Headaches are extremely common and account for one of the leading causes of disability in the United States, studies show around 95% of people will experience a headache disorder at some stage in their life(1).
This high occurrence is also found post-concussion. Headaches are one of the most frequently reported symptoms, prevalent in both acute and post-concussion syndrome patients. In most cases, headaches are benign and result from “functional dysfunction” rather than structural damage or serious pathology.
However, in some extreme cases, headaches can be early warning signs of severe injury. Recognizing these early warning signs is crucial to determine when further evaluation and emergency care may be necessary.
Finding relief from your concussion headache can be a difficult journey so we provided you with a road map to one of the most common symptoms following concussion injuries, giving you key insight on your headache subtype.
Headaches can present in various forms resulting in a wide range of symptoms, such as dull, sharp, or throbbing pain, and can occur in different locations, like temporal (“side”) or posterior occipital (“back/bottom”) regions.
Each symptom is unique and can provide clues on the underlying cause of your headache. Understanding your headache type is the first stop on your recovery road map. This is an important stop because it can be a dangerous one if missed.
For concussion patients who have experienced recent head trauma, it is crucial to distinguish between primary and secondary headaches.
Primary headaches are the most common form of headaches, accounting for 98% of all cases.(1) These headaches occur when the headache itself is the main issue, rather than being a symptom of an underlying condition or disease.
Secondary headaches are more severe and concerning because they arise from an underlying pathology rather than being a standalone symptom (i.e., they are “secondary” to some other problem). These headaches can indicate serious conditions such as intracranial hemorrhage, skull fractures, or vascular issues.
In cases of post-concussion and post-head trauma, it is crucial to identify key signs and symptoms known as “red flags” to determine when your headache could be a secondary headache requiring urgent medical intervention.
Red flags refer to warning signs that can present after an injury, indicating the need for further evaluation or emergency care. These can be both subjective symptoms and objective, observable signs. Head trauma raises the potential for serious pathology, and recognizing red flags helps clinicians identify early warning signs of severe injury, ensuring timely intervention and appropriate care.
The Canadian CT Head Rules are a set of guidelines designed to help medical providers determine when a patient with a head injury requires a CT scan to rule out serious pathology.
While these rules are exclusively for medical providers to make clinical decisions, it is valuable to understand as an individual experiencing severe headache because it can help inform your decision to see an emergency medical provider or to further your understanding of why imagining may be necessary:
Once we’ve ruled out any serious underlying pathology through a thorough evaluation and detailed patient history, we can begin to understand different dysfunctions to pinpoint the exact cause of your symptoms.
Following a concussion, many symptoms, including headaches, stem from functional dysfunctions that fall into the category of primary headaches.
Research indicates that these symptoms typically dissipate within 5-7 days (3,4,5,6,7), due to the metabolic cascade that occurs after a concussion. It is normal to experience headaches during this period as the body deals with an initial energy deficit. Once the normal metabolic healing process is complete, any lingering symptoms are usually due to functional dysfunctions. If symptoms, including headaches, persist beyond 30 days, it may be indicative of post-concussion syndrome (PCS).
Post-concussion syndrome (PCS) occurs when symptoms persist beyond 30 days (as defined by the CISG in the 2022 Amsterdam Consensus)). PCS can present with a range of symptoms, either multiple or singular, with headaches being one of the most common and persistent symptoms. These headaches can arise from various dysfunctions that develop following a concussion.
The most common causes of post-concussion headaches include:
Let’s explore each of these dysfunctions, examining how headaches can manifest in each category, along with their causes, typical presentations, and treatment options.
The neurometabolic cascade refers to the injury process and returning to metabolic and cellular stability following a traumatic brain injury. Seminal research by Giza and Hovda in 2001, repeated in 2014 identified this neurometabolic cascade, which helps explain why post-concussion headaches may develop(8). Post-traumatic headaches typically present within the first week after the injury. These headaches are typically short-lived, not often lasting longer than 3 months and tend to improve as the body progresses toward metabolic recovery. (Ashina, H., Eigenbrodt, A. K., Seifert, T., Sinclair, A. J., Scher, A. I., Schytz, H. W., … & Ashina, M. (2021). Post-traumatic headache attributed to traumatic brain injury: classification, clinical characteristics, and treatment. The Lancet Neurology, 20(6), 460-469.)
Inflammation is a normal and healthy response to injury, playing a crucial role in healing and recovery. However, when inflammation becomes chronic, it can lead to issues, including persistent headaches.
