It is not unusual to experience a headache or even migraine-like symptoms in the days after a head injury, but for many patients they are temporary issues. However, for others, they become long-term or even permanent fixtures in their lives after the traumatic brain injury (TBI)—taking on different forms for each patient. In this post, we describe the most common types of persistent headaches and migraines after TBI.
Overview of headaches after TBI
When a serious injury occurs to the head, brain and/or neck, the risk for long-term complications is significant. In particular, headaches and migraine attacks develop regularly after traumatic brain injuries (regardless of severity), with estimates of prevalence between 58-81% of patients.1 Here are a few more statistics worth noting:
Unfortunately, there are not many reliable indicators for how likely a head injury will result in chronic or persistent headaches. In fact, even the things you might expect would lead to these symptoms (severity of injury, location of injury, etc.) have inconsistent evidence to link them. However certain risk factors have emerged, such as: mild TBI or concussion vs more severe TBI; prior history of headache; and/or comorbid presence of post-traumatic stress disorder or other emotional symptoms. This makes proper identification of the different manifestations of chronic headaches very important to the outcomes of patients.
Five types of post-TBI headache disorders
Naturally, symptoms and experiences can vary for those with TBI. For this reason, there are specific types of headaches that patients can look out for:
- Persistent post-traumatic headache
- Migraine with or without aura
- Vestibular migraine
- Cluster headache
- Chronic tension-type headache
Persistent Post-Traumatic Headache (PTHA)
Post-traumatic headache represents the only headache disorder that is directly attributable to the brain injury, and, by definition, it occurs within 7 days of the injury or after consciousness is regained. Arguably, this headache type is an umbrella term to describe any ongoing head pain after the trauma—whether it is migraine, tension-type headache or another variety. At minimum, the distinguishing factor for chronicity is the fact that persistent post-traumatic headache lasts more than 3 months.
In addition, the International Headache Society classifies this type of headache as a secondary headache disorder when it manifests anew within a patient. Conversely, it can be a primary headache condition if a person already had a pre-existing headache diagnosis that was made worse or chronic as a result of the TBI. Regardless, post-traumatic headache is unique in that it often combines symptoms from all the other primary headache and migraine disorders—thus making it a diagnostic challenge.5 That said, evidence has shown subtle differences in triggers and even brain structure when compared with typical migraine, which may give a way forward for clearer identification.6,7
Migraine With Or Without Aura
Migraine with aura and migraine without aura are the most common of post-traumatic or post-TBI headache disorders. Veterans who endure a brain injury may be particularly vulnerable to the onset of migraine versus any other headache disorder.8 These types are differentiated primarily through the sensory symptoms that occur in conjunction with the direct head pain. For example:
Some have even hypothesized that disability may be one of the greatest predictors of migraine when compared with other headache-related conditions that follow TBI. This may be due to the higher risk for disability, prolonged recovery and other poor outcomes for those with TBI-caused migraine.9,10
As we have discussed, migraine with aura adds pre-attack visual and sensory disturbances to the list of symptoms. Although it is less frequent than migraine without aura in the general population, experts have shown that it may be the most likely headache disorder following sports-related traumatic brain injuries, occurring for approximately 45% of patients. This compares with about one in four who go on to develop chronic but non-aura migraine.11
A very specific type of migraine that can arise after TBI includes vestibular symptoms like dizziness, vertigo or motion-induced sickness. Vestibular migraine, as it is called, is one of the leading causes of ongoing post-injury dizziness; in fact, concussions and traumatic brain injuries represent a prominent risk factor for the development of vestibular migraine.12 That said, research has revealed very little about how often this migraine subtype occurs as a direct result of TBI, although we know that migraine-associated vertigo manifests regularly for many patients and can persist for several years.
