Post-traumatic Headache in Children and Adolescents

DOI: https://doi.org/10.1007/s11916- 021- 00967- y

Abstract-Summary The current review of post-traumatic headache in children and adolescents aims to review the pathophysiology, risk factors, clinical features, neuroimaging, and both acute and preventive treatment options.

Recent literature provides insight into specific risk factors in the pediatric age group for developing post-traumatic headache as well as unique pathophysiologic changes seen in neuroimaging and neurometabolic pathways.

Review of literature on pediatric post-traumatic headache reveals a growing understanding of the factors involved in developing headache after head trauma and the diagnosis/treatment of headache though future research will help further eluci- date these areas.

Introduction In the USA, there are nearly 1.7 million traumatic brain injuries (TBI) every year in adults and children, with post-traumatic headache being the most common symp- tom reported after a TBI [54].

A range of 30–90% of patients report headache as a primary symptom after TBI

with 18–22% of these patients reporting ongoing PTH after 1 year [55].

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Definitions Headache can be an isolated symptom or can be accompanied by other symptoms including dizziness, fatigue, reduced ability to concentrate, psychomotor slowing, memory issues, insomnia, anxiety, personality changes, and irritability [55].

If symptoms continue past 3 months, it is classified as persistent PTH, which is

seen in 18–65% of cases [54].

Most symptoms resolve in 3 months and is considered acute PTH [56]. About 45% of patients with a past history of headaches reported PTH [55]. PTH has very similar characteristics seen in primary headache disorders often resembling migraines with symptoms including pulsating characteristics, associ- ated nausea/vomiting, photo/phonophobia, and worsening pain with activity or tension-type headaches with a non-pulsating characteristic and neither photophobia or phonophobia [55].

Pathophysiology Imaging with brain MRI of adult patients with persistent post-traumatic headache (PPTH) revealed differences in brain structure when compared to patients with migraine and healthy controls.

In three of these areas (right supramarginal gyrus, right lateral orbitofrontal region, left superior frontal region), measurements were decreased in patients with PPTH compared with healthy controls without migraine [26].

Another study also found decreased cortical thickness in patients with PPTH and compared to healthy controls in several areas (left and right superior frontal, caudal middle frontal, and precentral, right supramarginal, right superior and inferior pari- etal, right precuneus region) and demonstrated a negative correlation between left and right superior frontal thickness with headache frequency [57].

MRS has demonstrated differences in neurometabolite concentrations (decreased NAA/creatinine and increased choline/creatinine ratios) in adult patients with PTH when compared to controls [58].

Risk Factors A large, prospective, controlled study of children after TBI showed that female sex and adolescence were associated with increased rates of headache following mild TBI [59].

A systematic review of sports-related concussion also found that female sex and adolescent age along with greater severity of acute and subacute symptoms and preinjury history of mental health issues or migraine headaches, were associated with increased risk of persistent post-concussive symptoms [60].

A recent retrospective cohort study of children with TBI did not find any statisti- cally significant differences in risk for headache based on age, sex, or other demo- graphic and injury characteristics [61].

Clinical Features The majority of patients with both acute and chronic/persistent post-traumatic head- ache phenotypically resemble migraine, followed by tension-type headache [62, 63].

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In one systematic review, the overall prevalence of chronic post-traumatic head-

ache was found to be 7.6% across studies [63].

Of the 29.3% of ED patients who developed post-concussive symptoms by fol- low- up at 3 months, headache was both a risk factor for the development of post- concussive symptoms, as well as the most commonly reported symptom at follow-up [64].

A preexisting or family history of migraine increases the likelihood of develop-

ing post-traumatic headache, namely migraine.

Neuroimaging Neuroimaging, including magnetic resonance imaging (MRI) and computed tomog- raphy (CT), is not recommended routinely for the evaluation of subacute or chronic post-traumatic headache.

