The traumatic event which causes the TBI generally causes headache of one or more kinds which can include muscular, cervicogenic and vascular. Muscular headache is associated with increased tension and spasm of the muscles in the scalp, neck and shoulders. Cervico-genic headache is associated with a pinched or stretched cervical nerve root. These headaches are potentially responsive to aspirin, Tylenol, anti-inflammatory medication, warm/cool compresses, physical therapy, acupuncture, nerve block injection to trigger points, and other treatments aimed at reducing the spasm and pain associated with muscle tightness. Behavioral change can help too. Instead of increasing activity at home or office when the tension headache starts, patients should slow down and rest. They should also avoid negative emotions and exposure to bright lights or loud noises, as these tend to trigger attacks of headache pain.
Vascular headache includes migraine, and much less commonly cluster headache. Migraine is an intense, throbbing headache often accompanied by hypersensitivity to light and sound, nausea, even vomiting. Classic migraine is preceded by preceded by a dazzling display of lights known as an aura. Other forms of migraine occur without aura, including post-traumatic migraine.
Migraine headaches are sometimes accompanied by dizziness, blurry vision, allodynia (extreme pain reaction to the slightest touch of the skin), bloodshot and teary eyes, edema, and other unpleasant symptoms. They leave the sufferer spent, weak and sleepy – making sleep one of the few restoratives. These headaches require medications which constrict swollen intra-cranial blood vessels and quiet clusters of cells in the brain called “migraine generators” such as those found in the trigemino-vascular systems associated with the trigeminal nerve. Contemporary neurologic literature identifies overexcitation of the neurons in the trigeminal nerve as one important mechanism in generation of migraine.
The trigeminal nerve (the 5th cranial nerve) arises at the base of the head and supplies the eyes, cheeks and jaw). The overexcited trigeminal precipitates rapid, dramatic swelling of blood vessels around the brain with release of inflammatory chemical substances (especially CGRP or calcitonin gene-related peptide) that perpetuate the vascular swelling and triggers excitatory changes in other neurons. During migraine the blood drained from the head by the jugular vein shows abnormal elevation of CGRP.
In head injury victims who develop migraine, the headache is often triggered by effortful visual or mental concentration. For such persons it literally hurts to think. The harder they concentrate on a task (such as reading) the more intense the headache until it evolves into a full blown migraine. Contrary to popular belief migraine is not a psychological disorder; it is most certainly a neurologic disorder. Migraine involves a “rolling tidal wave of pain.” If appropriate medications are taken within 90 minutes of onset (especially the serotonin boosting “triptans” like Imitrex), the first wave can be stopped before excitation spreads to other migraine generators.
If the headache is not stopped in time, the spread of the headache triggers odd sensations known as parasthesias (numbness and tingling in the head, face, jaw or tongue) and odd hypersensitivities (wherein light, sound or the touch of a comb on the hair, a breeze on the cheek or even the pressure of clothing can trigger agonizing pain). One client of our office suffered from unbearable scalp itch. If you are having these types of headaches after your head injury, it is imperative to tell your doctor. A scientific survey conducted for the National Headache Foundation presented in August 2000 showed that 52% of all migraine headache sufferers had not been diagnosed. See NHF HeadLines #115.
It is well established that a blow to the head can cause migraine of temporary or permanent duration, and this is recognized by the International Headache Society, which calls it post-traumatic migraine. A paradox recorded in the medical literature is that patients with mild head trauma tend to develop worse, more persistent headaches than patients with severe head trauma. Physicians retained by insurance companies to combat damage claims by victims of head injury say the opposite.
Disregarding the medical literature, they say mild TBI produces only mild headaches and that any mild TBI patient who complains of frequent, severe headaches is either a malingerer seeking money or an exaggerator seeking attention and sympathy. These physicians are not in touch with the facts. Headache is the most common complaint following mild TBI and the one that its victims tend to complain about the longest. Even 4 years post-trauma some 20-25% still complain of headache. When the post-traumatic headache is the migraine type, extra damage to the brain can occur from abnormally high quantities of blood surging through the cerebral arteries for an extended period of time during migraine attacks. K. Michael Welch of the Kansas University Medical Center just told the International Headache Society in July 2001 that frequent migraine leads to deposition of iron particles in the brain tissue with gradual destruction of the periaqueductal gray matter, the part of the brain responsible for blocking or suppressing pain messages.
