Post-Concussive Headaches and Dizziness Louise M. Klebanoff, MD

Post-Concussive Headaches and

Dizziness

Louise M. Klebanoff, MD

Associate Professor and Vice Chairman for Operations Chief, General Neurology

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

Historical Background

• Maty (1766): described persistent

post-concussive symptoms following trauma

• Boyer, Dupuytren, Cooper (mid-19th _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

Types of Post-Concussive

Headaches

• Muscle tension type headaches • Cervicogenic 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

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

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

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

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

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

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

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

Acute Migraine Therapy: Triptans

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

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

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

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,

atrio-ventricular 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

Behavioral and Physical

Therapies

• Relaxation training

• Hypnotherapy

• Cognitive-behavioral therapy

• Physical therapies:

– 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

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

Dizziness Following Concussion

Benign Positional Vertigo

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

– Section of the posterior ampullary nerve

Conclusions

• Headache and dizziness are key components of the

post-concussive 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