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The most common symptom of post-concussive syndrome (PCS) is post-traumatic headache (PTH) accompanied by photophobia. Post-traumatic headache is currently categorized as a secondary headache disorder with a clinical phenotype described by its main features and resembling one of the primary headache disorders: tension, migraine, migraine-like cluster. Although PTH is often treated with medication used for primary headache disorders, the underlying mechanism for PTH has yet to be elucidated. The goal of this narrative literature review is to determine the current level of knowledge of these PTHs and photophobia in mild traumatic brain injury (mTBI) in order to guide further research and attempt to discover the underlying mechanism to both symptoms. The ultimate purpose is to better understand the pathophysiology of these symptoms in order to provide better and more targeted care to afflicted patients. A review of the literature was conducted using the databases CINAHL, EMBASE, PubMed. All papers were screened for sections on pathophysiology of PTH or photophobia in mTBI patients. Our paper summarizes current hypotheses. Although the exact pathophysiology of PTH and photophobia in mTBI remains to be determined, we highlight several interesting findings and avenues for future research, including central and peripheral explanations for PTH, neuroinflammation, cortical spreading depolarization and the role of glutamate excitotoxicity. We discuss the possible neuroanatomical pathways for photophobia and hypothesize a possible common pathophysiological basis between PTH and photophobia.

Background: Post-traumatic headache is the most common and long-lasting impairment observed following mild traumatic brain injury, and frequently has migraine-like characteristics. The mechanisms underlying progression from mild traumatic brain injury to post-traumatic headache are not fully understood. The aim of this study was to develop a mouse model of post-traumatic headache and identify mechanisms and novel targets associated with this disorder., Methods: We combined the closed head weight-drop method and the nitroglycerin chronic migraine model. To induce mild traumatic brain injury, a weight was dropped onto intact crania of mildly anesthetized mice, and mechanical responses to chronic-intermittent administration of nitroglycerin, a human migraine trigger, were determined at multiple time points post-injury., Results: Low dose nitroglycerin (0.1 mg/kg) evoked acute periorbital and hind paw allodynia in both mild traumatic brain injury and sham animals. However, only mild traumatic brain injury mice developed chronic hypersensitivity to low dose nitroglycerin. Migraine medications, sumatriptan and topiramate, inhibited post-traumatic headache-associated allodynia. In addition, the delta opioid receptor agonist, SNC80, also blocked post-traumatic headache-associated allodynia. Finally, we examined the expression of calcitonin gene-related peptide within this model and found that it was increased in trigeminal ganglia two weeks post-mild traumatic brain injury., Conclusions: Overall, we have established a mouse model of post-traumatic headache and identified the delta opioid receptor as a novel therapeutic target for this disorder.

Background: Most persistent posttraumatic headaches (PPTH) have a phenotype that meets diagnostic criteria for migraine or probable migraine. Although symptoms of autonomic dysfunction have been well described among those with migraine, the presence and relative severity of such symptoms among those with PPTH have yet to be reported., Objective: The objective of this study was to assess and compare symptoms of autonomic dysfunction among those with PPTH attributed to mild traumatic brain injury (mTBI) vs migraine vs healthy controls using Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire scores., Methods: Individuals with PPTH (n = 56) (87.5% of whom had a migraine/probable migraine phenotype), migraine (n = 30), and healthy controls (n = 36) were prospectively assessed in this cross-sectional cohort study using the COMPASS-31 questionnaire. Total COMPASS-31 scores and individual domain scores (bladder, gastrointestinal, orthostatic intolerance, pupillomotor, secretomotor, vasomotor) were compared between subject groups., Results: COMPASS-31 mean total weighted score was 37.22 ± 15.44 in the PPTH group, 27.15 ± 14.37 in the migraine group, and 11.67 ± 8.98 for healthy controls. COMPASS-31 mean weighted total scores were significantly higher in those with PPTH vs migraine (P = .014), for PPTH vs healthy controls (P = .001), and for migraine vs healthy controls (P = .001). Those with PPTH had numerically higher scores for all COMPASS-31 domains compared to those with migraine, and the domain scores were significantly higher for orthostatic intolerance (PPTH = 4.80 ± 2.47 vs migraine = 3.33 ± 2.31, P = .027) and bladder (PPTH = 1.14 ± 1.45 vs migraine = 0.47 ± 0.73, P = .020). Among individuals with PPTH, post hoc correlations indicated a positive association between number of total lifetime TBIs with total weighted COMPASS-31 scores (rho = 0.32, P = .020), between years lived with headache and vasomotor domain subscores (rho = 0.27; P = .044), and between headache frequency with vasomotor domain subscores (rho = 0.27; P = .041)., Conclusions: Symptoms of autonomic dysfunction were greatest among those with PPTH compared to migraine and healthy controls. Among individuals with PPTH, number of lifetime TBIs was associated with greater symptoms of autonomic dysfunction, while greater headache burden was associated with higher vasomotor domain autonomic dysfunction subscores, potentially indicating that PPTH patients with higher disease burden have an increased risk for having autonomic dysfunction. Symptoms of autonomic dysfunction should be ascertained during the clinical management of patients with PPTH and might be a characteristic that helps differentiate PPTH from migraine., (© 2018 American Headache Society.)

Purpose of Review: The purpose of this review is to (1) describe factors both pre- and post-injury that are associated with post-concussion headache, (2) describe the influence of post-concussion headache on recovery following concussion, and (3) provide potential post-concussion treatment options that may reduce the burden of headache, as well as other symptoms to facilitate recovery., Recent Findings: Various factors may be associated with post-concussion headache presentation. These may include pre-injury or historical factors such as sex, family and self-history of headache and migraine, concussion history, and mood disorders. In addition, post-injury presentation factors for consideration may include injury mechanism, symptom clusters, cervicogenic dysfunction, and post-concussion physiologic dysfunction. Despite this complex interplay of factors, many treatment options may improve headache symptoms and recovery post-concussion including rehabilitation programs focusing on deficits such as visual-vestibular dysfunction, sub-symptom threshold exercise, and potential pharmacological interventions. Concussion is a complex injury that results in a variety of sequelae with headache being one of the most common. Understanding factors related to post-concussion headache presentation and the available options for treatment may improve patient care and outcomes post-concussion.

