Headaches After Concussion: Advanced Page
Contents
Description of Treatment Categories
Headache Subtypes:
Symptoms | Biology | Treatments
Symptoms | Biology | Treatments
Symptoms | Biology | Treatments
Symptoms | Biology | Treatments
Symptoms | Biology | Treatments
Description of Treatment Categories
There are several broad categories of treatments. Non-pharmacological includes devices that help with headaches, any therapy, for example massage or acupuncture, and behavioral changes. The other two categories are over-the-counter medications (buy at the drugstore) and prescription medications and injections.
Note: patients who have multiple types of headaches and may need specialized treatment for each sub-type.
This page provides detailed information about various headache treatments and the pathophysiology of post-concussive headaches. For a broader overview of post-concussive headaches, please visit our Headaches page.
Migraine
Symptoms can include:
Head-throbbing pain
Pain on one side of the head
Hypersensitivity to light and sound
Nausea
Dizziness
Pain worsens with activity
Vomiting (uncommon)
The biology of migraine headaches
Diagram by Micah Jay Strike
Migraines are a common subtype of post-concussive headache. On the anatomical level, concussions cause a neuron’s axon to stretch or break, resulting in an imbalance of chemicals in the brain. This imbalance can signal neurons to depolarize (a cell’s energy charge becomes less negative/more positive) when they’re not supposed to. This leads to changes in the permeability of the blood-brain barrier, which can activate the trigeminal afferent nerve, which supplies the skin, mucous membranes, and sinuses of the face. If the depolarization reaches these neurons and the trigeminal nucleus caudalis (pain sensor areas of the outer region of the brain, see image below), it can create an inflammatory response, causing pain and headache. Neurons and pain sensitivity receptors also become more sensitive to pain and stimuli. This increased sensitivity explains why symptoms of migraines include nausea, dizziness, and hypersensitivity to light or sound. An individual’s genetic predisposition may also affect one’s pain levels following a migraine or trauma.
Treatments
Non-pharmacological (non-medication) and behavioral changes
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Cefaly is a nerve stimulator for acute and preventative treatment of migraine headaches. Cefaly sends tiny electrical impulses to the trigeminal nerve, which is heavily involved in migraine pain. This reduces the frequency and intensity of migraine attacks. To learn more about Cefaly, visit our blog post about Cefaly or Cefaly’s website.
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Heat packs are a therapeutic treatment most commonly applied to the head and neck. Therapeutic heat helps underlying muscles relax. To learn more about using a Heatpack, visit the National Headache Foundation.
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Because concussions can affect the entire body, physical therapists can utilize a wide variety of physical therapy techniques for post-concussion headaches and decrease recovery time. Furthermore, the various sub-specialties of physical therapy can treat patients differently based on their symptoms. One systematic review found evidence that physical therapy can benefit concussion recovery by performing exercises that alleviate post-concussion symptoms, including stretching, strength, and range of motion exercises.
Over the counter (OTC) medications
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Magnesium oxide (PO magnesium) is a supplement that treats migraines. PO magnesium is an over-the-counter supplement. Take PO magnesium at least 2 hours apart from other medications, and take it with food. Check with your healthcare provider that it will not interact with other medications you are taking. Evidence for the effectiveness of this treatment is demonstrated by this study and on page 89 of this document from the VA and DoD.
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Melatonin is a supplement that supports concussion recovery by addressing headaches, neuroinflammation, and mood changes. Researchers believe that it helps with neuroinflammation because of its similar characteristics to a central nervous system therapeutic. Characteristics such as low toxicity, ability to cross the blood-brain barrier, and melatonin receptors that bind it to the central nervous system. Although more research is needed, studies show a promising trend. This study demonstrates evidence for its effectiveness. You can read about melatonin on our self-care page.
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Prescription Pharmacological (medication)
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Erenumub is an anti-migraine medication that works by preventing the start of the migraine. Erenurub targets the receptors for calcitonin gene-related peptide, a small protein involved in pain transmission in sensory nerves; its levels increase during a migraine. This study demonstrates evidence for its effectiveness. It is also addressed in this Concussion Alliance newsletter.
