Severe, chronic, continuous, or intermittent headaches lasting several days or weeks appear as the cardinal symptom of several cranial posttraumatic syndromes, separable in each instance from the headache that immediately follows head injury that may be due to scalp laceration, cranial or cerebral contusion, or increased intracranial pressure. These cranial pains are also differentiated from the more mundane postconcussive headaches detailed below. The headache of chronic subdural hematoma is deep seated, dull, steady, mainly unilateral and may be accompanied or followed by drowsiness, confusion, and fluctuating hemiparesis. In acute subdural hematomas, we have been impressed with the positional worsening of pain in some patients after lying down or leaning the head to one side. Tentorial hematomas produce the additional feature of pain in the eye. The head injury that gives rise to a subdural hematoma may have been minor, as described in
Chap. 34, and forgotten by the patient and family. Typically, the headache increases in frequency and severity over several weeks or months. Patients who have received anticoagulation are particularly at risk. Diagnosis is established by CT or MRI.
Chronic headache is certainly a prominent feature of the postconcussion syndrome, comprising dizziness, fatigability, insomnia, nervousness, irritability, and inability to concentrate. This type of headache and associated symptoms, which resemble the tension headache syndrome, are described fully in Chap. 34, “Craniocerebral Trauma.” The International Headache Society has classified persistence in this context as headache for longer than 3 months after injury. The patient with postconcussion syndrome requires supportive therapy in the form of repeated reassurance and explanations of the benign nature of the symptoms, a program of increasing physical activity, and the use of drugs that allay anxiety and depression. The early settlement of litigation, which is often an issue, works to the patient’s advantage.
Tenderness and aching pain sharply localized to the scar of a long previous scalp laceration or surgical incision represent in a different problem and raise the question of a traumatic neuralgia or neuroma. Tender scars from scalp lacerations may be treated by repeated subcutaneous injections of local anesthetics, which also acts as a diagnostic test.
With whiplash injuries of the neck, there may be unilateral or bilateral retroauricular or occipital pain, probably as a result of stretching or tearing of ligaments and muscles at the occipitonuchal junction or of a worsening of a preexisting cervical arthropathy. Much less frequently, cervical intervertebral discs and nerve roots are involved. However, it is questionable if chronic headache and vague neuropsychiatric symptoms can be attributed to whiplash (see Malleson); nevertheless, the International Headache Society retains post whiplash headache as a category, while noting that it has no typical characteristics.
One should also be alert to headache as a sign of carotid artery dissection after head or neck injury.
Headaches of Brain Tumor