Though common, headaches can be complex and elusive manifestations that can be difficult to treat. In general, there are over 150 kinds of headaches, from the dreaded “brain freeze” (yes, the National Institutes of Health includes this among its headache types) to the even more dreaded migraine. This vast diversity of headache types implies a wide variety of possible causes.

For clinicians who assist headache sufferers, this can make treatment a daunting task because knowing how to effectively treat something depends very much on knowing, first, what you are treating. This is true all the more for those who manage concussions, since concussion itself is a complex entity and the causes of headache in concussion sufferers can be explained by multiple phenomena.

This article serves as a guide for clinicians who wish to provide the best evidence-based care for patients with post-concussion headaches.

Headaches are one of the most typical symptoms reported after concussion. That being said, there is no such thing as a “concussion headache.” Rather, there are headaches that result from a concussion. Thus, it is better to call them concussion-related headaches.

For some patients, dysfunction in only one of these systems may be the culprit. For many, headaches will result from dysfunction in multiple regions. For example, a patient may be experiencing neck dysfunction secondary to a whiplash injury and blood flow abnormalities to their brain due to autonomic dysregulation. Both of these irregularities may result, or contribute to, headaches.

So, how do we offer treatment for something so potentially complex and multifaceted?

For clinicians, the precise cause of a patient’s post-concussion headaches—as common and predictable as the symptom might be—can be difficult to discern. But while the exact cause is not always clear at the onset, the most probable causes are. For this reason, the best way to treat a patient’s post-concussion headaches is to take a broad, careful, comprehensive, systematic, multimodal approach.

A Broad, Careful, Comprehensive, Systematic, Multimodal Approach.

So, what does this “broad, careful, comprehensive, systematic, multimodal approach” to treatment of concussion-related headaches look like in practice?

First—keep “first things” first. Since treatment is inextricably linked with the results of history-taking and physical examination, the three primary steps that precede and ultimately determine how best to treat concussion-related headaches include:

A good treatment plan is not something formulated arbitrarily, nor is it based solely on a practitioner’s preferences. A treatment plan should be a logical conclusion from more preliminary, carefully executed steps. So, steps 1-4 must come as a package deal.

Now let’s look at all four steps in some detail.

Step 1: Take a Thorough History.

As a trained clinician, you know how to execute good history-taking. Remember the principles you were taught in school and stay faithful to them.

For patients with post-concussion headaches, there is a critical distinction you will need to make. While all concussion-related headaches are post-concussion headaches, not all post-concussion headaches are concussion-related. Not every headache experienced after a concussion may be directly related to the head injury. So,

In fact, time could be the only thing relating a post-concussion headache to a concussion. Take Tom (an imaginary patient), for example: 

Tom suffered a concussion yesterday and is suffering from a tension-type headache today. To be sure, there is close temporal proximity between his head injury and his headache. At a glance, it seems obvious that this headache is related to the blow to the head he sustained yesterday. But what if Tom suffered from chronic tension-type headaches before sustaining his head injury? If so, it may be that some—or all—of his post-concussion headaches have no direct link to the brain injury he just sustained.

It is the clinician’s task to determine whether a patient’s post-concussion headaches are concussion-related. This is incredibly important, especially when making decisions concerning their return to school, work, and/or sport.

This distinction between post-concussion headaches and concussion-related headaches also highlights the importance of baseline testing. If a clinician has a valid baseline test at his disposal for a given patient who has suffered a brain injury, he will much more easily be able to determine the clinical significance of his patient’s post-injury symptoms, including headaches.

And of course, taking a good history will include ascertaining frequency, duration, intensity, character, relieving and aggravating factors, associated symptoms, and so on. The success of the steps that follow depend on this first step being done with thoroughness and precision. 

Take your time.

Ask all the questions.

Does the character, intensity, frequency and duration of your patient’s post-concussion headaches, and her associated symptoms, match those of her pre-concussion headaches? Let’s say they don’t. Her headaches are guilty until proven innocent—they are concussion-related.

Step 2: After a Thorough History, Conduct a Focused Physical Examination.

Step 3: Decide Top Differential Diagnoses

Now, there are two categories of headaches: primary and secondary. 

Primary headaches are idiopathic, and typically occur for no specific reason nor do they occur as the result of some other underlying cause. Examples include migraine headaches and tension-type headaches.

Secondary headaches occur directly as the result of underlying causes (usually of the head or neck). Most headaches are not secondary. An example of a secondary headache is a headache caused by an intracranial hemorrhage.

Your first priority as a healthcare provider managing patients with traumatic brain injuries is to rule out anything sinister. Thus, if your history and examination point toward a potentially life-threatening diagnosis, you must act quickly and get into emergent care immediately.

Is your patient’s headache a secondary headache?