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Botulinum Toxin, commonly called ‘Botox,’ is a prescription medication that treats migraines. The bacterium Clostridium botulinum produces the toxin that makes ‘Botox.’ Clostridium botulinum is commonly found in soil, plants, and soiled water. There are different brands of botulinum toxin. Specifically, dosages of Onabotulinum A helps treat chronic-type migraine headaches. Botulinum Toxin is injected into specific points around the head and neck to block the nerves so they produce less pain-inducing chemicals. Read more about it in this study.
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Topiramate is a medication that treats various types of post-concussive headaches. In a study, topiramate blocks neuronal firing in the trigeminocervical complex, preventing a migraine from happening. It reduces the easily excitable neurotransmitters while enhancing neurotransmitters that act as a calming agent. It also prevents nerves from sending rapid and repetitive signals. In a study conducted on patients, 10% of them reported cognitive complaints. Based on the numbers, topiramate does not cause cognitive impairment and doesn't reflect in cognitive functions.
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SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are medications that treat several conditions, including depression, PTSD symptoms, and migraines. They are important for managing mood change symptoms after a concussion..The link between serotonin and headaches is still unclear, but evidence suggests that low serotonin facilitates the activation of pain pathways that contribute to headaches. Read more about the evidence for their effectiveness here and here.
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Triptans are medications that are used as a preventative measure, taken at the onset of a migraine. Triptans work by stimulating an increase of serotonin in your brain, which can help stop migraines. Read more about the evidence for their effectiveness on page 30 of this document.
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Tricyclic antidepressants are medications that treat various types of post-concussive headaches. A type of tricyclic antidepressant, Amitriptyline, can also be used to treat insomnia. Tricyclic antidepressants are thought to preserve or increase neurotransmitters like serotonin, which helps treat migraines. Read more about the evidence for their effectiveness here and on page 89 of this source.
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Sphenopalatine Ganglion Block is a powerful method of reducing post-concussion headaches by blocking and reducing pain signals from nerves in the sphenopalatine ganglion and its neural connections. Different treatments include injections, transnasal, transoral, and Infrazygomatic Approach. Read more about these treatments in the National Library of Medicine.
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Propanal is known for treating repeated migraines. Usually used for heart problems, Proanal is a type of beta-blocker (a medication that lowers blood pressure). It stabilizes serotonin levels, preventing your blood vessels from widening. Read more about Propranolol on this page.
Cervicogenic headache
Symptoms can include:
Neck pain
Pain around the eye
Dizziness
Blurred vision
Balance problems
Poor concentration or memory
The biology of Cervicogenic headaches
Diagram by Micah Jay Strike
Neck trauma, whiplash, strain, or chronic spasms of the scalp, neck, or shoulder muscles can cause injury to the C1-C3 nerves in the cervical spine (neck). The pain could be referred pain, ( the pain originates in a different part of the body than it is felt). The cervical spine's superior three nerves (C1, C2, C3) are thought to be responsible for the pain experienced in cervicogenic headaches. Inflammation and neurotransmission through these injured nerves are thought to produce or exacerbate the pain of the headache. Any body part that the C1–C3 spinal nerves branch out to could be the source of pain for a cervicogenic headache. A primary example would be the shoulder area and the occipital area in the back of the skull, which have nerves connected to the C1-C3 spinal nerves.
Treatments
Non-pharmacological (non-medication) plus behavioral changes
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Cefaly is a nerve stimulator for acute and preventative treatment of migraine headaches. Cefaly sends tiny electrical impulses to the trigeminal nerve, which is heavily involved in migraine pain. This reduces the frequency and intensity of migraine attacks. To learn more about Cefaly, visit our blog post about Cefaly or Cefaly’s website.
