What Is The Epidemiology
There are 1.8 million cases of acute PTH and 400,000 chronic PTH cases every year in the United States civilian population.8 Military personnel and civilians, specifically amateur athletes, who sustained a TBI are at high risk of developing PTH. One study reports 37 percent of 978 US soldiers who sustained mild TBI developed PTH.9 Ten to twenty percent of amateur athletes with TBI develop PTH.10
National Pain Care Policy Act Into Law
The National Pain Care Policy Act resulted from the diligent work of several advocacy groups including the Pain Care Coalition , the American Pain Foundation and others. The PCC was organized in 1989 by the American Pain Society, American Association of Pain Medicine, and the AHS. These advocacy groups contributed to the inclusion of key components from the 2009 NPCPA into the Patient Protection and Affordable Care Act, the landmark healthcare reform bill.
The National Pain Care Policy Act of 2009 requires the Secretary of Health and Human Services seek to enter into an agreement with the Institute of Medicine to convene a Conference on pain, which may be a major way forward in the road to providing better care for servicemen with posttraumatic headache. The purpose of the conference is to address key medical and policy issues of pain care.
Secondly, training programs will be necessary to improve health care skills of assessing and treating pain. Lastly, Sections in the NPCPA also require that the Director of the National Institutes of Health continue to expand research through the NIH Pain Consortium. The Consortium is lead by directors of the NIH Centers for Complementary and Alternative Medicine, and Institutes of Nursing Research, Neurological Disorders and Stroke, Dental and Craniofacial Research, and Drug Abuse.
What Is The Pathophysiology
PTH occur due to injury 1) of nociceptor afferent fibers from the trigeminal nerve innervating the anterior head and scalp, face, leptomeninges and blood vessels and 2) from distal branches from C2 and C3 cervical spinal roots such as the greater and lesser occipital nerves innervating the posterior head and scalp. These two pathways convey painful signals to the spinal trigeminal nucleus with activation of second-order neurons that results in the process of central sensitization.17 At the cellular level, TBI induces a neuroinflammatory changes via microglia activation with the release of proinflammatory molecules such as interleukenes 1Î², 6, 8, and tumor necrosis factor . Inflammatory response also includes blood brain barrier abnormalities with extravasation of neurotrophils, plasma proteins, mast cell degranulation, and platelet aggregation.18 These neurochemical changes may trigger cortical spreading depression and release of calcium gene peptides from trigeminal nerve cell bodies. This will stimulate glia to release more inflammatory molecules causing more neuronal hyperexitability.19 Release of excitatory neurotransmitters such as acetylcholine, glutamate, and aspartate, and magnesium decrement and alter glucose metabolism are also implicated in PTH pathogenesis.17,20
Viewpoints: Assessing Disorders of Consciousness
Andrew M. Goldfine, MD
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Post Traumatic Stress Disorder And Migraine
Childhood maltreatment, abuse, or violence may lead to post-traumatic stress disorder at a later age. PTSD is a condition that results from exposure to an event that caused feelings of intense fear, helplessness, or horror. Many traumatic stressors exist. These include natural disasters and transportation accidents. Others are physical and sexual assault, such as rape and exposure to war or combat. Finding out about a traumatic event or about the violent death of a loved one may also lead to PTSD. The main symptoms of PTSD include: 1) re-experiencing the traumatic event through flashbacks or nightmares 2) avoiding reminders of the trauma 3) increased anxiety and emotional arousal such as feeling irritable, jumpy, or being easily startled and 4) feeling detached from others or emotionally numb. Other symptoms may include feeling angry, guilty, hopeless, and experiencing physical aches and pains, including headache.
Find Relief From Chronic Pain
There are a variety of treatments that can bring relief to physical and emotional symptoms. They include:
- Medicines. Over-the-counter anti-inflammatory and pain medicines are used in the first few weeks of post-traumatic headache, along with triptans, a type of medicine for migraines.
