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Objective: Headache is one of the most common physical symptoms after traumatic brain injury (TBI). The specific goals of this review include (1) determination of effective interventions for post-traumatic headache (PTHA), (2) development of treatment recommendations, (3) identification of gaps in the current medical literature regarding PTHA treatment, and (4) suggestions for future directions in research to improve outcome for persons with PTHA., Data Sources: Peer-reviewed studies in PubMed, CINAHL, PsycINFO, ProQuest, Web of Science, and Google Scholar: (1) including adult and child samples with mild, moderate, or severe TBI, whiplash, and postconcussion syndrome; (2) with clearly described interventions; (3) with headache treatment as a primary or secondary outcome; (4) published since 1985; and (5) written in English., Study Selection: Abstracts from 812 articles from the above searches were reviewed. All research types that studied the treatment of headache after TBI were included, and 64 of the 812 articles appeared to meet the inclusion criteria., Data Extraction: The 64 articles were reviewed in full and data were extracted; 36 met all criteria for inclusion. The final 36 articles were rated according to the American Academy of Neurology criteria for classifying therapeutic studies., Data Synthesis: No class I studies and only one class II study for the management of PTHA were identified. One class I and one class II study for whiplash-associated disorder with headache as an outcome were identified. Twelve studies met criteria for class III., Conclusions: No strong evidence from clinical trials is available to direct the treatment of PTHA. Some guidelines are offered for PTHA management based on primary headache categories and treatments. It is essential that well-designed clinical studies be conducted to inform clinicians on the management and prevention of PTHA chronicity., (Copyright © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

This paper aims to investigate the relevance of morphological changes in the main stabilizing structures of the craniocervical junction in persons with cervicogenic headache (CEH). A case control study of 46 consecutive persons with CEH, 22 consecutive with headache attributed to whiplash associated headache (WLaH) and 19 consecutive persons with migraine. The criteria of the Cervicogenic Headache International Study Group (CHISG) were used for diagnosing CEH; otherwise the criteria of the International Classification of Headache Disorders (ICHD II) were applied. All participants had a clinical interview, and physical and neurological examination. Proton weighted magnetic resonance imaging (MRI) of the craniovertebral junction, and the alar and transverse ligaments were evaluated and blinded to clinical information. The MRI of the craniovertebral and the cervical junctions, the alar and transverse ligaments disclosed no significant differences between those with CEH, WLaH and or migraine. The site of CEH pain was not correlated with the site of signal intensity changes of the alar and transverse ligaments. In fact, very few had moderate or severe signal intensity changes in their ligaments. MRI shows no specific changes of cervical discs or craniovertebral ligaments in CEH.

Background: To examine the prevalence and characteristics of acute posttraumatic headache (APTH) attributed to mild head injury within a prospective, observational study design., Methods: We recruited 100 patients with acute mild head injury as defined in the International Classification of Headache Disorders, 2nd Edition (ICHD-2) presenting to the department of trauma surgery at the Medical University of Vienna. Patients underwent a detailed telephone interview between days 7 and 10 and between days 90 and 100 after the injury., Results: The prevalence of APTH was 66%. APTH had occurred within 24 hours after the trauma in 78% and lasted for a median of 3.0 days. Headache was unilateral in 45%. Aggravation by physical activity, nausea and photo-/phonophobia was present in 49%, 42% and 55%, respectively. The prevalence of APTH was related to conditions of chronic pain (excluding headache), pre-existing episodic headache, number of posttraumatic symptoms, anxiety and depression. At follow-up at 90-100 days, posttraumatic headache had abated in all patients., Conclusions: APTH attributed to mild head injury is a common but self-limiting condition frequently showing migrainous features. Participants with chronic pain other than headache, pre-existing headache and affective disorders are at higher risk of developing APTH. None of the patients developed chronic posttraumatic headache.