Though rare, secondary headaches can be a warning sign of a more serious underlying condition. The SNOOP mnemonic may be used to screen for serious underlying causes of headache. SNOOP stands for:

S – systemic signs and symptoms

N – neurologic symptoms or signs

O – onset sudden

O – onset after the age of 40 years

P – change of headache pattern 

These details should be ascertained during your history and physical exam. Since 2003, when the SNOOP mnemonic was first proposed for primary care practitioners, more signs and symptoms have been added to the list. You can access the full list here.

Once you have ruled out secondary causes of your patient’s headaches, you will determine which primary headache is best indicated by the results of your history and physical exam.

Here are the diagnostic criteria for some of the more common primary headaches.

Migraine with/without aura

The famed neurologist and science writer Oliver Sacks writes in Migraine, “The cardinal symptoms of common migraine are headache and nausea . . . [but] great variability of symptoms is characteristic, not only of attacks in different patients, but between successive attacks in the same patient.” Migraine is a book-length reflection upon the many different—often perplexing—manifestations of this type of headache he had encountered in his practice.

The common migraine is most often unilateral, temporal (“behind the eye”), and usually lasts between 4-72 hours. They are moderate to severe intensity, often debilitating, and can have a pulsatile quality. Nausea or vomiting is often, but not always, present. The patient may report sensitivity to light (photophobia) and/or sound (phonophobia). Often, only resting in a quiet, dark room will relieve symptoms.

Migraine headaches may also be associated with an “aura.” The International Classification of Headache Disorders describes an aura as consisting of “visual and/or sensory and/or speech/language symptoms, but no motor weakness, and is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features and complete reversibility.”

Often migraine sufferers will describe which auras are typical for them. Some may experience an aura only some of the time.

Some who suffer from migraine headaches do not experience an aura at all.

Patients who have been suffering from migraines at a frequency of more than 15 days per month and a duration of over 3 months are classified as “chronic” migraine sufferers. Otherwise, migraine is classified as “episodic.”

Tension Headaches

Unlike migraines, tension-type headaches are typically bilateral. Patients may use words like “pressure” or “band-like” to describe their symptoms. These headaches may last minutes to days, may be associated with pericranial tenderness on palpation, and are mild or moderate in intensity. Episodes are often frequent for patients who suffer from tension-type headaches.

Also, in contrast to migraines, tension headaches do not produce nausea or vomiting, nor is sensitivity to light and/or sound reported. They are not aggravated by ordinary daily activities and do not interfere with routine activities as migraines do.

If a patient has suffered more than 15 tension-type headaches over a one month period for longer than 6 months, the headache is “chronic.” If less in frequency or duration, the tension headache is classified as “episodic.”

Cervicogenic Headaches

Cervicogenic headaches are secondary headaches caused by neck pathology. The underlying neck condition could be a soft tissue or joint disorder.

Like migraines, cervicogenic headaches usually affect one side of the head or face. Frequently, they begin at the suboccipital region of the neck and radiate unilaterally to the eye or the temple. Though the cervicogenic headache may present in similar fashion to a migraine, there are some differences to watch for. Unlike migraine, photophobia and phonophobia are rarely associated with cervicogenic headaches. Further, cervicogenic headaches do not tend to cause nausea or vomiting, nor are they as debilitating as migraines.

The hallmark signs of the cervicogenic headache are 1) associated neck pain or dysfunction, and 2) aggravation of the headache with neck movement. Clinical indications of neck-related headache include mechanical exacerbation of pain, reduced cervical range of motion, focal neck tenderness, and trigger points that refer to the head.

With these details in mind, you can now formulate a list of differential diagnoses pertaining to the headaches being suffered by your patient. It is important to remember that conditions don’t always happen with the clarity and coherence of a textbook description. So, your differential diagnosis list might evolve over time. The important thing is to narrow down your “best explanations” of the headaches to a few possibilities, and treat accordingly while remaining vigilant of any new rising signs or symptoms that may alter your primary diagnosis and thus your treatment plan.

Step 4: Provide treatment in accord with history and examination findings.

It is important to note the presence of any comorbidities that might influence your treatment decisions. These might include a history of conditions like:

• insomnia
• depression and/or anxiety
• hypertension
• asthma
• history of heart disease or stroke

When formulating a treatment plan, begin by making some basic, preliminary recommendations (diet, hydration, exercise, sleep) as part of your treatment plan for your patient with post-concussion headaches.

As you’ll recall, concussion injuries may cause dysfunction in a number of physiologic domains:

• the nervous system
• the visual system
• the circulatory system
• the gastrointestinal system
• the endocrine system
• the musculoskeletal system

Dysfunction in any of these areas may cause or exacerbate post-concussion headaches. As we have noted, it is often difficult to ascertain—especially in the initial days of treatment—which domains are most affected. Due to the etiological ambiguity that often exists in the beginning stages of concussion care, it is reasonable to initiate some degree of therapeutic intervention in all domains.

