Posttraumatic Headache: Basic Mechanisms and Therapeutic Targets

Joshua Kamins, MD; Andrew Charles, MD

Disclosures

Headache. 2018;58(6):811-826. 

In This Article

Other Therapeutic Approaches for PTH

Exercise

While it is clear that exercise may be contraindicated in the period immediately following TBI, there is growing evidence that introducing exercise at an appropriate time may have significant therapeutic benefit,[112,113] including potentially for posttraumatic headache. As discussed above, exercise–induced release of BDNF could play a role in this therapeutic benefit,[93,114] and it is also reasonable to hypothesize that exercise may help to restore normal neurovascular function. Patients with chronic headache disorders have reduced physical activity,[115] and although extensive evidence is lacking, exercise is commonly recommended as a therapy for migraine.[116] A better understanding of the optimal timing and type of exercise as a therapy for PTH would be helpful to provide more specific guidance to patients regarding this straightforward and sensible potential treatment.

Neuromodulation

Both supraorbital nerve stimulation and single pulse transcranial magnetic stimulation are now approved in the US as acute and preventive therapies for migraine.[117,118] The potential efficacy of these approaches for PTH has not been well studied, but given that recovery from concussion may involve brain plasticity mechanisms that could be targeted by neuromodulation, and the fact that these treatments have no cognitive or systemic side effects that may be problematic in the setting of concussion, clinical trials of neuromodulation approaches are clearly warranted for PTH.

Cognitive/Behavioral Approaches

One of the most effective treatments for the prevention of persistent concussion symptoms is anticipatory guidance and cognitive restructuring. Multiple studies demonstrate the importance of effective communication to explain concussion as a self–healing process, to manage expectations for recovery, and to provide coping skills to deal with physical, cognitive, and behavioral symptoms.[119,120] It is not uncommon for patients to attribute symptoms, particularly headache, to concussion when in fact they had a preexisting primary headache disorder, and in some cases it may be important to clarify this in order to provide patients with the most appropriate context in which to move forward with different types of therapy. An emotionally traumatic event occurring simultaneously with traumatic brain injury, as commonly seen in military veterans, may exacerbate the pathophysiological response, including PTH.[121] Similarly, ongoing PTSD or depression may potentiate the transition from transient to chronic PTH, and addressing these neuropsychiatric issues with either cognitive/behavioral approaches or in some cases pharmacotherapy is critically important in the effective management of PTH.[121]

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