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Manual therapy is a specialty of physical therapy that can help treat post-concussion headaches. It primarily involves the kneading and manipulation of muscles, joint mobilization, and joint manipulation. It often involves working on the biomechanical, tissue-based examination to determine the cause of post-concussion headaches.
Over the counter (OTC) medications
Prescription Pharmacological
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Tricyclic antidepressants are medications that treat various types of post-concussive headaches. A type of tricyclic antidepressant, Amitriptyline, can also be used to treat insomnia. Tricyclic antidepressants are thought to preserve or increase neurotransmitters like serotonin, which helps treat migraines. Read more about the evidence for their effectiveness here and on page 89 of this source.
Tension “Stress” headache
Symptoms can include:
Usually mild to moderate pain
Band-like pressure around the head or forehead
Joints in the jaw may be irritated, cramped or aching (could also be TMJ headache)
Usually NO nausea
Usually NO hypersensitivity to stimuli
The biology of Tension “Stress” headaches
Diagram by Micah Jay Strike
Tension headaches are the second most common type of post-concussive headache, behind migraines. Stress and mental tension may worsen a post-concussive tension headache, although the specific processes that contribute to this headache are still unclear. Studies have shown that emotional factors like stress, anxiety, and depression may also lead to the development of tension headaches.
It is currently believed that input from trigger points in inflamed or tender pericranial muscles causes pain pathways to be activated, causing headaches. Pericranial muscles are the outer bands of muscle surrounding the skull and neck, with trigger points often but not always starting from the third occipital nerve. This can result from changes in neurotransmitter concentrations, particularly serotonin by causing blood vessels to become dilated. An inadequate blood supply or disturbances in metabolism, capillaries, and mitochondria function in the tender areas may explain the pain.
In association with a concussion, injury to the neck or surrounding muscles of the face can produce conditions that are conducive to tension headaches.
Treatments
Non-pharmacological (non-medication) plus behavioral changes
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Dry needling is a physical treatment similar to acupuncture that treats various types of post-concussive headaches. According to the VA, dry needling is used for post-concussive headaches with “tension features.” It targets trigger points that cause the tension or pain of a headache. Read more from the VA here.
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Topiramate is a medication that treats various types of post-concussive headaches. In a study, topiramate blocks neuronal firing in the trigeminocervical complex, preventing a migraine from happening. It reduces the easily excitable neurotransmitters while enhancing neurotransmitters that act as a calming agent. It also prevents nerves from sending rapid and repetitive signals. In a study conducted on patients, 10% of them reported cognitive complaints. Based on the numbers, topiramate does not cause cognitive impairment and doesn't reflect in cognitive functions.
-
Botulinum Toxin, commonly called ‘Botox,’ is a prescription medication that treats migraines. The bacterium Clostridium botulinum produces the toxin that makes ‘Botox.’ Clostridium botulinum is commonly found in soil, plants, and soiled water. There are different brands of botulinum toxin. Specifically, dosages of Onabotulinum A helps treat chronic-type migraine headaches. Botulinum Toxin is injected into specific points around the head and neck to block the nerves so they produce less pain-inducing chemicals. Read more about it in this study.
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Tricyclic antidepressants are medications that treat various types of post-concussive headaches. A type of tricyclic antidepressant, Amitriptyline, can also be used to treat insomnia. Tricyclic antidepressants are thought to preserve or increase neurotransmitters like serotonin, which helps treat migraines. Read more about the evidence for their effectiveness here and on page 89 of this source.
Prescription Pharmacological
Neuritic and neuralgic headache
Symptoms can include:
Sharp, intense stabbing pain around the craniocervical junction (where the back of the head connects with the neck)
Tenderness or numbness upon touching the occipital region (back of the head)
Pain behind the eyes
Neck pain
The biology of neuritic and neuralgic headaches
Diagram by Micah Jay Strike
The occipital nerves sit at the back of your head. Injury or disruption to these nerves from a concussion can cause a painful condition called occipital neuralgia, which is one common type of neuralgic headache.
