After sustaining a concussion, also called mild traumatic brain injury (mTBI), one of the most common symptoms is post-traumatic headache. After a head injury, a headache can be caused by a variety of factors, including neck pain, changes in visual or vestibular function, mental health disorders, lack of sleep, and hormone changes, among others.
In a recent study, 74% of adolescents who reported to the emergency department after sustaining a head injury were experiencing headache symptoms at the time of intake (Ledoux et al., 2022).
Logically, to control headache symptoms, many patients want to turn to different pain medications to help reduce their symptoms. They feel like their headache is limiting their ability to focus on school and work, and reducing their headache will mean that they can more easily get back to everyday activities.
But is controlling headache symptoms with medications always the best idea?
In this blog post, we will discuss why taking pain medications for post-traumatic headaches may lead to some unintended consequences and why, in many cases, you may be better off avoiding medications while using other non-medication-based strategies to control your symptoms.
There are many different types of pain medications, each with its mechanism of action. For our discussion, we are going to focus mainly on NSAIDs and acetaminophen.
Opioids and other analgesics are not recommended for prolonged treatment of headaches so we will leave them out of our discussion.
NSAID stands for Non-Steroidal Anti-Inflammatory Drug and is a class of drugs that works primarily by blocking the COX family of enzymes that produce a group of inflammatory molecules called prostaglandins.
Some common examples of NSAIDs are:
NSAIDs are generally used for pain and inflammation management in acute injuries. Long-term overuse of NSAIDs (over months to years) can lead to some potentially severe side effects such as stomach ulcers and bleeding, kidney problems, and increased risk of heart attack or stroke.
Acetaminophen (Tylenol) is actually not an NSAID as its action for pain management is more related to blocking pain signaling than reducing inflammation in tissues. It can also help relieve pain after an acute injury. It may have more or less of an effect on pain depending on what condition it is being used for.
In addition, it has different risks associated with prolonged use, most notably the risk of liver damage.
“Acetaminophen toxicity is the second most common cause of liver transplantation worldwide and the most common in the U.S. It is responsible for 56,000 emergency department visits, 2600 hospitalizations, and 500 deaths per year in the United States. Fifty percent of these are unintentional overdoses.”
– Agrawal S, Khazaeni B. Acetaminophen Toxicity. [Updated 2023 Jun 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441917/
One important note is that – generally – NSAIDs and other pain medications are not interchangeable because of their notably different mechanisms of action.
It is very important to consult with a healthcare professional or pharmacist before taking NSAIDs or other pain medications to make sure that it is both an appropriate medication for your condition and that there are no potential side effects to using that medication, such as allergies or interactions with other drugs or medical conditions.
Pain medications are commonly used to treat various conditions today, so we generally regard them as first-line treatment for multiple conditions. However, in the case of concussions, the prolonged use of pain medication may worsen your concussion recovery rather than improve it.
Just because you are not feeling the symptoms of a headache doesn’t mean that your concussion is recovering optimally.
While initial symptom management of a concussion via the use of NSAIDs may intuitively sound like the best course of action, there are a few key points that need to be remembered:
Let’s expand on each of these points as they relate to concussion (mTBI) recovery.
As we previously discussed, the most common symptom after a concussion is post-traumatic headache. Many people then turn to pain medications to try and reduce their symptoms after injury. As it turns out, that may not be the best idea after all.
The recovery process after a concussion includes a step-wise, gradual return to school, work, and physical activity as laid out by these guidelines. To progress from one stage of recovery to the next, you need to be symptom-free in the previous stage for at least 24 hours.
The problem arises if you are using pain medications to lessen or mask your headache symptoms. You may not be aware of when you are entirely symptom-free in any given stage, and you may be progressing through the stages too quickly.
For example, if you are using pain medications to make it through a day in the office because the lighting and computer screen worsen your headache, you are actually not ready to be at that stage. That means you are overusing your brain for its current level of recovery, which can prolong symptom duration.
Additionally, if you are masking symptoms with medications, you may be more likely to return to physical activity too early and expose yourself to a second head injury before your first head injury has fully recovered.
Being fully aware of your symptoms because you are not masking them with painkillers, means that you will be more able to pace your activity correctly, take breaks as needed, and not take on too much cognitive load for your brain’s capacity.
This is most relevant in the acute (20-48hr) period after a concussion when we monitor for red flags. While intracranial bleeding after a concussion is relatively rare, it is estimated that 5-10% of mild traumatic brain injuries will have some intracranial bleeding, with it being more common in males and older adults (Bonney et al., 2020).
