatic headache worse?

Yes. Using pain relievers on many days each month can cause medication-overuse headache, a daily headache that persists until the overuse stops. Limit simple pain relievers to fewer than 15 days a month and triptans to fewer than 10.

Can a headache start days after a head injury?

Yes. Post-traumatic headache can begin up to 7 days after the injury. A headache that appears or worsens days to weeks later, especially in older adults or people on blood thinners, should be checked for a slowly developing bleed.