An answer to why chronic inflammation develops after a concussion can be found by looking at the gut-brain axis.
Recent research has revealed that a concussion can increase intestinal permeability, commonly referred to as “leaky gut.” This condition occurs when the delicate lining of the intestines becomes compromised, and an increasing number of inflammatory particles to pass into the bloodstream. These particles can trigger an inflammatory immune response, which in turn creates systemic inflammation throughout the body. (9)
Dietary and lifestyle interventions, along with targeted supplementation, can be highly effective in reducing inflammation and alleviating headache symptoms by having a positive effect on gut permeability. The gut-brain axis also plays a significant role in brain function, studies showing it influences memory, mood, and anxiety levels.
Trained concussion specialists have the tools to identify whether chronic inflammation is contributing to your headache symptoms and can guide you in making the necessary modifications to your daily life for symptom relief.
After a concussion, studies have shown that cerebral blood flow can be altered. In some cases, this can result in more overt altered autonomic function like POTS. Dysautonomia occurs when the autonomic nervous system, largely responsible for regulating blood distribution to different parts of the body during various activities, becomes disrupted. This system normally controls functions like heart rate and blood pressure during movement, but after a concussion, it can become impaired, resulting in an oxygen and energy mismatch leading to headaches.
Dysautonomic headaches often arise after physical or mental exertion and increased activity. As your body attempts to meet the increased demands, the impaired blood flow can result in headaches.
Treatment options for “autonomic headaches” have been well-studied, particularly through the work of John Leddy at the University of Buffalo. The Buffalo Concussion Treadmill Test is a valuable tool used to determine if a impaired blood flow is causing your headaches. It helps identify your sub-symptom threshold, which is the specific heart rate at which you should begin exercising to achieve symptom relief and correct the underlying dysfunction.
Cervical pain and headaches are closely linked due to their proximity and shared muscle attachments. As a result, neck pain and headaches often occur together. The forces generated during a concussion injury (70-120 G’s) are more than sufficient to cause a cervical spine sprain or strain (4.5 G’s)(10).
A decrease in range of motion, joint restrictions, and increased muscle tension can all lead to referred headaches. One of the most common causes of headaches following a concussion is tension-type headache (TTH), often triggered by “trigger point referral.”
Trigger points are proposed to be dense bands of muscle fibers that form due to joint restrictions or poor movement patterns, both of which are common after head or neck trauma.
As outlined by Travell and Simons(11), trigger points have the ability to refer pain to different areas of the body. For instance, a trigger point in the upper trapezius muscle can refer pain to the eye, even though the trapezius muscle is neither attached to nor near the eye. This referred pain can manifest as headaches in specific regions of the head.
Treatment for cervicogenic headaches typically involves a combination of joint manipulation, soft tissue therapy, and functional rehabilitation. These approaches work together to restore proper movement patterns, alleviate muscle tension, and reduce joint restrictions, ultimately leading to symptom relief.
The visual system is one of the three primary systems that tell your brain where you are in space, along with the cervical spine and vestibular system, they work in combination to take stimuli from the world around you to give you an accurate representation of space and time.
When a concussion occurs, the mechanisms responsible for coordinating eye movements can become disrupted. This includes processes like tracking a moving target (smooth pursuit), focusing on a specific point (fixation), bring your eyes together as a target moves closer to your face (convergence), etc…
When one or more of these visual mechanisms are impaired, other systems must compensate, leading to compensatory patterns. As a result, certain muscles and neural pathways are forced to compensate, causing strain and overexertion. This excessive demand on the visual and muscular systems can lead to increased concentration strain and, ultimately, headaches. When all these mechanisms function seamlessly together, the risk of overexertion and subsequent headaches is significantly reduced.
Your trained concussion specialist may have you perform a Vestibular Oculomotor Screening (VOMS) to determine areas of dysfunction. The findings found on a VOMS assessment can easily be paired with at-home exercises to correct the underlying cause of your headache symptoms.
Headaches can be a sign of serious underlying pathology or simply a primary symptom. Understanding the root cause of headaches is crucial in determining what specific treatment is right for you.
Once identified, headache subtypes can provide further information on your recovery timeline. Recovery is not uniform; symptoms can fluctuate, disappear and reappear over time. The primary concern is not just the headache symptom itself but identifying its underlying cause. If the underlying cause can be identified then a clear road map to recovery can be established.
Working with a trained concussion specialist will not only help manage your symptoms but also address the root cause of your concussion-related headaches, leading to comprehensive and lasting relief.
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