Headaches and Acquired or Traumatic Brain Injury - Fact Sheet

A strange feature is that the persistence of post traumatic headaches is not related to the severity of injury.

Most headaches following brain injury do not require surgical treatment. In some cases, particularly severe brain injury, surgical intervention may be required for conditions such as communicating hydrocephalus, carotid cavernous fistulas tension, pneumocephalus, brain abscesses and subdural haematomas. Appropriate clinical examination and diagnostic tests are needed to assess the form of treatment required.

Causes of Headaches

The brain itself is not a source of pain – ironically, nerves themselves don’t feel anything. Headaches arise from problems with a number of different structures both inside and outside the head. Those inside the head can be the dura, the venous sinuses, blood vessels and cranial nerves. Those outside the head can be the skin, muscles, nerves, arteries, and joint capsules, cavities within the head, nerves and the periosteum.

Should you be concerned?

When a headache first appears, how do you know whether it is something to be concerned about, or simply something which will go away with an over-the-counter pain killer, a glass of water and a lie down?

If you have a brain injury you should be concerned by novelty – any new or changed symptoms may be just part of life, but they may instead signal a worsening or even improving of your situation. See your doctor if you have any symptoms that are unusual, that unexpectedly increase in severity or that have a serious negative effect upon quality of life.

In addition to headaches that are caused by a brain injury, you may be having a reaction to medication, you may have an undiagnosed condition from the same event that resulted in the brain injury (for example whiplash from a car crash) or you may even have a completely unrelated medical condition.

The unfortunate truth is that some nerve damage, particularly in the neck or back, can result in incurable pain which must be treated with full-time medication. However there is nothing to be gained by putting up with pain until you can't do it any longer or by taking increasing amounts of over-the-counter medications until they are no longer effective.

What your doctor should be asking.

A post traumatic headache is only a symptom of an underlying disorder. Often a doctor may make this diagnosis and no further investigation is made of the problems causing the pain. The headache may be treated as neurovascular or migraine headache when the great majority are not primarily migraine type problems. There are different types of injuries that may create the pain generators of headache. Ideally your doctor should ask you questions about the injury.

Major types of headaches

The major types of headaches following trauma include musculoskeletal headache, tension-type headache and neuralgic (i.e. migraine) headache. Other rare causes of headache including seizure disorders, pneumocephalus (air in the head), cluster and paroxysmal hemicrania (severe and typically one-sided).

Appropriate medication could include tryptamines, ergotamine or corticosteroids. Relaxation training and biofeedback also should be considered. Newer techniques including the use of botulinum toxin injection into pericranial musculature should also be looked at.

There are many other types of headaches which can be diagnosed with tests such as MRI scanning of the brain, X-rays and magnetic resonance angiography.

Are headaches dangerous as well as unpleasant?

A headache can interfere with your judgement, cause fatigue and contribute to irritability or aggression as well as impair your ability to work, socialize or even simply keep your life in order. But is a headache directly dangerous?

Unfortunately, it seems that it is possible for a migraine to itself cause a brain injury. Studies have previously shown that migraine sufferers are at an increased risk of stroke and heart attacks and a recent study has found that during a migraine, as well as during stroke and head trauma, the brain can swell enough to restrict blood flow and starve cells of oxygen, a process known as Cortical Spreading Depression (CSD).

Medication

Pain management in brain injury is often difficult as medications may work against recovery. Many painkillers work against the re-emergence of the person’s mental and physical systems. Later, narcotics are a problem because of their potential for substance abuse and their negative side effect on the ability to think clearly.

Anti-inflammatory agents are appropriate for musculoskeletal pain, though doctors must stay alert for possible gastric problems. Patients with brain injury and spinal cord injury tend to have high acid content in the stomach and are susceptible to stomach ulcers which can be increased by these agents.

Antidepressants can be effective in controlling headache and nerve pain. These are not sedating except in high doses, and don’t depress the respiratory cycle.

Coping with Limitations

Lack of awareness, reduced attention and short-term memory and distrust can make it hard to help a person with a brain injury in coping with pain. First, the individual must understand the source of the pain. The pain should be explained in a manner that compensates for any cognitive deficits. Explanations should be provided in brief, concrete sentences. An understanding is needed of the benefits of treatment and how the treatment plan will help achieve these benefits.

Where to Get Help

There are support groups and medical facilities set up to help people cope with chronic pain. Contact your local doctor or Brain Injury Association to get the contact details in your state.

For more information on coping with chronic pain, see the Handling pain and brain injury fact sheet at www.braininjury.org.au

Further information