NR603 Week 1: Comparison of Migraine Headache and Post-Concussive Syndrome

Introduction This discussion focuses on comparing and contrasting migraine headaches and Post-Concussive Syndrome (PCS). PCS encompasses a broad range of signs and symptoms that typically occur after a head injury, while a migraine is a clinical condition that generally arises without any preceding head trauma. Despite these differences, both conditions can present with similar signs and symptoms, making a thorough history and physical examination crucial for an accurate diagnosis.

Presentation Patients with PCS usually have a history of head injury, which can vary in severity and may be recent, distant, or even unrecognized in cases of amnesia. PCS symptoms can be categorized into three groups:

• Somatic Symptoms: These include headaches, fatigue, photophobia, phonophobia, double vision, nausea, vomiting, and disturbed sleep patterns such as insomnia.
• Cognitive Symptoms: Difficulty concentrating, memory impairments, attention deficits, and mental fatigue are common cognitive manifestations of PCS.
• Affective Symptoms: Depression, emotional instability, anxiety, and mood swings, which were not present before the injury, are typical affective symptoms associated with PCS (March & Karakashian, 2018).

Patients presenting with a migraine may exhibit some of the same symptoms as those with PCS, but there are notable differences. Migraines rarely occur after a head injury, although it is possible. Migraines are generally classified into three types: without aura, with aura, and prodromal.

• Without Aura: This type typically involves unilateral head pain, nausea, vomiting, dizziness, photophobia, phonophobia, insomnia, fatigue, and occasionally clumsiness. Physical signs can include both bradycardia and tachycardia, as well as hypertension and hypotension, which may also be observed in head injury patients.
• With Aura: This type presents with the same symptoms as the “without aura” type but includes visual disturbances such as blurred vision, tracers, blind spots, and tunnel vision.
• Prodromal Migraine: This type differs significantly, with symptoms including a stiff neck, photophobia, food cravings, depression, hyperactivity, hypersomnia, thirst, diarrhea, anorexia, and constipation (Schub & Parks-Chapman, 2018).

Pathophysiology The pathophysiology of PCS is complex and primarily occurs at the cellular level, as neuroimaging studies often show no obvious structural brain damage. PCS is generally considered a result of mild traumatic brain injury. After a head injury, metabolic reactions in the brain become atypical. For instance, while blood glucose levels may rise, the brain consumes less glucose and significantly more oxygen than normal. These atypical cellular processes have led researchers to develop more effective treatments for PCS (Wright et al., 2013).

The pathophysiology of migraines is also not fully understood, though it is thought to involve the trigeminal vascular system, which controls neurogenic inflammation, meningeal vasodilation, and central sensitization of the brain. Low levels of serotonin may induce vasodilation on the brain’s surface, but this connection remains poorly understood. Various triggers, such as pregnancy, menstruation, hypertension, strong odors, tobacco use, motion sickness, sleep deprivation, and certain foods (e.g., red wine, chocolate, nuts), have been reported to provoke migraines (Schub & Parks-Chapman, 2018).

Assessment and Diagnosis For both conditions, the healthcare provider should conduct a thorough history and physical examination. A recent head injury history is more indicative of PCS, while a history of severe headaches without physical injury points towards migraines. The patient should be questioned about the headache’s location and severity, as migraines are typically unilateral with severe, debilitating pain. Although there is no specific lab test for migraines, serum and urine tests can help rule out infection, drug abuse, or organ failure. Subarachnoid hematomas can present with severe headaches and may be diagnosed with cerebral spinal fluid analysis. Migraines occurring fewer than 15 times a month over three months are considered episodic, while those occurring more than 15 times a month over three consecutive months are classified as chronic (Schub & Parks-Chapman, 2018).

PCS typically presents after a head injury, but not all head injuries are readily recognized or remembered, especially in cases involving multiple injuries, such as motor vehicle accidents. Providers should perform a detailed history and physical examination, establishing a cognitive baseline with input from family members or friends. Key information includes the duration, severity, and progression of symptoms, as well as any impact on daily life and work. Head injury screening tools, such as the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), assess the severity of PCS symptoms, scoring them on a scale from 0 (no symptoms) to 4 (severe problem). While a higher score suggests the presence of PCS, there is no definitive cutoff for diagnosis (Thomas, Skilbeck, Cannan & Slatyer, 2018).

Treatment Migraine treatment often yields good results, while effective treatments for PCS are more limited. Migraine management includes symptomatic relief using triptan agents, such as sumatriptan (100 mg orally, with a repeat dose in two hours if needed, up to 200 mg per day) (Epocrates, 2018). Non-narcotic analgesics like aspirin and ibuprofen, along with antiemetics like ondansetron and metoclopramide, may also be used. Prophylactic medications, including beta blockers, tricyclic antidepressants, and anticonvulsants, are effective for chronic migraines (Schub & Parks-Chapman, 2018).

For PCS, preventing further head injuries is paramount. Studies show that multiple head injuries within a short time can significantly prolong recovery and exacerbate PCS symptoms. This is particularly relevant for athletes and fall-risk patients. Athletes, in particular, may seek to continue playing, risking additional head injuries and delayed healing (Giza et al., 2017).

PCS treatment focuses on pain relief and monitoring for complications. Establishing a pre-injury baseline of physical and mental abilities aids in assessing cognitive changes. Pain management may include both narcotic and non-narcotic analgesics. Long-term effects of PCS, such as depression, anxiety, and insomnia, should be anticipated and treated appropriately. Rehabilitation services, including physical, psychiatric, and occupational therapy, should be encouraged. Educating caregivers on what to expect and when to seek medical care is crucial. Providing emotional support and referring patients to a higher level of care when necessary is also important.

Metabolic changes following a head injury, such as serum hyperglycemia, have been well-documented. Traditionally, hyperglycemia after a head injury was treated with intravenous insulin to maintain normal glucose levels. However, recent research suggests that this hyperglycemic state is a therapeutic response and should not be altered with insulin. Tight glycemic control with insulin has been found to increase cerebral glucose uptake, potentially leading to a cerebral metabolic crisis. While the mechanism behind this crisis is not fully understood, hyperglycemia may play a therapeutic role in traumatic brain injuries (Vespa et al., 2012).

The clinical advice to “sit it out” for athletes with possible head injuries is generally supported, but recent studies suggest that physical inactivity within the first seven days post-injury neither harms nor improves outcomes. However, mental inactivity during this period has been found to prolong healing. Cognitive exercises and mental stimulation, such as reading, writing, and engaging in conversations, are beneficial for patients with mild head injuries (Giza et al., 2017).