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Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.

This study addresses (1) the relationship between headache presence/intensity at time of testing and neurocognitive performance, and (2) the probability that testing triggers or intensifies pain. Subjects were 125 patients with chronic posttraumatic headache (mean = 2.67 years post injury) who completed a 4-hour test battery emphasizing memory. Comparisons of 34 individual tests/subtests and the five Wechsler Memory Scale-Revised (WMS-R) indices of relative memory impairment for 73 patients with no headache or mild headache versus 52 patients with moderate to severe pain revealed no significant differences. Testing intensified existing headaches for 55% but triggered headache for only 1 of 20 (5%; P =.00003). Results support the validity of neuropsychological test performance regardless of pain level, although testing can be painful.

Posttraumatic headache (PTHA) is a frequent occurrence following trauma to the head, brain, and/or neck. Estimates of persistence for 6 months are as high as 44%. Review of available studies examining the effect of headache on neuropsychological test findings reveals that chronic headache pain, and chronic pain generally, exerts a significant and negative effect that poses a challenge to differential diagnostic efforts in the evaluation of mild brain injury. Given that PTHA is the most common postconcussive symptom and most frequent type of posttraumatic pain associated with mild traumatic brain injury (TBI), it follows that resolution of the postconcussion syndrome, and successful posttraumatic adaptation, may frequently rely on success in coping with PTHA symptomatology. Viewing PTHA from a biopsychosocial perspective, a general outline is offered for improving both assessment and treatment of PTHA. In addition, the most promising psychology-based treatment interventions are reviewed.

The aim of the study was to compare the emotional profile of patients with persisting headache after brain concussion with that of patients with verified tension headache. Plutchik's index of emotions, including eight dimensions (reproduction, incorporation, lack of control, selfprotection, deprivation, op-positionism, exploration and aggressiveness), was used. Thir-ty-seven patients, 17 (seven males and ten females) with ten-sion headache and 20 (15 males and five females) with post-traumatic headache were analysed. The mean age was 32.12ą12.9 and 39.55ą12.29 years in the patients with tension headache and post-traumatic headache, respectively. The pa-tients from the two groups were matched according to the level of education. The use of t-test in comparative analysis yielded no statisti-cally significant difference in any of the examined dimensions between the two groups of patients. Results indicated the emo-tional profile of patients with the two types of headache to be compatible.

Patients with chronic posttraumatic headache (CPTH) after mild traumatic brain injury may develop multiple emotional, cognitive and somatic symptoms but these symptoms are often unspecific and reported among other headache patients, too. The aim is to investigate whether CPTH patients report more symptoms in general and with a higher severity of these symptoms than other headache patients.

This study sought to determine whether chronic post-traumatic headaches are different from or identical to the naturally occurring headaches. The chronic post-traumatic headaches of 48 patients were classified, as if they were natural headaches, by the diagnostic criteria of the International Headache Society. Thirty-six patients' headaches (75%) were chronic tension-type headache, 10 (21%) were migraine without aura, and 2 (4%) were unclassifiable. The characteristics and accompaniments of the headaches within each diagnostic group were then compared to those in a control group with natural headaches of the same type. No notable differences between the post-traumatic and control groups were found. Hence, chronic post-traumatic headaches have no special features, but are symptomatically identical to either chronic tension-type headache or migraine without aura (in this series of patients). This identity suggests that post-traumatic headaches are generated by the same processes causing the natural headaches, not by intracranial derangement from head blows or jolts.

Anger and depression are common affective concomitants of chronic headache. Previous research suggests that the affective component of headache may contribute to the patient's perceptions of the degree to which the headache is disabling. The present study examined the relationship between anger expression, anger suppression, depression, and headache-related disability (interference with function) in a sample of chronic posttraumatic headache patients. A path analytic model indicated a direct relationship between depression and perceived disability. Anger suppression and anger expression each had a direct influence on depression, but their effects on disability were mediated through depression. The results partially replicate a previous path analytic study of the relationships among these variables in a chronic headache sample.

We report the case of an 18-year-old male with a vascular-type headache occurring 3 days after a minor closed-head injury. The headache resolved completely, without recurrence, with a single dose of intravenous chlorpromazine. This case and the few others reported in the literature illustrate that the response of a headache to antimigraine therapy cannot be relied upon to diagnose or confirm a diagnosis of migraine headache, or to rule out other intracranial pathology.

