December 15, 2022
As the holiday season approaches, concussion recovery can become especially challenging. The hustle and bustle of the holidays often bring increased social expectations and overwhelming schedules that can cause additional…
Not many people go through life without experiencing at least one or two headaches. In fact, the stats show that about 95% of people will experience a headache at some point in their life, making headaches one of the top 10 causes of disability around the globe.
But not all headaches are alike, particularly those following a concussion. And it’s really important to know what type of headache you have, because knowing the type of headache will ultimately define what the treatment should be.
Complete Concussion Management (CCMI) system data shows that 82% of patients report having a headache 30 days after their concussion. However, only 78% of patients report having a headache within the first 10 days. So, the headache that comes on with concussion doesn’t necessarily mean that it’s due to the concussive injury, right as it happened. It may be something that happens after the fact. These headaches are called secondary headaches or post-traumatic headaches.
Secondary headaches develop within seven days after head trauma, and they can persist for months or even years.
The most common post-traumatic headaches are tension type, migraine, cervicogenic, ice pick headaches, occipital neuralgia, and something called medication overuse or rebound headaches.
Let’s take a look at each one.
The previous thought process on migraine headaches was that a reduction in blood flow to an area of the brain would cause, in some patients, what’s commonly known as an ‘aura’. This is where you may see color patterns. Over a 15-20-minute period, these patterns can creep into an individual’s visual field, and potentially even cause the temporary impairment of vision. This is typically the signal that a migraine is on its way. Once the headache begins, it comes on strong, and the aura (if present) immediately subsides.
Not everyone will experience auras prior to a migraine. The thinking used to be that a restriction of blood flow is what caused the aura, and the body reacted by dilating blood vessels, causing a massive, pounding, pulsatile type migraine headache.
Now we’re learning a little more about migraines and interestingly, the pathophysiology, or the process that occurs with migraine headaches, is very similar to what happens in concussion. It starts with an excitatory phase, followed by a release of pain enhancing chemicals causing your pain receptors to become more responsive.
Migraine headaches are generally throbbing and pulsatile in nature, usually on one side of the head and may be accompanied by nauseousness, vomiting and sensitivity to light and/or noise. They also have a definite end point, with the timeline for a migraine lasting anywhere from 3 to 72 hours in duration.
Typical treatment for migraine headaches is abortive medication. If you’re on one or more forms of medication and it does not resolve the pain, there’s a good chance the headache has been misdiagnosed.
There are also preventative type medications such as Botox injections, which paralyze certain muscles in the head and/or neck so they can no longer cause a pain referral. Another preventative treatment is avoidance of known triggers. For some this may be avoiding strenuous exercise, alcohol, or certain foods.
The best treatment for concussion patients, who have an injury and are dealing with inflammation, is to reduce that inflammation. This is why we have our patients focus on things like reducing their consumption of refined sugars, reducing stress, and getting increased (and better) sleep. All these things can help to reduce the chance of experiencing migraine headaches after a concussion.
There is also some overlap in headache types. Neck dysfunction may also contribute to migraine due to the Trigeminocervical Nucleus (TCN), located in the upper brainstem. This is where pain responses can cross over and intermingle with pain signals from the upper neck, resulting in referred pain through the trigeminal nerve and migraine headache.
The way we think about treating headaches in general at CCMI is to start with treatments that create lasting change and will be better for the patient long term, such as focusing on reducing inflammation. If that doesn’t work, we can always look into introducing medication. Often in healthcare we see the exact opposite, resulting in dependencies to those medications. For us, medications are always the very last resort.
These two headaches types are caused by similar things. Your neck is called your cervical spine, so ‘cervicogenic headache’ just means a headache that’s originating from the tissues of the neck (muscles and joints).
Tension type headaches involve muscles in the head, neck and face. So, things like your tiny upper neck muscles, your temporalis muscles on the head, your masseter muscles on the face and others can generate a tension type of pain that refers to your head.
Cervicogenic headaches are very common in PCS because whiplash and concussion occur at the same time. Both concussions and whiplash are caused by acceleration / deceleration injuries. Concussion requires forces anywhere in the neighbourhood of 60 to 120 Gs of acceleration and deceleration, while whiplash only takes four and a half.
So, if you’ve experienced a concussion, you’ve also received a whiplash, there’s just no way to avoid it. Due to this, you will have an underlying neck injury, which may result in neck dysfunction, and in turn create pain radiating up into the head. In some cases, your neck may not hurt at all, and so, many healthcare providers may miss the actual root cause of your headache.
Cervicogenic headaches can often be misdiagnosed as migraines, and as a result patients’ will be provided with medications that simply don’t work, because they’re not focused on the right mechanism.
The real mechanism is muscle and joint tension. Therefore, the medication that’s trying to stop the physiological process of the migraine is not going to be an effective form of treatment for that person.