Background: Cerebral edema peaks 36-72 h after moderate traumatic brain injury but thought to be uncommon after mild traumatic brain injury. Post-traumatic headache can develop 48-72 h post-injury, perhaps reflecting the developing cerebral edema. Pseudotumor cerebri can result from various causes, including cerebral edema, and is characterized by increased intracranial pressure, headache, visual, and other common symptoms. Our objective was to report a phenotypically identifiable post-traumatic headache subtype., Case Series Presentation: This case series of six pediatric patients with post-traumatic pseudotumor cerebri was assessed at 48-120 h post-primary injury with new or a change in symptoms such as headache, vision, auditory, balance, and cognition. Clinical findings included slight fever, neck/head pain, papilledema or cranial nerve deficit (6th), and lack of coordination. Elevated cerebral spinal fluid pressure was documented by lumbar puncture, with no infection. Symptoms improved with treatment specific to post-traumatic headache subtype (lumbar puncture, topiramate, or acetazolamide)., Conclusions: Recognition of specific post-traumatic headache subtypes after mild traumatic brain injury will expedite treatment intervention to lower intracranial pressure and resolve symptoms.

In the United States, up to 3.8 million people per year have sports-related mild traumatic brain injury frequently followed by a variety of headaches. Headaches associated with sports (exertional, weightlifter's, and external compression headache) are also reviewed., (© 2018 American Headache Society.)

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61-e68.]., (Copyright 2018, SLACK Incorporated.)

Aims: To investigate pain sensitivity by using quantitative sensory testing in older women with and without cervicogenic headache., Methods: A total of 18 older women (mean age ± standard deviation [SD] 64.28 ± 3.21 years) with cervicogenic headache and 17 healthy controls (65.18 ± 3.89 years) participated in the study. Pain thresholds (pressure, heat, and cold) and suprathreshold heat pain ratings (at 45° C, 47°C, and 49°C) were measured over the temporalis muscle, upper cervical spine, and tibialis anterior muscle. Analysis of variance was used to determine differences in pain outcomes between groups., Results: Compared to the control group, cold pain threshold in the cervicogenic headache patients was significantly decreased in the upper cervical region (P = .04) but not over the temporalis and tibialis anterior muscles (P > .05). There were no significant between-group differences in pressure pain threshold, heat pain threshold, or suprathreshold heat pain ratings at any sites (P > .05)., Conclusion: Older women with cervicogenic headache have localized pain sensitivity to cold stimuli, suggesting peripheral mechanisms underlie the hyperalgesia.

Background: No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpose of this study was to investigate whether mTIH in patients with TBI was associated with PTH and to evaluate its risk factors., Methods: Between September 2009 and December 2014, 1484 patients with TBI were treated at our institution, 57 of whom had mTIH after TBI and were include in this study. We performed propensity score matching to establish a control group among the 823 patients with TBI treated during the same period. Patients with TBI rated their headaches prospectively using a numeric rating scale (NRS). We compared NRS scores between mTIH group (n = 57) and non-mTIH group (n = 57) and evaluated risk factors of moderate-to-severe PTH (NRS ≥ 4) at the 12-month follow-up., Results: Moderate-to-severe PTH was reported by 21.9% of patients (29.8% in mTIH group and 14.0% in non-mTIH group B, p = 0.012) at the 12-month follow-up. The mean NRS was higher in mTIH group than in non-mTIH group throughout the follow-up period (95% confidence interval [CI], 0.11 to 1.14; p < 0.05, ANCOVA). Logistic regression analysis showed that post-traumatic seizure (odds ratio, 1.520; 95% CI, 1.128-6.785; p = 0.047) and mTIH (odds ratio, 2.194; 95% CI, 1.285-8.475; p = 0.039) were independently associated with moderate-to-severe PTH at the 12-month follow-up., Conclusions: Moderate-to-severe PTH can be expected after TBI in patients with mTIH and post-traumatic seizure. PTH occurs more frequently in patients with mTIH than in those without mTIH.

Objectives: To determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) in a prospective longitudinal observational multicentre study. Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression., Methods: This was a prospective observational study conducted between January 2013 and February 2014 in three trauma centres in the Netherlands. Patients aged 16 years and older with a GCS score of 9-15 on admission to the ED, with loss of consciousness and/or amnesia were prospectively enrolled. Follow-up questionnaires were completed at 2 weeks and 3 months after injury with the Head Injury Symptom Checklist, the Hospital Anxiety and Depression Scale and RTW scale., Results: In total, 628 patients were enrolled in the study, 469 completed the 2-week questionnaire (75%) at 2 weeks and 409 (65%) at 3 months. At 2 weeks, 238 (51%) had developed aPTH and at 3 months 95 (23%) had developed cPTH. Female gender, younger age, headache immediately at the ED and CT scan abnormalities increased the risk for aPTH. Risk factors for cPTH were female gender and headache at the ED. Patients with cPTH were less likely to have returned to work than those without cPTH (35% vs 14%, P=0.001). Patients with aPTH and cPTH more often report anxiety (20% and 28%, P=0.001) and depression (19% and 28%, P=0.001) after trauma in comparison with the group without PTH (10% anxiety and 8% depression)., Conclusions: PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction We report a case of cervicogenic headache caused by an intradural extramedullary tumor of the middle cervical spine, which has not previously been reported. Case presentation The patient was a 73-year-old male who visited a physician for a chief complaint of pain from the left lower jaw to the auricle and occipital region. The headache was induced with retroflexion of the neck. On cervical magnetic resonance imaging, an intradural extramedullary tumor was noted on the left side at the C4/5 level. The intradural tumor, which arose from the C5 nerve root, was excised and the pain was resolved. The pathological diagnosis was schwannoma. Conclusion Previously reported cases of spinal cord tumor-induced cervicogenic headache were due to upper cervical spinal tumors. This is the first report that a middle-lower cervical intradural extramedullary tumor caused cervicogenic headache.

