Migraine and Tension Headache: The Latest Treatment Options

1
Migraine and Tension Headache The Latest
Treatment Options
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C,
FAANP, CSP, FAAN, DCCPresident, Fitzgerald
Health Education Associates, Inc.North Andover,
MAFamily Nurse Practitioner, Greater Lawrence
(MA) Family Health CenterEditorial Board, The
Nurse Practitioner Journal, Medscape Nursing,
The Prescribers Letter, American Nurse Today
Member, Pharmacy and Therapeutics
CommitteeNeighborhood Health Plan, Boston, MA
2
Objectives

• Describe the assessment of the person with
  primary headache.
• Identify the most appropriate and efficacious
  treatment options.
• Summarize the guidelines for initiating headache
  prophylaxis with select medications including
  beta and calcium channel blockers,
  anticonvulsants and antidepressants.
  

3
What type of headache?Primary vs. Secondary

• Secondary HA
• Associated with or caused by other conditions
• Tumor
• Bleed
• Increased intracranial pressure (ICP)

• Primary HA
• Not associated with other diseases
• Migraine
• Tension-type
• Cluster

4
Per VA/DoD Interchangeable Terms

• Mild traumatic brain injury
• Concussion

• No universal standard criteria for definition of
  concussion/mTBI
• Diagnosis based primarily on the characteristics
  of immediate sequelae following event

5
Post Traumatic Brain Injury (TBI)/ Concussion
Headache

• Source- http//www.uptodate.com/contents/concussio
  n-and-mild-traumatic-brain-injury?sourcesearch_re
  sultsearchposttraumaticbraininjuryheadaches
  electedTitle17E150, accessed 02.21.13.

6
VA/DoD Clinical Practice Guideline for Management
of Concussion/mTBI

• Headache is the single most common symptom
  associated with concussion/mTBI and assessment
  and management of headaches in individuals should
  parallel those for other causes of headache.

7
Post Traumatic Brain Injury (TBI) Headache

• Estimated prevalence in TBI
• 25-78
• Greater HA prevalence, duration, severity post
  mild head injury compared with more severe trauma

8
Post Traumatic Brain Injury (TBI) Headache
(continued)

• Comorbidity
• Significant number of patients with pre-existing
  headaches
• Data conflict on whether this is risk factor for
  post TBI HA

9
Classification of Headache Associated with TBI

• International Headache Society (IHS) criteria
• Headache onset within 7 days post injury
• Per most sources, likely 3 months more reasonable

10
Post TBI Headache

• Tension-type headaches most frequently report
• 75-77
• More than one type of headache
• 27-75

• Migraine
• Post blast trauma, most common HA type reported
• Source- http//www.uptodate.com/contents/postconcu
  ssion-syndrome?sourcesee_linkanchorH8H8,
  accessed 02.21.13.

11
Please see table for diagnostic criteria for
primary headaches.
12
What causes primary headache?

• Likely a complex neurovascular event
• In health, balance between excitation, inhibition
  of nervous system

13
Genetic Component?

• Polygenetic
• Multiple mutations and variations noted
• Twin studies65 prevalence
• Likely X linked
• Correlation with motion sickness
• Source- J Neurol Neurosurg Psychiatry. 1995
  Dec59(6)579-85.
• http//emedicine.medscape.com/article/1142556-over
  view, accessed 02.21.13.

14
Genetic Component? (continued)

• Migraine with aura
• 4-fold increase risk in 1st degree relatives
• Migraine without aura
• 1.9-fold increase risk in 1st degree relatives
• Source- J Neurol Neurosurg Psychiatry. 1995
  Dec59(6)579-85., http//emedicine.medscape.com/a
  rticle/1142556-overview, accessed 02.21.13.

