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