Head trauma | Headache NewsBlog

Post-traumatic headaches are mostly migraines

By: Dr. Mauskop

24-04-2021

Brain disorders, Chronic migraine, Head trauma, Migraine

Post-traumatic headaches (PTH) are classified as a distinct category of headaches. There is growing evidence, however, that headaches that develop after a head injury are migraines.

A study just published in Cephalalgia by Dr. Ann Scher, her colleagues at the Uniformed Services University, and other researchers, showed that PTH and migraines are very similar. The only difference they found was that headaches occurring after a head injury tend to be more severe.

They studied 1,094 soldiers with headaches. 198 were classified as having PTH. These headaches were compared to those in the other soldiers. They looked for the presence of 12 migraine features: Unilateral location, photophobia, phonophobia, nausea, exacerbation of headache by routine physical activity, pulsatility, visual aura, sensory aura, pain level, continuous headache, allodynia (sensitivity to touch), and monthly headache days.

Soldiers with post-traumatic headache had a greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The authors concluded that post-traumatic headaches differ from non-concussive headaches only by severity and not by any other symptoms.

Another study published in 2020 by Dr. Håkan Ashina and his Danish colleagues showed similar results. They performed a detailed evaluation of 100 individuals with persistent PTH following a mild traumatic brain injury. They found that 90 of the 100 patients had migraines or migraines as well as tension-type headaches. The rest had only tension-type headaches.

These findings have important treatment implications. These patients should be treated like other patients with chronic migraine. Assigning these patients the diagnosis of chronic migraine allows them access to treatments such as Botox injections and CGRP drugs. Insurance companies will not pay for any of the expensive migraine therapies if a patient carries only the diagnosis of PTH.

Our experience and that of our colleagues suggest that Botox is indeed very effective for PTH.

Prolonged postconcussion headaches after mild head injury

By: Dr. Mauskop

08-01-2021

Chronic migraine, Head trauma, Headaches

Persistent post-traumatic headache (PTH), paradoxically, is more common after a mild traumatic brain injury (TBI) than after a severe one.

In a recently published study, researchers in Indiana examined possible factors that may predispose people to a persistent headache after a mild TBI. They recruited 44 adult patients with mild TBI in an emergency department of a trauma center.

Participants completed a variety of psychological questionnaires and underwent tests to measure innate pain control mechanisms. Participants were classified into persistent PTH and nonpersistent PTH groups based on the 4-month data.

The results showed that patients with mild TBI who developed persistent PTH had significantly reduced pain inhibitory capacity, higher rates of depression and pain catastrophizing following injury compared to those who did not develop persistent PTH. They also found that headache pain intensity at 1–2 weeks and pain inhibitory capacity at 1–2 weeks predicted persistent PTH at 4 months after the injury.

The authors concluded that persistent PTH is more likely in people with impaired endogenous pain modulatory function and psychological processes such as depression and catastrophizing.

Catastrophizing is defined as having irrational thoughts about pain being uncontrollable, leading to disability, loss of a job, partner, ruined life, etc. Catastrophizing can be measured by questions such as “I feel it is never going to get better”, “I can’t stand it anymore”, and others.

Catastrophizing has been shown to predict the degree of pain and disability in chronic low back pain and other painful conditions.

The good news is that cognitive-behavioral therapy, multimodal treatment, and acceptance and commitment therapy can reduce catastrophizing.

Marijuana protects brain in trauma

By: Dr. Mauskop

05-10-2020

Alternative Therapies, Brain disorders, Head trauma

Frequent use of marijuana has a negative effect on the developing brain. Researchers at Tulane and Dartmouth medical schools looked at the possible protective effect of marijuana in severe head injury. The results were recently published in an article, Preinjury Use of Marijuana and Outcomes in Trauma Patients.

They examined records of adults who presented to two large regional trauma centers between 2014 and 2018. They included patients who had detectable levels of delta-9-tetrahydrocannabinol (THC) in the blood. They excluded those who had other illicit drugs present.

Of the 4849 patients, 1373 (28.3%) had THC present in the blood. These patients tended to be younger, more likely to be males, and more likely to be injured by “penetrating mechanism” than those who did not have THC present. Patients with THC had a shorter hospital stay, shorter need for ventilation, and a shorter stay in the intensive care unit. The mortality rate was somewhat lower in the THC-positive group (4.3% versus 7.6%) but this difference did not reach statistical significance.