15
Pathophysiology of Primary Headache

• Genetic disorder
• Brain disease
• Most common chronic pain condition

• Source- Goadsby PJ et al. N Engl J Med
  2002346257-270

16
Primary Headache TypesTension-type headache
(TTH)

• TTH is the most common type of primary headache.
  Compared with migraine, the pain of TTH tends to
  be less severe, bilateral, nonpulsating, and not
  aggravated by routine physical activity. Symptoms
  associated with migraine attacks, such as nausea,
  phonophobia, or photophobia, are rarely present,
  but there can be symptomatic overlap.
• Source- Martin V, Elkind A. Diagnosis and
  classification of primary headache disorders. In
  Standards of care for headache diagnosis and
  treatment. Chicago (IL) National Headache
  Foundation 2004. p.4-18.

17
Primary Headache Types Migraine

• Migraine is a genetically influenced chronic
  brain condition marked by paroxysmal attacks of
  moderate-to-severe, throbbing headache with
  associated symptoms that may include nausea,
  vomiting, and photophobia or phonophobia.
• Source-Loder, E. Triptan Therapy in Migraine, N
  Engl J Med 2010 36363-70.

18
Is this really a migraine or something more
dangerous?

• Reassuring findings
• Positive family history of migraine
• Headache related to menstrual cycle
• Headaches preceded by typical aura
• Headaches remaining periodic and stable over time
  
• Normal physical and neurologic findings

19
Primary Headache TypesCluster

• Patients with cluster headaches generally rate
  the intensity of their pain as among the worst
  imaginable, and cluster headache may be the most
  severe of the primary headache disorders.
• Most often, cluster headache occurs once every 24
  hours for 6 to 12 weeks at a time, with remission
  periods typically lasting 12 months.

20
Primary Headache TypeCluster (continued)

• Transient autonomic symptoms
• Sympathetic hypofunction
• Miosis, ptosis
• Parasympathetic hyperfunction
• Rhinorrhea, lacrimation
• Onset often during REM sleep
• Source- Martin V, Elkind A. Diagnosis and
  classification of primary headache disorders. In
  Standards of care for headache diagnosis and
  treatment. Chicago (IL) National Headache
  Foundation 2004. p. 4-18.

21
Primary Headache Cluster Characteristics

• Restlessness93
• Pacing and rocking the head and trunk with head
  in hands
• Unilateral paingt90
• R-side head60
• Side shift during an attack16
• Different sides in subsequent attacks18

22
Primary Headache Cluster Characteristics
(continued)

• Photophobia56
• Phonophobia43
• Aura14
• Osmophobia23
• Source- http//www.aafp.org/afp/2005/0215/p717.htm
  l, accessed 02.21.13.

23
Primary Headache True or false?

• The initial onset of TTH and migraine usually
  occurs in childhood or early adulthood.
• The initial onset of cluster headache usually
  occurs in the later part of the 3d to early part
  of the 4th decade of life.

24
Primary Headache True or false?

• Most people who fulfill the criteria for migraine
  have not received this diagnosis from a
  healthcare provider.
• The majority of people with primary headache have
  seen a healthcare provider for this condition in
  the past year.

25
Primary Headache True or false?

• Cluster is the only primary headache type more
  common in men, with a ratio of approximately
  3.51 and 21.
• Patients typically have a single headache type.

26
American Academy of Neurology 4 HA Questions

• How often do you get severe headaches (i.e.,
  without treatment it is difficult to function)?
• How often do you get other (milder) headaches?

27
American Academy of Neurology 4 HA Questions
(continued)

• How often do you take headache relievers or pain
  pills?
• Has there been any recent change in your
  headaches?

28
American Academy of Neurology Imaging Algorithm
for Non Acute Headache

• Headachegt4 weeks duration and normal neurologic
  exam
• Comment on neuroimaging not likely to reveal
  abnormalities without alarm findings
• Available at http//www.aan.com/globals/axon/asset
  s/2356.pdf, accessed 02.21.13.

