What is a Post-Concussive Headache?
Post-Concussive Headaches
A concussion is a form of mild traumatic brain injury (mTBI). It changes how the brain works and can have a major impact on quality of life. Some people develop lasting symptoms after a concussion, which is called post-concussion syndrome.
A post-concussive, or post-traumatic, headache is head or neck pain that develops after a concussion. It may start suddenly or gradually. It may be constant or come and go. It can feel like a tension headache or a full migraine. These headaches are one of the most common features of post-concussion syndrome.
After any head injury, get emergency care right away for a headache that keeps getting worse, repeated vomiting, confusion, unusual drowsiness, slurred speech, weakness or numbness, a seizure, or one pupil larger than the other. If you are having thoughts of harming yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline, or call 911.
How Common Are Post-Concussive Headaches?
Traumatic brain injuries and concussions are a serious problem. Millions happen in the United States each year. The CDC reported that in 2014, there were about 2.87 million emergency department visits, hospitalizations and deaths related to traumatic brain injury in the U.S., including more than 837,000 involving children (1).
Headache is the most common symptom after a concussion (2). Post-concussive headaches seem to be more common in women and in older adults (3). More than 30% of people who have had a concussion report headaches that continue long after the injury (4).
What Causes Post-Concussive Headaches?
Concussions are common in sports, car crashes and falls, especially among older adults. Lasting post-concussive headaches may be linked to injury to the brain or brainstem that disrupts the nerves carrying signals to and from the brain (3). They may also come from injuries to the head or neck, muscle tension, stress, problems with the autonomic nervous system, or medication side effects.
What Are the Symptoms of Post-Concussive Headaches?
Symptoms depend on the type of headache. The most common types after a concussion are tension-type headaches and migraine without aura. Cervicogenic headaches, which come from the neck, are also very common when the neck was injured too (5).
Migraine. A migraine may or may not include an aura before or during the headache. Most auras are visual, such as blurred vision, loss of part of your vision, or seeing bright spots or flashing lights. The pain is often throbbing and usually on one side of the head. Nausea, vomiting and sensitivity to light and sound are common. Pain ranges from moderate to severe and can be truly debilitating (6).
Tension-type headache. This type is linked with muscle tension, muscle spasm or stress. It feels like a tight, squeezing band around the whole head or one side. Pain is usually mild to moderate and often gets worse as the day goes on. Many researchers now think tension-type headache and migraine may exist on a continuum (7).
Cervicogenic headache. This type comes from the muscles, joints and other structures of the neck, which have many pain-sensitive tissues. It can be caused by whiplash, sports injuries, inflamed muscles and joints, or irritated nerves. It is often linked with reduced neck movement, which can lead to stiffness that limits motion even more. Pain usually spreads from the neck to the back and sides of the head and sometimes the forehead. Over time, people often notice the headache more than the neck pain, so the neck can get overlooked (8).
Medication overuse headache. Taking pain relievers too often can lead to more frequent headaches, and missing a dose can bring on a headache. Cutting back suddenly on caffeine can also cause headaches (9). If you’re taking pain relievers often, talk with your doctor before making changes.
Living with chronic pain is exhausting, and many people with chronic post-concussive headaches feel worn out by them (10).
How Do Post-Concussive Headaches Affect Your Life?
Headaches are a major cause of disability and lost productivity. About 157 million workdays are lost each year in the U.S. because of headaches, costing about $50 billion in missed work and medical costs (11).
Headaches can also take a heavy toll on mental health. Chronic headaches are closely linked with depression and anxiety (12). Cervicogenic headaches have been linked with poor sleep, which can feed a cycle of low mood, more sleep problems and more headaches (13). Persistent post-concussion syndrome has also been linked to a higher risk of suicide (14), which is why getting support matters.
What Happens in the Brain With Post-Concussive Headaches?
Most people think of pain like an on-off switch: either something hurts and something is wrong, or it doesn’t hurt and everything is fine. But that’s not really how your pain system works.
A better comparison is the strength-tester game at a carnival. You swing the hammer, the puck shoots up, and if you hit hard enough, it rings the bell at the top. Your pain receptors are the hammer, and your pain threshold is the height of the bell. Ideally, the hammer hits softly and the bell sits high, so it takes a lot to ring it.
