Table of contents:
[01:44] Post-concussion headaches 
[06:51] Cause of post-concussion headaches
[09:51] Post-concussion headache history
[13:36] Post-concussion syndrome care
[16:02] Traumatic brain injury patient examination
[18:32] Concussion Care Clinic Virginia

Introduction to this episode on post-concussion headaches

In this second Concussion Stories episode with Dr. Zasler, we are zooming in on post-concussion headaches. Dr. Zasler has years of experience and has seen an incredible amount of patients with headaches post-concussion throughout his career.

Concussion Stories

[00:00 Melanie] Welcome to Concussion Stories, a Lifeyana podcast series filled with hope. I’m here to let you know that you are not alone in your concussion recovery. I’m Melanie and I spent more than six years experimenting, training and learning in order to heal myself from a very bad case of post-concussion syndrome. And today, I feel better than ever before.

In Concussion Stories we dig deep while discussing hopeful stories of recovery, as well as the hard stuff in the messy middle. If you’re struggling to focus, be sure to take breaks. Down in the description of each episode, you can find a table of contents, in case you want to skip ahead. Let’s dive right in. 

Dr. Nathan Zasler: part 2

[00:45 Melanie] This is number two of two Concussion Stories podcast episodes with Dr. Zasler. If you haven’t watched or listened to the first episode yet, I advise you to do so. In this episode, Dr. Zasler names the most common post-concussion headaches, and shares more about several of them. 

Long and technical episode

Please mind that that is quite a long episode and it contains a lot of information at once. So it might be a good idea to listen to it in chunks, or ask a loved one to listen to it and see if they recognize your kind of headache. 

Use the links in the transcript below

Also, Dr. Zasler is going to name a lot of difficult medical terms. This is needed in order to identify the specific post-concussion syndrome headaches that you might experience. But if you’d like to know what they mean, head on over to the podcast transcript on lifeyana.com to find links to pages explaining all medical terms he uses. Without further ado, let’s get this episode started. 

Post-concussion headaches

You can tell us a lot about headaches in post-concussion syndrome patients, right? Could you tell us a bit more about the context: how much does it occur? How normal is it or not? What do patients you see normally experience? Prognosis, diagnosis: anything that you want to shed a light on.

Post-brain injury headaches

[02:10 Dr. Zasler] Sure. Let me start by saying it’s not just a condition of post-concussive symptomatology, but it occurs in all severities of traumatic brain injury. 

What’s interesting is, and it’s not quite clear as to why, it seems like the incidence is higher in people with milder injuries: the mild traumatic brain injury category or post-concussive category, than in people with moderate to severe TBI (traumatic brain injury). Although the literature admittedly is somewhat mixed there. That’s point number one. 

Headaches caused by neck injury?

Point number two is: if it’s related to your brain being injured, it wouldn’t make sense that you should see more post-concussion headaches in people with milder injury. You would expect to see more of it in people with more severe injury. So I’ve made the argument over the years, that maybe it’s not all in the brain. 

In the last few years, probably the last 10 years, one of the things that’s been more widely acknowledged than written about, is the importance of the neck in the context of being a pain generator for post-traumatic headache. We’ll come back to that concept in a minute. 

Post-concussion headaches occur often

It is very common, at some point post-injury, to have a headache. Typically, headaches start early after the injury. It’s not something that comes on typically years after and is causally related. There are cases that are outliers where you can have late onset headache that ultimately is apportionable and related to the original injury, but those are exceptions. So most headaches come on fairly quickly after the injury. 

Now, there are lots of different reasons for having a headache after a traumatic event, like a concussion or more severe brain injury. 

Post-concussion migraines

All too often clinicians make a diagnosis and tend to go right to migraine as an explanation for post-traumatic headache pain. Clearly migraine is a cause and occurs in a certain percentage of patients. That percentage in my own opinion is still highly debatable, because the literature that has looked at the incidence of different headache subtypes has relied on the international headache classification, ICHD 3 (the current classification) as a sole driver of making the diagnosis. 

“Post-traumatic headache”

None of the studies that I am aware of have included careful histories in terms of headache histories, and careful physical exams directed at identifying headache pain generators. Oftentimes you see people receive a diagnosis of “Post-traumatic headache” – that’s the diagnosis. I see patients regularly who have been to multiple doctors and that’s the only diagnosis they have received. 

My response to that is: that doesn’t tell the patient anything they don’t already know. They know they had a trauma, they know they have a headache. How is that helpful? It’s not, because it doesn’t identify what the cause of the headache is. It doesn’t identify what should be done to treat the headache and modulate their symptoms. 

Physical examination is needed

90% of the patients I see with post-traumatic headache who come to me (typically tertiary referral), I start examining them. I tell them to lay down, I look at leg length discrepancy, pelvic alignment, do a neck and shoulder exam, I start to palpate their head and neck. And they go: what are you doing? I go: well, I’m examining you, this is an important part of the exam for headache. And guess what they say? 

