1. Brain Injury
  2. Guidelines
  3. Section 2
  4. Assessment and Rehabilitation of Brain Injury Sequelae

P. Pain and Headaches

Persons with traumatic brain injury (TBI) can suffer from pain and headaches immediately following their injury and throughout the period of recovery. Pain has a negative effect on cognitive recovery, sleep, mood, anxiety and can precipitate challenging behaviours. Some individuals can be managed with non-pharmacological strategies like cognitive behavioural counselling and biofeedback. Some individuals have pain related to the nerve injury (neuropathic pain) which requires treatments with different types of analgesic medications.

Clinicians should develop competency in comprehensive assessment of pain. Patients should be routinely asked about the nature and severity of pain. Ideally, brain injury services should have easy access to specialists in pain management.

Indicators exemples

  • Proportion of individuals with TBI who benefitted from a pain management protocol.
  • Proportion of individuals with TBI and post-traumatic headaches who received cognitive behavioural therapy (CBT).

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

Patient and Family Resource:

Other Resources:

Persons with TBI can suffer from pain and headaches immediately following their injury and throughout the period of recovery. Moreover delay in cognitive recovery, sleep disorders and fatigue, elevated levels of anxiety and depression and post-traumatic stress disorder are issues associated with pain (Dobscha et al., 2009; Hoffman et al., 2007). A lack of recognition or diagnosis of pain can lead to an increase in aggression and agitation, or an inability to participate or benefit from rehabilitation (Ivanhoe & Hartman, 2004; Sherman, Goldberg, & Bell, 2006); therefore, early detection and management of pain is important to minimize the use of maladaptive coping strategies and maximize an individual’s recovery. Several treatments have shown to be effective such as cognitive behavioral therapy, biofeedback and medication. Biofeedback, relaxation, meditation and cognitive behavioural therapy are often considered the standard of behavioural treatments for pain (Branca & Lake, 2004).

Biofeedback (thermal and EMG) as an intervention for post-traumatic headaches was studied by Tatrow, Blanchard, and Silverman (2003) in combination with progressive muscle relaxation. Improvements in post-traumatic headaches were seen for the majority of participants; four participants had a clinically significant improvement in headache activity, six had some improvement, two had minor improvement and two worsened (Tatrow et al., 2003). Cognitive behavioural therapy has also been shown to be effective in reducing post-traumatic headaches. In a pre-post study, Gurr and Coetzer (2005) investigated 20 participants with a mild to severe TBI. Following cognitive behavioural therapy, headache intensity and headache frequency significantly decreased (p=0.004). Headache disability also decreased as measured by the Headache Disability Inventory (p=0.001) and the Headaches Needs Assessment (p=0.02) (Gurr & Coetzer, 2005).

REFERENCES

Branca, B., & Lake, A. E. (2004). Psychological and neuropsychological integration in multidisciplinary pain management after TBI. J Head Trauma Rehabil, 19(1), 40-57.

Dobscha, S. K., Clark, M. E., Morasco, B. J., Freeman, M., Campbell, R., & Helfand, M. (2009). Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain Med, 10(7), 1200-1217

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). https://erabi.ca/.

Gurr, B., & Coetzer, B. R. (2005). The effectiveness of cognitive-behavioural therapy for post-traumatic headaches. Brain Inj, 19(7), 481-491.

Hoffman, J. M., Pagulayan, K. F., Zawaideh, N., Dikmen, S., Temkin, N., & Bell, K. R. (2007). Understanding pain after traumatic brain injury: impact on community participation. Am J Phys Med Rehabil, 86(12), 962-969.

Ivanhoe, C. B., & Hartman, E. T. (2004). Clinical caveats on medical assessment and treatment of pain after TBI. J Head Trauma Rehabil, 19(1), 29-39.

Sherman, K. B., Goldberg, M., & Bell, K. R. (2006). Traumatic brain injury and pain. Phys Med Rehabil Clin N Am, 17(2), 473-490, viii.

Tatrow, K., Blanchard, E. B., & Silverman, D. J. (2003). Posttraumatic headache: an exploratory treatment study. Appl Psychophysiol Biofeedback, 28(4), 267-278.

P

Priority

F

Fundamental

N

New Level of Evidence

A

B

C


P.1.1

C

Pain should always be considered if a person with traumatic brain injury presents agitation or has cognitive/communication issues, non-verbal psychomotor restlessness or worsening spasticity, with particular attention paid to non-verbal signs of pain (e.g., grimacing). 

(ABIKUS 2007, G73, p. 27)

Suggested tool: Algorithm for Agitation and Aggression

Last Updated June 2023

P.1.2

N

C

Individuals experiencing persistent pain following brain injury should be examined for musculoskeletal, visceral, central and peripheral nervous system causes of pain by a clinician experienced in neurological and musculoskeletal examinations to determine the likely cause of pain. 

Last Updated June 2023

P.1.3

N

C

In the absence of specific evidence on headaches related to moderate to severe acquired brain injury, recommendations for the individuals with mild traumatic brain injury can be extended as consensus level evidence.

REFERENCE:

Last Updated June 2023

P.1.4

N

C

When assessing persons with communication difficulties post traumatic brain injury for pain, collect extended history from all available sources and conduct a head-to-toe assessment, which will guide further investigations and treatment decisions. 

