The International Classification of Headache Disorders 2nd Edition



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5. HEADACHE ATTRIBUTED TO HEAD AND/OR NECK TRAUMA


5.1 Acute post-traumatic headache

5.1.1 Acute post-traumatic headache attributed to moderate or severe head injury

5.1.2 Acute post-traumatic headache attributed to mild head injury

5.2 Chronic post-traumatic headache

5.2.1 Chronic post-traumatic headache attributed to moderate or severe head injury

5.2.2 Chronic post-traumatic headache attributed to mild head injury

5.3 Acute headache attributed to whiplash injury

5.4 Chronic headache attributed to whiplash injury

5.5 Headache attributed to traumatic intracranial haematoma

5.5.1 Headache attributed to epidural haematoma

5.5.2 Headache attributed to subdural haematoma

5.6 Headache attributed to other head and/or neck trauma

5.6.1 Acute headache attributed to other head and/or neck trauma

5.6.2 Chronic headache attributed to other head and/or neck trauma

5.7 Post-craniotomy headache

5.7.1 Acute post-craniotomy headache

5.7.2 Chronic post-craniotomy headache

General comment

Primary or secondary headache or both?

When a new headache occurs for the first time in close temporal relation to a known trauma, it is coded as a secondary headache attributed to the trauma. This is also true if the headache has the characteristics of migraine, tension-type headache or cluster headache. When a pre-existing primary headache is made worse in close temporal relation to a trauma, there are two possibilities, and judgment is required. The patient can either be given only the diagnosis of the pre-existing primary headache or be given both this diagnosis and the diagnosis of headache attributed to the trauma. Factors that support adding the latter diagnosis are: a very close temporal relation to the trauma, a marked worsening of the pre-existing headache, very good evidence that the particular kind of trauma can aggravate the primary headache and, finally, improvement of the headache after recovery from the trauma.
Definite, probable or chronic?

In many cases of secondary headache, the diagnosis is definite only when headache resolves or greatly improves within a specified time after effective treatment or spontaneous remission of the causative disorder. In such cases this temporal relation is an essential part of the evidence of causation. This is not so in the case of trauma: causation is established by onset in close temporal relation to trauma, whilst it is well recognised that headache after trauma often persists. When this occurs, for example after head trauma, 5.2 Chronic post-traumatic headache is diagnosed. Until sufficient time for recovery has elapsed, the diagnosis of 5.1 Acute post-traumatic headache is definite if the criteria are fulfilled. The same applies after whiplash injury. There is no option for a diagnosis of Headache probably attributed to head and/or neck trauma.

Introduction


Headache is a symptom that may occur after injury to the head, neck or brain. Frequently, headache that results from head trauma is accompanied by other symptoms such as dizziness, difficulty in concentration, nervousness, personality changes and insomnia. This constellation of symptoms is known as the post-traumatic syndrome; amongst them, headache is usually the most prominent.

A variety of pain patterns may develop after head injury, and may closely resemble primary headache disorders – most frequently tension-type headache, in more than 80% of patients. In some cases, typical migraine with or without aura may be triggered, and a cluster-like syndrome has been described in a few patients.

It is easy to establish the relationship between a headache and head or neck trauma when the headache develops immediately or in the first days after trauma has occurred. On the other hand it is very difficult when a headache develops weeks or even months after trauma, especially when the majority of these headaches have the pattern of tension-type headache and the prevalence of this type of headache in the population is very high. Such late-onset post-traumatic headaches have been described in anecdotal reports but not in case-control studies.

There are recognised risk factors for a poor outcome after head injury or whiplash injury. Women have a higher risk for post-traumatic headache, and increasing age is associated with less-rapid and less-complete recovery. Mechanical factors such as the position of the head at impact – rotated or inclined – increase the risk of headache after the trauma. The relationship between severity of the injury and severity of the post-traumatic syndrome has not been conclusively established. Although there are some controversial data, most studies suggest that post-traumatic headache is less frequent when the head injury is more severe. However, the causal relationship between head and/or neck trauma and headache is difficult to establish in some cases with very mild trauma.

The role of litigation in the persistence of headache is still discussed, and some studies show a reduction of headache in countries where the accident victims do not receive compensation. 5.2 Chronic post-traumatic headache and 5.4 Chronic post-whiplash injury headache are often part of the post-traumatic syndrome in which the complex inter-relationship between organic and psychosocial factors is difficult to assess.