29
American Academy of Neurology Imaging Algorithm
for Non Acute Headache (continued)

• Headachegt4 weeks duration with alarm or other
  worrisome findings
• Comment made that head MRI and CT roughly
  equivalent in revealing abnormalities
• MRI better at revealing pathologic changes
• Available at http//www.aan.com/globals/axon/asset
  s/2357.pdf, accessed 02.21.13.

30
AAN Encounter Kit for Headache

• Available at http//www.aan.com/go/practice/qualit
  y/headache, accessed 02.21.13.

31
Evidence-based Guidelines for Migraine Headache
in the Primary Care Setting Pharmacologic
Management in Acute Attacks

• Available at http//www.aan.com/professionals/prac
  tice/pdfs/gl0087.pdf, accessed 02.21.13.

32
Primary Headache Treatment

• Goals
• Minimize symptoms
• Reduce disability
• Improve quality of life

• Categories
• Abortive
• Symptomatic
• Prophylactic

33
Acute Headache Medications

• Nonspecific Used for a variety of painful
  conditions
• Aspirin
• NSAIDs (ibuprofen, naproxen)
• Acetaminophen-aspirin-caffeine
• Excedrin
• Opioids

34
Acute Headache Medications (continued)

• Migraine specific but also used in tx of other
  primary HA types
• Ergots
• Triptans (5-HT1B/1D agonists)
• Used to treat non-pain symptoms
• Prochlorperazine
• Other antiemetics and GI medications such as
  metoclopramide (Reglan)

35
Who should get a triptan?

• Patients with mild to moderate disability who do
  not respond to other therapies
• Patients with substantial disability with their
  migraine
• Treatment outcomes improve when more disabled
  patients are treated with triptans.
• Patients who can take triptans safely
• Contraindicated in CVD, uncontrolled HTN

• Source- Lipton, RB. JAMA 20002842599-2605.

36
Abortive Pharmacologic Therapies 5HT 1B/1D
Receptor Agonists (Triptans)

• Block release of vasoactive peptides from
  perivascular trigeminal neurons through action at
  presynaptic 5-HT1D receptors
• Bind to presynaptic 5-HT1D receptors in dorsal
  horn, thought to block neurotransmitter release
  that activate second-order neurons ascending to
  thalamus
• Likely facilitate descending pain inhibitory
  systems

37
What do you need to know about the triptans?

• T ½
• Tmax
• Cmax
• Analgesic adjuncts

38
Please Refer to Table Comparing the Triptans
39
If one triptan does not work, should you try
another product in the class?
40
General Triptan Advise

• With initial triptan ineffective
• Maximize dose
• Try on two HA attacks
• If still ineffective
• Switch to different triptan
• Consider subcutaneous sumatriptan

41
General Triptan Advise (continued)

• Triptan monotherapy remains ineffective
• Try with other drugs, especially antiemetics or
  nonsteroidal antiinflammatory drugs (NSAIDs)
• Source- Goadsby, P. J. et al. N Engl J Med
  2002346257-270.

42
Fixed Dose Combination for Treatment of Migraine
Treximet

• Sumatriptan (Imitrex) w/ naproxen
• Naproxen sodium 500 mg with superior PK when
  compared to plain naproxen
• Sumatriptan (Imitrex) 85 mg
• Improved outcomes with pain/non pain migraine
  symptoms when compared to either medication used
  alone

43
Triptans Cost per Drugstore.com

• Sumatriptan 100 mg 9 tabs199
• Almotriptan 12.5 mg 12 tabs308
• Zolmitriptan 6.2 mg 6 tabs156
• Rizatriptan 10 mg 18 tabs479
• Frovatriptan 2.5 mg 9 tabs241

44
Headache Medications Cost per Drugstore.com

• Sumatriptan 85 mg with naproxen 500 mg
  (Treximet)9 tablets216.99
• Liquid ibuprofen 100 mg/5ml 4 oz5
• Ibuprofen 200 mg tabs, 100 tabs7
• Acetaminophen, butalbital, caffeine (Fioricet)
  100 caps39.99

45
Triptan-associated Drug-drug Interactions

• Use with caution if at all with monamine oxidase
  inhibitor inhibitors (MAOIs) or high-dose
  selective serotonin reuptake inhibitors (SSRIs)
• Cumulative serotonin effect
• TriptansSerotonin agonists
• SSRIsSerotonergic mechanismInhibit reuptake of
  serotonin
• Source- http//www.treximet.com, accessed
  02.21.13.