- Preventive medicines. If the headaches persist, your doctor may prescribe medicines to prevent them from happening. Anti-depressants, blood pressure medicines and anti-seizure medicines can help.
- Physical therapy. Exercises to loosen muscles and build strength may help stop or prevent frequent headaches after traumatic brain injury.
- Biofeedback and relaxation therapy. Learning how to manage pain and relax your mind and body can reduce stress and help prevent headaches.
- Nerve stimulators. When medicines dont work, a device that sends electrical signals to specific nerves in the neck can bring headache relief.
- Cognitive behavioral therapy. Some patients may find relief by working with a psychologist. A strategy called cognitive behavioral therapy can teach you how to manage certain situations so that you can change the way you and your body respond to them.
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What Type Of Injuries Cause Pth
Post-traumatic headaches may occur due to a traumatic brain injury . TBI may be found in both military and civilian populations. In military personnel, TBI are most commonly caused by blast explosions , falls , vehicle accidents , fragment or shrapnel and bullets .2 In the civilian population, TBI are most commonly caused by motor vehicle accidents , falls , occupational accidents , recreational accidents , and assaults .4 Falls account for most of TBIs in children between 0-4 years of age and adults over 75 years of age.5
What To Do For Headache After An Accident
If a person experiences a persistent headache after an accident, it is imperative to see a doctor, even after initial hospitalization following the incident. In a 2010 article for the Journal of Head Trauma Rehabilitation, John D. Corrigan and his fellow authors found that an estimated 43 percent of Americans live with disability one year after hospitalization from traumatic brain injury and 3.2 million live with residual disability. In order to avoid the worsening of issues and the development of long-term problems, one must address symptoms such as post traumatic headaches as soon as possible.
Make sure to consult specialists and professionals to care for you and assist you. Get comprehensive medical examinations. Cover all your basesfrom your primary care doctor to a neurologist, from a chiropractor to even a personal injury lawyer, should you need one. This helps make the situation more manageable and less stressful this way, if you do have post-traumatic headache and all the other post-traumatic symptoms that can come with a TBI, then you can focus on your healing and recovery.
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How Often Do Post
In the civilian population, 78 percent of PTH may persist after three months,11 35 percent persist after one year,12 24 percent persist after two years,13 and 24 percent persist after four years.3,14 Ninety eight percent of the soldiers who met the criteria for deployment-related concussion have headaches after three months of deployment. The prevalence of chronic daily headaches in returning veterans with deployment-related concussion headaches was 20 percent.6,15
Raising Awareness For Post
There has been significant increased awareness about the potential complications and risks related to concussion in the last few years. But Dr. Anderson still sees room for growth when it comes to educating people on post-traumatic headache.
We need to continue on this avenue to ensure patients, parents, physicians, coaches and the general public have the best available information to make informed decisions and help recognize the signs and symptoms of a concussion, he says. As part of this effort, I believe we still have significant work to do to raise awareness, particularly of post-traumatic headache.
Trent Anderson, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.
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Progression From Acute To Chronic Pth
Similar factors may be involved in the transformation of acute PTH to chronic PTH. Certainly, the reported inverse relationship between severity of injury and headache chronicity is intriguing and argues for other, equally important factors. The next illustration shows how mild TBI may lead into a vicious cycle of headache chronification.
The blast has two components: the physical impact produces an acute PTH, experienced after about 80% of mild TBIs. This can lead to medication useor overuseparticularly when the soldier is self-medicating without appropriate evaluation. Here, it is important to remember that caffeine is a drug that can readily perpetuate chronic headaches. There is also the psychological impactwhat the soldier saw, what he heard, what he smelled, and what he imagined. This can fuel the anxiety component of the vicious cycle and lead to non-restorative sleep.
What Is Post Traumatic Headache
Approximately 1.7 to 1.8 million people in the U.S. suffer from traumatic brain injury every yearprimarily due to falls, motor vehicle accidents, and direct hits to the head. Between 30 to 90 percent of these TBI patients develop head pain thats known as a post traumatic headache.
