Headache decreased fractional anisotropy at six months after injury.10 These and
other studies showed a positive correlation between degree and extent of DTI changes and subtle cognitive abnormalities in neuropsychologic tests. Headache was not specifically studied in these cases of post- traumatic head injury. Hopefully, future studies will confirm DTI abnormalities as biologic markers for mild head injury and as a prognostic tool for headache and other symptoms of CPTH.
In addition to the pathophysiologic changes that may or may not be present in patients with CPTH, psychologic, socioeconomic, and cultural factors must be considered. People with CPTH have higher degrees of psychopathology than those with other chronic pain syndromes.25 Depression and anxiety may be a response to chronic headache and in turn augment pain intensity. Chronic pain may lead to changes in behavior. Withdrawal from physical and social activities may lead to a loss of work, economic stress, and the break-up of relationships. In turn, these stresses tend to perpetuate headache.
Attention to pain plays a large role in its duration and intensity. This has therapeutic implications. On the one hand the physician or care-giver may make light of or ignore the patient’s headaches, or alternatively may reinforce the patient’s symptoms by issuing dire diagnostic labels, ordering many tests, and predicting poor prognosis unless extensive treatments are instituted. Unrelated to the severity of whiplash injury, victims of motor vehicle accidents who consulted physicians, chiropractors, physical therapists, and attorneys took longer to recover than those who did not.26
Expectation of pain may be a self-fulfilling prophesy. After a mild head injury, those patients who believed their symptoms would have serious consequences were at greatest risk for prolonged post-concussion syndrome.27
This result was unrelated to the severity of the injury, anxiety or depression. Expectations of pain and disability are greatly influenced by culture. Americans who had not experienced head trauma were asked to imagine symptoms that would be expected six months after a motor vehicle accident.28
Their answers were similar to a group who had
a head injury. Both groups reported symptoms of post-concussion syndrome; headache was at the top of the list, although the methodology of this study has been questioned.29
Canadians and
Lithuanians who had not been injured were asked a similar question.30 Forty-five percent of Canadians expected headache for months or years after a motor vehicle accident with loss of consciousness, but only 23% of Lithuanians matched this expectation. The expectation of chronic neck pain in Canadians and Lithuanians was 44 and 1%, respectively. The expectations of chronic post-concussion symptoms among Germans and Greeks were also much lower than in Canadians.31,32
Social and economic factors may play a role in CPTH. In evaluating patients with disability following head injury, 79% of those with mild head injury had headaches after three months.33
In those with longer-term
disability there had been lower levels of education, employment, and income; higher levels of life stresses were also noted in this group.
Although malingering is not common, the relationship of secondary gain to CPTH is problematic. Most people with head and neck injury return to work before litigation is settled, and CPTH as well as other symptoms
80
Non-pharmacologic measures are at least as important as drugs for the treatment of CPTH. As headache and other pain syndromes involve interactions of biology, behavior, emotions, cognition, and environmental factors, the concept and techniques of behavioral medicine are invaluable.40
The evidence-based data and meta-analyses
regarding behavioral medicine for headache have recently been summarized.40
The non-pharmacologic treatments include cognitive behavioral therapy, bio-behavioral training (biofeedback, relation training, stress management), education including lifestyle modification, and physical therapies. All are designed to enhance personal control. Cognitive behavioral therapy teaches methods to modify thoughts, feelings, and behavior. Patients learn to be aware of headache triggers, including the relationship of stress to headache. Counterproductive beliefs are identified. The patient should be educated regarding proper use of, compliance with, and adherence to therapeutic modalities. Education also includes recognition of the overuse of medication, the mechanism and potential triggers of headache, and the benign but chronic nature of headache. Psychologic comorbidities such as depression, anxiety, and obsessive–compulsive disorder have been noted in people with migraine and must be considered and treated in
US NEUROLOGY often persist after a favorable verdict.34 you have to prove you are ill, you cannot get well.”35
On the other hand, in litigation “if After head injury,
those with financial motives had more symptoms and disabilities than those in a control group.36
In Lithuania
and Greece, where litigation is minimal, there is a low prevalence of post-traumatic symptoms.30,38
In people hospitalized for post-
concussion syndrome, the duration of work loss was much greater in those who claimed compensation than those who did not.37
The best prognosis in people with whiplash
injuries was noted in those societies that have the fewest disability payments, no compensation for pain and suffering, and little litigation.26 In summary, the many organic, psychologic and external factors that may play a part in the development of PCTH are inextricably interwoven.
Treatment
The treatment of CPTH is similar to that of the primary headaches. Chronic tension-type headache is the most common manifestation of CPTH. A combination of pharmacologic and non-pharmacologic treatment modalities is superior to either one alone.39
Of the
pharmacologic agents, tricyclic agents such as nortripyline are the initial drugs of choice. All of the prophylactic agents used for chronic migraine may be tried including the antiepileptic agents (topiramate and divalproex), beta adrenergic blockers, and newer antidepressants. Exacerbations of headaches may be treated with triptans if the symptoms are those of migraine or with analgesics including opioids if necessary. As CPTHs occur daily or almost daily, the overuse of analgesics or other agents for acute headache is a major concern. Acute agents must be limited to two days per week to prevent the rebound perpetuation of daily headache (exceptions to this rule may be occasionally necessary). Occipital nerve blocks may be helpful. Hospitalization may be advisable to withdraw the patient from the over- use of analgesics including opioids, or for therapy with intravenous dihydroergotamine or other agents. Associated symptoms of depression, anxiety, and insomnia may aggravate and perpetuate CPTH. Treatment of these conditions may markedly improve the patient’s quality of life.
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