Pain signals from your head and face travel through your trigeminal nerve (15), which also carries pain signals from the blood vessels and membranes surrounding the brain. When pain receptors are pressed on or irritated by inflammation, they send signals to a group of nerve cells in the brainstem called the spinal trigeminal nucleus (16). This is the striker in our carnival game. It constantly receives input from the trigeminal nerve, from movement, from chemical byproducts and more.
Even when nothing is wrong, pain-sensing nerves have a natural background level of activity, and that activity rises when tissues are injured. If your brain didn’t manage this input, you’d be in pain all the time. So the brain has pathways that send signals down to calm the trigeminal nucleus, making sure normal background activity doesn’t register as pain. When this system works well, the bell sits high, and it takes a hard hit to feel pain.
The trigeminal system doesn’t only receive input from your head, face and brain. It also receives pain input from the top three segments of your neck, including the area at the base of your skull. If there’s enough pain input from your upper neck, the bell can start to ring and you feel a headache.
If that input is strong enough, pain can spread through the trigeminal system. You may feel pain not just at the base of your skull, but behind your eyes, in your forehead, in your jaw and in other areas served by this nerve.
This is a kind of crosstalk, much like how a heart attack can cause pain in the left arm even though nothing is wrong with the arm. Many of the pain receptors around the brain surround blood vessels, so when the trigeminal system is highly activated, you may feel throbbing pain with every heartbeat.
Your pain system works like the rest of your nervous system: the more it’s used, the better it gets at its job. Unfortunately, that means if the bell keeps ringing for a long time, the bell gets lower, and it takes less to trigger a headache. Eventually, even normal background input can be enough to set one off.
How Your Eyes, Inner Ear and Neck Connect to Headaches
Your neck can contribute to pain in many ways, and the causes aren’t always easy to find without careful testing. Tight muscles at the base of the skull can come from injured tissue, but they can also come from something as subtle as eye movement problems, mixed signals from the inner ear, trouble holding your eyes steady on a target, or trouble coordinating your eyes and head to follow a moving object. When your nervous system adapts poorly in these ways, the upper neck muscles can become tense, contributing to headaches (17).
Saccades are fast eye movements you use to build your view of the world and figure out where you are in it. Some saccades are reflexive, and others are under your control, such as self-paced saccades, where you move your eyes back and forth between two targets as quickly as you can. Research has found that people with post-concussion syndrome tend to make fewer self-paced saccades in a given time, and that this is linked to more symptoms. Imaging studies suggest this may be related to injury in pathways that generate saccades (18). Saccade problems have also been found in several types of headache, including migraine (19), tension-type (20) and cervicogenic headaches (21).
Research also shows that in post-concussion syndrome, eye movements may not recover along the usual path after a concussion, which may point to ongoing brain dysfunction. One study found that eye movement testing picked up problems that standard thinking-and-memory tests missed (22). This is one reason eye movement testing and training can be an important part of care after a concussion.
The vestibulo-ocular reflex (VOR) is another reflex that helps keep neck muscle tension normal (23). Your vestibular system sits deep inside your skull next to the hearing organ. There’s one on each side, and each has two kinds of sensors: the otoliths, which sense gravity and straight-line movement, and three semicircular canals, which sense head rotation in every direction. This system works closely with your vision.
The VOR combines information from your inner ear and your eyes so you can keep your eyes fixed on a target while your head moves. That information comes together in the brainstem, which can be injured in a traumatic brain injury.
The VOR can be affected by brain injuries of all severities (24), especially when the injury involves twisting or whiplash forces. This can make it hard to keep your eyes steady after a concussion, and people often describe blurry vision, dizziness, lightheadedness or unsteadiness.
To make up for this, you may have to make extra eye movements to find what you’re trying to look at. That matters because each eye movement comes with a small contraction of the muscles at the base of the skull to steady the head (25). In concussion, these reflexes can be significantly disrupted, affecting control of the eyes, the inner ear reflexes and neck muscle tone (26). More eye movements can mean more firing of the muscles at the base of the skull, which can lead to tight muscles, stiffness and pain.
The reflexes that control how much your head moves along with your eyes can also be affected. When your eyes fall short of a target, you tend to use your neck to make up the difference. This eye-head coordination is often disrupted after neck injuries and concussions, which can create abnormal neck muscle tension that may feed headaches (27).