Post traumatic headache, as defined by the International Headache Society, may develop within seven days of the injury/accident or after the patient regains consciousness following the injury. Post traumatic headache may resolve itself without treatment within three weeks, but that may not always be the case. Acute post-traumatic headaches last less than three months when the pain persists beyond three months, the case is considered chronic post traumatic headache. Since they occur on a daily or almost-daily basis, these post traumatic headaches can greatly affect a persons quality of life and function.
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Post Traumatic Headache Symptoms To Watch Out For
Post-traumatic headaches may present as tension-type headaches, which can be moderate to severe, and pulsating. This can come with symptoms of nausea and vomiting, as well as sensitivity to light and sound. Post traumatic headache can also be similar to a migraine: a nonpulsating headache that can be mild to moderate, with either light or sound sensitivity but no nausea and vomiting.
While post-traumatic headache mainly presents itself with pain, there are other issues or accompanying symptoms that come with it. The International Classification of Diseases, 10th revision , offers criteria for mild post traumatic headache and traumatic brain injury, which, aside from the headache, includes the following set of symptoms:
- General malaise
- Noise intolerance.
According to the ICD-10, sufferers of post traumatic headache can also experience a range of psychological and neurological symptoms, such as irritability, emotional instability, depression, or anxiety, as well as insomnia, decreased level of consciousness, reduced alcohol tolerance, and subjective difficulties with concentration or memory.
Congressionally Directed Medical Research Programs Fy2010
In response to this growing public health problems associated with TBI, the fiscal year 2007 marked a dramatic increase in psychological health and traumatic brain injury research when the Congressionally Directed Medical Research Programs was allocated an unprecedented $301million to advance the militarys understanding of these disorders. $151M is for research on Posttraumatic Stress Disorder and $150M for research on TBI. Despite the large burden in headache prevalence of those afflicted with TBI, headache disorders have been under-investigated and there are large gaps in our knowledge base of service-connected migraine and posttraumatic headache.
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Guidance For Primary Care
The aim of management is to exclude a causal secondary pathology, exclude MOH, and treat to closest phenotype. Secondary headache can be caused by:
Dissecting carotid artery. Dissection of carotid or vertebral artery can be found in 1% of all traumas that are imaged with angiography. The majority occur within 72 hours and 2% of patients can experience pain for months. The pain is ipsilateral to the injury and can be associated with Horners syndrome because of damage of the sympathetic plexus around the artery.
Intracranial haematoma. Fifteen per cent of patients with TBI demonstrate intracranial abnormalities. However, findings that alter management may be much lower.
Intracranial hypotension due to dural tear. This occurs particularly after injuries to the neck. Headache is relieved by lying flat.
Hypopituitarism. Hypopituitarism is largely unrecognised and may be as high as 27% in TBI cases because of damage to hypophyseal vessels or direct trauma to the gland. Undiagnosed pituitary adenoma can be a factor. Screening for pituitary dysfunction has been suggested at 3 to 6 months post-injury, when admission time is greater than 48 hours or when symptomatic. Relevant symptoms include fatigue, low mood, poor motivation, reduced appetite, sexual dysfunction, and oligomenorrhoea/amenorrhoea.
Progression From Episodic To Chronic Headache
To illustrate the process of transitioning from occasional or episodic headaches to chronic headaches, lets look at a model for the chronification process. With migraine, there is a genetic componentan inherited susceptibility. The susceptible individual then encounters an occasional migraine trigger and experiences occasional, or episodic migraine. These individuals are typically able to manage attacks with effective, acute, migraine medications, however, when individuals get into trouble with increasing frequency of headaches, they enter into a vicious cycle of progression to chronicity. Chronic migraine is marked by some degree of headache discomfort on at least half the days of the month, and, if left untreated, eight or more of these would become migraines.
