Management of Post-Concussion Headache

Critical First Step: Address Medication-Overuse Headache Risk

The American Academy of Neurology recommends that patients with a history of chronic headache use, such as this patient with 5 years of regular naproxen use, are at extremely high risk for medication-overuse headache (MOH), which occurs when acute medications are used ≥15 days/month for NSAIDs 1, 2
The International Headache Society notes that MOH paradoxically increases headache frequency and can lead to daily headaches, creating a vicious cycle that reduces responsiveness to all acute treatments 1, 2
The American Headache Society recommends abrupt withdrawal of the overused medication, accompanied by patient education about the mechanism of MOH, as the preferred approach to address MOH 1

The American College of Emergency Physicians suggests switching to acetaminophen 1000 mg as first-line acute treatment for post-concussion headache, as NSAIDs like naproxen should be avoided in the acute concussion period due to theoretical bleeding concerns 2, 3
The American Academy of Neurology recommends strictly limiting acetaminophen to no more than 2 days per week (10 days per month) to prevent recurrence of medication-overuse headache 2, 3

The American Headache Society recommends initiating preventive therapy immediately, rather than relying solely on acute treatment, for patients with a 5-year history of chronic headache requiring daily or near-daily medication 1, 4
The National Institute of Neurological Disorders and Stroke suggests amitriptyline 30-150 mg/day as a preferred first-line agent for patients with mixed migraine and tension-type headache 5, 6, 4
The American Academy of Neurology notes that propranolol 80-240 mg/day has consistent evidence for efficacy in migraine prevention and may be preferred if the patient has no contraindications (asthma, depression, fatigue) 5, 6

The American Headache Society recommends continuing preventive therapy for at least 6 months once sustained efficacy is achieved with no substantial adverse effects 1
The International Headache Society suggests that efficacy requires 2-3 months for oral agents before determining success or failure 2

The American Academy of Neurology recommends screening for and addressing obesity, caffeine overuse, obstructive sleep apnea, psychiatric comorbidities (anxiety, depression), and stress 4

The Centers for Disease Control and Prevention suggests ruling out red flags requiring urgent neuroimaging: thunderclap headache, progressive worsening, focal neurologic deficits, altered mental status, or fever with neck stiffness 2
The American College of Emergency Physicians notes that post-concussion headaches typically resolve within 3 months; if headaches persist beyond this timeframe, reassess for other primary headache disorders 4
The American Academy of Neurology recommends avoiding opioids and butalbital-containing compounds entirely, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 2

The American Headache Society recommends reassessing in 2-4 weeks to evaluate withdrawal symptoms, adherence to frequency limits, and tolerability of preventive therapy 1
The National Institute of Neurological Disorders and Stroke suggests using a headache diary to track frequency, severity, and medication use, as patients often underreport milder headaches 4