The mechanism could be related to the anti-inflammatory effects of marijuana mentioned in the previous post. Head trauma is known to trigger an immune response that leads to inflammation that in turn worsens brain damage. The researchers did not measure any inflammatory markers so this is just a speculation. It is also possible that the THC-positive group did better because it was significantly younger than the THC-negative group.

In another very large chart review study that looked at older trauma patients, intoxication with alcohol predicted better survival and shorter hospital stay. On the other hand, the presence of cocaine or marijuana worsened the prognosis.

In the US, trauma is the leading cause of death and disability in 18 to 44-year-olds. This is also the age group that is more likely to use marijuana. Consuming marijuana may increase the risk of trauma as suggested by the fact that THC-positive patients were more likely to have a “penetrating injury”. Despite the protective effect of marijuana, it is very likely that reducing its use will lead to fewer injuries and more lives saved.

Acetyl-leucine may help dizziness, vertigo and migraines

By: Dr. Mauskop

12-08-2020

Alternative Therapies, Chronic migraine, Head trauma, Headache medications, Headaches, Migraine, New treatments, Uncategorized

Acetyl-leucine (Tanganil) is an amino acid that has been available in France for over 60 years as a prescription drug. It is approved for the treatment of low blood pressure and dizziness. However, there are no published studies of this product for either low blood pressure or dizziness. There are some animal studies suggesting that acetyl-leucine works on brain cells responsible for the balancing of the body and motor control. It was also tested in animals whose inner ear balancing organ was destroyed on one side.

A group of German doctors, whom I know and respect, found it to be very effective in a prospective study of 10 patients with migraines. The dose was 5 grams daily. The usual recommended dose for dizziness and hypotension is up to 2 grams.

I occasionally recommend it to desperate patients with severe and persistent dizziness and vertigo that has resulted from a concussion or vestibular migraine.

While acetyl-leucine is not proven to be effective, it does not cause any side effects.

Acetyl-leucine is also being tested for some rare hereditary neurological disorders such as Niemann-Pick disease.

Eye exercises for head trauma and headaches

By: Dr. Mauskop

22-05-2020

Alternative Therapies, Head trauma, Headaches, Migraine

We recently started using RightEye eye-tracking equipment which can help our patients who are suffering from visual difficulties due to migraines, concussion, or traumatic brain injury (TBI). Many brain disorders can impair the control of eye movements. This can lead to incorrect information being passed from the eyes to the brain, which can worsen brain dysfunction. Eye strain can also contribute to migraines and post-concussion headaches.

The RightEye computer has a built-in infrared eye-tracking device that can accurately diagnose different abnormal eye movements. It tests smooth pursuit, vertical and horizontal saccades, reading, reaction time, and other functions. A recent study, Vertical smooth pursuit as a diagnostic marker of traumatic brain injury showed a correlation between moderate and severe TBI and abnormal eye movements.

Eye movement problems after TBI were also reported in a study published in the Journal of Neurotrauma , Eye Tracking Detects Disconjugate Eye Movements Associated with Structural Traumatic Brain Injury and Concussion.

A study in the journal Brain showed that eye movement difficulties were still present 3 to 5 months after the concussion and that they were not affected by the presence of depression or degree of intellectual ability. Compared with neuropsychological tests, eye movements were more likely to be markedly impaired in patients with many postconcussion symptoms.

While there are no studies showing that migraines improve with eye exercises, there is some evidence that symptoms of concussion which can include migraine headaches, do improve. A review of several published studies of vision therapy for post-concussion symptoms found it “promising”.

Why would we offer this eye movement therapy in the absence of definitive proof of its efficacy? Mostly because there are limited options for the treatment of concussion and migraines with prominent visual symptoms. We also consulted experts at SUNY College of Optometry in NYC and they were very positive about the potential benefits of this therapy.

The testing process takes about 10 minutes. If problems are found, patients are prescribed specific eye exercises that are done daily by logging into RightEye company’s portal.

