Headache & Pain
Headache associated with spontaneous spinal CSF leak
Nov. 20, 2023
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Toll Free (U.S. + Canada): 800-452-2400
US Number: +1-619-640-4660
Support: service@medlink.com
Editor: editor@medlink.com
ISSN: 2831-9125
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Headache is common following head injury. Most individuals recover within days, weeks, or months, but a minority of subjects may suffer from intractable posttraumatic headache despite treatment. Posttraumatic headache remains a subject of controversy concerning its pathophysiology. Litigation and medicolegal problems further complicate this issue. This article attempts to summarize current understanding of posttraumatic headache, including a brief historical review of the disease, the classification and diagnostic criteria, the epidemiology, clinical manifestations, pathophysiology, diagnostic evaluation, and management.
• Posttraumatic headache is common following head or neck trauma. | |
• The International Headache Society defines posttraumatic headache as “acute” if headache develops within the first 7 days after the accident and resolves within the first 3 months and “persistent” if headache lasts longer than 3 months. | |
• Underlying pathophysiological mechanisms associated with the development and maintenance of posttraumatic headache remains uncertain and may include psychogenicity and diffuse axonal injury. Different mechanisms may be involved in posttraumatic headache of civilians and that of combat soldiers. | |
• Therapeutic treatment of posttraumatic headache should be individualized and comply with the treatment options for the underlying or accompanying primary headache disorders it resembles. |
Headache following head or neck injuries has been reported for centuries. Although the proposed mechanisms for the generation and maintenance of posttraumatic headache have evolved over the years, the subject is still controversial (29).
In his book Posttraumatic Neurosis: From Railway Spine to Whiplash, Trimble traces the arguments that began in the 19th century (118). In 1882, Erichsen published a series of lectures concerning how mild head injuries or “spinal concussion” (so-called “railway brain” or “railway spine”) could result in severe disability (26). However, others casted doubt on the validity of “railway spine” incidence (104). The prevailing view in the 1800s was that headache and other sequelae of head injury were due to malingering or psychogenic or other functional disorders. Interestingly, these contradictory observations were made prior to the development and implementation of worker’s compensation and other liability laws (118). One hundred years later, in the chapter on posttraumatic headache in the Handbook of Clinical Neurology, Miller concluded that the posttraumatic syndrome was caused by compensation neurosis or psychoneurosis (84). In contrast, Symonds took an opposing position in the article “Concussion and its sequelae” (115).
In 1988, the International Headache Society Classification Committee provided the first formal definitions of acute and chronic posttraumatic headache (48). In 2004, the revised International Headache Society Classification of Headache Disorders (ICHD-II) categorized “headache attributed to head and/or neck trauma” into 12 subtypes (49).
In 2018, the International Classification of Headache Disorders, 3rd edition (ICHD-3) categorized “headache attributed to head and/or neck trauma” into eight subtypes:
• Acute headache attributed to moderate or severe traumatic injury to the head (ICHD-3 code 5.1.1, Table 1 and Table 2) | |
• Acute headache attributed to mild traumatic injury to the head (ICHD-3 code 5.1.2, Table 1 and Table 3) | |
• Persistent headache attributed to moderate or severe traumatic injury to the head (ICHD-3 code 5.2.1, Table 4 and Table 5) | |
• Persistent headache attributed to mild traumatic injury to the head (ICHD-3 code 5.2.2, Table 4 and Table 6) | |
• Acute headache attributed to whiplash (ICHD-3 code 5.3, Table 7) | |
• Persistent headache attributed to whiplash (ICHD-3 code 5.4, Table 8) | |
• Acute headache attributed to craniotomy (ICHD-3 code 5.5, Table 9) | |
• Persistent headache attributed to craniotomy (ICHD-3 code 5.6, Table 10) |
Diagnostic criteria: | |
(A) Any headache fulfilling criteria C and D | |
1. The injury to the head | |
(D) Either of the following: | |
1. Headache has resolved within 3 months after the injury to the head | |
(E) Not better accounted for by another ICHD-3 diagnosis |
Diagnostic criteria: | |
(A) Headache fulfilling criteria for Table 1 (5.1) Acute headache attributed to traumatic injury to the head | |
1. Loss of consciousness for more than 30 minutes |
Diagnostic criteria: | ||
(A) Headache fulfilling criteria for Table 1 (5.1) Acute headache attributed to traumatic injury to the head | ||
(B) Injury to the head fulfilling both of the following: | ||
1. Associated with none of the following: | ||
(a) Loss of consciousness for more than 30 minutes | ||
2. Associated, immediately following the head injury, with one or more of the following symptoms and/or signs: | ||
(a) Transient confusion, disorientation, or impaired consciousness |
Diagnostic criteria: | |
(A) Any headache fulfilling criteria C and D | |
1. The injury to the head | |
(D) Headache persists for more than 3 months after the injury to the head |
Diagnostic criteria: | |
(A) Headache fulfilling criteria for Table 4 (5.2) Persistent headache attributed to traumatic injury to the head | |
1. Loss of consciousness for more than 30 minutes |
Diagnostic criteria: | ||
(A) Headache fulfilling criteria for Table 4 (5.2) Persistent headache attributed to traumatic injury to the head | ||
1. Associated with none of the following: | ||
(a) Loss of consciousness for more than 30 minutes | ||
2. Associated, immediately following the head injury, with one or more of the following symptoms and/or signs: | ||
(a) Transient confusion, disorientation, or impaired consciousness |
Diagnostic criteria: | |
(A) Any headache fulfilling criteria C and D | |
1. Headache has resolved within 3 months after the whiplash | |
(E) Not better accounted for by another ICHD-3 diagnosis |
Diagnostic criteria: |
(A) Any headache fulfilling criteria C and D |
Diagnostic criteria: | |
(A) Any headache fulfilling criteria C and D | |
1. The craniotomy | |
(D) Either of the following: | |
1. Headache has resolved within 3 months after the craniotomy | |
(E) Not better accounted for by another ICHD-3 diagnosis |
Diagnostic criteria: | |
(A) Any headache fulfilling criteria C and D | |
1. The craniotomy | |
(D) Headache persists for more than 3 months after the craniotomy |
Posttraumatic headache research has been hindered by methodological problems, most particularly the heterogeneity of patient populations. Studies may include individuals with both trivial and significant head injuries as well as patients with definite abnormalities on testing and subjects with normal investigations. Furthermore, patients with symptom onset hours after injury have been included with those whose symptoms began months after injury. The ICHD-II provided the operational diagnostic criteria for posttraumatic headache. However, the temporal criterion of the acute and the chronic forms is artificial. Some experts disagreed that onset of headache should occur within 7 days from the injury (or after regaining consciousness) (134). The ICHD-3 suggests that there is not enough evidence at this time to change this requirement. It is the hope of the International Headache Society that clinicians and researchers alike will field-test the new diagnostic criteria in both epidemiological and clinical trials.
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MedLink®, LLC
3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122
Toll Free (U.S. + Canada): 800-452-2400
US Number: +1-619-640-4660
Support: service@medlink.com
Editor: editor@medlink.com
ISSN: 2831-9125