Headache occurring in a sports setting may be primary or secondary headache. Headache is the primary symptom reported after concussion. Cumulative incidence and prevalence of posttraumatic headache (PTH) are higher following mild traumatic brain injury (TBI) compared with moderate to severe TBI. Frequency is higher in those with more severe PTH. Migraine or probable migraine is the most common headache type after any severity TBI using primary headache disorder criteria. Management is empiric. Expert opinion recommends treating PTH according to clinical characteristics of primary headache. The most important factor in this approach is the recognition of the severity of headache., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Cogniphobia refers to avoidance of mental exertion out of a fear of developing or exacerbating a headache. Headaches are very common after mild traumatic brain injury (mTBI) and often become chronic. Cogniphobia is hypothesized to contribute to poor cognitive test performance and persistent disability in some patients with mTBI. Eighty patients with mTBI and post-traumatic headaches were recruited from specialty outpatient clinics. They completed a battery of questionnaires (including a cogniphobia scale) and neuropsychological tests (the National Institutes of Health Toolbox Cognition Battery and the Medical Symptom Validity Test) at 2-3 months post injury, in a cross-sectional design. Participants with more severe headaches reported higher levels of cogniphobia. Cogniphobia was associated with lower performance on memory testing (but not other cognitive tests), independent of headache severity. Participants who avoided mental exertion also tended to avoid physical activity and traumatic stress triggers. The findings provide preliminary support for the role of cogniphobia in persistent cognitive difficulties after mTBI, and suggest that cogniphobia may reflect a broader avoidant coping style.

Current events within the military and professional sports have resulted in an increased recognition of the long-term and debilitating consequences of traumatic brain injury. Mild traumatic brain injury accounts for the majority of head injuries, and posttraumatic headache is the most common adverse effect. It is estimated that between 30% to 90% of traumatic brain injuries result in posttraumatic headache, and for a significant number of people this headache disorder can continue for up to and over a year post injury. Often, the most severe and chronic posttraumatic headache has a migraine-like phenotype and is difficult to resolve. In this review we discuss the preclinical findings from animal models of posttraumatic headache. We also describe potential mechanisms by which traumatic brain injury leads to chronic posttraumatic headache, including neuroinflammatory mediators and migraine-associated neuropeptides. There are surprisingly few preclinical studies that have investigated overlapping mechanisms between posttraumatic headache and migraine, especially considering the prevalence and debilitating nature of posttraumatic headache. Given this context, posttraumatic headache is a field with many emerging opportunities for growth. The frequency of posttraumatic headache in the general and military population is rising, and further preclinical research is required to understand, ameliorate, and treat this disabling disorder. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Objective: To describe the diagnostic types and characteristics of headaches in soldiers with mild traumatic brain injury during the wars in Afghanistan and Iraq., Background: Persistent post-traumatic headache interferes with returns to activity or duty. The most commonly cited headache diagnosis after concussion is migraine. We hypothesize that headache diagnosis type, eg, migraine, is not sufficient to predict relationships with occupational outcomes after concussion., Methods: The study sample consisted of all new patients referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center over a 1-year time period. The design was retrospective and observational. Clinical data reported included demographics, causes of injury, headache characteristics, and headache diagnosis type. After reviewing records for retention or severance from military service, the primary occupational outcome measure was departure from service due to medical cause as determined by a Medical Evaluation Board (MEB). The primary outcome measure was to test the strength of association between leaving service for MEB and headache characteristics or diagnosis., Results: A total of 95 patients (94% male) with concussion described 166 distinct headache types, the most common being migraine (60%) and trigeminal autonomic cephalalgia (24%). A total of 25% of all patients remained on active duty. A continuous headache of any type was present in 75% of patients and of these, 23% remained on active duty. Of the 51% of patients who had both a continuous and non-continuous headache, 17% remained on active duty (P < .001). Therefore, we report that a continuous headache, regardless of diagnosis type was associated with negative occupational outcomes. Regardless of headache duration, headache diagnosis type alone was not associated with soldiers' separations from service., Conclusions: Persistent post-traumatic headache is most likely to present with continuous pain. Migraine is the most common primary diagnosis type. The presence of a continuous headache was strongly associated with negative occupational outcomes. Primary headache diagnosis type was not. Headache characteristics, therefore, may be more important than diagnosis type when determining active duty status. Further prospective research is indicated., (© 2017 American Headache Society.)

Headache is one of the most frequently reported symptoms following traumatic brain injury (TBI). Little is known about how these headaches change over time. We describe the natural history of headache in individuals with moderate to severe TBI over 5 years after injury. A total of 316 patients were prospectively enrolled and followed at 3, 6, 12, and 60 months after injury. Individuals were 72% male, 73% white, and 55% injured in motor vehicle crashes, with an average age of 42. Pre-injury headache was reported in 17% of individuals. New or worse headache prevalence remained consistent with at least 33% at all time points. Incidence was >17% at all time points with first report of new or worse headache in 20% of participants at 60 months. Disability related to headache was high, with average headache pain (on 0-10 scale) ranging from 5.5 at baseline to 5.7 at 60 months post-injury, and reports of substantial impact on daily life across all time points. More than half of classifiable headaches matched the profile of migraine or probable migraine. Headache is a substantial problem after TBI. Results suggest that ongoing assessment and treatment of headache after TBI is needed, as this symptom may be a problem up to 5 years post-injury.

Posttraumatic headaches (PTHs) are one of the most frequently reported symptoms after a sport concussion, and treatment options for chronic PTH are limited. In this report, we present a case of a 17-year-old boy with persistent PTH after a sport concussion successfully treated with an intranasal sphenopalatine block.