Brain is damaged by repeated head trauma, even without a concussion

By: Dr. Mauskop

01-05-2018

Brain disorders, Head trauma

A group of American and Israeli researchers published a study in the journal Brain, suggesting that hits to the head, even those that do not cause an overt concussion, contribute to the chronic traumatic encephalopathy (CTE). CTE has been found in many football players, combat veterans, and other athletes who suffer from repeated head injuries.

The current study examined brains of four teenage athletes who had sustained repetitive hits to the head in the days and weeks before their death. They did not have typical symptoms of concussion – headaches, dizziness, confusion, memory difficulties, or vision problems. One of them had an early-stage CE and two had accumulation of tau protein that is implicated in CTE and Alzheimer’s disease.

These researchers proceeded to create a mouse model of repetitive and subconcussive head trauma, which also showed that relatively mild repetitive head injuries lead to degenerative changes in the brain.

These findings are not very surprising – repeatedly hitting your head cannot be good for your brain, regardless of the severity of each injury. However, many questions remain unanswered – what is the role of certain genetic traits that are known to predispose to CTE, could magnesium, which is depleted by trauma, or other supplements help reduce the damage, and what other interventions could possibly protect the brain.

Certain drugs do not help concussion recovery, but other can

By: Dr. Mauskop

28-03-2018

Brain disorders, Head trauma, Headache medications

Several drugs are often used to treat symptoms of concussion, including an epilepsy drug, gabapentin (Neurontin), amitriptyline (Elavil) and other antidepressants.

A recent study by doctors at the University of Utah in Salt Lake City examined the role of medications in the treatment of concussions. They studied 277 patients who suffered a concussion and were seen at the local sports medicine clinic. Patients were evaluated for 22 symptoms including headaches. The patients were divided into three groups: those prescribed amitriptyline or nortriptyline, those who were prescribed gabapentin, and those who were not prescribed any medication at all.

Patients who were prescribed medications tended to have more severe headaches and other symptoms. However, headaches and other symptoms decreased significantly within days after the initial visit equally in all three groups.

This study does not prove that all treatments for postconcussion syndrome are ineffective. A recent presentation by Dr. Bert Vargas of the Sports Neurology and Concussion Program at the University of Texas Southwestern Medical Center in Dallas stressed that many migraine treatments can be very effective for postconcussion headaches and other symptoms. The features of postconcussion headaches often resemble migraines and migraine medications, such as triptans (sumatriptan, or Imitrex, and other) can be very effective. Unfortunately, only 2% – 5% of patients with posttraumatic headaches receive migraine drugs. The vast majority are treated with acetaminophen or NSAIDs, such as ibuprofen or naproxen.

Botox injections have also been reported to be very effective for postconcussion headaches, which has been my experience as well. Botox injections are approved by the FDA only for the treatment of chronic migraines. However, if headaches are accompanied by migraine features a diagnosis of posttraumatic chronic migraine can validly be made and then many insurance companies will pay for this treatment.

Dr. Vargas also noted that topiramate (Topamax), which is an epilepsy drug approved for the prevention of migraines, is not a good choice for posttraumatic headaches. Topiramate often causes cognitive side effects which can worsen the concussion-related cognitive problems, including impaired memory and concentration.

FDA approves the first blood test to diagnose concussion

By: Dr. Mauskop

11-03-2018

Chronic migraine, Head trauma, post-traumatic headache

The news headlines are filled with stories of professional football players suffering from brain damage, but you do not to have to participate in sports to sustain a concussion – it is an everyday occurrence. In the US, in 2013 there were 2.8 million concussion-related emergency room visits and hospitalizations with 50,000 people dying from brain injuries. Three out of four concussions are mild. However, even mild concussion can cause impaired thinking or memory, poor concentration and emotional problems.

The U.S. Food and Drug Administration has recently approved the first blood test to evaluate concussion in adults. The diagnosis of concussion or in medical lingo, mild traumatic brain injury (mTBI), has been based purely on the description of symptoms by the patient, neurological examination, including the 15-point Glasgow Coma Scale, and brain imaging, such as CT scan to detect brain damage or bleeding. The majority of patients with a concussion have normal MRI and CT scans. This new blood test will help health care providers decide if a CT scan is necessary. This will avoid unnecessary scans which expose patients to radiation. It should also save money.

