How should I manage a patient with concussion symptoms who is experiencing persistent headaches after the initial injury?

Management of a patient with concussion symptoms experiencing persistent headaches following the initial injury should begin with reassurance and education about the expected recovery process, emphasizing gradual return to normal activities and maintaining a regular schedule of activity and sleep to support recovery ¹. Persistent headaches after concussion are part of post-concussion syndrome, which may include other symptoms such as dizziness, cognitive difficulties, and sensitivity to light or noise ².

It is important to assess for and manage any comorbidities that may complicate recovery, such as anxiety, depression, or chronic pain, as mood symptoms are common after traumatic brain injury and can exacerbate headache symptoms ¹. Referral for cognitive behavioural therapy (CBT) may be appropriate if mood or anxiety symptoms persist beyond three months ¹.

Clinical evaluation should exclude other causes of persistent headaches, including neurological complications or hypopituitarism, which can present with non-specific symptoms after head injury; specialist referral to neurology or neuroendocrinology should be considered if focal neurological signs or endocrine dysfunction are suspected ¹,².

Pharmacological treatment of post-traumatic headache should be individualized, often mirroring treatment approaches used in primary headache disorders, but careful consideration is needed due to the concussion context. Recent expert consensus from the American Headache Society highlights that treatment may include analgesics, migraine-specific therapies, and preventive medications tailored to the headache phenotype, with attention to avoiding medication overuse and addressing comorbidities (Patterson Gentile et al., 2024).

Follow-up and support are essential, including providing written information and access to support organizations, and monitoring for any worsening or new symptoms that would necessitate urgent medical review ¹. Return to high-risk activities, including sports, should only occur after complete resolution of symptoms and completion of a graduated return-to-play protocol ¹.