Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion

Abstract

Background There is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury. Methods Adults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI). Results A total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness. Conclusions This study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.

Post-Traumatic Headache in Children after Minor Head Trauma: Incidence, Phenotypes, and Risk Factors

“…Moreover, there are multiple precipitant factors for headache, and many of these can be experienced by individuals after a concussion or traumatic brain injury (e.g., adverse psychological reactions to the injury-related circumstances, depressed or anxious mood, parental trauma-related anxiety [ 49 ], sleep deprivation, interrupted sleep, altered sleep–wake cycles, etc.) [ 50 ]. Therefore, the focus of the diagnosis and management of PTH should be on these aspects.…”

Sensory hypersensitivities are associated with post‐traumatic headache‐related disability

“…Sound hypersensitivity has been widely described after TBI. 10,[36][37][38][39] A recent prospective study of 302 individuals presenting within one week of a concussion reported photophobia in 74% and phonophobia in 72% of participants, 40 though little information was provided relative to the presence or chronicity of concurrent or pre-existing headache in this study. In contrast, these features have not been as widely studied in PTH.…”

“…Indeed, photophobia is considered a hallmark feature of the migraine attack, 5 though it is important to clarify that light sensitivity is not unique nor specific to migraine headache. In fact, light sensitivity in association with non‐migrainous headaches is a widely reported consequence of TBI, even in those without a history of migraine 40,43 . Analogously, allodynia, pressure‐sensitivity, and other sensory dysfunction (as discussed above), can be seen in both primary and secondary headache.…”

Primary Headaches and Physical Performance: A Professional Youth Female Soccer Team Study

“…Moreover, it should be investigated whether the concussion screening interventions address the delayed onset of symptoms [ 25 ]. Even a mild head injury or concussion can lead to long-term consequences [ 26 , 27 ]. Delayed effects of these events are common among retired athletes [ 28 ].…”

“…Hence, the risk of traumatic brain injury is higher in contact sports, causes long-term consequences and the recovery from such incidents is longer if the athlete had a history of migraines before the injury [ 11 , 12 , 27 ]. However, limiting physical activity has a negative effect on medical conditions, both physical and mental.…”