Headache is one of the most common symptoms after traumatic brain injury (TBI), and posttraumatic headache (PTH) may be part of a constellation of symptoms that is seen in the postconcussive syndrome. PTH has no defining clinical features; currently it is classified as a secondary headache based on its close temporal relationship to the injury. A growing number of studies are characterizing PTH by using primary headache classifications. Moderate to severe PTH that is often disabling may be classified as migraine or probable migraine and is found in substantial numbers of individuals. Recent data from civilian adult, pediatric, and military populations all find that PTH may be more of a chronic problem than previously thought, with a prevalence of close to half of the injured population. In addition, if PTH definitions are strictly adhered to, then many cases of PTH may be missed, thus underestimating the scope of the problem. New headaches may be reported well after the 7 days required for diagnosis of PTH by the guidelines of the International Classification of Headache Disorders, 2nd edition. A history of headache before a head injury occurs and female gender are possible risk factors for headache after TBI. Treatment of PTH may be acute or preventive, and recommendations are made for the use of migraine-specific acute therapy when indicated. Preventive therapy may be considered when PTH is frequent, disabling, or refractory to acute therapies. Comorbid conditions should be considered when choosing an appropriate preventive therapy. The symptom of headache as a "return to play" or "return to duty" barrier must be viewed in the context of other symptoms of mild TBI., (Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

Although theories regarding headache originating in the neck have existed for more than 150 years, the term "cervicogenic headache" originated in 1983. Early descriptions pinpoint the characteristic symptoms as dizziness, visual disturbances, tinnitus, and "posterior" headache, conceivably as a consequence of arthrosis, infliction upon the vertebral artery, or with a "migrainous" background and occurring in "advanced age." Cervicogenic headache (mean age of onset, 33 years) displays a somewhat different picture: unilateral headache, starting posteriorly, but advancing to the frontal area, most frequently the main site of pain; usually accompanied by ipsilateral arm discomfort, reduced range of motion in the neck, and mechanical precipitation of exacerbations (eg, through external pressure upon hypersensitive, occipital tendon insertions). Treatment options in treatment-resistant cases include cervical stabilization operations and extracranial electrical stimulation. In a personal, population-based study of 1,838 individuals (88.6% of the population), a prevalence of 2.2% "core" cases was found.

Rectus capitis posterior muscles are located in the suboccipital triangle and function in extension and lateral rotation of the head and neck. There are two of these muscles on each side: the rectus capitis posterior major and the rectus capitis posterior minor. In the present case we observed bilateral double rectus capitis posterior major muscle and bilateral absence of rectus capitis posterior minor muscle. The additional rectus capitis posterior major may put more strain to the spine of the axis and mean time the bilateral absence of rectus capitis posterior minor muscles will result in muscular in coordination in the suboccipital region while balancing the head. The present variation should be considered in the aetiology of cervicogenic headache.

Cervicogenic headache (CH) is pain referred from the neck. Two common causes are cervical facet arthropathy and occipital neuralgia. Clinical diagnosis is difficult because of the overlying features between primary headaches such as migraine, tension-type headache, and CH. Interventional pain physicians have focused on supporting the clinical diagnosis of CH with confirmatory blocks. The treatment of cervical facet arthropathy as the source of CH is best approached with a multidimensional plan focusing on physical therapy and/or manual therapy. The effective management of occipital neuralgia remains challenging, but both injections and neuromodulation are promising options.

Context: Studies have revealed the rates of posttraumatic stress disorder (PTSD) and concussion among US soldiers returning from combat, but only one study has focused on the subpopulation of soldiers with headache., Objectives: To determine the rate of PTSD among US soldiers with comorbid chronic posttraumatic headache attributed to head injury, to identify common mechanisms of head injury, and to identify the common challenges a healthcare provider must face when treating US soldiers with chronic posttraumatic headache attributed to head injury., Methods: Between July 2007 and December 2008, the author examined 42 US Army soldiers with complaint of chronic headache. In March 2009, the author retrospectively reviewed the outpatient records for diagnoses, mechanisms of injury, and challenges to treatment., Results: The rate of concussion, defined by the Defense and Veterans Brain Injury Center Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings, was 95%. The rate of PTSD, as determined either with the PTSD Checklist or by confirming a prior diagnosis by another healthcare provider, was 97.9%. Both rates are remarkably higher than rates reported in the literature. The most common mechanisms of injury were proximity to blast (18 [45.2%]) and direct target of blast (15 [35.7%]). The most common treatment challenges were overuse of headache-abortive medications (10 [23.8%]) and poor patient followup (7 [16.7%])., Conclusion: Physicians should be aware that the rates of PTSD and concussion for US soldiers, most often linked to involvement in or proximity to a blast, are higher for soldiers complaining of chronic headache. Physicians should also be aware of the potential for overuse of medications in this patient population.