[06:47 Melanie] Never done. 

[06:48 Dr. Zasler] Yeah, no one’s ever done that before. You can’t assess somebody with post-traumatic headache and not examine them properly.

Cause of post-concussion headaches

There are at least seven common things that can cause headache after injuries like post-concussion syndrome. I’ll just list off some:

1. migraine
2. tension headaches
3. TMJ problems (temporomandibular joint problems)
4. bruxing (grinding teeth)
5. supraorbital neuralgia
6. supratrochlear neuralgia
7. greater occipital neuralgia
8. lesser occipital neuralgia
9. referred pain from the neck (what’s called referred myofascial pain). 

Extra note on referred pain from the neck

Sometimes upper ligamentous injury and instability of the neck can cause the bones to be rotated. And when you adjust the bones, like an osteopathic doctor or chiropractor does, or someone who’s good with manual medicine, that can help particularly if it’s in the upper three levels of the neck. 

Sometimes instability is more significant and needs to be treated with anywhere from conservative management to potentially even albeit rarely surgical stabilization of the neck in more severe cases. 

Combined headache causes

So there’s a myriad number of different conditions and they don’t necessarily have to occur just by themselves. So you can have migraines with a cervicogenic component. You can have cervicogenic headache with occipital neuralgia headache with TMJ headache, and tension headache. 

Once you find one, it doesn’t mean that all that needs to be treated. You need to assess and treat holistically, in my experience, to optimize how patients do with their headache disorder.

PCS headaches are a psychosocial issue

Part of that also is treating how they’re dealing or coping with their pain. So, it’s not just a medical management issue. It’s a bio psychosocial issue if you will. Particularly with chronic pain, more so than with acute pain, there tend to be secondary issues that come about. 

So let’s make it simple: chronic headache is the only problem, that’s it. Anxiety disorders: much higher in those patient populations. Depressive disorders are much higher, too. There’s also interesting data showing that chronic pain can perpetuate PTSD (post-traumatic stress disorder). symptomatology. So if you’re trying to treat PTSD optimally and somebody has chronic post-traumatic pain and you’re not addressing the pain, you’re not optimally treating the PTSD. Those are just some examples. 

Post-concussion headache history

All those things are important in that context. 

Headache history

I sort of skipped over the history, but taking a history can be very helpful in terms of directing the physical exam. It’s important to look at some basic things. 

I like the mnemonic ‘COLDER’:

• C for the character of the pain. 
• O for onset:  is it rapid, or insidious? Does it come on slowly, or – boom! – is it just there? 
• The location of the headache: is it unilateral or bilateral, temporal, parietal, suboccipital? Where is it, and is it on both sides? Or is it all over: what’s called holocephalic? 
• What’s the duration? That’s the D.
• What’s the exacerbating factor, so what makes it worse? That’s E. 
• The R is what relieves it. Going into a dark room and going to sleep might relieve it. Taking Excedrin migraine, which is a medicine we have here, might relieve it. Having a massage might help. 

Additional headache characteristics

Some other things that need to be asked are: 

• the frequency of the headache, the severity of the headache (typically numerically ranked). 
• the functional consequences of the headache, meaning: can you go about your daily business? Or do you basically get debilitated and have to lay down, turn out the lights, take medicine, go to sleep at the other extreme? 
• time of day of the headache: certain headaches tend to occur more frequently at certain times a day. For example, frontal sinus headaches tend to be more common in the morning. Sleep apnea headaches are more common in the morning. Tension headache is more common in the afternoon, if you work a regular schedule. 
• Are headaches related to menses in women? If they are, then that’s more consistent with things termed catamenial migraine. So catamenial meaning: around the time of the period. 

Occipital neuralgia: a classic headache description

All those kinds of things need to be looked at in the context of taking a good headache history. If I hear from a patient: the headaches start in the back of my head, it shoots up, and sometimes it goes behind my eye – the first thing I think about is occipital neuralgia. That’s in fact a classic description for occipital neuralgia. 

A little side story. I was once at a conference, and I was talking about occipital neuralgia. A woman who had a brain injury and chronic migraines stood up impulsively and said: “My God, that’s my headache!”. I asked: “Do you mind if I come over there?” And I went, like midway back into the audience, and I stuck my finger in the back of her head and pushed on the occipital nerve. And she nearly went up to the ceiling. 

Nobody had found that before. So, this is a very treatable condition that this lady went years without a diagnosis for. She heard my description and said: that’s my headache. Some of these things are pretty classic in terms of their presentation. 

Post-concussion syndrome care

It belabors the point about the need to take time with patients. 

Managed care

We have a joke here in the United States about ‘managed care’. Have you heard of that term? Managed care is sort of an insurance company approach to cost savings. But the physicians who don’t like it, say it really means: we can’t manage, they don’t care. It may not mean much outside the American context, but… 

[14:12 Melanie] I got the idea. 