SYNOPSIS A variety of symptoms (postconcussion symptoms) have been consistently reported following mild head or neck injury. One symptom which may have been under reported is cognitive impairment. We conducted a retrospective study of 100 patients presenting for evaluation and treatment of posttraumatic headache at our headache clinic. Sixty-five percent reported difficulties with either memory, concentration, and/or thinking. The most common cognitive symptoms reported were concentration + memory problems, concentration + memory + thinking difficulties, concentration disturbances, and difficulty remembering, respectively. Subjects in both groups (with cognitive symptoms and without cognitive symptoms) were similar in age, but females seemed more predisposed than males to cognitive impairment following mild head injury. it is suggested that clinicians thoroughly evaluate patients for cognitive symptoms, particularly when patients have a permanent condition and are subsequently involved in litigation.

SYNOPSIS In the headache literature, there exists a great deal of discrepancy regarding when posttraumatic headache (PTH) may be classified as chronic. Although chronic pain is usually described as pain persisting for longer than six months, many view chronic posttraumatic headache as persisting for more than two months, including the International Headache Society criteria. Observations made by Brenner and Friedman in 1944 have been repeatedly cited for this determination. Surprisingly, a review of this original source revealed that the term “chronic“ was never used when discussing posttraumatic headache over two months duration. The authors, in fact, suggested two months as an “arbitrary” dividing line. Recent studies suggest that many patients with PTH continue to improve or change over the first six months but start to plateau after that time. We feel six months serves as a better time indicator for defining chronicity in cases of posttraumatic headache. This would be more consistent with the current literature concerning chronic pain and the International Headache Society criteria for chronic tension headache.

Little is known about chronic posttraumatic headache (PTH) in children and adolescents. In this study we report on symptoms, clinical findings, and management of all children seen in our headache clinic who presented with recurrent headache following head injuries. A total of 23 children were identified over a period of 4 years. Twenty-one children (13 male, eight female; mean age 11.2 years, age range 3.3 to 14.9 years, median 12.1 years) fulfilled the International Headache Society's clinical criteria for the diagnosis of chronic PTH. Mean duration of headache was 13.3 months (range 2 to 60 months, median 7 months). Children were followed up for a period of 5 to 29 months (mean 12.5 months, median 9 months). Head injuries were classified as serious in four patients and minor in 17. Clinical variables were compared between children with PTH and those without a history of head injury. The headaches were migraine in five patients, tension type in 13, and mixed in three patients. Tension-type headache was significantly more common in children with chronic PTH than in those with no history of head injury, but the clinical course was comparable in the two groups.

Symptoms of headache and vertigo were treated using direct hypnotic suggestions of symptom relief in 155 consecutive skull injured patients. Posttraumatic headache and vertigo were completely relieved after an average observation period of 1 year 10 months in 50% and 58% of the patients, and partially relieved in 20% and 16% respectively. Most of the relief was achieved after about 4 weekly sessions and, particularly with the headaches, only if treatment began within a few weeks of the injury. Therapeutic outcome was correlated with depth of hypnosis achieved for both headache (r = .44, p < .0001) and vertigo (r = .47, p < .0001) symptoms. Patients who could not even achieve light hypnosis obtained no therapeutic improvement, but patients who experienced only light hypnosis were as clinically responsive as those achieving deep hypnosis.

The sequelae of a head injury that had occurred at least six months previously, were examined in 457 patients. Neurological deficiencies, psychoorganic disturbances and disability caused by the injury correlated positively with its severity. Posttraumatic epilepsies were diagnosed approximately equally often in patients with minor head injuries and in those with more severe ones. It is probable that epilepsies have been diagnosed too often in patients with minor head injuries. Headache occurs significantly more often in patients with minor head injuries. This cannot be explained by the selection of patients alone. A hypothesis explaining the development of posttraumatic headache is presented and discussed.

1. In the majority of cases examined for their response to CO2, histamine and adrenalin no definite causal relationship could be found between headache and CSF-pressure or systemic blood pressure. 2. When the increased CSF-pressure was produced by intrathecal injection of saline, headache resulted in a high proportion of individuals and the headache was usually in direct proportion to the increased CSF-pressure. 3. No increased sensitivity to histamine could be found in individuals with migraine or posttraumatic headache, but nearly all of the latter category were sensitive to adrenalin, especially those with tangential gunshot wounds of the skull. 4. In most cases no congruity existed between the pharmacological categories previously described and their headache reactions.

