Concussion is back to be heavily reported in media, following the two unfortunate incidents that led to Miami Dolphins' quarterback Tua Tagovailoa apparent head injury and concussion.
As you may be aware, headache in general and migraine in specific are two common longterm complications of concussion injury. In the united states alone, it is estimated that 1.8 million individual develop post-traumatic headache every year. While the majoirty of these resolve over time, it is estimated that about 400,000 people go on to have chronic headaches and migraine.
Post-traumatic migraine is a frequent occurrence in any neurological or headache clinic. Unfortunately, it is also a frequent cause of frustration, as many patients are left without clear answers on why they have the headache, how long it will impact their life, and whether they will return to headache-freedom or not.
While trying to answer these questions, it is most important to differentiate two different types of head injuries:
1) Head trauma and brain concussion
When the head is directly hit, such as seen in assaults, items falling on the head, or running into stationary objects, the brain concussion within the skull can lead to a series of changes occuring over the ensuing days or weeks. Some of these changes include activation of inflammatory cells in the brain (called microglia), and reducing the threshold needed to activate pain and sensory pathway. In another word, it 1) creates an inflammation in the brain and surrounding layers, and 2) increases the sensitivity to all stimuli, including pain.
These two mechanisms are very similar to how migraine attacks happen, and hence it is easy to see how post-trauamtic headache can appear very migrainous in some individuals
Patients affected with this kind of injury usually describe a headache with very prominent light sensitivity, and they also complain of other concussion symptoms such as imbalance, memory and attention difficulties and fatigue.
2) Whiplash injury
This mechanism of injury can cause headache for a totally different reason; when the neck goes into rapid flexion-extension, such as when your car get hit from behind on a stop sign, then the structures of the cervical spine show some tearing. In the most severe cases, the cervical spine can get fractures (called hangman fracture) or even a seperation between the vertebral bodies. However, in the more-common, less-intense injuries, the joints of the cervical spine may show some minimal amount of damage. None the less, this damage is usually sufficient to irritate the joints on the long term and produce inflammatory changes (called arthritis). This in turn irritates the nerves that traverse from the neck to the headache (i.e. the occipital nerves), causing severe headaches that can be indistinguishable from migraine headache. You can read more about cervicogenic headache and the occipital nerves here and here.
These headaches are usually in the back of the head (occipital) and they radiate to the front of the head. They may be associated with light and noise sensitivity, but most importantly, they are always associated with tremendous neck pain and stiffness.
Why does it matter?
Understanding the difference between both types of headache is crucial in deciding on management. Real post-concussion migraine can be only treated by migraine preventative medications. They are reports that specifically point to the value of OnabotuliniumtoxinA (Botox) in the management of these headaches.
On the other hand, whiplash injuries and cervicogenic headache are better treated by addressing the neck pain and arthritis, either by soft-tissue massaging, improving mobility, strengthening the surrounding muscles (collectively via physical therapy), muscle ralaxants and anti-inflammatory medications, and/or injections.
It is also important to keep in mind that many individuals will have both types of injuries at the same time, such as falling to the ground with head hitting the ground and bouncing off. In these instances, combination of the two approaches will be of most value.
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