The Brain Trauma Indicator developed by Banyan Biomarkers, Inc. works by measuring levels of proteins, known as UCH-L1 and GFAP, that are released from the brain into blood and measured within 12 hours of head injury. Levels of these blood proteins after mTBI can help predict which patients may have brain lesions visible by CT scan and which won’t. Test results can be available within 3 to 4 hours.

The FDA based their approval on the data from a study of 1,947 patients with a suspected concussion. The Brain Trauma Indicator was able to predict the presence of intracranial lesions on a CT scan 97.5 percent of the time and those who did not have intracranial lesions on a CT scan 99.6 percent of the time.

It is not clear how this test will be used in the real world. If someone is sick enough to be brought to an ER, they are likely to get a CT scan, which is faster and avoids the 3-4 hour wait for the blood test results and the added cost of the blood test. People with a mild concussion who are not taken to an ER will not need the test because they are very unlikely to have visible brain injury on the CT scan. If symptoms persist for a while and the patient comes to our headache clinic, we obtain an MRI scan, which is more informative and avoids radiation, although it is more expensive.

Stem cells help stroke victims, will revolutionize medicine

By: Dr. Mauskop

30-10-2017

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma

There is little doubt that stem cells, along with genetics and computer science will revolutionize medicine. There are more than a dozen journals devoted to stem cell research and many general and speciality medical journals also publish research on stem cells, which means that a couple of hundred articles are published every month. At first, the research was stymied by the controversy about the fetal sources of stem cells. For the most part this problem has been circumvented by the discovery of other sources, such as umbilical cord, placenta, fat tissue, and other.

In neurology, multiple sclerosis, spinal cord injuries, and strokes have been the main targets of stem cell research. The latest study of stem cells for stroke victims conducted at Stanford by Gary Steinberg and his colleagues produced very encouraging results. This trial included only 18 patients, but they all had their stroke anywhere between 6 months and 3 years before the study – past the usual time where further recovery is expected. Improvement occurred in the majority of patients and the improvement was not affected by the age of the patient or the severity of the stroke. Although stem cells were injected directly into the brain through a small hole that was drilled in the skull, there were no serious complications or side effects. The researchers also noted that stem cells did not replace damaged cells but rather stimulated patients’ own repair mechanisms. This is at odds with the original idea that stem cells by their nature could turn into nerve cells or any other cells in the body to replaced damaged cells.

This stimulating (and anti-inflammatory) effect of stem cells was our reason for conducting a small pilot study of stem cells in patients with refractory chronic migraines, which was described in a previous post. We did not inject cells into the brain, but into the muscles around the head and neck. Three out of 9 patients showed some improvement. We used patients’ own cells extracted from their fat tissue, while the stroke study used cells derived from the bone marrow of a donor. The future of stem cell research clearly lies in the use of such off-the-shelf cells, which have been shown to be safe and are probably more effective than fat-derived cells.

Stem cell lines are being developed to treat different medical conditions – Asterias for spinal cord injury, Pluristem for radiation damage, and many other.

The same team of researchers and SanBio, Inc. the Japanese company that developed these stem cells are conducting another larger controlled trial. You can email stemcellstudy@stanford.edu for information about participating in this trial.

The effect of post-traumatic headaches on the brain

By: Dr. Mauskop

21-10-2017

Alternative Therapies, Botox, Chronic migraine, Head trauma, post-traumatic headache

Chronic pain is known to alter the structure of the brain. Mayo Clinic researchers used MRI scans to examine brains of 29 patients with post-traumatic headaches and compared their scans to those of 31 age-matched healthy volunteers. The average frequency of headaches was 22 days a month. Patients with post-traumatic headaches were found to have thinning of several areas of their cerebral cortex which are responsible for pain processing in the frontal lobes. Cortex covers the surface of the brain and contains bodies of brain neurons. Drs. Chiang, Schwedt, and Chong, who presented their findings at the annual meeting of the International Headache Society held last month in Vancouver, also discovered that the thinning was correlated with the frequency of headaches.

