Headache is common following traumatic brain injury (TBI) and the severity of the head injury has significant effects on the headache characteristics, according to study results published in PM & R.

Headache is a common symptom after TBI and frequently is persistent. The researchers previously reported on the results of 2 separate studies, showing that following moderate to severe TBI headache incidence was 71% and prevalence was 44% at 12 months, while following mild TBI the incidence and prevalence at 12 months were 91% and 58%, respectively.

The goal of the current study was to explore headache symptoms in patients following moderate to severe TBI compared with patients with mild TBI. Furthermore, they investigated these data from 2 different clinical perspectives: symptom-based specialists (including psychiatrists, neurologists or primary care providers) or headache specialists.

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The study included prospective enrollments of patients after hospitalization for TBI. Baseline data from patients with moderate to severe TBI was collected during inpatient rehabilitation and from patients with mild TBI within 1 week of injury. The researchers completed telephone follow-up at 1 year post-TBI. Self-reported headache characteristics included headache frequency, pain intensity, headache impact on daily life using the Headache Impact Test-6 (HIT-6), and depressive symptoms using the Physician Health Questionnaire (PHQ-9) measured 1 year after TBI.

The study cohort included 535 subjects (mean age, 44 years), including 346 patients with moderate to severe TBI and 189 patients with mild TBI who completed the assessment at 12 months post-injury. Most causes of injury were vehicular crashes (57%) and falls (26%).

A third of patients (33%; n=115) with moderate-to-severe TBI and more than half (58%; n=109) of patients with mild TBI had a new or worse headache at 12 months post-injury. Migraine or probable migraine-type and tension type headache were more common in patients with mild TBI (28% and 19%, respectively) compared with patients with moderate to severe TBI (20% and 5%, respectively). Significantly more patients with moderate to severe TBI reported no headache (55% vs 33%).

The impact of headache on daily function was significantly greater in patients with mild TBI, as severe impact on daily function according to HIT-6 score was more common in that group compared to patients with moderate to severe TBI (24% vs 14%). Furthermore, moderate or severe pain was more common in patients with mild TBI compared with patients with moderate to severe head injury (42% vs 27%, respectively).

When the researchers isolated patients who had a new or worse headache at 1 year, they found that headache frequency and pain scores were both higher in the moderate to severe TBI group, but there was no difference between groups in  headache impact.

Approximately one-third (35%) of patients with TBI and headache reported significant depressive symptoms at 1 year after TBI compared with 13% of patients with TBI and no headache. There was no difference in depressive symptoms between patients with mild and moderate to severe TBI groups.  

Providers of patients with TBI are more likely to evaluate and treat headache in individuals sustaining a mild TBI vs moderate to severe TBI. Headache specialists may encounter patients with moderate to severe TBI who report more frequent headache and greater pain intensity compared with patients with mild TBI.

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The researchers acknowledged several study limitations, including the smaller sample size in the mild TBI group, defining only 1 headache type per person, determining headache type by responses to a questionnaire, and the fact that no physical examination was performed.           

“These findings underscore the need for appropriate evaluation of the clinical symptoms and impact of headache, but also on possible psychiatric co-morbid conditions such as depression after TBI,” concluded the researchers. They add that these findings also suggest, “follow-up on symptoms such as headache needs to continue long after the acute period as persistence of headache is common.”


Hoffman JM, Lucas S, Dikmen S, Temkin N. Clinical perspectives on headache after traumatic brain injury [published online January 31, 2020]. PM R. doi:10.1002/pmrj.12338