He established this by using a form of MRI that maps iron concentration in the brain, and found it to be much higher in frequent migraine patients than in patients with episodic migraines or no migraines. The MRIs also showed erosion of the PAG in frequent migraineurs but not in the others. Once the PAG is damaged by iron, the patient will be susceptible to feeling severe pain at all times, not just during migraine. Therefore, says Welch, doctors must do all they can to prevent frequent recurrence of migraine. Depakote and Elavil have been used successfully in some patients to prevent migraines.
The most potent and fast acting migraine medications on the market today to stop or “abort” a migraine already in progress are known as triptans (the 5HT receptor agonists which mimic serotonin). These include Imitrex, Amerge and Maxalt. They work most effectively when taken rapidly after the first signs of headache onset, before the neurons in the occipital portion of the trigeminal nerve start an uncontrollable firing pattern that can take hours, even days to subside. These medications come in a fast dissolving pill that one can place under the tongue, like nitroglycerin for heart patients with angina. Since Imitrex is too strong for children, neurologists offer children Elavil (a tricyclic anti-depressant). The triptans stop or abort migraine headaches, which are already in progress.
Elavil is somewhat useful in headache prophylaxis, i.e. in preventing onset of new headaches. Still more useful in headache prevention are anti-convulsant medications such as Depakote, which blocks the enzyme that degrades GABA and thereby increases the supply of GABA in the brain, which places a neurochemical damper on spreading excitation. A neurologist will prescribe Depakote only when migraines are not responsive to abortives such as the triptans or the migraines are occurring with extreme frequency.
Depakote has bee shown to be safe and effective in large scale, double-blind, placebo controlled studies. Although cognitive problems following a TBI are significant, sometimes the most persistent and most disabling problem associated with a TBI is migraine. Sometimes it is insomnia with fatigue. Unfortunately some persons are burdened on a chronic basis with migraine and insomnia. Such patients deserve a comprehensive neurologic work up and aggressive treatment.
In litigation situations where the plaintiff complains of migrainous headache pain, but is disbelieved by the insurance company, some doctors resort to CT or MRI scans. This is a waste of time and money. Migraine is not a permanent, structural abnormality but a transient condition involving sudden expansion of blood vessels, blood flow changes and inflammation. A recent review showed that CT studies are not helpful and are almost always negative, see Headache 39:747-751 (Dec. 1999). If forensic proof of headache is needed, a SPECT scan showing blood flow changes or fMRI showing oxygenation changes in the blood would be a much higher yield choice.
Self-management of migraine is an essential part of living a better life. In his book Migraine, noted neurologist Oliver Sacks, M.D. points out that no matter how much tinkering your neurologist does with headache medication, your migraines will never be brought under lasting control without you taking the time to observe the patterns of your headaches – in particular what triggers them (e.g. red wine, fatigue) and what makes them better (e.g. rest). Chocoholics will be happy to learn there is no solid scientific proof that chocolate is a migraine trigger.
However, in the Jan. 25, 2000 edition of Neurology, Dr. Werner Becker of the University of Calgary, Canada, published a study indicating that changes in weather patterns, especially the onset of “Chinooks” (warm, westerly, high speed winds), was a clear trigger for migraine in chronic migraine patients. Migraine affects at least 15 million Americans 75% of them women. It is a serious public health problem. Surveys the NHF (National Headache Foundation) reveal that many migraine sufferers do not seek medical help. Some are so resigned to having headaches it does not even occur to them that life could be different or that anyone could help. Some tried inappropriate treatments which failed and left them pessimistic about medical help. Others fear being perceived as “crazy” because of the odd nature of their symptoms.
Avoidance of alcohol and stress, and getting lots of sleep can help reduce the frequency of migraine. TBI does not per se create a risk of alcohol abuse, except in persons who were abusing it before their injury. For those persons, rehab can include intervention to prevent relapse. Persons with a TBI face stress everyday associated with the frustration of forgetting what they just heard or read and from failing to perform tasks as quickly, efficiently or correctly as they once did. If they can learn techniques to lessen their levels of frustration and anger, this can help.
Unfortunately, the insomnia which accompanies TBI is rarely responsive to medications available at this time. Survivors of a TBI with insomnia and migraine face a difficult time, because they cannot get the sleep they need to “retune.”
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