Chronic Post-traumatic Headache— Understanding the Complexities and Treatment Options

As there are few or no objective signs of disease and standard laboratory tests and imaging studies often appear normal, chronic post-traumatic headache (CPTH) is frequently disrespected. Confusion about its legitimacy began with its initial recognition in the mid-19th century, followed by modern attempts to establish its criteria in the International Classification of Headache Disorders (ICHD). There are no distinct clinical features of CPTH. Most resemble tension-type headache, but symptoms of migraine and, rarely, of other primary headaches may occur. CPTH is often associated with the post-concussion/post-traumatic stress syndrome. Anatomic, physiologic, psychologic, socioeconomic, and cultural factors may contribute to the development of CPTH. Changes in diffusion tensor imaging, a refinement of magnetic resonance imaging (MRI), have been correlated with subtle cognitive abnormalities in neuropsychologic tests of patients after mild traumatic brain injury. These studies and others may prove to be biologic markers for headache and other symptoms of the post-concussion syndrome. The therapy of CPTH is similar to that of the phenotypically primary headaches. Avoidance of analgesic overuse, prophylactic medications, and, in particular, non-pharmacologic modalities are the basic elements. Active participation by patients in headache management and an empathetic physician are essential.