Headaches Persist Five Years After Traumatic Brain Injury

SAN DIEGO—New or worse headaches may persist five years after traumatic brain injury (TBI), according to results of a prospective study presented at the 58th Annual Scientific Meeting of the American Headache Society. “Results suggest that ongoing assessment and treatment of headache after TBI is needed as headache remains a potential problem even five years post injury,” the researchers said.

Headache is one of the most common symptoms in patients with TBI, but the characteristics of headache after brain injury are not well defined, and prior estimates of the prevalence of headache after TBI have been based on retrospective studies.

To assess the natural history and features of headache after TBI, Sylvia Lucas, MD, PhD, Clinical Professor of Neurology and Neurological Surgery at the University of Washington in Seattle, and colleagues conducted a prospective study in civilian patients with TBI. Participants were enrolled during inpatient rehabilitation hospitalizations at seven centers. Researchers conducted follow-up phone interviews with participants at three, six, 12, and 60 months. One-year follow-up data were published in the Journal of Neurotrauma in 2011.

Sylvia Lucas, MD, PhD

The investigators obtained five-year follow-up data for 316 participants. Participants had an average age of 42. Seventy-two percent were male, 73% were white, and 74% had completed high school. Most injuries involved motor vehicle crashes, and patients mostly had moderate to severe TBI. Patients may have sustained other injuries in addition to TBI. Only 17% had pre-injury headaches.

High Prevalence

Compared with pre-injury, the prevalence of new or worse headache was high and remained so over time: 38% at baseline, 37% at three months, 33% at six months, 34% at one year, and 35% at five years. Average headache pain on a 0-to-10 scale remained high over time, ranging from 5.5 at baseline to 5.7 at five years. Headache Impact Test scores showed a substantial impact of headache on quality of life, with mean scores of 57.1 at three months and 56.5 at five years. The proportion of patients with headaches occurring several times per week or daily was 50% at three months and 36% at five years.

Patients may have had subsequent concussions or new-onset primary headache disorders during the study, but the researchers believe that most of the headaches are related to the initial injury.

Dr. Lucas and colleagues determined whether patients’ headache characteristics matched those of primary headache disorders described in the International Classification of Headache Disorders, second edition (ICHD-2). They found that migraine was the most common headache type (approximately 59%), followed by tension-type headache (approximately 14%). About a quarter of the headaches were not classifiable using ICHD-2 criteria.

Effective Interventions?

Neurologists should educate primary care physicians about the persistent nature of headache after TBI. “Be prepared never to cut those strings to your patients because they may be back really needing help to deal with their headaches,” Dr. Lucas said.

Future studies should assess the effectiveness of interventions. “The next step is treatment studies to look at whether the frequency, severity, and the impact of headache after TBI can be decreased with effective pharmacologic or nonpharmacologic methods,” Dr. Lucas concluded.

—Jake Remaly