The aim of the study was to investigate clinical features of headache associated with minor versus moderate to severe traumatic brain injury and of posttraumatic versus primary headache in children and adolescents. Study group included 74 patients after mild (n = 60) or moderate to severe (n = 14) traumatic brain injury identified by retrospective review of the computerized files of a tertiary pediatric headache clinic. Forty patients (54%) had migraine-like headache, 23 (31.1%) tension-like headache, and 11 (14.9%) nonspecified headache. Fourteen patients (53.8%) had allodynia. In comparison with 174 control patients, the study group had a significantly lower proportion of patients with migraine-like headache and a higher proportion of male patients and patients with allodynia. There was no statistically significant correlation of any of the clinical parameters with the type or severity of the posttraumatic headache or rate of allodynia. The high rate of allodynia in the study group may indicate a central sensitization in posttraumatic headache., (© The Author(s) 2016.)

Background: Chronic post-traumatic headache (PTH) is one of the most common symptoms of mild traumatic brain injury (mTBI) but its underlying mechanisms remain unknown. Inflammatory degranulation of dural mast cells (MCs) is thought to promote headache, and may play a role in PTH. Whether mTBI is associated with persistent degranulation of dural MCs is yet to be determined., Methods: Histochemistry was used to evaluate time course changes in dural MC density and degranulation level in concussive head trauma and blast mouse models of mTBI. The effects of sumatriptan and the MC stabilizer cromolyn sodium on concussion-evoked dural MC degranulation were also investigated., Results: Concussive head injury evoked persistent MC degranulation for at least 30 days. Blast trauma gave rise to a delayed MC degranulation response commencing at seven days that also persisted for at least 30 days. Neither sumatriptan nor cromolyn treatment reduced concussion-evoked persistent MC degranulation., Conclusions: mTBI evoked by closed head injury or blast exposure is associated with persistent dural MC degranulation. Such a response in mTBI patients may contribute to PTH. Amelioration of PTH by sumatriptan may not involve inhibition of dural MC degranulation. If persistent dural MC degranulation contributes to PTH, then cromolyn treatment may not be effective., (© International Headache Society 2015.)

Purpose: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches)., Methods: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles., Results: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful., Conclusions: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

Post-traumatic headache (migraine) is the most common symptom of concussion and traumatic brain injury. An expert opinion-based review along with a literature review (PubMed) was conducted looking at known interventional procedures for post-traumatic headache using the keywords post-traumatic headache, post-traumatic migraine headache, concussion, mild traumatic brain injury, and traumatic brain injury and the following categories: mechanism, pathophysiology, treatment, physical therapy, neurostimulation, Botox@/Onabotulinum toxin, and surgical intervention. The results returned a total of 181 articles of which 52 were selected. None of the articles included randomized placebo-controlled studies, and most were either prospective or retrospective case analysis and/or review articles or consensus opinion papers, with most studies yielding positive results. Despite a lack of hard evidence, interventional procedures, alone or in combination, appear to be an effective treatment for post-traumatic headaches.

Post-traumatic headache can occur after any traumatic brain injury, regardless of severity. Headache is consistently the most common symptom following concussion and occurs in over 90% of athletes with sports-related concussion. Despite this prevalence, the complaint of headache after a possible concussive injury is often dismissed. Even when sports-related concussion is accurately diagnosed, many athletes fall victim to mismanagement of this associated symptom by clinicians who are not well-versed in headache treatment. Furthermore, benign headaches may also occur incidentally in the context of head trauma. This complex, and often non-specific, nature of headaches provides a significant challenge in return to play decision-making. Post-traumatic headaches are generally categorized according to primary headache disorders in an attempt to guide treatment; however, there is minimal medical literature on headache management in the concussed athlete. There is clearly a continued need for prospective studies of existing treatments and new approaches.

Objective: The term "post-traumatic migraine" (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion., Methods: Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache., Results: The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster., Conclusions: PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients., (© International Headache Society 2015.)

Objective: Mild traumatic brain injury (mTBI) can lead to psychiatric and somatic symptoms for some patients, including posttraumatic headache (PTH) and depression. This study attempted to further establish the relationship between PTH and depression following mTBI and investigate whether the presence of PTH immediately following injury can identify patients at risk for developing depressive symptoms up to 6 months later., Methods: This study was a secondary analysis of data from Head Injury Serum Markers for Assessing Response to Trauma (HeadSMART), a prospective study of adult patients in the emergency department with head injury. Participants included 265 patients who met criteria for mTBI and completed the Rivermead Post-Concussion Symptoms Questionnaire, to identify PTH within 24 hours after injury, and the Patient Health Questionnaire-9, to assess depressive symptoms during follow-up. Measures were completed at the initial visit immediately after the injury in the emergency department and at 1-, 3-, and 6-month follow-up visits., Results: Patients with acute PTH (aPTH) at time of injury were more likely to report PTH at 1, 3, and 6 months. They also had more severe depressive symptoms and a greater likelihood of clinically significant depression at all time points., Conclusions: Patients with aPTH within 24 hours after injury were more likely to report continued symptoms of PTH and clinically significant depression at 1, 3, and 6 months. These findings provide support for using the presence of aPTH in the emergency department following mTBI as an indicator for monitoring persistent PTH and depressive symptoms in the postacute recovery period., Competing Interests: The authors report no financial relationships with commercial interests.

