Month: October 2017

Previous posts provide general information on post-traumatic headache and Ontario Neurotrauma Foundation’s recommended approach to medication for post-traumatic headaches. This post describes my personal experience with headache medications and my views on the use of medication for post-traumatic headache pain. I have tried numerous different headache medications over the years since my accident. This post describes them in detail.

For the first month after my headaches first set in, I tried Tylenol, Advil/Ibuprophen, and prescription-strength Naproxen (my doctor indicated it would also help with any brain swelling) but these didn’t help with the pain. Frustrated, I went back to my family doctor who switched me to Gabapentin, which is supposed to work “prophylactically” (i.e. prevent the headaches before they start) but you must work up to the desired dosage slowly. Her recommended daily dosage of 600mg Gabapentin took away the constant headache as long as I lay perfectly still, but I still had extreme light and noise sensitivity and many common, everyday things such as reading, TV, computer screens, car rides, two people talking at the same time, any type of music and many more things would trigger an instant headache.

Eventually another doctor diagnosed me with two types of headaches – migraines and tension headaches. To try to prevent both headache types, he recommended I slowly increase the Gabapentin all the way up to 2,100mg/day (spread over four daily doses). For the migraine headaches, I was to take 5-10mg of Rizatriptan  as soon as I was sensing the start of a migraine. I was someone who at that point rarely took any medication so I was extremely hesitant to follow this advice. I worried about negative side-effects like liver damage and I felt the headaches were a form of information from my brain, giving me signals about what I shouldn’t be doing. I felt the additional medication could mask this information and allow me to do things I shouldn’t be doing. When I went for my next appointment and hadn’t increased my medication as the doctor had asked, it was explained to me that the body heals better when it is not in pain and that allowing the pain to continue on an ongoing basis could create a chronic pain syndrome. With that additional information I then followed the recommendations. An additional daily prescription was also added for 30mg of Amitriptyline, which although usually prescribed as an anti-depressant, in a much lower dose can also be used to prevent migraine headaches and help with nerve pain and sleep issues. This combination of pain medication, when combined with lifestyle changes and the use of pacing and planning including stopping an activity before or as soon as the headache started, took away the constant headache but still did not prevent the headache from starting with even very mild cognitive effort.

Months later, after triggering a brutal migraine that lasted for five days and nights straight and wouldn’t respond to medication, I went to the hospital and they gave me Metoclopramide intravenously and it quickly got rid of the migraine, but the effect was only temporary. I was then prescribed a 10 mg pill form of Metoclopramide that I took twice daily (with no changes to the other medications I was on). For me, this drug did wonders. It allowed me to tolerate much more cognitively before the headache was triggered. However, having read about the potential side effects, I was worried about being on it for a long time so eventually I weaned myself off of it.

A year later  since I was still very limited in what I could handle cognitively and was not living anything close to a normal or desired quality of life, it was recommended I try switching the Gabapentin to 300mg of Lyrica (aka Pregabalin). He explained that these two drugs are very similar, but Lyrica has been known to provide better relief for nerve pain. To make the switch I had to slowly wean off of the Gabapentin and slowly wean onto the Lyrica. The increase in symptoms in between showed me how much the medication was actually doing for me. This amount of pain medication allows me to keep practicing doing the things that trigger headaches and I am slowly increasing the number of minutes I can do them before the headache is triggered.

My Thoughts on the Use of Medication For Post-Traumatic Headache

To this day (several years later) I have not been able to reduce the dosage of Lyrica. I don’t like that I am dependant on it, but it allows me to function at a certain level of cognitive effort before the headaches are triggered and I wouldn’t want my capabilities to be any less than they currently are. I have been able to wean off of the Amitriptyline though and I save the Rizatriptan for those times when I have overdone it and triggered a migraine. By implementing proper pacing and planning of my activities, using Mindfulness techniques and by immediately stopping whatever activity has triggered the headache, I am able to reduce the number of migraines, their severity and my need for additional Rizatriptan medication.

There is no one medication that will work for everyone’s post-traumatic headache. My suggestion is to be persistent and willing to work with your doctor to try different options, to maintain a headache journal so you can provide him/her with accurate information about your headaches, their severity and triggers, how often you have had to take extra medication and whether it worked. It is unfortunate that you may have to take medication for a longer period than you would like but it can increase your quality of life.

 

 Disclaimer: The information contained in this post and others like it is intended for information purposes only and is not meant to be a substitute for appropriate medical advice or care. If you believe that you or someone under your care has sustained a concussion I strongly recommend that you contact a qualified health professional for appropriate diagnosis and treatment. The collaborators have made responsible efforts to include accurate and timely information; however, the individuals and organizations listed on this website make no representations or warranties regarding the accuracy of the information contained and specifically disclaim any liability in connection with the content on this site.

In order to best treat or prescribe the most appropriate medication for a headache, doctors need to know what types of headaches you’re having and the root cause. A previous post provides general information on the types of post-traumatic headache and recommended medication for the first 24-48 hours. This post provides Ontario Neurotrauma Foundation’s recommended approach to medication for post-traumatic headaches after that initial 48 hours, the risks of using too much medication and the importance of maintaining a headache journal.

