post head injury headache · 2019. 4. 3. · distinct headache types. pathophysiology of ppth vs...
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Post Head Injury Headache
Ishaq Abu-Arafeh Consultant in Paediatrician,
Royal Hospital for Children, Glasgow, UK
Scottish Acquired Brain Injury Network 19 June 2018
Glasgow
Disclosure
• International Headache Society: Invited Speaker
• European Headache Federation conferences: Invited Speaker
• Migraine Trust: Invited Speaker at International Symposia
• AMGEN: Paediatric migraine advisory Board – from 2015
• RB pharmaceuticals: Childhood Headache advisory Board – 2016/2017
Plan of presentation
• Epidemiology – Headache in children and adolescents – Head injury in children and adolescents – Post-concussion syndrome – Headache following head injury
• Chronic/Persistent posttraumatic headache – Definition – Criteria for diagnosis – Pathophysiology – Clinical features and headache types – Management – Prognosis
World prevalence of headache in children and adolescents
Prevalence in Adults
Systematic review of prevalence in child population Abu-Arafeh et al, DMCN, 2010
Female > male
World prevalence of migraine in children and adolescents
Migraine in adults, Lipton et al, 2007
Abu-Arafeh et al, DMCN, 2010 Systematic review of prevalence in child population
Female > male
Female > male
Primary Headaches Secondary Headaches Other Headaches
1. Migraine
2. Tension-Type Headache
3. Trigeminal Autonomic Cephalalgias
4. Others
1. Head trauma 2. Cranial vascular
disorder 3. Non-vascular
intracranial disorder 4. Substance use or
withdrawal 5. Infection 6. Disorder of
homoeostasis 7. Other craniofacial
disorder (eyes, ears, nose, sinuses, teeth)
8. Psychiatric disorder
1. Painful cranial neuropathies and other facial pains
2. Other headache disorders
International Classification of Headache Disorders ICHD – 3 (2018)
Incidence of head injury
• 3 /1000 children/year admitted to hospitals for head injuries
• Male 65%
• Causes: – Falls 46%
– RTA 21%
• Severity: – Mild TBI 83% – Moderate 9%
– Severe 6%
– Died <1.0%
0
20
40
60
80
100
120
140
160
180
200
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age in years
Ch
ildre
n w
ith h
ead
inju
ry
Hawley et al, Injury, 2002
Post-traumatic syndrome 98 children with mild head trauma
Symptoms 24 hours from injury 4-6 weeks after injury
Headache 91 16
Fatigue 88 13
Nausea 79 3
Recurrent Vomiting 58 2
Dizziness 51 2
EEG abnormalities (slow waves) 64 25
Neurological abnormalities (Fine motor, sensory, coordination)
32 0
Psychiatric symptoms: 18
Sleep disturbances, Affect instability,
Anxiety, Short memory disturbance inattention,
lack of drive,
10 10
5 3 5
Korinthenberg et al, Brain and Development, 2004
A study of 1953 youths within 30 days of mTBI- median 10 days
Hewer et al, Cephalalgia, 2016
Post-concussion symptoms after mild head injury 670 children
Post concussion symptoms 670 children
Present after 3 months 11%
Persist after 1 year 2%
Common post-concussion symptoms: 1. Somatic complaints:
1. headaches, 2. dizziness, 3. nausea, 4. fatigue, 5. sleep disturbances,
2. Cognitive deficits : 1. poor concentration, 2. memory problems, slow thinking
3. Emotional symptoms: Depression and irritability Barlow et al, Pediatrics, 2010
Headache following head injury in children
• Headache is common following head injury
– Acute headache resolves within 3 months
– Non-specific headache
– Chronic or persistent headache continue for over 3 months
Headache (any type) post head injury
Authors Year Number
head injury
Age range
(years)
Number (%)
With PTH
Method Criteria
Lanzi 1985 138 3-17 41 (30%) retrospective Valqhuist
Lemka 1999 100 3-14 27 (27%) prospective None
Lanser 1988 129 <14 24 (19%) prospective None
Nečajauskaitė 2005 102 4-16 72 (71%) retrospective None
Moscato et al* 2005 98 3-18 26 (26.5%) prospective ICHD-2
Hilger, Balgaj 2009 353 3-18 132 (37%) Prospective None
Blume et al 2012 462 5-17 195 (42%) Prospective none
TOTAL 1382 3-18 523 (39%)
Male: Female 2:1 Follow Up: 3 mon – 6 years
Shaw, Morozova, Abu-Arafeh, Pain Management, 2018, 8(1):57-64
Chronic Posttraumatic headache: ICHD- 2 (2004)
Persistent Posttraumatic Headache: ICHD- 3 (2018)
Definition of CPTH/PPTH ICHD- 2 and 3
• A new headache disorder OR a pre-existing headache that becomes worse in
frequency or severity following head injury • The onset of headache is:
– within one week after minor head injury – or from regaining consciousness – or after the discontinuation of medications that may
impair sensation of pain.
• Continues to recur for a period of at least 3 months.
Prevalence of PPTH in children and adolescents: Systematic Review
PPTH is the most common secondary headache in children and adolescents
Shaw, Morozova, Abu-Arafeh, Pain Management, 2018, 8(1):57-64
Pathophysiology of PPTH
• The pathophysiology of CPTH is not well understood
• Possible mechanisms supported by fMRI and PET following minor head injury: – A widespread stretching or shearing injuries to the axonal network.
