Major cultural and psychological differences influence the incidence and chronicity of post-traumatic headaches. In cultures where stoicism is high and the expectations of post-traumatic headaches are low, the incidence and chronicity are quite low. However, in cultures where stoicism is low and expectations of post-traumatic headaches are high, the incidence and chronicity are quite high. Consequently, highly developed societies report higher incidences than the less developed ones, and thus the definition of post-traumatic headaches continues to evolve.
Post-traumatic headaches can include migraine headaches, tension headaches, cluster headaches, neck-strain headaches, whiplash headaches and mixed headache syndromes. Pre-existing headaches can also worsen after trauma. Thus, post-traumatic headaches represent a wide spectrum of headache types, with most patients experiencing more than one type at any one time. “How many types of headache do you have?” is a good question to ask patients who have suffered from head or neck trauma. With millions of concussions occurring globally, post-traumatic headaches have become a common cause of physical and mental disabilities.
Different studies from different parts of the world report post-traumatic headaches in 30% to 90% of those injured. Headaches may begin soon after the injury or may develop weeks, months or even years later. Although most post-traumatic headaches do improve with time, about a quarter may persist longer than a year and some may even become persistent, lasting for many years or even for life.
A prospective study from Seattle (Lucas et al. Cephalalgia, Vol. 34(2) 2014) followed 212 post-traumatic patients for a year. They recorded headaches in more than half of the patients, and found that most headaches began within the first three months, and tended to persist for a year or more in about one third of sufferers. Headaches that were severe and occurred soon after trauma, in contrast to those that developed later on, portended frequent and chronic headaches. About two thirds of the headaches began more than one week after the injury, and about half of the headaches were migraine types.
Unlike the many other headache types where women constitute the majority of sufferers; in the Seattle study, men and women were equally represented. Moreover, those over age 60 tended to develop fewer headaches than their younger counterparts.
Common Imaging-studies of the head and neck are always done but are seldom helpful. If they show minor structural changes, these changes do not correlate with the clinical state and persist unchanged whether the headaches resolve, improve, or become chronic. Imaging-studies mainly serve to rule out some of the serious structural consequences of trauma such as fractures, hematomas, contusions, intracranial bleeds, or brain edema.
Whereas soft-tissue bodily injuries usually heal quickly, neck injuries do not seem to heal well in post-traumatic headache victims. Moreover, the disturbances to head and neck that cause the post-traumatic headache syndrome are submicroscopic, metabolic, neurochemical, and may only be detected with special research tools that are not yet applicable to clinical use. Invisible, nonstructural, and poorly understood nerve cell changes are what define post-traumatic headaches today.
The management of post-traumatic headaches is complex and not standardized. Headache doctors tend to treat post-traumatic headaches according to the types they manifest. If the types are mainly episodic migraine and tension, then the usual treatments for these two types are given. If the headache is continuous and persistent, other treatments are tried based on the physician’s experience and the available literature. Treatments are individualized and they vary widely, and may involve medications, injections, physical therapy, exercises, and psychotherapy. Moreover, therapeutic trials, which may work for one individual, may not work for another.
Head and neck trauma not only can cause new headaches, it can also worsen the preexisting ones plus add new headache types to them. It is fortunate that most patients do improve with time, but the sizable minority of chronic sufferers does present an ongoing therapeutic and medical challenge.