Post-Concussive Headaches and Dizziness Louise M. Klebanoff, MD Associate Professor and Vice Chairman for Operations Chief, General Neurology Department of Neurology
Disclosures: None
Introduction: Headaches Post-concussive headaches are a key feature of the more complex post-concussive syndrome Loss of consciousness is not required for the development of post-concussive headaches In most patients, post-concussive headaches occur within 7-10 days of injury and resolve within three months Up to 30% of patients report headaches continuing long after the injury Patients > 40 years old Patients with previous concussions
Historical Background Maty (1766): described persistent postconcussive symptoms following trauma Boyer, Dupuytren, Cooper (mid-19 th century): reported headache and other symptoms following closed head injuries Ericksen (1882): argued that mild head injury or concussion of the spine could result in severe disabilities due to damage to the central nervous system
Controversy Many symptoms of post-concussive syndrome were thought to be malingering Ericksen (1882): argued that head injury did not occur in the absence of obvious external injury Functional disorder neurosis Rigler (1981) Compensation neurosis Evidence of anatomic abnormalities is minimal The risk of post-concussive headaches does not appear to be correlated with the severity of the head injury
Few post-concussive headaches require surgical intervention
Red Flags Increasing headache frequency/severity Chronic daily headaches unresponsive to treatment Headaches always on the same side Headaches associated with seizures Headaches with an abnormal neurological examination Headaches precipitated by exertion, strain or positional changes Headaches that awaken the patient over time
Types of Post-Concussive Headaches Muscle tension type headaches Cervicogenic headaches Migraine headaches
Tension Type Headaches Duration 30 minutes 7 days Characteristics: Bilateral Pressing/tight (non-pulsatile) Mild-moderate intensity Not aggravated by routine physical activity No nausea or vomiting No photophobia or phonophobia
Cervicogenic Headaches Occur following injury to the muscles and soft tissues of the neck ( whiplash ) Nerves in the tissues and bones of the neck have branches that travel to the skull and scalp and cause headache Start in the neck, shoulders, back of the head Can travel anteriorly over the top of the head Neck movement or positioning can make the pain worse Range from mild to severe Usually no associated features
Migraine Headaches At least two of the following: Unilateral location Pulsatile quality Moderate-severe intensity Aggravated by routine exertion At least one of the following: Nausea and/or vomiting Sensitivity to light and noise Up to 31% of patients will have aura on some occasions
Migraine Pathophysiology Migraine is a primary disorder of the brain Migraine is NOT a caused by a primary vascular event Neurovascular headache: a disorder in which neural events result in the dilation of blood vessels which in turn results in pain and further nerve activation Basic Biological Problem: dysfunction of brainstem or diencephalic nuclei that are involved in the sensory modulation of craniovascular afferents Activation in the brainstem during migraine attacks has been detected with PET scanning
Post-concussive Headache Treatment No specific treatments of post-concussive headaches Patient education Lifestyle changes to avoid triggers Regular sleep (especially awakening time) Regular meals (no skipping, no sugar loading) Hydration Exercise Avoidance of peaks in stress/relaxation Avoidance of dietary triggers
Acute Headache Treatments Over the Counter Analgesics and NSAIDS: Important to treat early Important to treat with adequate dose 900 mg aspirin 1000 mg acetaminophen 500-1000 mg of naproxen 400-800 mg ibuprofen Anti-nausea drugs (or drugs that increase gastric motility) may facilitate absorption of the primary drug Overuse must be avoided (< 2-3 days per week)
Analgesic Overuse Analgesic overuse MUST be avoided Analgesic overuse/rebound headaches can evolve into chronic daily headaches Prophylactic agents are NOT effective in the setting of analgesic overuse/rebound headaches Restrict use to 2-3 days per week
Acute Headache Treatments Avoid opiates Mask pain without suppressing the pathophysiological mechanism of the headache May leave the patient cognitively impaired Addiction risk Offer no advantages over more specific headache therapies