As with any headache, the ever-expanding SNNOOP10 mnemonic is helpful to

assess for red or “orange” flags warranting neuroimaging [65].

The PECARN (Pediatric Emergency Care Applied Research Network) traumatic brain injury algorithm is a helpful and well-validated tool in the emergency depart- ment to determine the need for CT imaging in “clinically important traumatic brain injury” with patients presenting within 24 h of minor head trauma [66–68].

As diagnostic imaging becomes more sophisticated and accessible, it is likely that neuroimaging will occupy a more important role in characterizing structural or functional injury and prognosticating outcomes, even in patients with mild head trauma [69].

Management The majority of patients with mTBI recover within a couple weeks of injury.

In one study of 11–22 years old with concussion, 69.2% reported headache at 1 week, 24.8% with headache at 28 days, and only 5.2% with headache at day 90 [70]. In another prospective cohort study of pediatric patients with mTBI by Blume and others in 2012, headache was reported in 43% of subjects with mTBI 3 months after injury.

Acute PTH Once structural pathology like intracranial hemorrhage has been excluded, the treat- ment of acute PTH involves anti-inflammatory medications like ibuprofen and acet- aminophen, as well as lifestyle factors [71].

These include stress, sleep, hydration, nutrition, exercise (which will be dis-

cussed later), and the ever-present screen time.

Although triptans have not be systematically studied in pediatric PTH, these have commonly been used to treat PTH beyond its application for migraine headache.

Preventative Treatment of persistent post-traumatic headache poses perhaps an even more diffi- cult challenge, and there are no randomized control studies to guide treatment choices.

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There are few studies that exclusively examine the treatment of persistent PTH in pediatric patients, so most of the recommendations are extrapolated from both adult and migraine literature.

Novel anti-CGRP antibodies are currently being studied in the pediatric popula- tion, but in a recent paper from headache experts, these agents could be considered in patients who have failed conventional treatment [72].

One retrospective study of 14 patients in whom the majority experienced a high

headache burden, occipital nerve blocks were helpful in 64% of patients [73].

Cognitive behavioral therapy (CBT) has evidence for efficacy in treatment of pediatric headache and migraine, and may even be superior to pharmacological approaches [74].

Return to Learn and Return to Sport While strict rest is encouraged 24–48 h after injury, there is increasing evidence that aerobic exercise can promote recovery.

There is reported a “window of vulnerability” with increased risk of concussion 7–10 days after injury, but daily activities can commence after a short period of rest and progress to increasing levels of aerobic activity, barring exacerbation of symp- toms [75].

“Return to learn” should always be prioritized before “return to play.” In regard to PTH, possible strategies to facilitate “return to learn” include fre- quent breaks, allowing a student to rest in a quiet area, and decreasing headache “triggers.”

Differences in Pediatric vs. Adult Post-traumatic Headache Unintentional falls and motor vehicle crashes were the most common mechanisms of injury contributing to a TBI diagnosis in which the patient was hospitalized.

These two principal mechanisms of injury accounted for 52.3% and 20.4%,

respectively, of all TBI-related hospitalizations.

It is likely that substantial differences exist in the etiology, mechanism of injury, clinical expression, evaluation, and management between the pediatric and adult populations, though sparse comparisons exist in the literature.

The evaluation and management of pediatric post-traumatic headache likely has substantial differences from the e/m of adult post-traumatic headache as outlined in the management section.

Conclusion Pediatric post-traumatic headache is the most common symptom after a mild trau- matic brain injury and is typically treated as one would approach a primary head- ache disorder, like migraine headache or tension-type headache.

As we begin to better understand the pathophysiology of post-traumatic head- ache and its unique challenges in the developing brain, this extrapolation may not be as straightforward.

Acknowledgement A machine generated summary based on the work of Doll, Elizabeth; Gong, Paul; Sowell, Michael; Evanczyk, Lauren 2021 in Current Pain and Headache Reports.

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Mild traumatic brain injury affects the features of migraine