Posttraumatic Headache: What Works, What Doesn't

Andrew N. Wilner, MD; Nina Riggins, MD, PhD


May 03, 2023

This transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I'm your host, Dr Andrew Wilner, reporting virtually from the 2023 American Academy of Neurology (AAN) meeting in Boston, Massachusetts.

Today, I have the pleasure of speaking with Dr Nina Riggins, associate professor of neurology at the University of California, San Diego (UCSD), and a specialist in headache. Dr Riggins is participating in a panel discussion at AAN on posttraumatic headache. Welcome, Dr Riggins.

Nina Riggins, MD, PhD: Thank you so much for having me here. Hello from the American Academy of Neurology.

Rest vs Return To Play

Wilner: Thanks for joining us. I have many questions. Of course, we see many headache patients, and now there are so many patients with headache related to a head injury. For the patients I see, we do the MRI and it looks fine, but they have headaches. The headaches might last a day, a week, a month, or 6 months. It's really hard to get a handle on these patients.

I want you to help me clarify the recommendations. I remember we used to say that the patients need to rest. Then, no, the patients need to be active. Then, it's return to play. When should they be active and go back to school? They shouldn't use video games, but they can use video games?

What are the recommendations now? For example, my nephew's playing soccer. There was a big play, he ended up on the ground, he's dazed, and then he develops headaches every day. I'm sure you see similar patients. What do you tell them?

Riggins: Posttraumatic headache is a big issue in our headache center. We do have people of younger age who can develop headaches that are persistent, even after mild traumatic brain injury. It can be daily and lead to different complications. One of those we usually address would be medication overuse headache.

One of the things we have to consider, even for someone who has whiplash, is that this person may have a genetic predisposition or has had migraine headache before and takes more nonsteroidal medications or any other pain medications. We have to really watch out for that.

Back to the question about return to play. We do want this person to be asymptomatic and not on medications for posttraumatic injury before this discussion of returning. We would like them to be functioning well in school and at work, and then, we can discuss return to play. We want kids and adults to be very safe.

Wilner: Number one, you've got to be back to baseline before you're going to risk banging up your head again. Is that what I'm hearing?

Getting Back to Baseline

Riggins: Yes. There is a risk for repeat brain injury. We really want to make sure that we're not adding on to that risk. We would like people to be at their baseline before they return to usual activity. How do we get to baseline is also a big question, right?

Wilner: Thank you. That was exactly where I was going with this. How do we get them better?

Riggins: How do we get them better? At this point, we don't have FDA-approved treatments specific for posttraumatic headache, so we have to go with what we already developed for types of headache that they have that are similar: most often, migraine or tension headache.

We know much more, and we use many more treatments nowadays. Very often, new classes of medications are used, such as calcitonin-gene related peptide–blocking medications. We have big and small molecules. The different medication classes are expanding, and we're extremely proud of that.

Lifestyle is also so important. It is extremely important to discuss with patients the importance of regular sleep. Some articles even bring up that napping during the day may be not as beneficial because it disturbs the sleep cycle. Walking is excellent, so maybe increasing physical activity gradually.

Headache likes regularity in meals and in hydration. Definitely hydrate, definitely eat regularly, and sleep on time. A patient can start walking every day and then gradually increase exercise.

There are different rules in different articles. They propose monitoring. One discusses a 10-point scale. If you feel that your symptoms are going above two points up, then scale back. Thankfully, we don't tell our patients to lie down and not do anything. That's in our past. The increase in regular physical activity, as tolerated, is very useful.

I love exercise. We do have studies showing that when patients exercise, even for migraines, three times per week for 30-40 minutes, it's comparable to our strongest medications.

We work very closely with our colleagues in sport concussion and vascular neurology. I work with vascular neurology and vascular neurosurgery all the time. We're watching out for complications. We're watching out for new symptoms.

One of the things could be tinnitus. Sometimes during trauma, one can develop connections between different vessels that are not supposed to be connected. We discover everything can be pretty much fixed and we work together with our surgical colleagues on that. Then, we have return to play.

Wilner: It's really a healthy lifestyle, which everybody should do anyway, right?

Riggins: Yes.

Wilner: Eat right, sleep right, and then activity as tolerated. Don't lie in bed all day. If you go for a long walk and you get dizzy, you've got to go lie down. It's really a commonsense approach, it sounds to me, for healing.

Vagal Nerve Stimulation

Riggins: Thank you, yes. That's an excellent summary. We do have another branch of treatments that I didn't mention. We have medications, lifestyle, and we do have devices. Brain injury can lead to multiple changes. A person can be genetically predisposed. It can be axonal injury. It also can be neuroinflammation and different metabolic changes in the brain.

We do have devices, and there is a very interesting branch of literature coming out right now about a few of them. One is vagal nerve treatment, which is actually being studied for long COVID. They have shown in articles now that inflammatory markers are going down. We have to wonder whether we can use some of our devices more widely; there are five FDA-cleared devices on the market here now for treatment of migraine and some of them for treatment of different types of headache.. When we have migraine-like headache in a person who had traumatic brain injury, we try migraine treatments.

We need more research for specific posttraumatic headache. At this point, we do have electrical and magnetic stimulators. They're called neuromodulation. They usually have a wonderful side-effect profile.

Wilner: You mentioned vagus nerve stimulation. Is that the vagus nerve stimulator that I'm familiar with, the one that we use for epilepsy?

Riggins: For epilepsy treatment, you actually have to do many more things than we're doing with our vagal nerve neuromodulation. Ours is external.

Wilner: That's a big difference.

Riggins: Yes. It goes right here on the neck. A person can titrate it up and down. It's approved for migraine or cluster and hemicrania. Now, a few centers are doing different posttraumatic and post-COVID research.

Wilner: I've been hearing about virtual reality. Are there any virtual reality programs for people with headache?

Riggins: Absolutely. There's a big body of literature coming out about the use of virtual reality. For different posttraumatic syndromes, and of course, PTSD, we're all using biofeedback virtually. It really works.

Dr Mia Minen, my colleague at the American Headache Society, has wonderful publications about the use of teleheadache and about muscle relaxation. Of course, we're all familiar that there are a few types of actions of virtual reality. One can be simply distraction from surroundings by putting on glasses or a helmet. They did research in waiting rooms and in infusion centers. It really can take out this component of the environment that can be disturbing for patients.

To add to that, we do worry if a person has migraine or posttraumatic headache with light sensitivity. We have to take it in consideration. At UCSD, we are running randomized controlled trial with glasses. It's not virtual reality, but it's blue-light-blocking glasses. Randomly, we assigned a placebo type of glasses and one that blocks blue light with a special lens. We're enrolling people who have had brain trauma in the past. I hope that at one of the next ANN conferences, we can present it.

Wilner: I'm looking forward to that. The lenses block blue light. Is that right?

Riggins: Right.

Wilner: In San Diego, you've got a large amount of light.

Riggins: Absolutely.

Wilner: A large amount of sunlight there — you're going to have to use pretty strong glasses. I think we're running out of time. Is there anything you'd like to add?

Riggins: I want to say that screen time also plays a role in what we do nowadays, right? It brings up neck components. I would say, don't forget about the neighbor to the head and address any neck components.

To summarize, collaboration really matters. We have a long way to go to study which treatments are the best. That's why getting together here at AAN is so wonderful. Thank you so much for highlighting this excellent AAN conference. It's a big anniversary for us, and it's a pleasure to be here.

Wilner: Thank you, Dr Riggins. I'm Dr Andrew Wilner, reporting for Medscape. Thanks for joining me.

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