46
Spectrum of Clinical Findings in Serotonin
Syndrome
Boyer E and Shannon M. N Engl J Med
20053521112-1120
47
Findings in a Patient with Moderately Severe
Serotonin Syndrome
Boyer E and Shannon M. N Engl J Med
20053521112-1120
48
Intervention in Serotonin Syndrome

• Mildly ill
• Hyperreflexia, tremor, afebrile
• Supportive care
• Removal of precipitating drugs
• Benzodiazepines
• Source- Boyer E and Shannon M. N Engl J Med
  20053521112-1120.

49
Intervention in Serotonin Syndrome (continued)

• Moderately ill
• Aforementioned findings, fever, cardiorespiratory
  abnormalities
• Aggressive correction of cardiorespiratory and
  thermal abnormalities
• Administration of 5-HT2A antagonists such as
  cyproheptadine (Periactin) with a dose
  range12-32 mg/24h so that up to 95 of serotonin
  receptor sites are occupied
• Source- Boyer E and Shannon M. N Engl J Med
  20053521112-1120.

50
Ergot Derivatives

• Mechanism of action
• Bind to 5HT 1b/d receptors
• Similar to triptans
• Source- http//www.uptodate.com/contents/acute-tre
  atment-of-migraine-in-adults?sourcesearch_result
  searchmigrainetreatmentselectedTitle17E150,
  accessed 02.21.13.

51
Dihydroergotamine (DHE 45)

• Alpha-adrenergic blocker
• Weaker arterial vasoconstrictor and more potent
  venoconstrictor than ergotamine tartrate
• Potent 5-HT 1b/1d receptor agonist

52
DHE Precautions

• Do not use
• Within 24 hours of administration of triptans.
• In uncontrolled hypertension (blood
  pressuregt165/95).
• History of ischemic heart disease including
  angina.

53
DHE Precautions (continued)

• Do not use (cont.)
• In Prinzmetal angina (atypical angina),
  peripheral vascular disease.
• During pregnancy and lactation.

54
DHE Precautions (continued)

• If patient has chest pain or severe anxiety
  following the first dose of DHE, do not repeat.
• With IV use, consider use with antiemetic and
  analgesic.
• Also available in nasal spray

55
DHE Most commonly use in patients who are

• Experiencing severe migraine headache.
• In status migrainosus or have rebound withdrawal
  type of headaches.
• Only received opioids for severe headaches.
• Have not responded to triptans in the past.

56
Algorithm for DHE Use in Migraine

• American Academy of Neurology Use of DHE in
  Migraine
• Available at http//www.aan.com/globals/axon/asset
  s/2353.pdf, accessed 02.21.13.

57
NSAIDs

• Quick onset?
• Duration of action?
• If one fails, ditch the whole class?

58
NSAIDs (continued)

• Mechanism of action
• Inhibits enzyme that converts arachidonic acid to
  prostaglandins (COX)
• Prostaglandins are an important chemical
  nociceptive stimulator Produced as a
  consequence of tissue injury

59
NSAIDs (continued)

• COX-1 Constitutive enzyme, always present in
  serum
• Found in gastric and intestinal mucosa, kidneys,
  platelets, vascular endothelium
• COX-2 Induced in response to injury
• Produces prostaglandins important to the
  inflammatory cascade and pain transmission

60
COX-1, COX-2 Inhibitors

• Comprise majority of NSAIDs currently available
• Ibuprofen
• Ketoprofen
• Naproxen sodium
• Etodolac
• Ketorolac

61
Analgesic Agents in Migraine and Tension-type
Headache

• Consider as first-line drug, due to safety,
  efficacy, cost
• Ibuprofen, maximum dose 2.4 g/d
• Greatest clinical effect with high dose use (i.e.
  gt800 mg at HA onset, repeat in 3 h if needed, do
  not exceed daily total dose as above
• Naproxen 750-1250 mg per day
• 500 mg at HA onset, repeat in 3 h if needed, do
  not exceed daily total dose as above
• Are all forms equivalent?