Acute Migraine Therapy: Triptans Selective pharmacology (activate serotonin 5-HT 1B/1D receptors) Established efficacy based on well-designed controlled trials Moderate side effect profile Tingling paresthesias Dizziness, flushing, neck pain or stiffness Well-established safety record Disadvantages: Higher cost Restricted use in setting of cardiovascular disease
Acute Migraine Therapy: Triptans Sumatriptan (Imitrex) Naratriptan (Amerge) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Almotriptan (Axert) Eletriptan (Relpax)
Preventive Therapies Consider preventive therapies when: Headaches significantly interfere with daily routine despite acute treatment Acute medications fail, are contraindicated or cause troublesome adverse events Acute medications are overused The patient has frequent (> 2 per week) headaches Patient preference
Preventive Therapies Medication Options: Antiepileptic drugs Antidepressants Beta-blockers General rules: start low, go slow Remind patients that this takes time About 2/3 of patients given a prophylactic agent will have a 50% reduction in headaches Mechanism of action: modifies brain sensitivity
Preventive Therapies Amitriptyline (Elavil) Dose: 25-75 mg at bedtime Side effects: drowsiness, dry mouth, constipation Nortriptyline (Pamelor) may be better tolerated Gabapentin (Neurontin) Dose: 300-3000 mg daily Side effects: tiredness, dizziness
Preventive Therapies Divalproex (valproate) (Depakote) Dose: 400-600 mg BID Side effects: drowsiness, weight gain, tremor, hair loss, fetal abnormalities, hematologic and liver abnormalities Topiramate (Topamax) Dose: 25-200 mg daily Side effects: confusion, paresthesias, weight loss Selective serotonin reuptake inhibitors Dose: depends on specific agent Side effects: anxiety, insomnia, sexual dysfunction
Preventive Therapies Verapamil Dose: 120-320 mg daily Side effects: constipation, leg swelling, atrioventricular conduction disturbances Beta-adrenergic-receptor antagonists: Propranolol (Inderal) Dose: 40-120 mg BID Metoprolol (Lopressor) Dose: 100-200 mg/day Side effects: fatigue, postural dizziness Contraindications: asthma
Behavioral and Physical Therapies Consider behavioral or physical treatments: Patient preference Poor tolerance of medications Medical contraindications to medications Insufficient or no response to medications Pregnancy, planned pregnancy or nursing History of long-term, frequent or excessive use of analgesics or acute therapies Significant stress or deficient stress-coping skills
Behavioral and Physical Therapies Relaxation training Hypnotherapy Cognitive-behavioral therapy Physical therapies: Acupuncture TENS Occlusal adjustment Cervical manipulation (not chiropractic manipulation Occipital Nerve Block Botox
Nutraceutical Treatments Magnesium Dose: 250-750 mg/day Side effects: diarrhea Riboflavin (Water-soluble vitamin B2) Dose: 100-400 mg/day Side effects: bright yellow-orange urine
Nutraceutical Treatments Feverfew (member of the daisy family) Dose: 125-mg daily Side effects: GI idsturbance Butterbur (Petasites hybridus) Dose: 75-mg twice a day Side effect: burping Coenzyme Q10 Dose: 150-mg/day Side effects: infrequent GI distress, skin reactions
Dizziness Following Concussion Poor equilibrium Feeling off-balanced Light-headedness Giddiness/floating Disorientation Vertigo: Environment swims Whirling/Spinning To-and-fro Up-and-down
Benign Positional Vertigo Recurrent momentary episodes of vertigo brought on by changes in head position - Neck extension - Rolling over in bed - Arising from bed - Bending down Vertigo starts after a latency, builds to a peak and then subsides after about 1 minutes
Benign Positional Vertigo Positional testing: Lay patient down quickly from a seated position with the head and neck extended to one side Vertigo with rotatory nystagmus Pathophysiology: Otoconia (calcium carbonate crystals) in the posterior semicircular canal ampulla, displaced from utricle and saccule
Vertigo - Treatment Vestibular therapy Labyrinthe suppressants: Meclizine Diazepam Surgical intervention: Section of the posterior ampullary nerve Obliteration of the posterior semicicrular canal
Conclusions Headache and dizziness are key components of the postconcussive syndrome The pathophysiology is not well-understood Detailed neurological history will help establish the headache type and guide treatment A careful neurological examination will exclude ominous causes of headache and dizziness Therapies include: Medications for acute and preventive treatment of headache Physical therapy for cervicogenic headache and vertigo Supportive care Patient and practitioner education and patience
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