THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI

1
THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES
AFTER TBI

• Olli Tenovuo
• MD, PhD
• Department of Neurology
• University of Turku, Finland

2
Background

• TBI has long been an underestimated area in
  clinical medicine, especially in regard to its
  significance for public health.
• There are still major gaps in our knowledge of
  some very central issues. One of these is the
  co-occurrence of chronic pain and TBI.

3
Background

• The co-morbidity of chronic pain and TBI is
  highly complex ? clear diagnostic and treatment
  guidelines, applicable at an individual level,
  cannot be expected.
• This should not hamper progression in research
  and clinical care of these patients.

4
The spectrum

• Chronic pain syndromes after TBI
• chronic headache
• facial pain
• neck pain
• shoulder pain
• pain in the extremities (painful hemisyndrome)
• rare pain syndromes

5
Contents of the presentation

• A clinical and diagnostically oriented review of
  the most important pain problems after TBI,
  especially
• chronic headache
• chronic facial pain
• chronic neck pain
• central pain

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Chronic posttraumatic headache

• The ICHD-II classification (2004)
• Headache develops within 7 days after (mild -
  severe) head injury
• Headache persists gt 3 months after the injury

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The ICHD-II classification

• 5.2.2 Chronic posttraumatic headache attributed
  to mild head injury
• A. Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with at least one of the
  following
• 1. Either no loss of consciousness or loss of
  consciousness for lt 30 mins duration
• 2. GCS 13
• 3. Symptoms and/or signs diagnostic of concussion
• C. Headache develops within 7 days after head
  trauma or after regaining consciousness after
  head trauma
• D. Headache persists for 3 months after head
  trauma

8
Problems in definition

• The concepts of head injury and brain injury have
  been mixed
• The definition of mild HI lacks the duration of
  posttraumatic amnesia as a criteria
• within 7 days or after regaining consciousness
  in mild injury???
• persists for 3 months but how often does it
  have to occur?

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The ICHD-II classification

• 5.2.1 Chronic posttraumatic headache attributed
  to moderate or severe head injury
• A. Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with at least one of the
  following
• 1. Loss of consciousness for gt 30 mins
• 2. GCS lt 13
• 3. Posttraumatic amnesia for gt 48 hrs
• 4. Imaging demonstration of a traumatic brain
  lesion (cerebral hematoma, intracerebral and/or
• subarachnoid hemorrhage, brain contusion, and/or
  skull fracture)
• C. Headache develops within 7 days after head
  trauma or after regaining consciousness after
  head trauma
• D. Headache persists for 3 months after head
  trauma

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Problems in definition

• The concepts of head injury and brain injury have
  been mixed
• PTA gt 48 hrs why this limit??
• Imaging demonstration of a traumatic brain
  lesion Is skull fracture a brain lesion?
  Axonal injury or oedema are not brain lesions?
• Within 7 days what about PTA gt 7 days?
• Persists for 3 months at which frequency?

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And further critique

• Why should the TBI severity be included in the
  criteria?
• The time limits are artificial and do not base on
  any evidence
• The role of frequent extracerebral causes
  (especially concomitant neck injury) has been
  neglected
• - should the research of posttraumatic headache
  really be based on these criteria?

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An alternative definition

• Chronic posttraumatic headache
• Headache that usually develops within 3 months
  after an injury to the head or neck and is not
  better explained with non-traumatic causes after
  a thorough clinical history and examination,
  including appropriate imaging and laboratory
  studies. After developing, the headache should
  occur at least weekly for at least 6 months.
• A new official definition for clinical and
  research purposes should be made urgently,
  including the definition for various subtypes.

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How common is chronic posttraumatic headache?

• The figures have been very variable, depending on
  the study population, protocol and headache
  criteria
• The available data suggest that headache follows
  head injury in 50 to 80 of patients acutely and
  continues in 20 to 30 1 to 2 years later (Couch
  JR, Lipton RB, Stewart WF, Scher AI. Head or neck
  injury increases the risk of chronic daily
  headache. A population-based study. Neurology
  20076911691177)

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Subacutely

• 100 sequential admissions with mild TBI (as
  defined by American Congress of Rehabilitation
  Medicine, 1993), and 100 matched minor injury
  controls with nondeceleration injuries
• 15.34 of those with minor head injury continued
  to complain of persistent posttraumatic headache
  at 3 months compared to 2.2 of the minor injury
  controls
• (Faux S, Sheedy J. A Prospective Controlled
  Study in the Prevalence of Posttraumatic Headache
  Following Mild Traumatic Brain Injury. Pain Med
  2008, Epub ahead of print)