It has been suggested that differential diagnosis of headaches should consist of a robust subjective examination and a detailed physical examination of the cervical spine. Cervicogenic headache (CGH) is a form of headache that involves referred pain from the neck. To our knowledge, no studies have summarized the reliability and diagnostic accuracy of physical examination tests for CGH. The aim of this study was to summarize the reliability and diagnostic accuracy of physical examination tests used to diagnose CGH. A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in four electronic databases (MEDLINE, Web of Science, Embase and Scopus). Full text reports concerning physical tests for the diagnosis of CGH which reported the clinometric properties for assessment of CGH, were included and screened for methodological quality. Quality Appraisal for Reliability Studies (QAREL) and Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) scores were completed to assess article quality. Eight articles were retrieved for quality assessment and data extraction. Studies investigating diagnostic reliability of physical examination tests for CGH scored poorer on methodological quality (higher risk of bias) than those of diagnostic accuracy. There is sufficient evidence showing high levels of reliability and diagnostic accuracy of the selected physical examination tests for the diagnosis of CGH. The cervical flexion-rotation test (CFRT) exhibited both the highest reliability and the strongest diagnostic accuracy for the diagnosis of CGH., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Context: Pediatric concussions are common, and emphasis on correct diagnosis and management is stressed in consensus guidelines. Medications may have a role in management of concussion, but no consensus exists regarding appropriate pharmacologic therapy., Evidence Acquisition: Nonsystematic review., Study Design: Clinical review., Level of Evidence: Level 4., Results: There is limited evidence for hypertonic saline to improve posttraumatic headache in the emergency department setting. There is essentially no evidence for the use of any other medication in management of pediatric sport-related concussion., Conclusion: Further research is necessary to determine whether there is benefit to the use of any pharmacotherapy in the management of pediatric-aged athletes with concussions.

Introduction: Chronic headaches following concussion are debilitating and difficult to treat. Commonly employed initial therapeutic modalities include pharmacologic, physical, and psychological interventions. Despite these efforts, a subset of patients with chronic pain remains. Peripheral nerve surgery has never before been reported as an effective treatment for the management of post-concussion headaches. In this study, we report on our early outcomes following peripheral nerve surgery for this novel indication., Methods: A retrospective review of 28 consecutive patients with post-concussion headaches who underwent occipital nerve surgery was performed. Preoperative and postoperative headache pain was evaluated on visual analog scale (VAS) in 24 patients with at least 6 months follow-up., Results: The average VAS headache pain reduced from 6.4 preoperatively, to 1.4 (P < 0.0001). Twenty-one patients (88%) had a successful outcome of at least a 50% reduction in their VAS following peripheral nerve surgery. Additionally, twelve patients (50%) were pain free at time of final follow-up. There were no surgical complications., Conclusions: Early results indicate peripheral nerve surgery is a safe and effective new therapy for post-concussion headaches in the properly selected patients, whose chronic pain persists despite initial treatments by a neurologist, specialized in headache management. Future studies should focus on larger patient populations, and examine the long-term durability of outcome. In the meantime, an interdisciplinary approach involving neurologists and a peripheral nerve surgeon is suggested for the care of patients with refractory chronic post-concussion occipital neuralgia and other post-traumatic chronic headaches., (© 2015 Wiley Periodicals, Inc.)

Headache is the most common symptom after traumatic brain injury (TBI). TBI has become a global health concern with an estimated 2.5 million reported TBIs per year in the USA alone. Recent longitudinal studies of posttraumatic headache (PTH) show a high cumulative incidence of 71 % after moderate or severe TBI and an even higher cumulative incidence of 91 % after mild TBI (mTBI) at 1 year after injury. Prevalence remains high at over 44 % throughout the year after moderate or severe TBI and over 54 % after mTBI. A prior history of headache is associated with a higher risk for PTH, whereas older age appears to be protective. Gender does not appear to be a risk factor for PTH. Most PTH has clinical diagnostic criteria meeting that of migraine or probable migraine when primary headache disorder classification criteria are used, followed by tension-type headache. There are no evidence-based treatment guidelines for PTH management; however, expert opinion has suggested treating the PTH using primary headache disorder treatment recommendations according to its type.

Objective: Mild traumatic brain injury affects over one million pediatric patients annually. Minimal data and no guidelines exist regarding treatment of posttraumatic headache (PTH). The current study investigated treatment and outcomes in patients with posttraumatic headache., Methods: Medical records of all patients (age 13-18 years of age) seen at a regional concussion program from 2006 to 2011 were reviewed. Statistical analysis using SAS 9.2 was conducted to determine the effectiveness of treatment as well as the association of gender, concussion history, and football participation on the duration of posttraumatic headache., Results: Four hundred subjects met the inclusion criteria. Females were more likely to report posttraumatic headache than males (90% vs. 79%, P = 0.004), more likely to be prescribed amitriptyline (24% vs. 13%, P = 0.004), and had a significantly longer recovery time (median, 80 days versus 34 days, P < 0.001). Seventeen percent of subjects were prescribed amitriptyline for treatment of posttraumatic headache, of which 82% reported a beneficial effect. There was no difference in the percentage of posttraumatic headache or recovery time in football players versus other male athletes from other sport mechanisms., Conclusion: Females are more likely to report posttraumatic headache than males and also take longer to recover. Amitriptyline appears to be well-tolerated and an effective treatment strategy for patients with posttraumatic headache. Among pediatric patients evaluated in a concussion clinic, there is no difference in the proportion of football players reporting headaches compared with male players of other sports., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose/objectives: The purposes of the study were to (1) develop a prospective, real time, age-appropriate, and appealing prototype of an electronic headache pain diary for children and (2) evaluate the clinical feasibility and utility of the diary for the assessment and documentation of concussion headache., Design: A mixed-methods design of qualitative interviews and a quantitative survey was used., Setting: The setting was a sports medicine concussion clinic., Sample: The sample included 2 independent groups of 30 children (females n = 36, males n = 24) each aged 12 to 17 years, with postconcussion headache and pediatric concussion expert clinicians (n = 5)., Methods: During phase 1 of the study, subjects were interviewed individually about their headaches and their ideas for an electronic diary. A prototype was developed using these children's interview data. In phase 2 of the study, both children and clinicians piloted the prototype. Clinicians' survey data regarding the feasibility and utility of the diary were examined using thematic and descriptive analyses., Results: The phase 1 sample recommended a diary with calendar and clock functions, head views, menus (eg, pain descriptors), soft colors, a choice of pain assessment scales, and the ability to personalize it. All of the children thought that the new Headache Electronic Diary for Children With Concussion (HED-CC) would be helpful to track their headache and reported that other children with concussions would be likely to use it. Participants recommended improvement of the head views and clock function. In phase 2 of the study, all clinicians reported that the new HED-CC measure was feasible and useful for the assessment and documentation of headache., Conclusions: The new HED-CC provides for thorough assessment and documentation of postconcussion headache. Proactive, real-time measurement helps children remember the details of their headache pain and correlating events/circumstances. An appealing, age-appropriate measure increases the likelihood of children's symptom tracking and data accuracy. The HED-CC will improve clinicians' understanding of postconcussion headache and guide treatment. Additional testing with a larger sample is required to establish clinical application benefits and improve reliability/validity of the new measure.