Ontario Neurotrauma’s Concussion Guidelines’ Recommended Approach to Medications

The Guidelines provide the following medication suggestions for post-traumatic headaches:

1. For certain headaches consideration may be given to using acute headache medications, limited to <15 days per month:-Over-the-counter or prescription NSAIDs (e.g., Tylenol);
   -Acetylsalicylic acid;
   -Acetaminophen; and
   –Combination analgesics (with codeine or caffeine).
2. For migraine headaches, migraine-specific triptan class medications may be effective to abort the headaches but should be limited to <10 days per month.
3. Narcotics should be avoided or restricted to “rescue therapy” for acute attacks when other first- and second-line therapies fail or are contraindicated.
4. Medications that work prophylactically (i.e. prevent headaches) should be considered if headaches are occurring too frequently or are too disabling, or if acute headache medications are contraindicated, poorly tolerated, or being used too frequently.

These Guidelines also indicate “post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to a neurologist, pain management specialist, or traumatic brain injury clinic is recommended”.

The Problem with Overuse of Pain Medication

Patients suffering from post-traumatic headache may over-use pain medication (known as analgesics). Doctors are aware that this over-use can perpetuate the problem and become the cause of the headaches. Even an over-the-counter medication like Tylenol if over-used can start to cause headaches when it wears off. This is known as “The Rebound Effect”. Doctors need to provide their patients with clear guidance as to the maximum number of days in a month they can take any medication that falls into this category. The Ontario Neurotrauma’s Concussion Guidelines indicate the medications that fall into this category should be used no more than 10 days per month to avoid rebound headaches.

The Importance of a Headache Journal

It is important to maintain a daily headache journal in order to accurately know how many days you are using headache medication. This will help you provide your doctor with all the necessary information for him/her to accurately diagnose and treat the headaches. See the Concussion Guidelines mentioned above for details to include in this journal and suggested places to keep it in order to remember to complete it daily.

 

In Conclusion

It’s clear that medication for post traumatic headache is a complicated subject. It will take considerable effort by you and your doctor to develop a treatment plan that works best for you. A later post describes the many medications I have personally tried.

 

 Disclaimer: The information contained in this post and others like it is intended for information purposes only and is not meant to be a substitute for appropriate medical advice or care. If you believe that you or someone under your care has sustained a concussion I strongly recommend that you contact a qualified health professional for appropriate diagnosis and treatment. The collaborators have made responsible efforts to include accurate and timely information; however, the individuals and organizations listed on this website make no representations or warranties regarding the accuracy of the information contained and specifically disclaim any liability in connection with the content on this site.

Background

According to the Ontario Neurotrauma Foundation’s Concussion Guidelines, headache is the most common symptom following a mild traumatic brain injury (mTBI).  They say “Studies to date have documented that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache. Several researchers have reported that post-traumatic headache is more common after mild TBI than after severe TBI.”

Guidelines

Ontario Neurotrauma’s Concussion Guidelines suggest during the first 24-48hrs giving acetaminophen or acetaminophen/codeine for headaches (e.g., Tylenol).  It’s important to note the vast majority of people with post-traumatic headache improve within days or weeks; however, for some individuals, headaches continue for months or years. Unfortunately there aren’t clear guidelines doctors can use to help guide their post traumatic patients who continue to experience this symptom.

Assessment

According to these same Concussion Guidelines there is a lack of research in this area so doctors are left to use their own experience and expertise. Their approach should include:

1. Determining which type of headache the patient is experiencing (migraine, tension-type, neck referral or occipital nerve) and trying to identify possible root causes.
2. Making suggestions for lifestyle changes and non-pharmaceutical approaches to reducing the severity and frequency of headaches (such as pacing and planning of activities and alternative strategies to relaxation – all subjects to be discussed in subsequent posts).
3. Making suggestions/giving prescriptions for medication (a topic discussed in my next post).

Additional Sources of Information

In addition to reading the Ontario Neurotrauma Foundation’s Guidelines for Concussion/Mild Traumatic Brain Injury Modules Two (“Management of Concussion/mTBI”) and Six (“Post Traumatic Headache”) I also recommend:

• Podcast by the Director of Brain Injury Programs, Northeast Center for Special Care titled “A Pain in the Brain – The Problem of Headache After Traumatic Brain Injury”
• Webcast with Dr. Keith Sequira, Parkwoods Hospital titled “Dealing with Headaches and Pain Following ABI”.
• I also found it helpful to meet with Michael Zitney, a Toronto doctor specializing in chronic headaches and chronic pain.

I will provide additional information about medications for post-traumatic headache in a subsequent post.

 Disclaimer: The information contained in this post and others like it is intended for information purposes only and is not meant to be a substitute for appropriate medical advice or care. If you believe that you or someone under your care has sustained a concussion I strongly recommend that you contact a qualified health professional for appropriate diagnosis and treatment. The collaborators have made responsible efforts to include accurate and timely information; however, the individuals and organizations listed on this website make no representations or warranties regarding the accuracy of the information contained and specifically disclaim any liability in connection with the content on this site.