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And in the long run

• A Norwegian study compared the prevalence of
  headache in a cohort with previous
  hospitalization for head injury (22 yrs earlier)
  and matched controls
• In multivariate conditional regression analysis
  among 192 responding case/control pairs, there
  was no evidence of higher odds of headache gt 1
  day per month (odds ratio, OR 1.04, 95 CI
  0.561.92, p 0.90) compared with controls.
• (Nestvold K, Staven M. Headache 22 Years after
  Hospitalization for Head Injury Compared with
  Matched Community Controls. Neuroepidemiology
  2007 29113120)

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The type of posttraumatic headache
Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
Walker WC Characteristics and treatment of
headache after traumatic brain injury A focused
review. Am J Phys Med Rehabil 200685619627.
17

• We performed a systematic literature review on
  this topic and found that many patients with PTH
  had clinical presentations very similar to
  tension-type headache (37 of all PTH) and
  migraine (29 of all PTH).
• Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
  Walker WC Characteristics and treatment of
  headache after traumatic brain injury A focused
  review. Am J Phys Med Rehabil 200685619627.

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The profile of posttraumatic headache
Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
Walker WC Characteristics and treatment of
headache after traumatic brain injury A focused
review. Am J Phys Med Rehabil 200685619627.
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Chronic posttraumatic headache
Periodic / daily
Episodic
Continuous
Cervical / occipital
Frontal, frontotemporal, ribbon-like, variable
Neck-derived headache
With cervical signs
Without cervical signs
Analgetics 3 days / week
No
Orofacial dysfunction
Psychogenic
Yes
Visual dysfunction
Medication overuse headache
Idiopathic
Hormonal insufficiency
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Chronic episodic posttraumatic headache

• Migrainous (with migrainous characteristics)
• Neuritic (with neuralgic signs and localization)

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Chronic periodic posttraumatic headache

• Muscular source (with muscular signs and
  localization)
• Migrainous (with characteristics of prolonged
  migraine)
• Cervical (with cervical signs, precipitating
  factors, cervical / frontal localization)

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Some important notes

• The spectrum of acute and subacute posttraumatic
  headaches is much wider
• In a minor but significant portion of patients,
  the clinical history, examination and
  consultations reveal no clear causes for the
  persisting headache.
• In many of these, the headache clearly
  accompanies tiredness or fatigue. Treating a
  sleep problem or fatigue may offer a relief.

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Some important notes continued

• The often underdiagnosed post-traumatic hormonal
  insufficiency may also cause headache, and must
  be kept in mind as a treatable cause.
• Cervicogenic headaches are underdiagnosed
  suggestive features
• rotatory injury mechanism
• acute neck pain and restricted movements
• weakness, numbness or pain in the extremities
• cervical pain and impaired mobility persist for
  weeks after the injury

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Some important notes continued

• Clinical signs of cervicogenic headache
• asymmetrically impaired cervical mobility
• pain or tingling produced by rotation or flexion
  extension
• local tenderness in palpation of the C I-II
  vertebrae
• Further evaluation should preferably happen with
  functional cervical MRI, which is able to show
  eventual disruptions of the alar or transverse
  ligaments

25
Kaale BR, Krakenes J, Albrektsen G, Wester K.
Head position and impact direction in whiplash
injuries associations with MRI-verified lesions
of ligaments and membranes in the upper cervical
spine. J Neurotrauma. 2005 Nov22(11)1294-302
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Chronic neck pain after TBI

• Is usually accompanied by headache, at least
  intermittently
• May stem from bony or soft tissue injuries
• The clinical assessment should include detailed
  injury reconstruction, skilled examination of the
  cervical function and neurological examination of
  the cranial nerves and upper extremities

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Chronic neck pain after TBI

• Sensory disturbances in the upper extremities or
  C I-II region should raise a suspicion of nerve
  root injury or posttraumatic syringomyelia
• Imaging of traumatic lesions in the cervical
  spine requires expertise and normal results do
  not necessarily mean normal anatomy
• An experienced physiotherapist or specialist in
  physical medicine is invaluable

28
Chronic facial pain after TBI

• May have multiple aetiologies, such as
• Trigeminal injury
• Orofacial dysfunction
• Sinus disturbance
• Upper cervical lesions
• Orbital lesions
• Atypical facial pain

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• Irritation to structures innervated by the
  cervical sensory nerves can activate the
  trigeminal nucleus along with the
  trigeminovascular system and result in referred
  pain to the anterior or frontal aspect of the head