There has been intense controversy about postconcussion syndrome (PCS) since Erichsen's publication in 1866 on railway brain and spine. Headache as a result of trauma is one of the most common secondary headache types. Posttraumatic headache (PTH) remains a very controversial disorder, particularly with relation to chronic PTH following mild closed-head injury. PTH is one of several symptoms of PCS, and therefore may be accompanied by additional cognitive, behavioral, and somatic problems. PTH also is an important public health issue due to its associated disability and often refractory clinical course. While current awareness of PTH has become more prominent due to increased scrutiny given to both combat-related and sports-related head injuries, directed treatment remains a difficult challenge for physicians. Because of the frequently associated medicolegal aspects, PTH is one of physicians' least favorite types to treat. The article reviews both PCS and PTH.

Objective: To compare the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain., Methods: A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity., Results: At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache (p < 0.001). In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group., Conclusion: All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of training to be undertaken by patients with severe cervicogenic headache.

Traumatic brain injury (TBI) is highly prevalent in the United States and a common cause of posttraumatic headache (PTH) and disability. The criteria that define PTH include timelines and features that are not based on clearly established physiologic data and may result in the underrecognition and incorrect treatment of these headaches. A clear understanding of the classification of PTH becomes even more elusive when one takes into account combat-related head injuries, which are also highly prevalent and frequently lead to headaches with features that are different from those suffered by civilians with PTH. The fact that tension-type headache phenotypes are uncommon in military personnel with PTH suggests that there are features unique to the combat environment, which may predispose to the development of migraine. Further insight may also be obtained from soldiers with PTH with regard to the true pathophysiology and timelines of headache in the context of TBI.

Objective: This case report discusses the treatment of 2 patients with cervicogenic headache (CHA) attending the Outpatient Clinic of the Hungarian National Institute for Rheumatology and Physiotherapy (Budapest, Hungary) and reviews the pathophysiology, therapeutic strategy, and problems associated with the treatment of CHA., Clinical Features: Patient 1 was a 27-year-old female who sustained a whiplash injury. A sharp, shooting headache developed, readily induced, and aggravated by just bending the neck backward or by turning her head. Magnetic resonance imaging revealed a disk protrusion at C4-C5 pressing the anterior cerebrospinal space. Patient 2 was a 62-year-old female who sustained a whiplash injury; her cervical movements became restricted, which precipitated headaches. Magnetic resonance imaging revealed a paramedian disk hernia between the C4 and C5 vertebrae that intruded into the right ventral cerebrospinal space., Intervention and Outcome: After 4 weeks of manipulative therapy for patient 1, both active and passive range of motion returned to normal, and the high tumor necrosis factor-alpha (TNF-alpha) level (63 pg/mL) was substantially reduced (28 pg/mL). Patient 2 was started on manipulative therapy twice a week for 4 weeks; after 2 months, the patient became symptom-free, and high TNF-alpha level (72 pg/mL) was reduced greatly (35 pg/mL)., Conclusion: Two patients with whiplash injury and disk herniation developed CHA associated with very high TNF-alpha levels. After manipulative therapy, these patients became symptom-free, and their TNF-alpha levels decreased substantially.