Symptoms of more severe conditions after a concussion, including brain bleeding, are:
You will want to consult a healthcare practitioner before starting an early course of any pain medications after sustaining a head injury because you also don’t want to be masking these symptoms of a potentially serious head injury such as brain bleeding.
In addition, NSAID medications act as blood thinners, so if there is an intracranial bleed present, blood thinners can increase the rate of bleeding and potentially increase the seriousness of the bleed. Therefore, pain medications from the NSAID family, including ibuprofen (Advil, Motrin) and acetylsalicylic acid (Aspirin), should be avoided in the first 24 hours after a concussion.
The good news is that acetaminophen (Tylenol) does not act as a blood thinner, so your healthcare provider may recommend a short course of acetaminophen for pain management once they have ruled out any more serious underlying conditions.
For a reminder of the red flag symptoms of a concussion, please see our other blog post here.
Rebound headaches, sometimes called “Medication Overuse Headaches (MOH),” are a potential side effect of prolonged pain medication use after post-traumatic head injury. A rebound headache occurs after the medication that you are taking to control your headache has worn off, leading to a worse “rebounding” headache than you had before you took the medication. This can lead to more medication use, and the vicious cycle continues.
The general recommendations to prevent rebound headaches from occurring are using medications to control headaches less than 15 days per month for simple over-the-counter drugs and less than 10 days per month for opiates or triptans (Fischer et al., 2023).
If you believe that you may be experiencing rebound/MOH headaches due to medication use, a great way to monitor is to keep a headache diary including headache frequency, intensity, medication use that day, sleep quality, meal timing, etc.
This diary can be very helpful for your medical provider as it gives them in-depth insight into your headache profile and will allow them to recommend the appropriate treatment for your specific condition.
Post-traumatic headaches are classified as secondary headaches, meaning that they are headaches caused by something else (i.e., another condition). However, it is also possible that after sustaining a concussion, there is a worsening of a different primary headache, such as migraines or tension-type headaches.
If this is the case, your medical provider may suggest medication to help control your symptoms that is not an over-the-counter analgesic but more specific to the condition you are experiencing – or a non-medicinal treatment (e.g., manual therapy, corrective exercise, etc.).
Headache symptoms from various causes can overlap, change, and shift, so it can be difficult sometimes to know exactly what type of headache you are experiencing. As previously recommended, this is a great reason to maintain a headache journal and seek out the advice of a trained concussion management provider.
The effect of NSAIDs on the healing of various tissues in the body is a growing area of research, but generally, trends toward the idea that NSAIDs may impair the healing of various injuries. This is thought to be due to their inhibition of inflammation, which is critical for the healing process (Wheatley et al., 2019).
Unfortunately, there are no randomized control trials on the effects of taking NSAIDs and concussion recovery time specifically. Some researchers have looked at concussion databases comparing people who did or did not take medication and how long it took for them to recover from a concussion. The results were generally mixed (Ledoux et al., 2022; Petrelli et al., 2017).
There is currently no evidence as to whether NSAID overuse can slow concussion recovery, but in other muscle and joint conditions, there is emerging evidence that NSAID use may actually increase healing time because it delays the healing response (DuBois, 2020).
We don’t have enough data to say one way or the other about concussions. Still, it may be better to err on the safe side and try to limit NSAID use after a concussion until more data is available, and if for no other reason than to minimize the chance of a “false/masked” clearance decision.
If you are struggling with post-traumatic headaches and are looking for non-medication-based treatment options, we have a variety of other blog posts that can give you in-depth advice and guidance on your different options.
Here are some of our most popular:
Generally, headache management is multifactorial, with no one treatment effectively managing headaches in all patients. Therefore, maintaining a consistent bedtime and wake time, consuming consistent meals with no skipped or delayed meals, good hydration, regular low-intensity cardiovascular exercise, use of relaxation, stress management, and mindfulness-based strategies are all good practices to optimize your recovery, and limiting the symptom burden of headaches (Silverburg et al., 2019).
In conclusion, headaches after a traumatic brain injury are a very common symptom that can have a significant effect on your ability to get back to your daily activities. While it may seem like taking pain medications to reduce the headache is making your concussion better, it may just be masking the symptoms and leading to less-than-optimal recovery.
In general, medication should be avoided in the first 24-48 hours, especially the NSAID class of drugs, as they can mask red flag symptoms and may increase the risk of brain bleeding. After the first 48 hours, pain medications are safe to take. Still, you should take the lowest effective dose to control your symptoms to reduce your risk of rebound headaches and ensure that you are not pushing your brain too hard during the recovery process. Remember, taking pain medication does not improve recovery time; if anything, it may increase it.
If you have any questions or concerns about using medication to control your concussion symptoms, you should reach out to a healthcare practitioner who is trained in concussion management.
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