How one enters the vicious cycle likely differs to some degree from individual to individual, and is a matter of debate among headache specialists. This illustration shows entering the circle through non-restorative sleep, which can be attributed to any of a vast array of issues. Chronic, poor sleep is a risk factor for progression to more frequent headaches. Then, if drugs are taken for each attack, medication overuse or rebound headaches can ensue, perpetuating the headaches.
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Epidemiology Including Risk Factors And Primary Prevention
PTH is more frequent after mild TBI than moderate or severe TBI, and resembles multiple types of headache, such as migraine-type or tension-type headaches.2 Migraine-type headaches are more prevalent and can occur in patients regardless of either a pre-injury history or family history of migraine.3
PTHs account for approximately 4% of all symptomatic headache disorders and is known to be one of the most common consequences of mTBI.4 Annually, it is estimated that 69 million people experience a traumatic brain injury worldwide, with > 3.8 million individuals in the United States being diagnosed with a mTBI yearly.5 Additionally, population-based studies estimate the one-year prevalence of persistent PTH to be .21%, with a lifetime prevalence of 4.7% in men and 2.4% in women. A considerably negative socioeconomic effect has also been reported among people with PTH, as 35% do not return to work within 3 months post-injury.6 PTH appears to be most common after mTBI compared to moderate or severe injury, most commonly resulting from motor vehicle related events , followed by falls , sport related events , and violence 5-7%).7
What Health Care Providers Should Know
The most important thing health care providers can do when determining if a patient has post-traumatic headache is ask the right questions. Ask patients about the characteristics of their headache: Do they have nausea, vomiting, light sensitivity or sound sensitivity? In addition, be on the lookout for red flags that might indicate someone isnt experiencing migraine or post-traumatic headache, but another form of headache. One red flag, Dr. Vargas says, could be a positional quality to the headache, which could indicate a low-pressure headache due to a cerebrospinal fluid leak that can occur in the setting of head trauma. Once you feel like you have a pretty firm grip on what type of headache youre dealing with, then follow the treatment algorithms that we currently accept for those subsets of headache, Dr. Vargas says.
Bert Vargas, MD, FAHS, is a member of the American Headache Society, a professional society for doctors and other health care workers who specialize in studying and treating headache and migraine. The Societys objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Societys work and find out how you canbecome a member today.
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What Are The Signs And Symptoms Of A Cpth
Signs and symptoms depend on where you were injured:
- Mild to severe headaches that affect both sides of your head and may pulsate
- Pain that happens almost every day or is worse with activity
- Trouble concentrating or remembering things, depression, or anxiety
- Being sensitive to light or noise
- Dizziness, trouble sleeping, or fatigue
Headaches And Migrainous Symptoms
Posttraumatic headache is one of the most common symptoms following concussions, and may occur in 30â90% of those with concussion . Despite being classified as a âsecondary headache,â PTHA frequently assumes characteristics of a primary headache disorder, such as migraine or tension-type headaches. The headache may be further classified temporally into acute or persistent . While TBI often results in acute headaches, persistent PTHA, particularly migraine, can last beyond 1 year in 15â65% of patients, regardless of headache severity . Sawyer et al. found that patients with PTHA fell into four categories most of their patients were in the chronic or worsening groups.
Fig. 6.1. Neurometabolic cascade of concussion. TBI, traumatic brain injury.
Postconcussion ionic flux and altered cortical excitability have much in common with the âspreading depression of Leao,â which has been implicated in migraine pathogenesis. Direct cortical recordings demonstrate waves of spreading-depression-like activity after more severe TBI, concomitant with evidence of a metabolic crisis in severely injured patients . A report of significant cerebral edema after mTBI in a family pedigree with the CACNA1A mutation for familial hemiplegic migraine further illustrates the connection between ionic flux and TBI pathophysiology .
Ronald G. RiechersII, … Robert L. Ruff, in, 2015
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