The International Classification of Headache Disorders does not separate the moderate from severe/very severe traumatic brain injury (TBI), since they are all defined by Glasgow coma scale (GCS) < 13. The distinction between the severe and very severe TBI (GCS < 8) should be made upon coma duration that in the latter may be longer than 15 days up to months in the case of vegetative state. Post-traumatic amnesia duration may double the coma duration itself. Therefore, the 3-month parameter proposed to define the occurrence or resolution of post-traumatic headache (PTH) appears inadequate. Following TBI, neuropathic pain, central pain, thalamic pain, combined pain are all possible and they call for proper pharmacological approaches. One more reason for having difficulties in obtaining information about headache in the early phase after regaining consciousness is the presence of concomitant medications that may affect pain perception. Post-traumatic stress disorder (PTSD) develops days or weeks after stress and tends to improve or disappear within 3 months after exposure; interestingly, this spontaneous timing resembles that of PTH. In our experience the number of TBI patients with PTH at 1-year follow-up is lower in those with longer coma duration and more severe TBI. Cognitive functioning evaluated after at least 12 months from TBI, showed mild or no impairment in these patients with severe TBI and PTH, whereas they have psychopathological changes, namely anxiety and depression. The majority of patients with PTH after severe/very severe TBI had skull fractures or dural lacerations and paroxystic EEG abnormalities. The combination of psychological changes (depression and anxiety) and organic features (skull fractures, dural lacerations, epileptic EEG abnormalities) in PTH may be inversely correlated with the severity of TBI, with prevalence of psychological disturbances in mild TBI and of organic lesions in severe TBI. On the other hand, only in severe TBI patients with good cognitive recovery the influence of the psychopathological disorders may play a role. In fact, the affective pain perception is probably related to the integrity of cognitive functions as in mild TBI and in severe TBI with good cognitive outcome.

We report a rare case of severe facial pain and headache due to cervical spondylosis successfully treated by surgical intervention. A 48-year-old woman had been suffering from severe left side facial pain and headache since she was 44 years old. Analgesics were not effective. At 48 years of age, a magnetic resonance imaging of the cervical spine revealed a degenerated disk at the C5/6 level with encroachment on the foramina and the cord. Anesthetic blockade to the C5/6 facet joint was effective, but was temporary. After the anterior decompression and stabilization using a titanium cage, the pain disappeared completely and has not recurred through 1 year of follow up. This report indicates that lower cervical root compression may cause cervicogenic headache, which can be treated effectively by surgical intervention.

The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to the International Headache Society (IHS) classification. The objective of this study was to evaluate the several forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39%) and 14 (34.1%) patients respectively. The time interval between HI and the onset of headache was less than seven days in 20 patients (48.7%) and longer than 30 days in 10 (24.3%) patients. The results suggest that PTC may arise after a period longer than is accepted at the present by the IHS.

Objective: To establish the prevalence of post traumatic headache, persisting at 3 months following minor traumatic brain injury., Design: A prospective controlled study of patients admitted with a diagnosis of mild traumatic brain injury and matched orthopedic controls over 12 months during 2004., Setting: A level two inner city Emergency Department in Sydney, Australia., Patients: One hundred eligible sequential admissions with mild traumatic brain injury as defined by American Congress of Rehabilitation Medicine, 1993, and 100 matched minor injury controls with nondeceleration injuries., Interventions: Subjects were part of a study on prediction of postconcussive syndrome and had neuropsychological tests, balance test and pain recordings taken at the time of injury, at 1 month and at 3 months post injury., Outcome Measures: Main measures were the reporting of headache "worse than prior to the injury" and concordant with the definition of Posttraumatic Headache according to International Headache Society Classification of Headache Disorders 2003., Results: 15.34% of those with minor head injury continued to complain of perisistant posttraumatic headache at 3 months compared to 2.2% of the minor injury controls., Conclusions: To the authors' knowledge this is the first controlled prospective study in the prevalence of posttraumatic headache following mild traumatic brain injury.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare headache syndrome classified among the trigeminal autonomic cephalalgias. It is usually idiopathic, although infrequent secondary forms have been described. Recently the term short-lasting unilateral headache with cranial autonomic symptoms (SUNA) has been defined by the International Headache Society (ICHD-2) as similar to SUNCT with less prominent or absent conjunctival injection and lacrimation. We report two patients with paroxysmal orbito-fronto-temporal pains, phenotypically suggesting SUNA, occurring after traumatic head injury.

The prevalence of cervicogenic headache (CEH) is only vaguely known. Furthermore, it is a common belief that in migraine without aura (MwoA), neck symptoms frequently occur and that MwoA and CEH may pathogenetically be intimately related. In the Vågå study, 1838 18-65-year-old citizens (88.6% of that age group) were studied with face-to-face interviews and a thorough neck examination. For CEH, the Cervicogenic Headache International Study Group criteria were used, and for MwoA, the IHS criteria. The extent of cervical involvement was assessed by the 'CF' ('features indicative of cervical abnormality'). CEH prevalence was 4.1%. 'CF' was 2.37 in CEH vs 0.93 in M-A. CEH criteria, e.g. mechanical attack provocation, were present many times more frequently in CEH than in MwoA. Conversely, migraine criteria, e.g. photophobia, were >/= 2.6 times higher in MwoA than in CEH. CEH is unlikely to be a subgroup of MwoA.