5.1 Acute post-traumatic headache

5.1.1 Acute post-traumatic headache attributed to moderate or severe head injury

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Head trauma with at least one of the following:

1. loss of consciousness for >30 minutes

2. Glasgow Coma Scale (GCS) <13

3. post-traumatic amnesia for >48 hours

4. imaging demonstration of a traumatic brain lesion (cerebral haematoma, intracerebral and/or subarachnoid haemorrhage, brain contusion and/or skull fracture)

C. Headache develops within 7 days after head trauma or after regaining consciousness following head trauma

D. One or other of the following:

1. headache resolves within 3 months after head trauma

2. headache persists but 3 months have not yet passed since head trauma



5.1.2 Acute post-traumatic headache attributed to mild head injury

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

  1. Head trauma with all the following:

1. either no loss of consciousness, or loss of consciousness of <30 minutes’ duration

2. Glasgow Coma Scale (GCS) >13

3. symptoms and/or signs diagnostic of concussion


  1. Headache develops within 7 days after head trauma

D: One or other of the following:

1. headache resolves within 3 months after head trauma

2. headache persists but 3 months have not yet passed since head trauma

Comment:

Mild head injury may give rise to a symptom complex of cognitive, behavioural and consciousness abnormalities and a GCS of >13. It can occur with or without abnormalities in the neurological examination, neuroimaging (CT scan, MRI), EEG, evoked potentials, CSF examination, vestibular function tests and neuropsychological testing. There is no evidence that an abnormality in any of these changes the prognosis or contributes to treatment. These studies should not be considered routine for patients with ongoing post-traumatic headache. They may be considered on a case-by-case basis, or for research purposes.

5.2 Chronic post-traumatic headache

Comment:

Chronic post-traumatic headache is often part of the post-traumatic syndrome which includes a variety of symptoms such as equilibrium disturbance, poor concentration, decreased work ability, irritability, depressive mood, sleep disturbances, etc. The relationship between legal settlements and the temporal profile of chronic post-traumatic headache is not clearly established, but it is important to assess patients carefully who may be malingering and/or seeking enhanced compensation.

5.2.1 Chronic post-traumatic headache attributed to moderate or severe head injury

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Head trauma with at least one of the following:

1. loss of consciousness for >30 minutes

2. Glasgow Coma Scale (GCS) <13

3. post-traumatic amnesia for >48 hours

4. imaging demonstration of a traumatic brain lesion (cerebral haematoma, intracerebral and/or subarachnoid haemorrhage, brain contusion and/or skull fracture)

C. Headache develops within 7 days after head trauma or after regaining consciousness following head trauma

D. Headache persists for >3 months after head trauma



5.2.2 Chronic post-traumatic headache attributed to mild head injury

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Head trauma with all the following:

1. either no loss of consciousness, or loss of consciousness of <30 minutes’ duration

2. Glasgow Coma Scale (GCS) >13

3. symptoms and/or signs diagnostic of concussion

C. Headache develops within 7 days after head trauma

D. Headache persists for >3 months after head trauma

Comment:

Mild head injury may give rise to a symptom complex of cognitive, behavioural and consciousness abnormalities and a GCS of >13. It can occur with or without abnormalities in the neurological examination, neuroimaging (CT scan, MRI), EEG, evoked potentials, CSF examination, vestibular function tests and neuropsychological testing. There is no evidence that an abnormality in any of these changes the prognosis or contributes to treatment. These studies should not be considered routine for patients with ongoing post-traumatic headache. They may be considered on a case-by-case basis, or for research purposes.

5.3 Acute headache attributed to whiplash injury

Diagnostic criteria:

  1. Headache, no typical characteristics known, fulfilling criteria C and D

B. History of whiplash (sudden and significant acceleration/deceleration movement of the neck) associated at the time with neck pain

C. Headache develops within 7 days after whiplash injury

D. One or other of the following:

1. headache resolves within 3 months after whiplash injury

2. headache persists but 3 months have not yet passed since whiplash injury

Comments:

The term whiplash commonly refers to a sudden acceleration and/or deceleration of the neck (in the majority of cases due to a road accident). The clinical manifestations include symptoms and signs that relate to the neck, as well as somatic extracervical, neurosensory, behavioural, cognitive and affective disorders whose appearance and modes of expression and evolution can vary widely over time. Headache is very common in this post-whiplash syndrome. The Quebec Task Force on Whiplash-Associated Disorders has proposed a classification in five categories that may be useful in prospective studies.

There are important differences in the incidence of post-whiplash syndrome in different countries, perhaps related to expectations for compensation.


5.4 Chronic headache attributed to whiplash injury

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. History of whiplash (sudden and significant acceleration/deceleration movement of the neck) associated at the time with neck pain

C. Headache develops within 7 days after whiplash injury

D. Headache persists for >3 months after whiplash injury



Comment:

Chronic post-whiplash injury headache is often part of the post-traumatic syndrome. There is no good evidence that ongoing litigation, with settlement pending, is associated with prolongation of headache. It is important to assess patients carefully who may be malingering and/or seeking enhanced compensation.

