Post traumatic headaches - how can physio help?

What is a post-traumatic headache?

It is a headache which can occur following any brain injury, and is one of the most common complaints following a mild traumatic brain injury. (Ref 1-4)

Often the headache will resolve quickly following the original injury, but in some clients the headache persists. If it continues beyond 3 months, it is termed chronic.

What types of post traumatic headaches are there?

There are many causes and types of headaches and it is important to have a reliable diagnosis, so that the appropriate treatment can be determined.

The Ontario Neurotrauma Foundation has identified four common types in adults following a mild traumatic brain injury:

1. Migraine without aura

2. Frequent episodic tension-type headache

3. Primary stabbing headache

4. Occipital neuralgia

Headaches may be made up of more than one of these types.

You can get more detailed information here: http://braininjuryguidelines.org/concussion/

It’s important to note that headaches can also be caused by medication over-use. These are called rebound headaches. Your doctor will assess whether medication is the possible cause and develop a plan with you to deal with the problem.

What can physio do to help?

Once an assessment has been completed, your physiotherapist can help by advising, guiding and treating the following areas:

1. Pain, by using modalities such as heat, ice, acupuncture, manual therapy or Integrative Manual Therapy as needed.

2. Head and neck posture.

3. Stretches for the neck and upper body.

4. Strengthening for the neck and upper body when appropriate.

5. Cardiorespiratory exercise. Some headaches are aggravated by exercise. Your physiotherapist will guide you to the most appropriate program for you.

6. All exercise must be performed in a graduated way so that there are minimal injuries, and you are successful in getting the benefits from your program.

R. Sian Owen PT

Registered Physiotherapist

1.Gladstone J. From psychoneurosis to ICHD-2: an overview of the state of the art in post-traumatic headache. Headache. 2009;49(7):1097-1111.

2. Dikmen S, Machamer J, Fann JR, Temkin NR. Rates of symptom reporting following traumatic brain injury. J Int Neuropsychol Soc. 2010;16(3):401-411.

3. Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85(7):619-627.

4. Lew HL, Poole JH, Guillory SB, Salerno RM, Leskin G, Sigford B. Persistent problems after traumatic brain injury: The need for long-term follow-up and coordinated care. J Rehabil Res Dev. 2006;43(2):vii-x.

I just got back from a most informative and exciting course on Post Concussion Syndrome with Jacquie van Ierssel PT, a physiotherapist who has developed “R2P”, a systematic and evidence- based approach to identify causes of concussion symptoms and create a treatment plan. It was great to see how much physiotherapy can do to help. Thank you Jacquie!

I want to share some of my learning with you, and in the next few blogs I plan to do just that.

First of all:

What is post concussion syndrome, or persistent post concussion symptoms as it is now being called?

Up to 15% of people with concussion may have persistent symptoms. The Ontario Neurotrauma Foundation guidelines recommend a referral for a specialized assessment if symptoms persist at one month post injury. (1)

The diagnosis is based on symptoms (see below) and your Doctor may use diagnostic criteria from the World Health Organisation and/or the Diagnostic and Statistical Manual of Mental Disorders. Because symptoms can be the same as in a variety of other conditions, obtaining the correct diagnosis can be difficult.

The following are common symptoms: (from Willer and Leddy (2))

Physical: headache, nausea, vomiting, blurred or double vision, seeing stars or lights, balance problems, dizziness,sensitivity to light or noise, tinnitus.

Behavioural or emotional: drowsiness, fatigue or lethargy, irritability, depression, anxiety, sleeping more than usual, difficulty falling asleep.

Cognitive: feeling “slowed down”, feeling “in a fog” or “dazed”, difficulty concentrating, difficulty remembering.

Symptoms do vary. Some people experience three or four while others may be dealing with more, and they can persist for months and even years.

What happens in treatment?

Education is a key component. Treatment will focus on addressing the physical/cognitive/psychological challenges arising from the concussion. A team approach works best for managing persistent post concussion symptoms.

What can the physiotherapist do to help?

The physiotherapist can help treat post traumatic headaches, dizziness and poor balance (vestibular problems), fatigue, and vision (ocular motor). After an in-depth assessment the physiotherapist can provide a program specifically designed to address your problems. Appropriate exercises will help to improve sleep and mood, as well providing physical benefits such as increased strength, better balance and posture and improved exercise tolerance. The physiotherapist will also work with other healthcare providers as needed.

I will go into more detail about treatment in my next blog.

(1) onf.org/documents/guidelines-for-concussion-mtbi-persistent-symptoms-second-edition

(2) https://www.ncbi.nlm.nih.gov/pubmed/16901381

R. Sian Owen PT

Registered Physiotherapist