Migraines are throbbing and pulsatile headaches, whereas cervicogenic and tension type headaches are characterized by dull, constant, aching pain that lasts anywhere between one hour and one week. These headaches may also be accompanied by nauseousness, vomiting, dizziness, sensitivity to light and noise, blurred vision, and are usually located on the same side of the head.
Again, we see a lot of patients prescribed medications to deal with cervicogenic and tension type headaches, when often physical therapy and light exercise is the right way to go.
The greater and lesser occipital nerves originate from the little muscles in the back of your head and travel up the back of the scalp. If there’s too much pressure on these nerves, which can be due to arthritis in the upper part of the neck or muscle tension, it can cause them to become extremely irritated.
When a headache has more of a burning sensation rather than a dull throb or sharp stab, we know that we’re looking at some sort of nerve-type pain. Just remember dull throb is muscular pain… sharp stab is usually joint pain… and a burning sensation means nerve pain.
Occipital neuralgia is a nerve-based pain characterized by a constant burning or stabbing pain that can last anywhere from weeks to months.
Medications such as over the counter anti-inflammatories and muscle relaxants are often prescribed in these cases. Sometimes nerve blocks or Botox injections are prescribed to relieve tension on the muscles in the back of the head. Again, we tend to focus on natural, long-lasting treatments and recommend our patients get manual therapy to relieve the nerve tension.
These are very severe and sharp headaches that come out of nowhere. Luckily they only last about 5 to 10 seconds and then they’re gone. There are also no lingering effects.
They’re called icepick headaches because you’re sitting there, minding your business when all of a sudden, and without warning, it feels like someone has stabbed you in the head with an icepick. There is intense pain for a few seconds and then, it’s all over.
While these headaches are intense, they are totally benign and non-life-threatening. The verdict is still out on what exactly causes these headaches. Because they happen so quickly, there’s no real way to study them.
To review, icepick headaches, though totally benign, are very severe and sharp in nature and typically last between 5 to 10 seconds.
These types of headaches are quite common in concussion patients. In extreme cases, a patient may be prescribed prophylactic medications similar to the ones commonly prescribed for migraines. At CCMI, we always have patients start with the basics: reduce your stress, reduce your inflammation, improve your sleep, exercise more and eat right. We have also had success with neck manual therapy.
Rebound headaches are extremely common, particularly in concussion patients because they are caused by taking medications over and over again to treat the headache! So, it’s a vicious cycle.
Tylenol is notorious for causing rebound headaches. You get a headache; you reach for Tylenol and it takes the pain away. Do this enough and over time your body will form a dependency. Now when you DON’T take Tylenol, you get a headache, which is actually a withdrawal symptom. Hence the term “rebound headache.”
When you create a dependency to over-the-counter pain medications, it is incredibly difficult to remove them, because your headaches seem to get worse. The worst offenders tend to be aspirin, acetaminophen, Excedrin, opioids and migraine medications. Again, once you’re not taking your migraine medication anymore, you start getting headaches, so you think your migraines are back.
Rebound headaches are characterized by a constant dull or aching pain. Unlike tension or cervicogenic headaches, rebound headaches typically begin 2 – 10 days after discontinuing a medication.
Our recommended treatment is to find natural non-prescription remedies for your headaches, so you don’t become dependent on pain relievers. This is exactly why we leave medication intervention as a very last resort.
These are the ones that should be taken very seriously right away. These are headaches that could be indicative of an aneurysm or stroke. They come on suddenly, out of nowhere and are very severe; commonly termed ‘Thunderclap Headaches’. Unlike icepick headaches, scary headaches do NOT go away after a few seconds. They actually get worse and more intense over time because something more serious is occurring. No medication and no amount of rest will help.
Get to an emergency room as soon as possible.
When we have a patient that comes in after a concussion, the first thing we do is put them on a treadmill, because we’re looking for any blood flow issues that may be leading to their headaches. If they don’t show any blood flow issues, then we move into the next phase of assessment, which is usually looking at potential vestibular and ocular motor issues. After that, we’re going to assess the neck.
While assessing the neck, we’ll palpate (push on) various tissues and joints to try and provoke or recreate the headache following typical referral patterns. Once we know the referral patterns and can reproduce or increase the severity of the headache, then we can identify exactly what’s causing it.
This means we can determine the targeted or RIGHT treatment to relieve your headache in a natural and permanent way.
The below table is a summary of the common headaches types discussed above and a good reference to review against your symptom patterns and characteristics.
The biggest takeaway is that no matter what type of headache (except for scary headaches which require immediate medical attention), the first line of defence should never be medication. At CCMI, we always start with treatments that are natural, restorative and long-lasting. Let’s reduce inflammation and reduce stress. Let’s clean up the diet and aim for more sleep and exercise. If the root cause of your headache is a neck injury, then let’s focus on treating your neck issues.
By leaving medications as a last resort for treatment, patients have less side effects and longer lasting results. We also connect patients with chiropractors and physiotherapists who can relieve tension and joint issues and improve neck function.
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