Objective: Posttraumatic headache (PTH) may affect neurocognition after sports-related concussion. To our knowledge, no studies have examined how PTH affects balance after concussion using dynamic posturography. The purpose of this study is to compare balance after concussion between athletes reporting PTH and athletes not reporting PTH., Methods: We conducted a retrospective, repeated-measures design with participants grouped by presence of postinjury report of headache. Balance testing was conducted on 108 concussed collegiate athletes (age, 18.83 +/- 1.27 yr; height, 180.92 +/- 10.01 cm; mass, 83.29 +/- 19.62 kg). Presence of PTH during the first postinjury test session (group) and test time (baseline, postinjury) served as the independent variables. The composite equilibrium score and the somatosensory, vestibular, and visual ratio scores served as dependent variables. A 2 x 2 mixed model analysis of variance was used to analyze each outcome measure., Results: Significant decreases in all four measures assessed were noted after concussion compared with preseason baseline measures (P < 0.05). Significant group by test-time interactions were observed, suggesting that composite equilibrium (F1106 = 6.6089; P = 0.012) and vestibular ratio (F1106 = 7.156; P = 0.009) scores are affected by the presence of PTH. Athletes reporting PTH also demonstrated worse visual ratio scores compared with individuals not experiencing PTH (F1106 = 4.26; P = 0.041). No other significant findings were observed for the somatosensory ratio score., Conclusion: Current literature proposes that PTH is associated with cognitive deficits. Our study indicates that PTH may also contribute to increased balance deficits. We believe the deficits may be a result of increased sensory organization challenges after injury. Clinicians should be mindful of these findings when managing concussed athletes reporting headache.

Whiplash is a controversial concept. The real nature and prevalence of whiplash-related headaches are not known. To address this issue, the history of severe trauma was collected from occipital/nuchal headache-cervicogenic headache, migraine and tension-type headache patients attending a neurology office. The two last groups of patients had significantly less history of trauma in their medical records, with longer time span between the injury and the headache onset. Whiplash may induce preferably cervicogenic and tension-type headaches.

This was a prospective, observational study of children aged 3 to 15 years admitted to hospital with head injury (HI). Demographic data and information on the nature of the HI, and history of premorbid headache were collected. A structured telephone questionnaire was used to interview parents and children 2 months after injury and at 4-monthly intervals for up to 3 years, if headache was reported. One hundred and ninety children were admitted with HI. Data were available on 117 children (81 males, 36 females; mean age 8y 5mo [SD 3y 1mo]). HI was minor in 93 patients and significant in the rest. Minor HI was defined as a closed injury, no loss of consciousness, and a Glasgow Coma Score (GCS) of 13 to 15. Significant HI was associated with loss of consciousness for >30 minutes, GCS of <13, and post-traumatic amnesia for >48 hours. Eight children (five males, three females; mean age 10y 7mo [SD 2y]) reported chronic post-traumatic headache (CPTH). Five children had episodic tension-type headache and three had migraine with or without aura. Headache resolved over 3 to 27 months in all except one child who was lost to follow-up. Premorbid headache in three children transformed in frequency and type following HI. These patients were excluded from the study. CPTH is common after minor and significant HI. It has the clinical features of tension-type headache and migraine and has a good prognosis.

In 2004 cervicogenic headache was introduced into ICD-10 classification. The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.

The aim of this report is to give information on the definition, clinical characteristics and therapy of cervical headache with comprehensive guidelines for patients on daily living activities with cervical pain and headache. This information has been designed to help the patients understand of their disability and in learn how to protect themselves.