Chronic pain, especially headache, is an exceedingly common complication of traumatic brain injury (TBI). In fact, paradoxically, the milder the TBI, the more likely one is to develop headaches. The environment of injury and the associated comorbidities can have a significant impact on the frequency and severity of headaches and commonly serve to direct management of the headaches. Trauma likely contributes to the development of headaches via alterations in neuronal signaling, inflammation, and musculoskeletal changes. The clinical picture of the patient with post-traumatic headaches is often that of a mixed headache disorder with features of tension-type headaches as well as migrainous headaches. Treatment of these headaches is thus often guided by the predominant characteristics of the headaches and can include pharmacologic and nonpharmacologic strategies. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, primarily impaired sleep. Nonpharmacologic interventions for post-traumatic headaches include thermal and physical modalities as well as cognitive behavioral approaches. As with many postconcussive symptoms, headaches can lessen with time but in up to 25% of patients, chronic headaches are long-term residua., (© 2015 Elsevier B.V. All rights reserved.)

A comparison has been made between the cervicogenic headache criteria in the new IHS classification of headaches (3rd edition-beta version) and The Cervicogenic Headache International Study Group's (GHISG) criteria from 1998. In a more recent version, the CHISG criteria consist of 7 different items. While "core cases" of cervicogenic headache (CEH) usually fulfill all 7 criteria, the IHS classification--3rd edition beta version--fulfills only 3 criteria. Although the new three beta version represents an improvement from the previous one, it does not quite seem to live up to the expectations for a diagnostic system for routine, clinical use.

Objectives: The primary goal of this study was to evaluate the incidence and characteristics of posttraumatic headache attributed to mild brain injury in military personnel in Iran within a prospective and observational study design., Methods: A prospective observational descriptive study was conducted with a cohort of military personnel under military education during a 6-month period at the Military Education Center in Isfahan, Iran. 322 military personnel under education were selected randomly and were given a 13-item mild brain injury questionnaire accompanied with affective disorders and headache questionnaires and were reevaluated after a 3-month interval., Results: A total of 30 (9.3 %) of the 322 military personnel met criteria for a mild brain injury. Among them, 18 personnel (60 %) reported having headaches during the 3-month reevaluation. PTHs defined as headaches beginning within 1 week after a head trauma were present in 5.6 % of military personnel under study during 6 months. In total, 67 % of posttraumatic headaches (PTH) were classified as migrainous or possible migrainous features. Patients with affective disorders such as posttraumatic stress disorder and depression were at a higher risk for developing PTH following mild brain injury (p < 0.05). PTH did not relate to demographic factors such as age or type of trauma., Conclusions: Posttraumatic headache attributed to mild brain injury is a common disorder in military personnel. Migrainous features are predominant among them in comparison with the general population. PTH is not related to a type of trauma, but has association with affective disorders.

Both primary headaches and minor head injuries are common in children. If headache presents for the first time or becomes exacerbated soon after head injury it is described as post-traumatic headache (PTH). Acute PTH resolves within 3 months from injury, but chronic PTH continues beyond 3 months. The pathogenesis of PTH is not well understood. Several mechanisms were proposed such as axonal injuries and disturbances of cerebral metabolic processes. The clinical features of PTH are those of primary headache disorders such as migraine and tension-type headache and usually follow a favorable prognosis. Investigations and management should therefore be relevant to the type of headache and focused on clinical needs of the child.

Headache is the most frequent reason for referral to an outpatient neurology and pain physician practice, with post-traumatic headache (PTH) accounting for approximately 4% of all symptomatic headaches. Headache following trauma has been reported for centuries. In this unique case report we will discuss the clinical course and successful headache treatment of a 57-year-old man diagnosed with PTHs. He suffered from chronic, intractable headaches resistant to multidisciplinary medical management for 4 years. A trial of electrical neuromodulation of the C2-C3 branches within the great auricular nerve (GAN) distribution was proposed as a potential long-term treatment for his chronic, intractable headaches after having several prior headache attacks successfully aborted with ultrasound-guided GAN blocks. Six months after permanent peripheral neurostimulator implantation, the patient reported a greater than 90% reduction in headache frequency, and was able to wean off all his previous prophylactic and abortive headache medications, with the exception of over-the-counter ibuprofen as needed. Subcutaneous electrode application over the branches of C2-C3-namely greater, lesser, and the least occipital nerves-for the treatment of chronic, intractable headache is not a new concept within pain medicine literature. However, subcutaneous electrode application, specifically over the GAN, is unique. The following case report chronicles the novel application of ultrasound-guided peripheral nerve stimulation of the GAN as an effective and safe long-term treatment for chronic, intractable primary headache. The positive outcome chronicled in this case presentation suggests that peripheral nerve stimulation of the GAN should be considered for highly select cases. To our knowledge, this is the first such case report describing GAN as a target for the management of PTH in the literature.