Background Chronic headache following traumatic brain injury (TBI) sustained in military service, while common, is highly challenging to treat with existing pharmacologic and non-pharmacologic interventions and may be complicated by co-morbid posttraumatic stress. Recently, a novel form of brainwave-based intervention known as the Flexyx Neurotherapy System (FNS) that involves minute pulses of electromagnetic energy stimulation of brainwave activity has been suggested as a means to address symptoms of TBI. This study reports on a clinical series of patients with chronic headache following service-connected TBI treated with FNS. Methods Nine veterans of the wars in Afghanistan and Iraq with moderate to severe chronic headaches following service-connected TBI and complicated by posttraumatic stress symptoms were treated in 20 individual FNS sessions at the Brain Wellness and Biofeedback Center of Washington (in Bethesda, Maryland, USA). They periodically completed measures including the Brief Pain Inventory-Headache (BPI-HA) past week worst and average pain ratings, the Posttraumatic Stress Disorder Checklist-Military version (PCL-M), and individual treatment session numerical rating scale (NRS) for degree of cognitive dysfunction. Data analyses included beginning to end of treatment t-test comparisons for the BPI-HA, PCL-M, and cognitive dysfunction NRS. Results All beginning to end of treatment t-test comparisons for the BPI-HA, PCL-M, and cognitive dysfunction NRS indicated statistically significant decreases. All but one participant experienced reduction in headaches along with reductions in posttraumatic stress and perceived cognitive dysfunction, with a subset experiencing virtual elimination of headaches. One participant obtained modest headache relief but no improvement in posttraumatic stress or cognitive dysfunction. Conclusions FNS may be a potentially efficacious treatment for chronic posttraumatic headache sustained in military service. Further research is needed to investigate the efficacy of FNS within a randomized, controlled clinical trial, to identify characteristics of those most likely to respond, and to explore underlying mechanisms that may contribute to improvement.

BACKGROUND Posttraumatic headache (PTH) occurs in up to 82% of patients with traumatic brain injury (TBI). Posttraumatic stress disorder (PTSD) occurs in 39% of those with PTH. This study evaluates whether PTSD affects PTH disability. METHODS Eighty-six patients with TBI were prospectively evaluated in a secondary care trauma center. Headache disability was assessed using the Headache Impact Test version 6 and signs indicative of PTSD using the PTSD Check List Civilian version. RESULTS Increased PTSD-type symptoms were significantly associated with increased headache disability (p

This monograph is the second volume of an intended series on research and clinical studies on headache. The editor-in-chief, Dr. Arnold P. Friedman, and his editorial staff are well qualified by interest and original contributions in the field to permit them to choose material for such a review of what is going on in the field. This issue is composed of five separate articles, all of which are reviews with the addition of some original material. The first four chapters deal specifically with migraine. The fifth and longest chapter (52 pages) deals with chronic posttraumatic headache. The last two chapters cover the psychoanalytic aspects of head pain and the psychotherapy of headache. All contributions are thought-provoking and interesting. Several of them merit special consideration. Heyck presents an unusual hypothesis about the pathogenesis of migraine supported by some evidence. He suggests that the opening of arteriovenous shunts

One of the most frequent sequelae to injury of the head is posttraumatic headache. Sufferers from this complaint all too often wander from doctor to doctor, from clinic to clinic and, alas! from lawyer to lawyer under the unjust suspicion of being neurotic or malingering. Posttraumatic headache associated with dizziness forms a clinical entity which is described by these patients in altogether typical fashion. The patient's description of his symptoms makes the diagnosis certain and allows the understanding physician to recognize the true sufferer and to distinguish him from the neurotic patient and the malingerer. In 1927 this condition was described as a disease entity by one of us (W. P.). 1 The fact that the procedure of treatment resulted in relief of symptoms in each of the reported cases was the final proof that the syndrome was a true one and that the underlying pathologic change, whatever it might

In a previous communication, 1 two of us discussed the mechanism of headache produced experimentally by the intravenous injection of histamine, emphasizing the significance of the secondary rise in arterial pressure in the production of the headache. It was found that in patients suffering from post-traumatic headaches such an injection usually "reproduced" the posttraumatic headache (i. e., was followed by a headache which was the same in character and location as the usual post-traumatic one). The conclusion was drawn that the injection of histamine activated a physiologic mechanism similar to that concerned in the production of the majority of post-traumatic headaches. In the present paper, we wish to report the results of further studies bearing on the mechanism of headaches produced by the intravenous injection of histamine and on the relation between such headaches and various other types of headache encountered clinically. From the facts observed certain conclusions can be

A study of the curve for the sugar content of the blood following encephalography was undertaken to determine whether the findings would throw light on the mechanism of regulation of the blood sugar and would be of diagnostic value in neurologic problems. Studies of the sugar content of the blood following encephalography were made on seventy-five patients in the neurologic and neurosurgical service of Dr. Temple Fay, at the Temple University Hospital. There were twenty-eight males and forty-seven females, ranging from 10 to 62 years of age. The majority were in the 10 to 30 year age group (graph 1). These patients were grouped as follows: those with neurologic conditions, such as posttraumatic headache, spasmodic torticollis, Little's disease, postencephalitic parkinsonism and Friedreich's ataxia (fifteen); those with tumor of the brain (ten), and those with convulsive disorders (fifty). Mader 1 in 1928 and 1932 studied the changes in the blood sugar