Study Design: Case report and clinical discussion., Objective: To describe a case of persistent posttraumatic headache associated with the presence of a paracondylar process, and the result of surgical resection of this osseous anomaly., Summary of Background Data: The paracondylar process is one of a group of congenital anomalies of the craniovertebral junction. This heterogenic group is classified in the literature based on embryologic origin. In general, the paracondylar process has little or no clinical significance. There are some cases reporting symptoms related to the paracondylar process, especially after head trauma. Few report improvement after surgery., Methods: We describe a case of a 21-year-old woman who was seen for severe persistent daily headache and neck pain after minor head- and neck injury. Clinical examination revealed tenderness and an abnormal structure in the right cervico-occipital region by palpation. A conventional radiograph and computed tomography scan of the craniovertebral junction revealed a paracondylar process on the right side of the skull., Results: After resection of the paracondylar process, headache and cervical pain were substantially reduced., Conclusion: This case underlines the possible clinical significance of congenital anomalies of the craniovertebral junction. They can become symptomatic after head trauma, causing headache and/or cervical pain. Surgical extirpation can relieve these symptoms.

Chronic post-traumatic headache (PTH) always arises from some sort of head injury such as mild traumatic brain injury or concussion. The terminology and definitions for these injuries remain controversial and continue to evolve. This article reviews and updates current terminology and definitions for these head injuries, along with current concepts of pathophysiology. The second portion of this article considers the persistence of the other symptoms associated with chronic PTH, which constitute the post-concussive disorder. PTH is the most common symptom after a head injury, but post-concussive symptoms often complicate the clinical picture and must be considered in the overall management of the chronic PTH patient.

Since many years we routinely use diagnostic selective nerve root blocks (SNRB) at our department when evaluating patients with cervical radiculopathy. Frequently patients who also presented with headache reported that the headache disappeared when the nerve root responsible for the radicular pain was blocked with local anaesthetics. Headache has been described as a companioning symptom related to cervical radiculopathy but has never before been evaluated with SNRB performed in the lower cervical spine. For this reason we added to our routine an evaluation of the response from the SNRB on headache in patients with cervical radiculopathy. The aim was to describe the frequency of headache in patients with cervical radiculopathy and its response to a selective nerve root block of the nerve root/roots responsible for the radiculopathy. Can nerve root compression in the lower cervical spine produce headache? In this consecutive series of 275 patients with cervical radiculopathy, 161 patients reported that they also suffered from daily or recurrent headache located most often unilaterally on the same side as the radiculopathy. All patients underwent a careful clinical examination by a neurosurgeon and a MRI of the cervical spine. The significantly compressed root/roots, according to the MRI, underwent SNRB with a local anaesthetic. The effect of the nerve root block on the radiculopathy and the headache was carefully noted and evaluated by a physiotherapist using visual analogue scales (VAS) before and after the SNRB. All patients with headache had tender points in the neck/shoulder region on the affected side. Patients with headache graded significantly more limitations in daily activities and higher pain intensity in the neck/shoulder/arm than patients without headache. After selective nerve root block, 59% of the patients with headache reported 50% or more reduction of headache and of these 69% reported total relief. A significant correlation was seen between reduced headache intensity and reduced pain in the neck, shoulder and arm. The result indicates that cervical root compression from degenerative disease in the lower cervical spine producing radiculopathy might also induce headache.

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

The main objective of the present investigation was to clarify the long-term natural course of cervicogenic headache (CEH) after whiplash injury. Whiplash patients (n=587) were initially followed up for a year after their emergency service consultation. De novo unilateral CEH seemed to be present in 8% (n=48) at six weeks and in 3% (n=20) at one year. Previous car accidents, pre-existing headache, and neck pain were more frequent among individuals with chronic CEH than in those without CEH at one year. Patients affected by headache with CEH characteristics at one year were followed up for five more years, at the end of which seven (35%) still had such headache, although the attack frequency had reduced appreciably. Forward radiating pain could still generally be precipitated from areas along the occipital tendons ipsilaterally. Increased tenderness in these areas could also be found on the previously symptomatic side in the patients who were now asymptomatic.