This study did not address possible treatments, but it would make sense that with better control of headaches, this brain atrophy might be reversible. To treat post-traumatic headaches we often use Botox injections, which have been shown to help posttraumatic headaches. Even though Botox is approved only for chronic migraines, many patients with post-traumatic headaches do have symptoms of migraines and can be diagnosed as having post-traumatic chronic migraines (without such a designation insurance companies may not pay for Botox). We also check RBC magnesium, CoQ10 and other vitamin levels, which are often low in chronic headache sufferers and if corrected, can lead to a significant improvement. Epilepsy drugs and anti-depressants can also help.

While the above mentioned treatments can help headaches and potentially could reverse brain atrophy, there is only one intervention that has been shown to increase the thickness of the brain cortex on the MRI scan. This intervention is meditation. And this effect was demonstrated in several studies. An 8-week course of mindfulness-based stress reduction led to a measurable increase in the gray matter concentration of certain parts of the brain cortex. A pilot study of migraine sufferers showed that meditation has a potential not only to restore thickness of the brain, but also to relieve migraines.

In one of my previous blog posts that described a sceintific study of meditation, I mentioned several ways to learn meditation: Free podcasts by a psychologist Tara Brach an excellent book, Mindfulness in Plain English by B. Gunaratana, and several apps – Headspace, 10% Happier, and Calm. You can also take an individual or a group class, which are widely available.

More support for the use of Botox in posttraumatic headaches

By: Dr. Mauskop

30-06-2017

Botox, Chronic migraine, Head trauma, post-traumatic headache

Concussion, even when it is mild, can result in a post-concussion syndrome. The main symptom is a headache and it is present in 60% of people within the first year after a mild traumatic brain injury. In people with personal or family history of migraines these headaches are often post-traumatic chronic migraines. Post-traumatic headaches and other symptoms such as dizziness and difficulty with vision, concentration and memory are often difficult to treat. However, an effective treatment of headaches often leads to an improvement in other symptoms as well.

Treatment with epilepsy drugs (Topamax, Depakote, Neurontin), blood pressure medications (propranolol), or antidepressants (Elavil, Cymbalta) can be effective in some, but not in all and not without side effects. Botox injections have been very effective without any serious side effects in many of my patients and similar results have been published by other doctors (see here and here).

Dr. Sylvia Lucas of University of Washington in Seattle presented her experience with the treatment of posttraumatic headaches with Botox at the annual meeting of the American Headache Society held in Boston last month. She described 15 patients who sustained a mild traumatic brain injury and suffered from chronic migraines for an average of 8 months prior to being treated with Botox. After a series of three Botox treatments given every 3 months most patients had a significant improvement in the number of headache days, as well as improved physical and social functioning, emotional well-being, energy level and a reduction in pain. As expected, no patient experienced any serious side effects.

Hyperbaric oxygen for traumatic brain injury and postconcussion syndrome

By: Dr. Mauskop

12-05-2017

Alternative Therapies, Brain disorders, Head trauma

Inhalation of pure oxygen under high flow is an effective treatment for an acute cluster headache, although not migraines. Headache is one of the most common symptoms of traumatic brain injury and postconcussion syndrome and there is evidence that oxygen under pressure can help those conditions.

A review article on the use of oxygen to treat mild and moderate traumatic brain injury and postconcussion syndrome was recently published in Neurology. THe authors reviewed 5 previously published studies and concluded that hyperbaric oxygen in fact does help patients with brain trauma and postconcussion syndrome.

While cluster headache patients can breathe in oxygen through a mask from a tank of oxygen delivered to their home, hyperbaric oxygen requires a special room or a chamber. Hyperbaric means that oxygen is under increased pressure, although the authors report that moderate pressure (between 1 and 2 ATA) may be better than high pressure. Even hyperbaric air, that is normal air under pressure, may have beneficial effects.

The authors conclude that, there is sufficient evidence for the safety and preliminary efficacy from clinical data to support the use of hyperbaric oxygen in mild to moderate traumatic brain injury and postconcussion syndrome. They also state that “It would be a great loss to clinical medicine to ignore the large body of evidence collected so far that consistently concludes that hyperbaric oxygen is effective in treatment of brain injuries.”

Fortunately, there are many hospitals and private clinics all around the country that offer hyperbaric oxygen. They often advertise its use for a variety of unproven indications, but if you suffer from a traumatic brain injury, this treatment may be worth trying. A major obstacle though could be the cost of treatment since insurance companies are not likely to cover this treatment.