Although more rare, cluster headaches are pretty terrible, and that is before you learn that they have been nicknamed ‘suicide headaches’ to describe the blinding pain (usually behind one eye) that arrives in bouts or clusters. Similar to vestibular migraine, not much is known about the general prevalence of post-TBI cluster headache, but patients with cluster headache may endure more traumatic brain injuries over their lifetime versus people with migraine. This could indicate a higher risk to develop cluster headaches or that TBI functions as a direct cause of the disorder.13
Chronic Tension-Type Headache
Tension-type headaches, or ‘stress headaches’ as they have sometimes been termed, lack the typical features of migraine but can be no less persistent or painful. Although they represent the most common form of headaches among the general population, they seem to present less often after TBI than migraine—affecting between 22-40% of patients depending on the cause and severity of injury.11,14 As far as symptoms go, pain is the primary issue, and it generally impacts both sides of the head. Chronic tension-type headache may include enhanced sensitivity to light or sound, but not both together.15
Clearly, chronic headaches are a major concern for survivors of traumatic brain injuries. They can have different features and symptoms and even evolve over time without any predictable risk factors. Regardless, they can have a disabling impact on those who have to endure them and therefore require proper diagnosis and treatment.
Additional reading, headache and migraine:
Additional reading, TBI and concussion:
1Irvine KA, Clark JD. Chronic Pain After Traumatic Brain Injury: Pathophysiology and Pain Mechanisms. Pain Med. 2018 Jul 1;19(7):1315-1333. doi: 10.1093/pm/pnx153.
2Lew 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 Jul;85(7):619-27.
3Stacey A, Lucas S, Dikmen S, et al. Natural History of Headache Five Years after Traumatic Brain Injury. J Neurotrauma. 2017 Apr 15;34(8):1558-1564. doi: 10.1089/neu.2016.4721. Epub 2017 Jan 18.
4Couch JR, Stewart KE. Headache Prevalence at 4-11 Years After Deployment-Related Traumatic Brain Injury in Veterans of Iraq and Afghanistan Wars and Comparison to Controls: A Matched Case-Controlled Study. Headache. 2016 Jun;56(6):1004-21. doi: 10.1111/head.12837. Epub 2016 May 30.
5Hong CK, Joo JY, Shim YS, et al. The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study. J Headache Pain. 2017;18(1):48. doi:10.1186/s10194-017-0755-9
6Silverberg ND, Martin P, Panenka WJ. Headache Trigger Sensitivity and Avoidance after Mild Traumatic Brain Injury. J Neurotrauma. 2019 May 15;36(10):1544-1550. doi: 10.1089/neu.2018.6025. Epub 2019 Jan 11.
7Schwedt TJ, Chong CD, Peplinski J, Ross K, Berisha V. Persistent post-traumatic headache vs. migraine: an MRI study demonstrating differences in brain structure. J Headache Pain. 2017;18(1):87. Published 2017 Aug 22. doi:10.1186/s10194-017-0796-0
8Vargas BB. Posttraumatic headache in combat soldiers and civilians: what factors influence the expression of tension-type versus migraine headache? Curr Pain Headache Rep. 2009 Dec;13(6):470-3.
9Bennett-Brown C, Ostrowski-Delahanty S, Johnson T, Victorio MC, Klein S. Migraine phenotype prolongs recovery time in traumatic brain injury (TBI). Neurology 2018 Dec;91(23, Supp 1):S17-S18.
10Anderson K, Tinawi S, Lamoureux J, Feyz M, de Guise E. Detecting Migraine in Patients with Mild Traumatic Brain Injury Using Three Different Headache Measures. Behav Neurol. 2015;2015:693925. doi:10.1155/2015/693925
11Seifert T. Migraine with aura is the predominant phenotype among acute post-traumatic headache in sports. Neurology 2018 Dec;91(23, Supp 1):S28-S29.
12Ahmad H, Arshad Q, Roberts R, et a. lCHRONIC DIZZINESS POST TRAUMATIC BRAIN INJURY: A CROSS-SECTIONAL STUDY. Journal of Neurology, Neurosurgery & Psychiatry 2016;87:e1.
13Lambru G, Matharu M. Traumatic head injury in cluster headache: cause or effect? Curr Pain Headache Rep. 2012 Apr;16(2):162-9. doi: 10.1007/s11916-012-0248-0.
14Lucas S, Hoffman JM, Bell KR, Dikmen S. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia. 2014 Feb;34(2):93-102. doi: 10.1177/0333102413499645. Epub 2013 Aug 6.
15Ruff RL, Ruff SS, Wang XF. Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. J Rehabil Res Dev. 2008;45(7):941-52.
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