Objective: Validate the clinical criteria, which, when absent, would make it safe to bypass CT scan examination in mild cranial injuries., Material: and methods. Prospective study including 285 patients with mild cranial injury with a Glasgow score of 15, a normal clinical examination but transitory loss of consciousness or suspected transitory loss of consciousness. The following clinical parameters were systematically reviewed: history of stroke; post-injury headache; post-injury vomiting; alcohol, medication, or drug intoxication; clinical signs of cervico-cranio-facial injury; post-injury convulsions; or coagulation impairment. Systematic CT exploration looked for cranial, encephalic, and facial lesions and individualized the lesions requiring neurosurgical or maxillofacial treatment., Results: Of the patients studied, 7% presented a cranioencephalic lesion and 7% a facial bone lesion. Neurosurgical intervention was necessary in 0.4% of the patients and maxillofacial surgery in 2.5%. Patients with a positive CT all had at least one clinical risk factor and patients with cranioencephalic lesions had at least two risk factors present. Had patients with no risk factors not been scanned, 15% of the patients would not have had the CT procedure., Conclusion: Selecting CT indications in cases of mild cranial injury with loss of consciousness using a simple and validated evaluation can save 15% of CT procedures without missing any cranial, encephalic, or facial lesions.

Purpose: To evaluate the repetitive occipital nerve blocks using a nerve stimulator in the treatment of cervicogenic headache., Methods: This prospective noncomparative clinical interventional case-series study included 47 patients suffering from cervicogenic headache using a repetitive guided occipital nerve blockade., Results: Forty-one patients (87%) required more than one injection to achieve six-month pain-relief period. For every three years of headache history, the outcomes demonstrated that a patient needed one additional injection to the basic injection., Conclusion: The repeated nerve stimulator-guided occipital nerve blockade is a treatment mode that may relieve cervicogenic headache with no recurrence for at least six months in addition to alleviation of associated symptoms.

Cervicogenic headaches are a relatively new nosological entity. The diagnostic criteria are still under discussion. They are rare: the diagnostic is based on anamnestic and clinical considerations. Rx investigation is mandatory. The aetiology is multifactorial. In case of cervical trauma, the relationship with the primary peripheral lesion must be carefully discussed. The actual opinion from the neurophysiological point of view is based on the hypothesis of "central hypersensitivity". This progressive dysfunction is probably modulated by genetic characteristics: the mechanism is triggered by the initial peripheral nociceptive input. In chronic situations, psychosocial factors are important. The treatment must be considered individually. It is based on a pharmacological approach and, in selected cases, includes anaesthetic block.

Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH). Although most PTH resolves within 6-12 mos after injury, approximately 18-33% of PTH persists beyond 1 yr. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Although there is no universally accepted protocol for treating PTH, many clinicians treat PTH as if they were managing primary headache. As a result of the heterogeneity in the terminology and paucity in prospective, well-controlled studies in this field, there is a definite need for conducting double-blind, placebo-controlled treatment trials in patients with PTH.

Autoantibodies (aAB) to AMPA (Glu R1 subunit) and NMDA (NR 2A subunit) glutamate receptors were studied in blood serum of 60 children, aged 7-16 years, with chronic posttraumatic headache after mild skull injury. All the children were divided into 2 groups: group 1 included 48 children with concussion of the brain, group 2--12 children with brain contusion. Group 1 was divided into 2 subgroups: subgroup 1a comprised 34 children with single concussion and subgroup 1b--14 children with repeated concussion. The aAB level was determined 6 months and 1 year after skull injury. The aAB concentration was expressed in percents to the control level being considered significant if the increase was higher than 120%. The increased NMDA aAB level was observed during the first year after skull injury. In the la subgroup, the NR2 aAB level in blood serum was 145 +/- 12,6%, in the 1b one--108 +/- 12,4%, in group 2--165 +/- 34%. The content of aAB to AMPA receptors was elevated only in children of lb subgroup and group 2 (150 +/- 16,8% and 167 +/- 31,3%, respectively). The EEG examination of this group revealed the nonspecific paroxysmal discharges in 18% of cases and epileptiform activity in 6% of children. The results obtained suggest that children with posttraumatic headache have elevated levels of aAB to glutamate receptors, hyperstimulation of which reflects hypoxic processes in the brain, and are in need of metabolic therapy.