NOTE: Some individuals with moderate to severe brain injury will be able to provide their own medical history. When this is not possible, family and care providers can be consulted to provide collateral information and report on the duration, frequency and intensity of pain.

Last Updated June 2023



P.2.1

P

N

C

Rehabilitation programs for individuals with acquired brain injury should have protocols in place for the assessment and management of pain. Pain characteristics, associated functional impact, response to treatment, and adverse treatment reactions should be monitored closely and reassessed at regular intervals. This information should guide decision making regarding the need for treatment escalation, de-escalation, or withdrawal.
 
Consideration should be given to concurrent mental health difficulties which have the potential to impact one’s experience of pain.

(Adapted from ABIKUS 2007, G74, p. 27)

Last Updated June 2023

P.2.2

N

C

Education should be provided to healthcare professionals and caregivers regarding hypersensitivity, neurogenic pain, as well as how best to assist with the movement of a paretic limb during transfers and other activities. 

(Adapted from ABIKUS 2007, G74, p. 27)

Last Updated June 2023

P.2.3

P

B

Cognitive behavioural therapy (CBT) can be considered to reduce pain symptoms and improve coping and function while living with the symptoms in individuals with post-traumatic headaches.  

REFERENCE:

Last Updated June 2023

P.2.4

B

Biofeedback can be considered to reduce pain symptoms in individuals with post-traumatic headaches. 

REFERENCE:

Last Updated June 2023

P.2.5

P

C

Pregabalin may be considered for reducing central neuropathic pain caused by injuries to the brain or spinal column. 

NOTE: Given the potential for adverse reactions to these medicines, non-pharmacologic treatment strategies should be pursued and optimized prior to initiating pharmacotherapy. Funding for non-pharmacologic therapy should be sought wherever possible to minimize reliance on pharmacological therapy. 

Suggested tool: Health Canada Indications of Use

REFERENCE:

Last Updated June 2023

P.2.6

N

C

The primary care provider should take a comprehensive headache history (see Table 6.1) in order to identify the headache subtype(s) that most closely resemble(s) the patient’s symptoms.

REFERENCE:

Last Updated June 2023

P.2.7

N

C

Primary care providers and healthcare professionals treating patients’ headaches should perform neurological and musculoskeletal examinations including the cervical spine and vestibular system.

REFERENCE:

Last Updated June 2023

P.2.8

N

C

Care providers should establish the degree of headache-related disability (taking a biopsychosocial approach) to assist the development of a treatment plan and subsequent monitoring of the response to treatment. (i.e., non-pharmacological and/or pharmacological).

REFERENCE:

Last Updated June 2023

P.2.9

N

C

Personal, environmental, work-related, school-related, and physical factors such as neck pain should be identified and addressed as potential headache contributors.

REFERENCE:

Last Updated June 2023

P.2.10

N

C

Patients with functionally limiting or atypical headache symptoms should be considered for referral to an interdisciplinary concussion clinic, neurologist or headache clinic.

REFERENCE:

Last Updated June 2023

P.2.11

N

C

Education should be provided to the patient on the lifestyle strategies (see Appendix 6.6 and Table 6.2) useful for minimizing headache occurrence and/or decreasing the impact of headaches when they occur (i.e., maintaining consistent bed and wake times, consuming consistent meals with no skipped or delayed meals, good hydration, regular low-intensity cardiovascular exercise, use of relaxation, stress-management, and mindfulness-based strategies).

REFERENCE:

Last Updated June 2023

P.2.12

N

C

All patients with post-traumatic headache should be encouraged to maintain an accurate headache and medication diary (see Appendix 6.4) and to bring it to every follow-up visit with their clinician.

REFERENCE:

Last Updated June 2023

P.2.13

N

C

Patients may use acute headache medications to try to reduce the severity, duration, and disability associated with individual headache attacks. The use of these medications needs to be limited in frequency to minimize the potential for medication overuse (rebound) headache:

  1. Over the counter analgesics (e.g., acetaminophen, ibuprofen, acetylsalicylic acid, naproxen, effervescent diclofenac) should be used less than fifteen days per month.
  2. Combination analgesics (i.e., with caffeine or codeine) and migraine-specific triptans should be used less than 10 days per month.

REFERENCE:

Last Updated June 2023

P.2.14

N

C

Migraine-specific acute therapies should be trialed when non-specific acute therapies are incompletely effective for migrainous-type post-traumatic headaches. Triptans can be used for migrainous-type headaches less than 10 days per month.

REFERENCE:

Last Updated June 2023

P.2.15

N

C

Due to a multiplicity of potential adverse consequences (addiction, dependency, rebound headache), narcotic analgesics should be avoided or restricted solely to “rescue therapy” for acute attacks when other first- and second-line therapies fail or are contraindicated. When utilized, narcotics should be stringently restricted to no more than twice weekly.

REFERENCE:

Last Updated June 2023

P.2.16

N

C

When headaches occur too frequently (e.g., more than 10 days per month) or are functionally disabling, prophylactic therapy should be considered.

REFERENCE:

Last Updated June 2023

P.2.17

N

C

Post-traumatic headaches may be unresponsive to conventional treatments. If headaches remain inadequately controlled, referral to a neurologist, headache specialist, or interdisciplinary concussion clinic is recommended.

REFERENCE:

Last Updated June 2023