Acute and Chronic Management of Posttraumatic Headache in Children

A Systemic Review

Carlyn Patterson Gentile MD, PhD; Ryan Shah BS; Samantha L. Irwin MSc, MB, BCh, BAO, FRCPC; Kaitlin Greene MD; Christina L. Szperka MD, MSCE, FAHS


Headache. 2021;61(10):1475-1492. 

In This Article

Abstract and Introduction


Objectives: The goal of this paper is to provide a compilation of the evidence for the treatment of posttraumatic headache (PTH) in the pediatric population. Headache features and timing of therapy were considered.

Background: Headache is the most common symptom following mild traumatic brain injury (mTBI), affecting more than 80% of children and adolescents. It is unclear whether treatment for PTH should be tailored based on headache characteristics, particularly the presence of migraine features, and/or chronicity of the headache.

Methods: Systematic literature searches of PubMed, Embase, Scopus, and Cochrane databases (1985–2021, limited to English) were performed, and key characteristics of included studies were entered into RedCAP® (Prospero ID CRD42020198703). Articles and conference abstracts that described randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series were included. Participants included youth under 18 years of age with acute (<3 months) and persistent (≥3 months) PTH. Studies that commented on headache improvement in response to therapy were included.

Results: Twenty-seven unique studies met criteria for inclusion describing abortive pharmacologic therapies (9), preventative pharmacotherapies (5), neuromodulation (1), procedures (5), physical therapy and exercise (6), and behavioral therapy (2). Five RCTs were identified. Studies that focused on abortive pharmacotherapies were completed in the first 2 weeks post-mTBI, whereas other treatment modalities focused on outcomes 1 month to over 1-year post-injury. Few studies reported on migrainous features (7), personal history of migraine (7), or family history of migraine (3).

Conclusions: There is limited evidence on the timing and types of therapies that are effective for treating PTH in the pediatric population. Prospective studies that account for headache characteristics and thoughtfully address the timing of therapies and outcome measurement are needed.


Headache is the most common symptom following mild traumatic brain injury (mTBI). Posttraumatic headache (PTH) is reported by more than 80% percent of children and adolescents.[1] Eight percent of children who have had head trauma will have headache that persists beyond 3 months,[2] fulfilling International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria for persistent headache attributed to trauma or injury to the head and/or neck, here termed persistent PTH.[3] Migraine is the most common phenotype of PTH in children and is seen in up to 55% of cases.[4] Prior work in children suggests that PTH with migrainous features[5–9] or a personal or family history of migraine is associated with prolonged recovery.[5,6] The PTH "migraine phenotype" may represent a subset of patients who would benefit from more directed headache management.[9] This is of particular interest in the pediatric population due to the high incidence of migraine in the teenage years and early twenties.[10] In this age group, individuals prone to developing migraine may not have exhibited symptoms yet and mTBI may act as a triggering event for migraine.[11] Three reviews have focused on PTH treatment in the past decade.[12–14] Although informative, only one looked exclusively at children,[14] and none reported the presence of migrainous features.

The objective of this review was to identify randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series of youth (<18 years) with acute or persistent PTH that assessed the effect of pharmacologic, procedural, and non-pharmacologic treatments on headache improvement. Headache characteristics, including presence of migrainous features, and the timing of therapies were evaluated when available. This review identifies gaps in knowledge regarding the management of pediatric PTH to help guide future treatment trials.