62
You see a woman with a chief complaint of
headache.

• You can give her one tablet of any of the
  following. Which is the best choice?
• Naproxen (Naprosyn)
• Naproxen sodium (Aleve, Anaprox)
• Enteric coated naproxen

63
In Healthy Volunteers

• Time to Cmax of naproxen forms
• Naproxen sodium1 h
• Naproxen1.9 h
• EC naproxen4 h

64
Analgesic Agents in Migraine and Tension-type
Headache

• If required, parenteral form
• Ketorolac 30-60 mg IM
• No more than 3 X week due to risk of
  nephrotoxicity
• Per NHF Guidelines

65
Alternatives to triptans?
66
Fioricet

• is a combination of caffeine, butalbital, and
  acetaminophen. Whereas caffeine enhances the
  analgesic properties of acetaminophen,
  butalbitals barbiturate action enhances select
  neurotransmitter action, helping to relieve
  migraine and tension-type headache pain.

67
Fioricet (continued)

• Butalbital-containing analgesics may be
  effective as backup medications or when other
  medications are ineffective or cannot be used.
  Because of concerns about overuse,
  medication-overuse headache, and withdrawal,
  their use should be limited and carefully
  monitored.
• Source- Silberstein, S., McCrory, D. (2001)
  Butalbital in the Treatment of Headache History,
  Pharmacology, and Efficacy. Headache The Journal
  of Head and Face Pain Volume 41 Issue 10 Page
  953-967.

68
Corticosteroids in the Treatment of Migraine

• Indicated in intractable migraine
• No more than 1/month
• Prednisone
• 20 mg QID X 2-6 days
• Dexamethasone
• 1.5 mg BID X 2 days
• 16 mg IM
• Source- http//www.headaches.org/education/NHF_Hea
  dLines_Excerpts/Case_Studies_in_Headache_Archive/C
  S_153, accessed 02.21.13.

69
Lidocaine Nasal Spray

• Virtually no systemic absorption
• Not FDA approved for this use
• 4-10 solution
• 1 squirt to nostril on side of pain
• Repeat q 1h
• Alternative- Soak Q-tip, leave in nostril

70
Lidocaine Nasal Spray (continued)

• Efficacy
• 50 reduction in pain by 55 patients
• 42 relapse in 2-4 hours
• Studied in cluster with similar efficacy
• Source- Maizels, M, et al. (1996) JAMA
  276(4)319-321, http//www.factsandcomparisons.com
  /assets/hospitalpharm/OFF2.pdf, accessed
  02.21.13.

71
NHF Guidelines for Abortive Therapies

• Position on using opioids
• Use when other therapies have been ineffective
• Give in adequate amounts if needed
• Limit to 2/days/week

72
Intervention in Cluster Headache

• Each with50-60 efficacy
• Oxygen7 L per minute for 15 minutes via face
  mask
• Sumatriptan 6 mg subcutaneously
• Or
• Sumatriptan 20 mg nasal spray
• Source- http//www.aafp.org/afp/2005/0215/p717.htm
  l, accessed 02.21.13.

73
Use of Abortive Therapies

• Excessive use of abortive therapies can lead to
  rebound headache.
• Consider use of prophylactic therapy if following
  guidelines are exceeded.