Cervicogenic headache is pain referred to the head from a source in the cervical spine or mediated by cervical nerves. Clinical features allow for no more than a diagnosis of probable cervicogenic headache. Definitive diagnosis requires evidence of a cervical source of pain. For most treatments, the evidence is limited or poor. Many patients with probable cervicogenic headache can be managed with exercise therapy, with or without manual therapy. Intractable cervicogenic headache can be investigated with controlled diagnostic blocks of the upper cervical joints and treated with thermal radiofrequency neurotomy. Other interventions are experimental or speculative., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: This study identifies the relationship between a test for post-traumatic headache and a marker for acute stress in rodent models of traumatic brain injury., New Method: C57BL/6 mice and Sprague Dawley rats were divided into Controlled Cortical Impact (CCI) injury, craniotomy (CR), and incision groups. Periorbital and paw allodynia were evaluated using the von Frey test prior to injury and up to four weeks post-operatively. Serum corticosterone was evaluated in groups with and without mild restraint., Results: Periorbital and forepaw thresholds, but not hindpaw thresholds, were reduced in CCI and CR mice compared to incision (p<0.0001 and p<0.01). In contrast to mice, reduced periorbital and forepaw periorbital thresholds were found in CCI rats but not CR rats compared to incision (p<0.0001). Right periorbital thresholds were reduced compared to left thresholds for both rat and mouse at one week (p<0.01), but there were no side differences for forepaw thresholds. Hindpaw thresholds did not change from baseline values for any groups of mice or rats. In mice serum corticosterone levels were increased at one, two and four weeks post-CCI and CR, while the levels for rats were not different from incision (p<0.0001). Corticosterone levels were not different in mice subjected to restraint compared to no restraint., Comparison With Existing Methods: This study presents novel data for allodynia in a rat model of TBI, and differences among mouse and rat species., Conclusions: Mechanical allodynia occurs independent of evoked restraint stress, while hypothalamic pituitary adrenal axis activity is dependent on head trauma and species., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: Many studies have indicated that cervicogenic headache may originate from the cervical structures innervated by the upper cervical spinal nerves. To date, no study has investigated whether narrowing of the craniovertebral angle (CVA) or cervicomedullary angle (CMA) affects the three upper cervical spinal nerves. The aim of this study was to investigate the effect of CVA and/or CMA narrowing on the occurrence of cervicogenic headache., Materials and Methods: Two hundred and five patients diagnosed with cervicogenic headache were included in the study. The pain scores of patients were determined using a visual analog scale. The nonheadache control group consisted of 40 volunteers. CVA and CMA values were measured on sagittal T2-weighted magnetic resonance imaging (MRI), on two occasions by two radiologists. Angle values and categorized pain scores were compared statistically between the groups., Results: Intraobserver and interobserver agreement was over 97% for all measurements. Pain scores increased with decreasing CVA and CMA values. Mean angle values were significantly different among the pain categories (P < 0.001). The pain score was negatively correlated with CMA (Spearman correlation coefficient, rs, -0.676; P < 0.001) and CVA values (rs, -0.725; P < 0.001)., Conclusion: CVA or CMA narrowing affects the occurrence of cervicogenic headache. There is an inverse relationship between the angle values and pain scores.

Background: Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI)., Methods: We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache., Results: Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods., Conclusions: Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.

Background: Headache (HA) following traumatic brain injury (TBI) is common, but predictors and time course are not well established, particularly after moderate to severe TBI., Methods: A prospective, longitudinal cohort study of HA severity post-TBI was conducted on 450 participants at seven participating rehabilitation centers. Generalized linear mixed-effects models (GLMMs) were used to model repeated measures (months 3, 6, and 12 post-TBI) of two outcomes: HA density (a composite of frequency, duration, and intensity) and HA disruptions to activities of daily living (ADL)., Results: Although HA density and ADL disruptions were nominally highest during the first three months post-TBI, neither showed significant changes over time. At all time points, history of pre-injury migraine was by far the strongest predictor of both HA density and ADL disruptions (odds ratio (OR) = 8.0 and OR = 7.2, averaged across time points, respectively). Furthermore, pre-injury non-migraine HA (at three and six months post-TBI), penetrating-type TBI (at six months post-TBI), and female sex (at six and 12 months post-TBI) were each associated with an increase in the odds of a more severe HA density. Severity of TBI (post-traumatic amnesia (PTA) duration) was not associated with either outcome., Conclusion: Individuals with HA at three months after moderate-severe TBI do not improve over the ensuing nine months with respect to HA density or ADL disruptions. Those with pre-injury HA, particularly of migraine type, are at greatest risk for HA post-TBI. Other independent risk factors are penetrating-type TBI and, to a lesser degree and post-acutely only, female sex. Individuals with these risk factors should be monitored and considered for aggressive early intervention.

Aim: Post-traumatic headaches (PTHs) following mild traumatic brain injury (mTBI) are common; however, few studies have examined the characteristics of PTHs or their response to treatment. The aims of this study were (1) to describe the clinical characteristics of PTH in a prospective cohort of children presenting to a paediatric emergency department with mTBI, and (2) to evaluate the response of PTH to treatment., Method: The emergency department cohort was obtained from a prospective longitudinal cohort study of symptoms following mTBI (n=670; 385 males, 285 females) and a comparison group of children with extracranial injury (n=120; 61 males, 59 females). A retrospective chart review of a separate cohort of children from a brain injury clinic (the treatment cohort) treated for PTH was performed (n=44; 29 females, 15 males; mean age 14 y 1 mo, SD 3 y 1 mo). The median time since injury was 6.9 months (range 1-29 mo). The mean follow-up interval after treatment started was 5.5 weeks (SD 4.3 wks)., Results: Among the emergency department cohort (n=39; 20 males, 19 females; mean age 11 y 1 mo, SD 4 y 3 mo) 11% of children were symptomatic with PTHs at a mean of 15.8 days (SD 11.6d) post injury. Three months post injury, 7.8% of children complained of headaches; of those, 56% had pre-existing headaches and 18% had experienced migraine before the injury. Although headache type varied, 55% met the criteria for migraine. A family or past medical history of migraine was present in 82% of cases. Among the treatment cohort, medications included amitriptyline, flunarizine, topiramate, and melatonin, with an overall response rate of 64%., Conclusion: This is the first prospective cohort study to describe the clinical characteristics of PTHs following mTBI in children. Migraine was the most common headache type seen; other headaches included tension-type, cervicogenic, and occipital neuralgias, and 64% responded to treatment. Referral to a headache specialist should be considered, especially when the features are not typical of one of the primary headache disorders., (© The Authors. Developmental Medicine & Child Neurology © 2013 Mac Keith Press.)