5.5 Headache attributed to traumatic intracranial haematoma

Coded elsewhere:

Headache attributed to traumatic intracerebral and/or subarachnoid haemorrhage or to traumatic intracerebral haematoma is coded as 5.1.1 Acute post-traumatic headache attributed to moderate or severe head injury or 5.2.1 Chronic post-traumatic headache attributed to moderate or severe head injury.

5.5.1 Headache attributed to epidural haematoma

Diagnostic criteria:

A. Acute-onset headache, no other typical characteristics known, fulfilling criteria C and D

B. Neuroimaging evidence of epidural haematoma

C. Headache develops within minutes to 24 hours after development of the haematoma


  1. One or other of the following:

1. headache resolves within 3 months after evacuation of the haematoma

2. headache persists but 3 months have not yet passed since evacuation of the haematoma



Comment:

Epidural haematoma occurs within hours of head trauma which may be moderate. It is always associated with focal signs and disorders of consciousness. Emergency surgery is required.

5.5.2 Headache attributed to subdural haematoma

Diagnostic criteria:

A. Acute or progressive headache, no other typical characteristics known, fulfilling criteria C and D

  1. Neuroimaging evidence of subdural haematoma

  2. Headache develops within 24-72 hours after development of the haematoma

  3. One or other of the following:

1. headache resolves within 3 months after evacuation of the haematoma

2. headache persists but 3 months have not yet passed since evacuation of the haematoma



Comments:

Different types of subdural haematomas should be differentiated according to their temporal profile. In acute and subacute haematomas, which usually occur after obvious head trauma, headache is frequent (11-53% of cases) but commonly overshadowed by focal signs and disorders of consciousness. In chronic subdural haematomas, headache is more frequent still (up to 81%) and, though moderate, can be the leading symptom. The diagnosis can be difficult, because the causative head trauma is often trivial and may have been forgotten by the patient. Chronic subdural haematoma should always be considered in an elderly patient with a progressive headache particularly if there is some cognitive impairment and/or mild focal signs.

Bilateral subdural haematomas may be a complication of CSF hypotension. Headache attributed to these is coded here. In such cases, the headache is initially postural and may either remain predominantly postural or become continuous.


5.6 Headache attributed to other head and/or neck trauma

5.6.1 Acute headache attributed to other head and/or neck trauma

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Evidence of head and/or neck trauma of a type not described above

C. Headache develops in close temporal relation to, and/or other evidence exists to establish a causal relationship with, the head and/or neck trauma


  1. One or other of the following:

1. headache resolves within 3 months after the head and/or neck trauma

2. headache persists but 3 months have not yet passed since the head and/or neck trauma



5.6.2 Chronic headache attributed to other head and/or neck trauma

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Evidence of head and/or neck trauma of a type not described above

C. Headache develops in close temporal relation to, and/or other evidence exists to establish a causal relationship with, the head and/or neck trauma

D. Headache persists for >3 months after the head and/or neck trauma



5.7 Post-craniotomy headache

5.7.1 Acute post-craniotomy headache

Diagnostic criteria:

A. Headache of variable intensity, maximal in the area of the craniotomy, fulfilling criteria C and D

B. Craniotomy performed for a reason other than head trauma1

C. Headache develops within 7 days after craniotomy

D. One or other of the following:

1. headache resolves within 3 months after craniotomy

2. headache persists but 3 months have not yet passed since craniotomy



Note:

1. When the craniotomy was for head trauma, code as 5.1.1 Acute post-traumatic headache attributed to moderate or severe head injury.

5.7.2 Chronic post-craniotomy headache

Diagnostic criteria:

A. Headache of variable intensity, maximal in the area of the craniotomy, fulfilling criteria C and D

B. Craniotomy performed for a reason other than head trauma1

C. Headache develops within 7 days after craniotomy

D. Headache persists for >3 months after craniotomy



Note:

1. When the craniotomy was for head trauma, code as 5.2.1 Chronic post-traumatic headache attributed to moderate or severe head injury.
Comments:

Immediate post-operative headache may occur in up to 80% of patients after craniotomy but resolves in most patients within 7 days. Fewer than one-quarter develop persistent (>3 months) headache related to the surgical procedure. Posterior fossa procedures, especially suboccipital craniotomies performed for acoustic neuromas, are more likely to be associated with post-craniotomy headache.

The pathogenesis of chronic headache after craniotomy is unclear but may involve meningeal inflammation, nerve entrapment, adhesion of muscle to dura or other mechanisms. Modifications in the operative procedure, including the use of osteoplastic cranioplasty, may lead to a reduction in the incidence of post-craniotomy headache by preventing adhesion of muscle and fascia to the underlying dura.


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5.3, 5.4 Acute and chronic headache attributed to whiplash injury

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5.7 Post-craniotomy headache

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