74
Frequent Headaches Prophylaxis Indications

• Two or more HA monthly
• Absolutely indicated for 2 HA days per week
• HA duration
• gt2 days with disability
• Treatment
• Refractory to current abortive agents
• Intolerance to abortive agents
• Overuse of abortive agents

75
Headache Prophylaxis

• Typically need 1-2 months therapy before effect
  seen
• Expect
• 50 reduction in HA in about 2/3 of all patients
• Possibly easier to control HA

76
Headache Prophylaxis (continued)

• Use prophylaxis for 3-6 months then try a taper
  off the medication slowly
• Helps break headache cycle
• Allows lifestyle modification to be used
• Eliminate, limit use of certain drugs
• Estrogen, progesterone
• Vasodilators
• Many analgesic agents

77
Options for Headache Prophylaxis

• Goadsby, P. J. et al. N Engl J Med
  2002346257-270.
• Standards of care for headache diagnosis and
  treatment. Chicago (IL) National Headache
  Foundation 2004.
• UpToDate Preventive treatment of
• migraine in adults,
• Available at
• http//www.uptodate.com/contents/preventive-treatm
  ent-of-migraine-in-adults?sourcesearch_resultsel
  ectedTitle17E150H11, accessed 02.21.13.

78
Options for HA Prophylaxis Demonstrated Efficacy

• Older options generally have little recent study
  on efficacy but long term observational study on
  effectiveness
• Beta adrenergic antagonist
• Propranolol 40-120 mg BID

79
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Calcium channel blocker
• Verapamil best studied with varying reports of
  efficacy in migraine and tension-type HA
• Best studied in cluster at doses 360-480 mg/d

80
Options for HA ProphylaxisDemonstrated Efficacy
(continued)

• Serotonin antagonists
• Cyproheptadine (Periactin) 4-8 mg qd
• Acceptable for use in children, associated weight
  gain
• Serotonin-NE reuptake inhibition with tricyclic
  antidepressant
• Nortriptyline 10-75 mg qd
• Amitriptyline 25-75 mg qd

81
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Valproate 500-1500 mg total daily dose
• Mechanism of action
• By reducing high-frequency neuronal firing and
  sodium-dependent action potentials and enhancing
  GABA effects
• In above-mentioned dose range, significantly
  more effective than placebo, odds ratio 2.74, 95
  CI 1.48-5.08

82
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Gabapentin 900-2400 mg qd
• Similar in structure to neurotransmitter GABA but
  likely hits other receptors
• Mechanism on action not fully understood, likely
  worse via voltage-gated N-type calcium ion
  channels, therefore minimizing pain transmission

83
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Gabapentin 900-2400 mg qd (cont.)
• Higher dose usually more effective
• 50 reduction in HA frequency at end of 4 weeks

84
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Topiramate 25-200 mg qd
• Potential mechanism of action
• Blocks neuronal voltage-dependent sodium
  channels, enhances GABA(A) activity, antagonizes
  AMPA/kainate glutamate receptors, and weakly
  inhibits carbonic anhydrase

85
Options for HA Prophylaxis Demonstrated Efficacy
(continued)

• Topiramate 25-200 mg qd (cont.)
• Mean monthly migraine frequency decreased
  significantly at 100 or 200 mg/day compared with
  placebo
• At 50 mg/day, migraine frequency reduction does
  not achieve statistical significance

86
Per American Academy of Neurology

• Feverfew, riboflavin, and magnesium as possible
  preventative treatments for migraine
• Source- Silberstein SD. Practice parameter
  Evidence-based guidelines for migraine headache
  (an evidence-based review) Report of the Quality
  Standards Subcommittee of the American Academy of
  Neurology. Neurology 200055754-62.
• Additional information on each product at
  http//naturaldatabase.therapeuticresearch.com,
  accessed 02.21.13.