Furthermore, the sharp, shooting sensation in the occipital nerve area associated with neuralgic headaches can stem from a pinched or injured nerve in the cervical spine. Injury or inflammation to blood vessels in the brain or neck can also injure the nerves and cause shooting pain associated with neuralgic headaches.
Treatments
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Tricyclic antidepressants are medications that treat various types of post-concussive headaches. A type of tricyclic antidepressant, Amitriptyline, can also be used to treat insomnia. Tricyclic antidepressants are thought to preserve or increase neurotransmitters like serotonin, which helps treat migraines. Read more about the evidence for their effectiveness here and on page 89 of this source.
-
Sphenopalatine Ganglion Block is a powerful method of reducing post-concussion headaches by blocking and reducing pain signals from nerves in the sphenopalatine ganglion and its neural connections. Different treatments include injections, transnasal, transoral, and Infrazygomatic Approach. Read more about these treatments in the National Library of Medicine.
-
SNRIs (serotonin-norepinephrine reuptake inhibitors) are medications that treat several conditions, including depression, PTSD symptoms, and migraines. They are important for managing mood change symptoms after a concussion.
Prescription Pharmacological
TMJ Headache
Symptoms can include:
Jaw pain
Restricted jaw movement
Clicking when jaw opens
Tight facial or jaw muscles
Earache
The biology of TMJ headaches
Diagram by Micah Jay Strike
A blow to the jaw or a whiplash injury during a concussive event can result in a TMJ headache. Inflammation in the temporomandibular joint (TMJ) can spread to nearby muscles and joints in the jaw, creating a painful sensation and muscle tightness that translates into a headache. However, the correlation between pain and injured tissues is often not obvious; not all patients have a clearly identifiable physical condition.
MRI studies in TMD (temporomandibular disorders) have provided evidence for changes within the pain stimulus pathway involving different parts of the brain like the trigeminal nerve root, subnucleus caudalis (SpVc), and thalamus. These new findings could be the cause of pain in TMJ headaches.
The resources we used to create this page can be found here. An overview of post-concussive headache information and their common symptoms and treatments can be found here.
Treatments
Non-pharmacological (non-medication) plus behavioral changes
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Therapeutic cold blocks or slows down nerve conduction. At first, the cold will cause muscles to tighten, but after a while, it relaxes the muscles because of the restricted nerve conduction.
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Because concussions can affect the entire body, physical therapists can utilize a wide variety of physical therapy techniques for post-concussion headaches and decrease recovery time. Furthermore, the various sub-specialties of physical therapy can treat patients differently based on their symptoms. One systematic review found evidence that physical therapy can benefit concussion recovery by performing exercises that alleviate post-concussion symptoms, including stretching, strength, and range of motion exercises.
Prescription Pharmacological
-
Botulinum Toxin, commonly called ‘Botox,’ is a prescription medication that treats migraines. The bacterium Clostridium botulinum produces the toxin that makes ‘Botox.’ Clostridium botulinum is commonly found in soil, plants, and soiled water. There are different brands of botulinum toxin. Specifically, dosages of Onabotulinum A helps treat chronic-type migraine headaches. Botulinum Toxin is injected into specific points around the head and neck to block the nerves so they produce less pain-inducing chemicals. Read more about it in this study.
-
Tricyclic antidepressants are medications that treat various types of post-concussive headaches. Amitriptyline can also be used to treat insomnia. Tricyclic antidepressants are thought to preserve or increase neurotransmitters like serotonin to help treat migraines. Read more about the evidence for their effectiveness here and on page 89 of this source.
For more information about concussion-related headaches, please visit our main Headaches resource.
Some people recover quickly from headache after concussion, but others take much longer. How do we know as soon as possible what will be the case for someone who has had a concussion? A recent study in Cephalalgia by Marbil and colleagues tracked the progression of headaches over time in children after a new concussion. They found that post-concussion headaches were common and were more severe in those with a history of headache prior to concussion.