Your preliminary treatment recommendations, though broad and basic, will benefit all physiological systems simultaneously. This is the foundational part of any further focused treatment strategy you employ.

Preliminary Treatment Recommendations

• Clean up the diet.
• Recommend supplements.
• Optimize hydration.
• Exercise below symptom threshold
• Improve sleep quality.

These basic recommendations alone, especially when implemented together simultaneously, will provide a deceivingly powerful aid to recovery. Each recommendation is likely to positively enhance function and repair in all affected systems and tissues.

1. Clean up the diet.

Food is medicine. Simple dietary changes can have a hugely positive impact on concussion symptoms like headaches:

Recommendations include avoiding/reducing foods like:

• alcoholic drinks
• sweets
• preservatives/processed foods
• gluten (especially white breads and pastas)
• bad oils (vegetable, corn, safflower, margarine, canola, soy, peanut)
• dairy products

These foods are pro-inflammatory and can be replaced with healthier options like organic fruits and vegetables, fresh fish (especially salmon, mackerel, herring), and free range, grass fed meats.

Increasing “good” fats may also be beneficial (eg., olive oil, coconut oil, flax seed oil, avocado, almonds, etc) for a recuperating nervous system. These changes may help to offset an ongoing inflammatory response and reduce headache symptoms.

Increasing fermented foods like sauerkraut, kimchi, and kefir can assist in replenishing the gut microbiome with “good” flora, which has tremendous implications for both digestion and brain function. Fermented foods are at least as effective as probiotic supplements—if not better—and they taste far better.

2. Recommend supplements.

Although still in its infancy, there is increasing support for various supplements such as Omega-3 fatty acids, creatine, curcumin, magnesium glycinate, and Coenzyme Q10 (CoQ10). For post-concussion therapeutic protocols, these supplements should be taken at the recommended doses for either 4 weeks for acute cases or 8-12 weeks for chronic cases.

***Keep in mind these are general recommendations and other considerations (age, pregnancy, comorbidities, drug interactions, etc) should be considered before making actual supplement recommendations to patients.

Omega-3 fatty acids are essential for brain development and healthy function. They have also been shown to have an anti-inflammatory effect on the brain. Studies in animal models have suggested that omega-3 supplementation improves cognitive function, reduces nerve swelling, stabilizes cellular energy production and increases nerve repair. Two common forms are EPA and DHA. While both are beneficial, a high DHA supplement is recommended since it is found more abundantly in the brain. 1.5g of high DHA supplement, twice daily, is recommended.

Creatine monohydrate is another supplement that has shown promise in traumatic brain injury research. Creatine is a molecule stored in the muscles, brain, and other organs that plays a key role in maintaining energy homeostasis. Not only can it replace decreased creatine levels resulting from concussion, but it can reduce symptoms and speed recovery. As one study puts it, “There is significant overlap between the neuropathology of mild traumatic brain injury (mTBI) and the cellular role of creatine, as well as evidence of neural creatine alterations after mTBI.” Dosing should be no more than 5g per day.

Curcumin is another supplement that may be beneficial due to its high potential to reduce neuro-inflammation and oxidative stress. To optimize its anti-inflammatory and antioxidant properties, the recommended dose for concussion recovery is 400 mg 3 times daily, with food. To maximize absorption, supplements should be taken with black pepper or healthy fats.

Magnesium plays a wide variety of roles in human physiology, and having adequate levels is critical to an optimally functioning nervous system. Magnesium supplementation has been shown to have a therapeutic effect for headache sufferers, including migraine and tension-type headache sufferers. Studies indicate that magnesium levels plummet with traumatic brain injury, and thus magnesium supplementation may play an important role in post-concussion treatment. Magnesium glycinate is the recommended form as it is easier on the stomach compared to others. Recommended daily dose is 200-400 mg for a post-concussion protocol.

CoQ10 is a molecule produced in the body that aids mitochondria during energy production and is a part of the endogenous antioxidant system. In multiple studies, CoQ10 has been shown to have beneficial effects in reducing duration and frequency of migraine attack. Recommended dose is 100 mg, 3 times per day (300 mg total per day).

3. Optimize hydration.

The human body is about 60% water. The brain is over 70% water. It goes without saying, then, just how important hydration is for concussion recovery specifically and human performance in general. Studies indicate that even mild dehydration can impair brain function. For instance, a study published in The Journal of Nutrition concluded that “in healthy young women, mild levels of dehydration result in adverse changes in key mood states such as vigor and fatigue as well as increased headaches and difficulty concentrating.” Several other quality studies have reported similar findings.