The encouraging news is that these factors can be measured and trained. Research on therapies that combine visual, vestibular and body-position training has found that these functions can change in a relatively short time, along with improvements in symptoms (28).
How Are Post-Concussive Headaches Usually Treated?
There are many types of headache treatment, from prescription pain medications to procedures that block or disable pain nerves. Many people improve with treatment, but some continue to have symptoms. Many people spend years searching for answers, seeing many providers and trying many treatments (29). Millions of people live with long-term effects of brain injuries, and some have nearly given up hope of getting their lives back.
We created the NeuroRescue Program for people like you, with the goal of supporting your recovery from concussion so you can get back to doing the things you love.
How the NeuroRescue Program Can Help
Our care is designed to work alongside your physician, neurologist and other providers, never in place of them. Please don’t change or stop any medication without talking with your prescriber.
We evaluate the many factors that may be contributing to your headaches. This includes the muscles, joints, ligaments and nerves of your neck and jaw, the nervous system pathways that control them, and the brain and brainstem systems that normally calm pain and keep your eye movements stable and accurate. We bring all of this together into a personal plan aimed at the factors driving your symptoms.
One of the brain’s most important jobs is figuring out where you are in the world. It uses your inner ear to sense where your head is in relation to gravity and how it’s moving, your muscles and joints to sense where your body is and what it’s doing, and your eyes to sense where you are in relation to everything around you. Your brain combines all of this into a picture of where you are, so you can respond to the world around you.
A concussion is rarely just an injury to the eyes, the inner ear or the neck alone. It often affects how well these systems work together. That’s why we look at all of them together.
Research suggests spinal adjustments may do more than move a joint. Studies using EEG, brain stimulation and brain imaging have found that adjustments can produce short-term changes in how the brain processes sensory and movement information, including in the prefrontal cortex and the areas that plan and control movement (30, 31, 32, 33). Researchers are still working to understand how long these changes last and how they relate to symptoms, but they help explain why we look at how your whole nervous system is working, not just your spine.
Depending on your needs and test results, your program may include eye movement training, vestibular rehabilitation, and exercises that combine visual, vestibular and body-position input (28); care for the muscles and joints of your neck and jaw, including chiropractic adjustments when appropriate and other therapies for neck injuries (34, 35, 36); non-invasive electrical stimulation of the trigeminal nerve (37), vagus nerve (38) or occipital nerve (39), which have been studied for headache pain; and light therapy, also called photobiomodulation (40). Transcranial magnetic stimulation (TMS) has been studied for post-concussive symptoms and headaches (41, 42). At our clinic, TMS is provided by our psychiatric mental health nurse practitioner, who will evaluate whether it may be appropriate for you. Some programs include mild hyperbaric therapy as a structured recovery option between more demanding therapy sessions.
No two brains are alike, and no two NeuroRescue Programs are the same. The therapies we recommend are always chosen based on your testing and exam findings.
How the NeuroRescue Program Works
Your NeuroRescue Program begins with your Discovery Day. We start with a detailed history of your condition and your life on a timeline. This helps us understand the factors that may have contributed to where you are now, and identify related conditions that may be making it harder to move forward.
We measure how your visual, vestibular and balance systems are working through computerized analysis of your eye movements, inner ear reflexes and balance under different conditions. Our testing includes videonystagmography and saccadometry to measure several types of eye movements, the video head impulse test to measure inner ear reflexes, and CAPS computerized posturography to assess your balance under different sensory conditions. We also use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and your perception of vertical in a virtual reality environment.
We combine this with a thorough physical and neurological exam of your sensory, motor, autonomic and cognitive systems. We also review any relevant lab work, imaging and prior testing, and integrate it with our findings.
Together, this helps us understand which parts of your nervous system are working well, which are struggling, and how quickly they tire. We use that information to design your personal NeuroRescue Program, aimed at improving function in the systems that need support and helping them work together. Our testing also helps us decide when to push and when to let you rest.
Our goal is to help you get your headaches under better control, so you can think more clearly, move more freely and get back to more of the things you enjoy.
Your Next Step
Living with post-concussive headaches can be exhausting and discouraging, but you don’t have to keep searching alone. To find out if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
It’s never too late to take the next step.
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