– Associated or followed by metabolic cerebral disturbances
– Altered haemodynamics and cerebral blood flow.
– Abnormal release of excitatory neurotransmitters and other
neuroinflammatory peptides may initiate headache and perpetuate its chronicity.
– Psychosocial factors may also play a role in the pathogenesis of PPTH
Structural brain differences in patients with PPTH vs migraine – 3T MRI
Schwedt et al, J Headache and Pain, 2017
i
Compared with healthy controls, patients with PPTH had less cortical thickness in bilateral frontal regions and right hemisphere parietal regions.
Structural brain differences in patients with PPTH vs healthy control– 3T MRI
Chong et al, Headache, 2017
Pathophysiology of PPTH
• A substantial overlap in symptoms between PPTH and migraine
• The structure of several brain regions differed in individuals with PPTH compared to those with migraine.
• These structural differences suggest that the pathophysiology of PPTH might be different than that of primary migraine
• These also support the classification of PPTH and migraine as distinct headache types.
Pathophysiology of PPTH vs migraine
Chong et al, Headache, 2017
• A previous history of headache
• Possible role of repetitive head trauma and the development of headache
• Mild to moderate head injury
• Genetic predisposition
• Female gender
• The presence of comorbid psychiatric disorders
Risk factors for PPH
Psychological co-morbidities PPTH vs healthy control
Chong et al, Headache, 2017
PPTH (33) Mean (SD)
Control (33) Mean (SD)
P value
Age 36 (20.5) 33 (15.5) 0.56
Female 13 19 0.21
Headache days/m 16 (9) NA
State anxiety 38 (28) 23 (8) <0.001
Trait anxiety 46 (22) 26 (10.5) <0.001
Beck Depression inventory 16 (14.5) 1.0 (2.5) <0.001
Psychological co-morbidities PPTH vs patients with primary migraine
PPTH (28) Mean (SD)
Migraine (28) Mean (SD)
P value
Age 35.1 (9.6) 37.5 (8.5) 0.33
Female 9 19 0.02
Headache days/m 16.6 (7.8) 16.4 (8.1) 0.93
State anxiety 39.3 (14.4) 32 (7.9) 0.02
Trait anxiety 47.2 (12.6) 36.4 (9.8) <0.001
Beck Depression inventory 18.6 (9) 6.1 (5.3) <0.001
Schwedt et al, J Headache and Pain, 2017
Headache phenotypes of PPTH Population-based
Cohort Follow up studies Authors CPTH Migraine
+/- aura ETTH/ CTTH
Mixed headaches
Unclassified/ Others
Kuczyncki et al
(2013) 39 21 2 0 16
Kirk et al (2008) 11 5 5 1 0
TOTAL 50 26 (52%) 7 (14%) 1 16
Shaw, Morozova, Abu-Arafeh, Pain Management, 2018, 8(1):57-64
Clinical Features of PPTH Clinic patients
Clinic Patients Authors CPTH Migraine
+/- aura ETTH/ CTTH
Mixed headaches
Unclassified/ Others
Eidlitz-Markus et al
(2016) 74 40 23 0 11
Kuczyncki et al
(2013) 44 17 4 4 19
Callaghan et al
(2001) 21 5 13 3 0
TOTAL 139 62 (45%) 40 (29%) 7 30
Shaw, Morozova, Abu-Arafeh, Pain Management, 2018, 8(1):57-64
Children and families seek medical advice:
– The headache has not resolved several months after head injury
– The headache is too frequent or severe
– The headache is interrupting education
– Psychological co-morbidity: anxiety, mood swings, depression
– Concerns regarding any underlying brain injury
– Demanding brain scans
– Demanding cure !!!!
Clinical presentation of PPTH
• History
• History
• History
• Clinical and neurological examination
• Psychological and emotional assessment
• Rarely investigations needed – reassurance for difficult to reassure families
Clinical assessment of PPTH
• Assess for medication overuse – Paracetamol or ibuprofen on more that 15 days per
month OR
– Sumatriptan on at least 12 days per month
– for at least 3 consecutive months
• Assess for other substance dependence such as
caffeine rich drinks (coffee, tea, fizzy drinks, energy drinks, etc)
Clinical assessment of PPTH
• Explain the disorder and its nature to child and parents
• Explore possible MOH and treat if present
• Address psychological comorbidities if present
• Agree strategy to treat acute attacks
• Agree strategy for preventative therapies: – Non-pharmacological healthy life style
– Preventative medication – dosage and course length
– Psychological therapies
Management of PPTH
• Good overall prognosis of psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents
Emery et al, Can J Psychiatry, 2016
Prognosis of Posttraumatic syndrome
• Short term follow up studies:
– Generally good outcome
– Majority resolve within 12 months
– Less than quarter of PPTH persisted beyond 1 year
• Long term studies are needed
Prognosis of Posttraumatic Headache
• Headache is common after head injury – 40%
• PPTH reported in 7.6% following head injury
• PPTH is most common secondary headache in children and adolescents
• More than half of children with PPTH have migraine like symptoms
• Pathophysiology and MRI studies suggest PPTH is a separate entity from migraine
• High prevalence of psychological comorbidities with PPTH
• Similar treatment strategies to primary headaches
• Good general prognosis
SUMMARY Posttraumatic Headache