Acute and Chronic Management of Posttraumatic Headache in Children

A Systemic Review

Carlyn Patterson Gentile MD, PhD; Ryan Shah BS; Samantha L. Irwin MSc, MB, BCh, BAO, FRCPC; Kaitlin Greene MD; Christina L. Szperka MD, MSCE, FAHS


Headache. 2021;61(10):1475-1492. 

In This Article


We did not identify any studies that provided good quality evidence for treatment of PTH in children and adolescents. This finding is unchanged from systematic reviews of pharmacologic and procedural PTH treatment in adults and children,[12,13] and from a review of postconcussive symptoms including headache.[14] We expanded on this work by focusing specifically on headache in the pediatric population, including a broader range of treatments, and assessing for the presence of migrainous headache features and/or family and personal history of migraine in the reviewed studies. Limitations of the study design include that the searches were limited to identifying articles in English that were published in 1985 or later.

Treatments that have been studied include abortive and preventative medications, procedures, neuromodulation, PT, exercise, collaborative care models, and behavioral therapies. There were two RCTs that supported the use of acetaminophen and ibuprofen[17] and IV HTS[23] in acute PTH. Overall evidence for preventative therapies was significantly limited by small sample sizes and lack of comparator groups. There was poor, but consistent evidence to support the use of occipital nerve blocks to treat acute and persistent PTH; however, sample sizes were small, and lacked appropriate comparator groups. The greatest number of prospective studies with comparator groups focused on nonpharmacologic strategies used to treat postconcussive symptoms including PT, exercise therapy, and collaborative care models. However, in most cases, headache was not the primary outcome, but rather one of multiple postconcussion symptoms being measured on an inventory. Further research is needed to assess the specific impact of these therapies on PTH.

Defining Headache Characteristics Following mTBI

Although PTH is considered its own entity,[3] there has been an effort to identify features of other primary and secondary headache disorders in PTH. A predisposition to migraine appears to act as a catalyst for PTH development,[48] and some cases of PTH may be the abrupt onset of trauma-triggered migraine.[11] A recent prospective multicenter cohort study demonstrated that those reporting migrainous headache <8 weeks post-mTBI were more likely to have a prolonged recovery, and were more likely to be prescribed preventative migraine medication.[9] The authors proposed that migraine phenotype may represent a target for early intervention. We found that while many studies evaluated migraine-directed therapies, relatively few studies specifically reported on the presence of migrainous headache features and/or family or personal history of migraine. Studies that did target specific headache phenotypes reported high efficacy rates, although these were notably limited by small sample size and study design.

The severity and frequency of PTH may also impact the efficacy of treatments. Chan et al. found that subjects who had a head CT in the ED were more likely to not respond to a combination of IV abortive therapies,[25] with need for CT as a potential surrogate for symptom severity. While relatively few studies reported the presence of constant or daily PTH, this is a particularly critical group to focus efforts on due to high disease burden.

Acute Versus Persistent PTH

There was variability in the definition of persistent symptoms and the timing of preventative therapy initiation with 1 and 3 months being the most common cutoffs. This likely stems from different definitions of "persistent" in the mTBI literature, which range from 2 weeks up to 3 months.[49] ICHD-3 criteria define persistent PTH as >3 months.[3] Expert opinion has suggested that early treatment with preventative medications may be able to prevent the development of persistent PTH.[50] However, there is no clear evidence-based determination of when it is most appropriate to switch focus from abortive to preventative pharmacologic therapies based on the results of this current review.

Considerations for Future Clinical Trial Design

We propose the following recommendations based on our review:

  1. There is a need to establish standardized and validated metrics to measure headache improvement in PTH. Although guidelines to determine the efficacy of abortive therapies in children with migraine have not been established, in adults, the International Headache Society (IHS) recommendation for measuring pain resolution at 2 h as a primary endpoint and change in 4-point severity scale as a secondary endpoint[51] would also be relevant for PTH. In children, the IHS recommends measuring the efficacy of preventative therapies as the change in total headache days/month.[52] Measuring the number of severe headache days/month in addition may more effectively capture improvement for individuals with continuous headache. The PedMIDAS[53] should be used as a metric of headache-related disability, which has been validated for time intervals as short as 1 month.[54]

  2. Consensus is needed on what constitutes persistent symptoms for research studies and when to start preventative therapies. We propose defining persistent symptoms as 4 weeks or longer. Consensus is that symptoms persisting past the acute period (defined as 4 weeks for school-age children) usually do not have a single etiology, but rather involve a complex interplay between multiple biopsychosocial factors leading to a more complicated recovery.[55] This definition diverges from the ICHD-3 criteria for persistent PTH[3] but would encourage early headache intervention to prevent the development of prolonged symptoms.[50]

  3. Risk factors for prolonged recovery including family and personal history of migraine, and the presence of migrainous features with headache shortly after mTBI should be reported and taken into consideration in both research studies and clinical management of PTH.[5,6,9]

  4. Headache characteristics, including the presence of MOH, should be considered when choosing the most appropriate treatment. ICHD-3 criteria[3] can be used to identify the characteristics and/or presence of other headache disorders following mTBI. Research is needed to understand whether mTBI can provoke other primary or secondary headache disorders and establish potential shared pathophysiologic mechanisms.