87
Feverfew, Riboflavin, Magnesium Daily Dose

• Typically start with riboflavin and magnesium,
  add feverfew if needed
• MOA not well understood
• Feverfew 100 mg
• Riboflavin 400 mg
• Magnesium 360 mg

88
Recommendations for Post TBI HA Management

• Amitriptyline
• Helpful for post-traumatic tension-type
  headaches, also nonspecific symptoms including
  irritability, dizziness, depression, fatigue, and
  insomnia

89
Recommendations for Post TBI HA Management
(continued)

• Propranolol
• Alone or in combination with amitriptyline alone
  helpful in a small series for post-traumatic
  migraine

90
Recommendations for Post TBI HA Management
(continued)

• Analgesia overuse
• Monitor analgesic use due to high rate of
  analgesic overuse as contributor in 19-42
• Response to analgesic withdrawal as favorable as
  patients whose headaches were not post-traumatic

91
End of Presentation!Thank you for your time and
attention.

• Margaret A. Fitzgerald,
• DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC
• www.fhea.com e-mail cs_at_fhea.com

92
Post-concussion/mTBI Related Symptoms Post-concussion/mTBI Related Symptoms Post-concussion/mTBI Related Symptoms
Physical Symptoms Headache, dizziness, balance disorders, nausea, fatigue, sleep disturbance, blurred vision, sensitivity to light, hearing difficulties/loss, sensitivity to noise, seizure, transient neurological abnormalities, numbness tingling Cognitive Symptoms Attention, concentration, memory, speed of processing, judgment, executive control Behavior/ emotional Symptoms Depression, anxiety, agitation, irritability, impulsivity, aggression
Symptoms that develop within 30 days post injury
Source- VA/DoD Clinical Practice Guideline for
Management of Concussion/mild Traumatic Brain
Injury, April 2009.
93
Criteria for characterizing post-traumatic
headaches as tension-like (including
cervicogenic) or migraine-like based upon
headache features.
Headache Feature Headache Type Headache Type
Headache Feature Tension-like (include ceriogenic pain) Migraine-like
Pain Intensity Usually mild-moderate Often severe or debilitating
Pain Character Dull, aching, or pressure. Sharp pain may be present, but is not predominant Throbbing or pulsatile, can also be sharp/stabbing or electric-like
Duration Usually less than 4 hours Can last longer than 4 hours
Phono- or photo-phobia One but not both may be present One, or both usually present
Able to carry out routine activities/work Usually Usually not, or with a decreased level of participation
94
Headache Feature Headache Type (cont.) Headache Type (cont.)
Headache Feature Tension-like (include ceriogenic pain) Migraine-like
Location Bilateral frontal, retro-orbital, temporal, cervical and occipital, or holocephalic Usually unilateral and may vary in location among episodes
Nausea or malaise Not present Usually present
Palpable muscle tenderness or contraction Pericranial muscles including temporalis, masseter, pterygoid, posterior neck muscle, sternocleidomastoid, splenius or trapezius Localized muscle tenderness is not typical, muscle tenderness may be present with long duration headaches
Source- VA/DoD Clinical Practice Guideline for
Management of Concussion/mild Traumatic Brain
Injury, April 2009.
95
Classification of TBI Severity
Criteria Mild Moderate Severe
Structural imaging Normal Normal or abnormal Normal or abnormal
Loss of consciousness (LOC) 0-30 min ?30 min and lt24 hrs ?24 hrs
Alteration of consciousness/mental state (AOC) A moment up to 24 hrs ?24 hours. Severity based on other criteria ?24 hours. Severity based on other criteria
Post-traumatic amnesia (PTA) 0-1 day ?1 and lt7 days ?7 days
Glascow Coma Scale (best available score in first 24 hours) 13-15 9-12 lt9
Alteration of mental status must be immediately
related to the trauma to the head. Typical
symptoms would be looking and feeling dazed and
uncertain of what is happening, confusion,
difficulty thinking clearly or responding
appropriately to mental status questions, and
being unable to describe events immediately
before or after the trauma event.
Source- VA/DoD Clinical Practice Guideline for
Management of Concussion/mild Traumatic Brain
Injury, April 2009.