Aim: To research possible associations between previous exposure to specific torture techniques and prevalent pain in the head and face, back, and feet., Methods: 221 refugees, 193 males and 28 females, previously exposed to torture in their home country, were subject to a clinical interview at a rehabilitation clinic for torture victims. The interview focused on exposure to torture and somatic symptoms prevalent at examination., Results: The mean number of times imprisoned was 2.3; the mean number of months imprisoned was 19.7; the mean duration from initial imprisonment to final release was 3.7 years; and the mean duration from final release to preliminary interview was 8.4 years. The most frequent physical torture method reported was beating (92.3%) and the main mental torture method was deprivation (84.6%). Pain in the head and face was found to be strongly associated with torture against head and face (OR 3.89, 95% CI 1.49-10.20) and with the cumulative number of physical torture methods exposed to. Pain in the back was associated with sexual torture (OR 2.75, 95% CI 1.07-7.12). Besides beating of the lower extremities (OR 5.98, 95% CI 2.47-14.48), the strongest predictor for pain in the feet was general abuse of the whole body (OR 5.64, 95% CI 1.93-16.45)., Conclusion: In spite of many factors being potentially co-responsible for prevalent pain, years after the torture took place it presents itself as strongly associated with specific loci of pain, with generalized effects, and with somatizing.

A short cut review was carried out to establish whether headache was a significant indicator of the severity of head injury in children. 301 papers were found using the reported searches, of which 2 presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. It is concluded that headache is not an independent risk factor for intracranial injury in children.

A discogenic cervical headache is a subtype of cervicogenic headache (CEH) that arises from a degenerative cervical disc abnormality. The purpose of this study was to evaluate the clinical outcome of percutaneous endoscopic cervical discectomy (PECD) for patients with chronic cervical headache due to soft cervical disc herniation. Seventeen patients underwent PECD for intractable headache. The inclusion criteria were soft disc herniation without segmental instability, proven by both local anesthesia and provocative discography for headache unresponsive to conservative treatment. The mean follow-up period was 37.6 months. Fifteen of the 17 patients (88.2%) showed successful outcomes based on the Macnab criteria. Pain scores on a visual analog scale (VAS) improved from a preoperative mean of 8.35 +/- 0.79 to 2.12 +/- 1.17, postoperatively (P < 0.01). The mean disc height decreased from 6.81 +/- 1.08 to 5.98 +/- 1.07 mm (P < 0.01). There was no newly developed segmental instability or spontaneous fusion on follow-up radiography. In conclusion, PECD appears to be effective for chronic severe discogenic cervical headache under strict inclusion criteria.

Background and Purpose: Headache after a head injury is one of the most frequent symptoms in patients after craniocerebral trauma. The aim of the study was to investigate changes in brain perfusion in patients with chronic post-traumatic headache a long time after craniocerebral trauma. PWI gives us the exact information about the brain circulation., Material and Methods: Clinical measures included 52 patients (24 women and 28 men) aged from 20 to 56 years (mean age 42.3 years) suffering from chronic post-traumatic headache after moderate and severe craniocerebral trauma, 6-18 months after the head injury. The Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) were used to evaluate the severity of the head injury. The PWI (Perfusion Weighted Imaging) study was made in all patients., Results: In the study group in the PWI study the domination of perfusion disturbances in frontal lobes were seen in 38 patients (59.6%). Statistical analysis showed no significant correlation between character, intensity, localization of headache and changes in the PWI. In 22 patients with localized headache the highest percentage of changes in PWI matched with localization of headache were observed in frontal lobes--40.9% in the right frontal lobe, 31.8% in the left frontal lobe, and in the right temporal lobe--22.7%. In accessible references no publications concerning changes in the PWI in chronic post-traumatic headache were found., Conclusions: The results suggest the occurrence of brain perfusion disturbances a long time after craniocerebral trauma, which were most marked in frontal lobes, without any statistically significant correlation with chronic post-traumatic headache.

In a series of 81 patients with chronic cervicobrachialgia, 54 (67%) reported that they also suffered from recurrent headache. Forty-four (81%) of these patients were classified as having cervical headache, 5 as having migraine, 2 with tension-type headache, and 3 patients were not classifiable according to the diagnostic system of the International Headache Society (IHS). Patients with headache presented significantly higher tenderness scores and pain intensity in the neck-shoulder-arm region than patients without headaches. Twenty-three (52%) of the 44 patients with cervical headache reported that their headache had improved after treatments directed towards their cervicobrachialgia. The IHS classification system of cervical headache is discussed.