6.1

Perform a repeat medical assessment on all patients presenting with post-concussion headaches 1-2 weeks following acute injury.

Include a focused history, physical examination, and consideration of diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 6.1: Post-Concussion headache algorithm.

6.1a

Take a focused clinical history.

Level of Evidence:   

Collect details that help to classify or characterize the headache subtype(s) that are present. 

• Headache onset, location, quality or character, severity, and frequency.
• Factors that elicit or worsen headaches (e.g., bright lights, reading, exercise, foods, etc.).
• Factors that alleviate headaches.
• Associated symptoms (e.g., aura, photosensitivity, dizziness, eye strain, neck pain).
• The presence of red flags which may indicate a more severe brain injury or other intracranial pathology (e.g., worsening headaches, repeated vomiting, weakness or numbness of the extremities, visual changes). 
• The level of disability associated with the headache (e.g., missed days from school).
• Use of medications or other substances.
• Psychological or social factors or conditions that can be associated with stress and headaches (e.g., mood or anxiety disorders) (Domain 8: Mental Health).
• Assess how much headaches affect day-to-day activities.
  • Link: pedMIDAS Headache Severity Tool for Children aged 4-18.
• Disturbed sleep.
• Personal and family history of headaches and headache disorders (e.g., migraine).
• Future participation in full-contact sport or high-risk activities.

6.1b

Perform a focused physical examination. 

Level of Evidence:   

• Vital signs (resting heart rate and blood pressure).
• A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait and balance testing) Tool 2.1: Physical Examination.
• A cervical spine examination (palpation, range of motion, provocative cervical spine tests). Tool 2.1: Physical Examination.
• With appropriate experience, consider performing an examination of vision, oculomotor and vestibular functioning (Domain 10: Vision, Vestibular, and Oculomotor Function).

6.1c

Consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Level of Evidence:   CT.  MRI.

See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.

6.1d

Classify and characterize the headache subtype based on the clinical history and physical examination findings. 

Level of Evidence:   

Tool 6.1: Post-Concussion Headache Algorithm.

Link: International Classification of Headache Disorders (ICHD-III)*.

Common prolonged post-concussion headache subtypes include: 

• Migraine, tension, or cluster headaches. 
• Cervicogenic headaches. 
• Physiological or exercise-induced headaches.
• Headaches associated with prolonged visual stimulation.
• Occipital neuralgia.

* “Reproduced with permission of International Headache Society”.

6.2

Provide general post-concussion education and guidance on headache management.

6.2a

Advise on non-pharmacological strategies to minimize headaches including sleep hygiene, activity modifications, limiting triggers, and information on screen time. 

Level of Evidence:  

• Tool 2.7: Strategies to Promote Good Sleep and Alertness.
• Link: Sleep for Youth. CHEO Sleep Hygiene handout
• Recommendation 2.4c: Advise on the use of computers, phones, and other screen devices. 

6.2b

Encourage patients with headaches to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation threshold. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Physical activity. Cognitive activity.

See Recommendation 2.3.

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

6.2c

Consider suggesting the use of a headache and medication diary in order to monitor symptoms and medications taken. Use clinical judgment and an individualized approach on use or duration of this strategy. 

Level of Evidence:  

Link: Headache and Medication Diary (Boston Children’s Hospital)

6.2d

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Advise on limiting the use of these medications to less than 15 days a month and avoiding “around-the-clock” dosing to prevent overuse or rebound headaches. I.e., advise that children/adolescents avoid using over the counter medications at regular scheduled times throughout the day.

Level of Evidence:  

6.3

Refer patients who have prolonged post-concussion headaches for more than 4 weeks to an interdisciplinary concussion team or to a sub-specialist for further evaluation and management. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence:  

Prolonged headaches in pediatric concussion patients can be difficult to classify and manage and can co-occur with other prolonged post-concussion symptoms (dizziness, neck pain, sleep disturbance, cognitive or mood challenges). 

If an interdisciplinary concussion team member is not available:

• Consider appropriate referral to interdisciplinary professionals who have competency-based training and clinical experience to independently manage the identified headaches and headache disorders.

If a child/adolescent with prolonged post-concussion headache has not had a recent vision assessment, refer to an optometrist for an assessment.

6.4

Consider initiating pharmacological therapy to treat and manage prolonged headaches while waiting for the interdisciplinary concussion team or sub-specialist referral. 

Level of Evidence:   

For patients with post-traumatic headaches that are migrainous in nature, the use of migraine-specific abortants such as triptan class medications may be used if effective. Due to the risk of developing medication-induced headaches, limit use of abortants to fewer than 6-10 days per month.

Tool 6.2: General Considerations Regarding Pharmacotherapy.

Tool 6.3: Approved Medications for Pediatric Indications.

Prophylactic therapy should be considered:

• If headaches are occurring frequently.
• If headaches are disabling.
• If acute headache medications are contraindicated or poorly tolerated or are being used too frequently.

6.5

Recommend a medical follow-up to reassess clinical status if headaches persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (prior to 4-weeks after the acute injury) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence: Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. 

Level of Evidence: B 

See Recommendation 2.2: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.