In general, it is well established that dehydration can be the sole cause of headaches in otherwise healthy individuals. People recovering from a traumatic brain injury should, all the more, stay properly hydrated.

So, how much water should our patients be drinking? The general recommendation is about 2-3 L per day but challenge your patient to drink at least 3 L per day. You should also encourage your patient to refrain from dehydrators like coffee, tea, energy drinks, and alcohol.

And yes, you might as well acknowledge at the onset that hydrating more—even without the dehydrators—will mean peeing more. Just reassure that this is a small price to pay, annoying as it is, for what is gained in exchange. Dehydration is one of the great enemies of recovery and performance.

Now a pro tip for your patients (and perhaps for you too!):

Remember that an eight hour sleep is an eight hour fast. Unless you’re hooked up to an IV, a good night’s sleep is always going to leave you under-hydrated. Consuming a large shot of water first thing in the morning will get the brain and body on track immediately at the day’s onset, raising the likelihood of healing and performance optimization.

Begin each day, immediately upon waking, by downing a large (.5 to 1 L) drink of water with a pinch of salt. After this, during the first hour of the day—while you pray, or meditate, or read, or plan your day—keep a glass or bottle of water close at hand to sip on.

4. Exercise below symptom threshold.

A common consequence of concussion and associated whiplash injuries to the cervical spine is blood flow dysregulation to the brain. Unimpeded and properly regulated blood flow to the brain (and throughout the body) is known to be an important consideration in headache etiology as well.

Exercise is an excellent way to restore proper blood flow to the brain and, in turn, may be part of (or entirely) the solution to the headaches being suffered by your concussed patients.

Encourage your patient to be as physically active as they can be provided they are not exacerbating their symptoms (though they may still be symptomatic) and as long as they are avoiding any high risk activities that put them at an increased risk for a second impact.

For athletes or people who are ordinarily very physically active, you may choose to run a Buffalo Treadmill Test at 5-7 days post-concussion to determine exactly what your patient’s sub-symptom threshold is (or at what intensity they can exercise before increasing symptoms). This will then inform your exercise recommendations and expedite their recovery and return-to-play.

5. Improve sleep quality.

Not only is lack of sleep associated with headache onset in general, but it is also linked with an increase in headache severity.

The average healthy adult requires 7-8 hours of quality sleep per night. Someone recovering from a brain injury needs more, for it is during sleep—and especially during the deepest phases of a night’s sleep—that most of the body’s restorative processes really take off.

This can be a tricky element of the post-concussion treatment plan because a common symptom of concussion is difficulty sleeping. Given both the importance of sleep for recovery and the common post-concussive predisposition to sleep deprivation, the care provider is obliged to offer advice and reassurance in this critical area.

Here are some recommendations you may provide to your patients to increase sleep quality:

• Get up at the same time every morning.
• Avoid caffeine
• Exercise in the morning
• Lower room temperature during sleep period.
• Avoid bright light after supper
• Avoid napping during the day (or keep the nap to less than 20 mins)
• Take potentially sleep assisting supplements like melatonin or magnesium

With the foundations for recovery in place—diet, hydration, exercise, sleep—you can now provide specialized, evidence-based treatment in accord with whichever headache profile best fits what your patient is experiencing.

Primary Headache Treatment Recommendations:

What kind of headache are you treating? Does your patient’s post-concussion headache take on more of a migraine quality? Are they unilateral and associated with nausea and sensitivity to light?

Are they associated with neck pain and made worse by cervical spine movement? Are they bilateral and feel band-like like tension headaches?

Based on whatever you ascertain from the history and physical examination, you will now add a more specific, evidence-based headache treatment protocol to your concussion management plan.

Final Thoughts.

If a patient comes to you with a head injury and related pain in their head, you have a plethora of treatment options at your fingertips. But remember: your first duty is to check for red flags, that is, to rule out an emergent cause of headache.

Though your patient may be inclined to turn immediately to nonsteroidal anti-inflammatory drugs, reassure them that there are plenty of other conservative options that may help them. (In the beginning hours and days after concussion, pain medications are discouraged anyhow because they can mask concussion symptoms that may be important to be aware of.)

Finally, it is important to remember that treatment is not just something the clinician does. It is a partnership between clinician and patient, and requires an alliance on both ends. You must do your part, but your patients must do theirs as well. Keep an open line of communication with your patients and always be ready to adapt the plan. Further, as you offer your treatment plan and move forward with it, don’t over promise on the anticipated outcomes but assume a balanced posture that exudes both reassurance and realism, optimism and patience.

Almost always, if you remain faithful to evidence-based protocols such as those adopted by the professionals in Complete Concussions clinics, your patients will get better—the headaches go away. People will get their lives back. And when they do, the people you have helped will be more thankful for your assistance than you will ever know.