Lack of evidence for brain-trauma-induced headache: a prospective study

Background: Headache is a frequent complaint in the medico-legal evaluation of brain trauma victims. However, the etiology of so-called posttraumatic headache remains controversial, and data from systematic prospective assessments of headache syndromes following brain trauma is scarce.

Purpose: To investigate the frequency, type, course, and treatment response of headache syndromes in patients with brain injury.

Methods: In a prospective study the 124 consecutive patients (mean age 42 years, 27% female) with mild (3%), moderate (8%), or severe (89%) brain injury, defined by criteria of the National Institute of Health Traumatic Coma Data Bank, were assessed. The mean time interval between brain trauma and study inclusion was 28 days (range 3–103 days). Causes of brain trauma were motor vehicle (61%), work-place and home accidents (38%), and other trauma events (1%). Headache was classified as migrainous, tension type, unclassified, and headache associated with infections and surgical procedures. Duration (episodic, chronic) and frequency (single versus recurrent episodes) of headaches were recorded.

Results: During a mean observation period of 68 days (range 2–247 days) no patient (0%, CI 0% to 3%) revealed chronic or recurrent episodic headaches of migrainous, tension or unclassified type. A total of 21 patients (17%, CI 10% to 24%) patients reported rapidly reversible non-recurrent headaches associated with infections (n=12), neurosurgical interventions (n=6), and falls with head trauma during rehabilitation (n=3). One additional patient persistently complained of a circumscribed local pain on scalp palpation. The frequency of headache syndromes neither differed significantly in strata of mild to moderate versus severe brain trauma nor by brain lesion pattern (cerebral contusion versus normal imaging) or clinical outcome (normal to mild versus disabling deficit). Analyses by headache subtypes, by different causes of brain trauma, and restriction of the analyses to patients without persistent impaired vigilance or communication revealed similar results.

Conclusion: In the setting of early brain trauma rehabilitation, our findings suggest (1) a low incidence and minor clinical importance of headache syndromes following brain trauma and (2) offer no support for a biological link of so-called posttraumatic headache with brain trauma.

Tab.1: Age, gender, headache syndromes, brain trauma severity, cause, morphology, and clinical outcome in 124 brain trauma patients

* give other # by brain imaging & Rankin scale score >1
age (mean, SD)			41,8	(16–83)
female gender (n,%)			33	(26.6%)		95% CI[19,08–35,29]
headache
	any		22	(17,8%)		95% CI[11,46–25,62]
		migrainous		0	(0%)
		tension headache		0	(0%)
		unclassified		12	(54,5%)	95% CI[32,21–75,61]
		other*		10	(45,5%)	95% CI[24,38–67,78]
braintrauma
	severe		110	(88,7%)		95% CI[81,78–93,68]
	moderate		10	(8,1%)		95% CI[03,93–14,33]
	mild		4	(3,2%)		95% CI[00,88–08,05]
	contusion#		77	(62,1%)		95% CI[52,94–70,65]
	intracraniell/haemorrhagia#		104	(83,9%)		95% CI[76,19–89,86]
clinical outcome by vigilance
	coma		0	(0%)
	comavigile		15	(12,1%)
	supor		2	(1,6%)
	somnolence		0	(0%)
	vigilant		107	(86,3%)

Tab.2: Age, gender, brain trauma severity, cause, morphology, and clinical outcome in brain trauma patients with (n=22) and without (n=102) headache

95% Cl: 95% confidence interval; * non significant
		Headachegroup		noheadache
age (mean, SD)		44.3	(16–80)	41.1	(17–83)*
female gender		7	(31.8%)	26	(25.5%)
		(95% Cl[13,86–54.87])		(95% Cl[17,37–35.07])*
braintrauma
	severe	20	(90,9%)	90	(88,2%)
		(95% CI[70,83–98.88])		(95% CI[80,35–93.77])*
	moderate	2	(9.1%)	8	(7.8%)
		(95% CI[01,12–29.16])		(95% Cl[03,44–14.87])*
	mild	0	(0%)	4	(3,9%)
				(95% CI[01,07–09.73])*
	contusion	18	(81,8%)	77	(75,5%)
		(95% CI[59,71–94,81])		(95% Cl[65,97–83.46])*
	intrac. haemorrhagia	18	(81,8%)	98	(96,07%)
		(95% Cl [59,71–94.81])		(95%Cl [90,26–98,92])*
clinical outcome by vigilance
	coma	0		0
	comavigile	0		15
	stupor	0		2
	somnolence	0		0
	vigilant	22		107