Despite an incidence of approximately 3.8 million sports-related concussions per year, the pathophysiological basis of this injury remains poorly understood. Associated post-traumatic headache, both acute and chronic, can also provide a unique treatment challenge for medical personnel. The presence of new onset or persistent headache following injury often complicates return to play decisions. It is also now evident that recurrent head trauma may be associated with the development of some chronic neurodegenerative disorders. Although anecdotal reports and consensus guidelines are utilized in the management of sports concussion and associated post-traumatic headache, further evidence-based data are needed. Improved prevention and management of this injury will occur with ongoing educational and research efforts. As such advances are made, it is imperative the headache specialist have continued understanding of this evolving field., (© 2013 American Headache Society.)

Bogduk et al. (1988, Spine 13:2-8) noted that the joints and ligaments at the cervico-occipital region are susceptible to whiplash injury. The upper three cervical sinuvertebral nerves (SVNs) at the craniovertebral junction (CVJ) are thought to be responsible for mediating pain from the ligaments, dura mater, and soft tissues of the posterior cranial fossa and upper cervical column. The purpose of this study was to describe in detail the origin and course of the SVNs at C0-C1, C1-C2, and C2-C3 intervertebral levels and their anterior intraspinal distribution. A sample comprising 10 adult, 12 fetal (crown rump length = 155-250 mm), and three stillborn neonatal (n = 50 sides) embalmed cadaveric cervical spines was microdissected (Carl Zeiss, Jena, Germany, 8-40× magnification). A laminectomy of the cervical spine with an occipital craniectomy (seven adult and all fetal specimens) or a horizontal section of the intervertebral levels was performed (three adult specimens) to expose the craniocervical canal. In both adult and fetal specimens, all three cervical SVNs arose from two roots, a somatic root (from the spinal nerve or ventral ramus or both) and a sympathetic root (from the vertebral artery plexus or superior cervical ganglion). The C1 and C2 SVNs were variable in number. The C2 and C3 SVN innervated most of the structures at the CVJ as well as the basiocciput region. The C1 SVN supplied a very small part of the atlanto-occipital joint area. The intraspinal courses of all three SVNs consisted of ascending and descending branches closely adherent to the arteries of the CVJ. They supplied the dura mater, the ligaments, adjacent joints, and soft tissues by tiny branches from the main branches. The detailed origins and course are described., (Copyright © 2012 Wiley Periodicals, Inc.)

CGH is a common entity that has been assessed historically in various medical disciplines. Currently, CGH is a controversial topic whose existence has supporters and naysayers. The difficulty evaluating CGH is caused by a lack of objective findings on imaging and biologic tests. Patients present with pain but often with a lack of hard, concrete physical findings. Other clinical diagnoses may confound the clinical presentation of patients. The concomitant presence of ON and migraine headaches has been noted in the literature. Positive analgesia after interventional techniques remains the major way to consider the diagnosis in potential patients with headaches. Although the IHS has acknowledged CGH as a secondary headache in its diagnostic schema, more research, specifically randomized double-blinded evaluations of patients with CGH, are required. These data would be deemed as objective gold-standard evidence to lead us from controversy to collaborative agreement regarding the fate of CGH. What is certain regarding CGH is that a cooperative effort should be considered in the treatment of the patients between evaluating physicians, interventional pain physicians, surgeons, and physical therapy providers. This multidisciplinary effort can lead to the effective management of CGH., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The subjective complaints in patients with TBI (Traumatic Brain Injury) may persist for years. The most frequent complaints are headache, dizziness, drowsiness, mood disturbances, and memory and concentration disturbances. It is assumed that these complaints are caused by injury itself on one hand and psychological, emotional and motivation factors on the other., Aim: Evaluation of late posttraumatic complaints in patients with TBI more than a year after the trauma, and establishing their correlations to the severity of TBI and involvement in the lawsuits for financial compensation (litigation)., Materials and Methods: Ninety patients with the diagnosis of TBI were divided, according to the severity of the injury, in two groups: mild and with moderate-to-severe. The second classification criterion was litigation. A subjective complaints scale has been designed for the purpose of this research taking into consideration both anamnesis and hetero-anamnesis data., Results: Cognitive disturbance, aggressiveness and sleep disturbance are more frequently reported by the subgroup of moderate-to-severe TBI patients, and they have not been related to the litigation. Posttraumatic headache (PTH) turned out to be a distinctive complaint regarding both classification criteria. Vegetative disturbances are significantly related to litigation, but not to the degree of injury., Conclusions: Predictive complaints reflecting the severity of TBI are memory deficit, concentration problems, and aggressiveness and sleep disturbance. Vegetative disturbances are predictive in relation to compensation claims. PTH is important from the forensic point of view for the patients with moderate to severe TBI.

Pediatric traumatic brain injury is a common occurrence, and even an ostensibly mild injury may result in disabling posttraumatic headaches. The headache may result in a number of subsequent unremitting symptoms refractory to many standard headache therapies. Current treatment recommendations are sparse because there is a lack of clinical trial data recommendations and outcomes. From these 2 cases, we report the effectiveness of steroids for severe posttraumatic headache, along with recommended treatment strategies for acute pain management and prevention.

We present a series of four patients with neurological symptoms following head injury. In each case neuroimaging was normal, but careful examination demonstrated altered sensation over the distribution of the supraorbital nerve. We discuss traumatic supraorbital neuralgia and how it differs from the more commonly reported idiopathic form.