Pediatric Posttraumatic Headache

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Concussion and mild traumatic brain injury are common injuries in pediatrics, and posttraumatic headache is the most common complaint following them. Although most children and teens recover from a simple, isolated concussion without incidents within 1-2 weeks, some develop symptoms that can last for months. It is important to manage both acute and persistent posttraumatic headaches appropriately to speed recovery, minimize disability, and maximize function. In this article, we review the definitions, epidemiology, and current recommendations for the evaluation and treatment of acute and persistent posttraumatic headaches. Although this is still a developing field and there is much that we still need to learn about concussion and the best strategies to prevent and treat these injuries and their sequelae, we hope that this review will help providers to understand the current evidence and treatment recommendations to improve care for children with concussion and mild traumatic brain injury.

Introduction

Traumatic brain injury (TBI) is one of the most common injuries in the pediatric age group. It is estimated that as many as 500,000 children younger than 15 years sustain TBIs that require hospital-based care in the United States, and most of these injuries are mild in severity.1 A national cross-sectional study in the United States estimated that 1 of every 220 pediatric patients seen in emergency departments (EDs) receive a diagnosis of mild TBI (mTBI).2 Headaches are the most common symptom after mTBI or concussion and often occur with a constellation of physical, cognitive, emotional, and behavioral signs and symptoms. Headaches may affect a child’s ability to function and participate in school and extracurricular activities, which can cause disability and impair his or her quality of life.3 This review focuses on persistent posttraumatic headaches after mTBI and concussion. Chronic or persistent headaches refer to those that last longer than 3 months following a TBI, which is consistent with the classification of persistent posttraumatic headaches in the International Classification of Headache Disorders–3 (ICHD-3) beta.4 Although concussion and posttraumatic headaches are rapidly evolving areas of study, there is an unfortunate lack of definitive scientific evidence at this time on these topics in pediatrics. This article reviews the current definitions and epidemiology of pediatric posttraumatic headache and discusses current theories and recommendations for the assessment and management of persistent posttraumatic headache in pediatrics.

Section snippets

Definitions

The ICHD, 3rd edition, beta version, classifies posttraumatic headaches as acute if lasting less than 3 months and persistent if lasting more than 3 months.4 This period is consistent with the ICHD-II diagnostic criteria,5 although the term persistent has been adopted in place of chronic. The classification for persistent posttraumatic headache is summarized in the Table. Although the ICHD-3 beta criteria state that posttraumatic headaches begin within 7 days after injury to the head or after

Epidemiology

Although most children and adolescents with mTBI recover within a few weeks, some patients continue to have persistent symptoms for many weeks and months following injury. A prospective controlled study by Barlow et al6 compared 670 patients presenting to an ED with mTBI and 197 patients with extracranial injury (ECI). At 3 months after injury, 11% of patients with mTBI were symptomatic compared with 0.5% of those in the ECI group; however, the prevalence of symptoms decreased over time, with

Evaluation of Pediatric Posttraumatic Headache

Although there are no strict criteria for determining who will develop persistent headache following concussion, it is important to gather information to rule out other secondary headaches and significant primary headache disorders and to identify those who may be at risk. We briefly discuss assessment of acute posttraumatic headache and focus on assessment of persistent headache following concussion or mTBI.

Treatment

Headache is the most common symptom following concussion, yet there is a paucity of evidence regarding the safety and the efficacy of treatments for posttraumatic headaches.7, 24, 25 As most clinicians who manage concussions and posttraumatic headaches can attest, these persistent headaches can be difficult to treat. There are currently no established guidelines for the treatment of posttraumatic headaches, and practices can vary widely from one clinician to another.26 Moreover, there are

Conclusion

In summary, headaches are common following pediatric concussion and mTBIs. Although acute posttraumatic headaches resolve within a few weeks for most of the children, a significant minority develop persistent posttraumatic headaches that can cause significant disability and disruption of academic, athletic, family, and social activities. Although there are no formal guidelines for the management of persistent posttraumatic headache, it is important to complete a thorough evaluation, rule out

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