Post-concussion patients need longer consultations

[14:13 Dr. Zasler] Mine is: the way medicine is going these days, physicians are pushed to produce and make money and patient care tends to suffer in most clinical contexts where there’s corporate oversight, and the push to produce and generate revenue. 

So there’s less time spent with patients, your kind of case and other people who’ve had post-concussive disorders or more severe brain injuries. You can’t take 5-10 minutes and keep justice to the kinds of things that need to be discussed, or examined or followed up on.

[15:03 Melanie] It’s way too complex.

Integral brain injury care  

[15:05 Dr. Zasler] Right. You know, I don’t know if the expression is in Dutch, but have you heard the expression: hammers see nails?

[15:14 Melanie] No. I learn something new every time.

[15:18 Dr. Zasler] So hammer see nails simply means: you see relative to your perspective. So a surgeon sees surgical issues. A psychiatrist sees mental health issues.

[15:32 Melanie] Now I get it. I think we have something similar. Yeah.

[15:36 Dr. Zasler] So my point is: you can’t be a hammer. You have to be much more holistic and understand all the different variability and contributors to how these injuries – and it’s not just the brain injury – but how these traumatic events affect the individual.

Traumatic brain injury patient examination

[16:02 Melanie] I think that’s the main thing that, from my perspective, most people who have lingering symptoms, and a lingering headache… Or even: the headache that is the most prominent symptom that they have remaining from concussion or other brain injuries. But I mostly speak with people with post-concussion syndrome.

Post-concussion headache is the most common symptom

[16:23 Dr. Zasler] Sure, and that’s by far the highest incidence of physical symptoms amongst all physical symptoms that occur after concussion.

[16:33 Melanie] Yeah. They have been to chiropractors, they have been to functional neurologists, they have been…. Well, the list is so long what everybody spends their money on. But still, they aren’t helped: they still have these headaches. And sometimes it feels to a lot of them like Pandora’s box, right? Nobody is able to help me.

Holistic concussion care is needed

[16:58 Dr. Zasler] You can’t look at the patient like this, whether it’s a headache or anything else for that matter.

[17:03 Melanie] Exactly. Yes. And that is, is that something that you do? So if the trouble doesn’t seem to be superficially physical, but it could be biological, or hormones, or psychological, for example. How do you proceed if you can’t use your hands?

[17:29 Dr. Zasler] I’m sorry, I always want to use my hands, because touching is part of a good exam. But are you asking in the context of: if you don’t find physical exam abnormalities that explain the pain?

Examine the whole person

[17:44 Melanie] Exactly. Do you, for example, do a test of hormone levels? Or do you have a psychologist who’s helping you, for example? How do you approach that?

[17:54 Dr. Zasler] I’m pretty weird… When I say weird, I mean: I’m atypical in terms of some of the testing that I do. In terms of looking at how people are coping with pain, how people are doing psychologically in terms of testing for anxiety, depression, and PTSD. So I really try to look, as I said, at the whole person and take those things into consideration in the context of any assessment, not just a headache assessment.

Concussion Care Clinic Virginia

[18:32 Melanie] Could you tell us a little bit more about your clinic, where can people find you?

Outpatient practice

[18:38 Dr. Zasler] My outpatient practice at Concussion Care Clinic in Virginia, is an outpatient practice. I have a few practitioners who work with me; it’s not a big place. It’s a small clinic, kind of ‘boutique medicine’ as we say in the United States. I have a neuro optometrist, a neuro endocrinologist and a physical therapist who work with me very closely. 

Brain injury specialists network

It’s really focused on good quality assessment and comprehensive management. I have a network of clinicians that we work with outside of the clinic, all of whom I’ve worked with for many years. They have lots of experience dealing with different kinds of issues associated with brain injury, whether it’s neurosurgeons, neuro otologists, audiologists, etc. 

The emphasis in my clinic is on transdisciplinary care, holistic care, and taking the time that’s needed with patients to really try and do as good a job as possible. 

Thanking Dr. Zasler

[20:02 Melanie] Thank you so much for sharing your time and your experience. And it’s been lovely talking with you. It feels like a meeting of minds.

[20:13 Dr. Zasler] It was nice hearing your story and your outcome, and how hope and motivation were key to that which I think is a good topic for another discussion.

[20:23 Melanie] Yes, it will be: we will have plenty to talk about. 

What do you take away?

[20:28 Melanie] Now, I would love to hear from you. What do you take away from this episode? Is there something that you can apply to your life right away? Head on over to lifeyana.com and leave your comment now. 

And if you want to hear and read more Concussion Stories, actionable steps and inspiration, be sure to subscribe to the Lifeyana email list while you’re there, so that you never miss out on new materials we constantly make for you. If you want to support this podcast, head on over to www.patreon.com/concussionstories.

Thank you for listening to this Concussion Stories episode by Lifeyana. May you be well and may you be happy.