Q&A: Understanding of post-traumatic headache increases, but unmet needs remain

A review published in The Lancet Neurology provides a summary of the classification and management of post-traumatic headache, a “disabling secondary headache disorder” often attributed to traumatic brain injury.

The review briefly examined the progress made in the last 10 years to understand the clinical characteristics of this disorder. According to the researchers, post-traumatic headache “is increasingly being recognized as a heterogenous headache disorder” in which patients are classified into different disease phenotypes. Each of these phenotypes may have different responses to specific therapies, but “such considerations are not accounted for in three iterations of diagnostic criteria published by the International Headache Society,” Håkan Ashina, MD, of the Danish Headache Center and the department of neurology at Rigshospitalet Glostrup and the faculty of health and medical sciences at the University of Copenhagen, and colleagues wrote.

Ashina and colleagues examined five specific domains in their review: classification of post-traumatic headache, clinical characteristics, post-traumatic headache in specific populations, clinical management and potential pharmaceutical treatment options. The first four domains included a section on key messages.

The lack of evidence-based approaches led clinicians to select treatments based on the primary headache phenotype, such as migraine and tension-type headache, and the ones that are “most compatible with the clinical picture.” The researchers wrote that “a concerted effort” is required to address these issues, one that should include large, prospective cohort studies and randomized clinical trials. Such an effort would lead to better characterization of disease as well as an increased availability of evidence-based treatment choices.

Healio Neurology spoke with Ashina to learn more about the impetus for the review as well as the ways in which more research in post-traumatic headache would impact treatment outcomes.

Healio Neurology: What prompted this research?

Ashina: There was a need for an up-to-date paper that covers what we know about post-traumatic headache (PTH). In addition, we wanted to provide clinicians with a proposed treatment algorithm based on expert opinion due to the scarcity of data from clinical trials.

Healio Neurology: How common is post-traumatic headache after TBI?

Ashina: PTH is very common following TBI. Prospective cohort studies have found that most people with TBI develop acute PTH within hours to days after their head trauma. Acute PTH subsequently remits in some people, whereas others experience persistence, and sometimes chronification, of headache for years and in some cases even decades (ie, persistent PTH). It merits emphasis that people with PTH often develop chronic headache within weeks or months of the head trauma, whereas the process of chronification usually takes years or decades in people with migraine. This fact makes PTH a highly disabling neurologic disorder.

Healio Neurology: How is the condition currently managed?

Ashina: Evidence-based clinical management of PTH is currently limited by the scarcity of data from clinical trials. At present, clinicians tend to treat PTH with acute and preventive medications that are used for migraine or tension-type headache. The reason for this approach is that the headache features, that are reported by people with PTH, most often resemble migraine and tension-type headache.

Healio Neurology: What are the greatest unmet needs in this area?

Ashina: There are three huge unmet needs that should be addressed in the coming years. First, we need epidemiologic studies to determine the prevalence of persistent PTH at 3 months, 6 months and 12 months or more after TBI. Second, we need large cohort studies to ascertain the most common clinical features of PTH and subsequently raise awareness among clinicians on PTH symptomatology. Lastly, we need randomized controlled trials to establish evidence-based acute and preventive medications for PTH.

Healio Neurology: How would research in these areas impact the management of these patients?

Ashina: It would facilitate more informed clinical decision-making and better treatment outcomes for the millions of people who are adversely affected by PTH. It should also be underscored that people with PTH often report other post-concussive symptoms as well, such as sleep disturbances, concentration difficulties, anxiety and depression. An initial clinical assessment must therefore account for all common TBI-related sequelae.

Healio Neurology: What are you hoping readers will take away from your paper?

Ashina: I hope that it will create more awareness about PTH among all stakeholders: patient representatives, policymakers, funders, clinicians and researchers. For clinicians specifically, this paper should provide them with the necessary to tools to establish the diagnosis of PTH and initiate acute and preventive medication therapy based on our proposed treatment algorithm.

Reference:

Ashina H, et al. Lancet Neurol. 2021;doi:10.1016/S1474-4422(21)00094-6.