Increasingly we are seeing children in the days to weeks following traumatic brain injuries in the Pediatric Emergency Department. Most often these children present with persistent headaches. After a discussion with he family about how neuroimaging is unlikely to benefit the majority of patients it is time to discuss treatment considerations.*

*Side Note: In my experience it is more common than you’d think to see a patient for the first time in the ED several days after the TBI – during this initial visit parents are still invariably worried about intracranial hemorrhage or other life threatening concerns. Discuss the literature with them as warranted.

What follows is a quick hit style discussion of a potential treatment plan.

  • Most post traumatic headaches (PTH) closely resemble other headache disorders like tension headaches and migraines without aura
  • Though persistent PTH are defined by three months of symptoms many patients present to the ED long before that. See Babcock et al. and Barlow et al.
  • Kids more at risk for acute PTH ((within 7 days of the injury) are hard to suss out. Perhaps younger (5-12 year olds) in more moderate or severe TBI but adolescents in mild TBI.
  • Make sure to discuss activity restrictions both before and after pharmacologic treatment.
  • As an outpatient it is recommended that patients stay adequately hydrated on non-caffeinated beverages and to use NSAIDs no more than 3 doses/week and no more than 2 per day in order to avoid analgesic overuse.
  • Second line outpatient may be triptans – but note they are more likely to be helpful the earlier you take them.
  • Emergency Department therapy is similar to migraines in some respects, and at least based on early reports may help more than half of all patients. Potential options include:

    An NSAID + ondansetron if you wish to try oral therapy first

    The combo of prochlorperazine/metoclopramide +/- ketorolac and IV fluids

    IV valproate if the initial IV therapy helps, but not enough

    Please see my Why We Do What We Do on antiemetics in migraines for a whole lot more.

  • Some physicians will give a dose of a steroid (methylprednisolone or dexamethasone) if the headache is abated in order to potentially reduce the risk of recurrence. This has been studied in migraines in adult, but there is no good literature in PTH to support this practice at this time.
  • I would not start preventative medicines in the ED (amitriptyline, anti-epileptics etc,.). Furthermore, sending a patient home without specific followup (sports medicine, neurology, rehab) is suboptimal care.