THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI

1. THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI Olli Tenovuo MD, PhD Department of Neurology University of Turku, Finland

2. Background • TBI has long been an underestimated area in clinical medicine, especially in regard to its significance for public health. • There are still major gaps in our knowledge of some very central issues. One of these is the co-occurrence of chronic pain and TBI.

3. Background • The co-morbidity of chronic pain and TBI is highly complex → clear diagnostic and treatment guidelines, applicable at an individual level, cannot be expected. • This should not hamper progression in research and clinical care of these patients.

4. The spectrum Chronic pain syndromes after TBI • chronic headache • facial pain • neck pain • shoulder pain • pain in the extremities (painful hemisyndrome) • rare pain syndromes

5. Contents of the presentation A clinical and diagnosticallyorientedreview of the mostimportant pain problemsafter TBI, especially • chronicheadache • chronicfacial pain • chronicneck pain • central pain

6. Chronicposttraumaticheadache The ICHD-II classification (2004): • Headache develops within 7 days after (mild - severe) head injury • Headache persists > 3 months after the injury

7. The ICHD-II classification 5.2.2 Chronic posttraumatic headache attributed to mild head injury • A. Headache, no typical characteristics known, fulfilling criteria C and D • B. Head trauma with at least one of the following: • 1. Either no loss of consciousness or loss of consciousness for < 30 mins duration • 2. GCS ≥ 13 • 3. Symptoms and/or signs diagnostic of concussion • C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma • D. Headache persists for 3 months after head trauma

8. Problems in definition • The concepts of headinjury and braininjuryhavebeenmixed • The definition of mild HI lacks the duration of posttraumatic amnesia as a criteria • ” within 7 days or after regaining consciousness” – in mild injury??? • “persists for 3 months” – but how often does it have to occur?

9. The ICHD-II classification 5.2.1 Chronic posttraumatic headache attributed to moderate or severe head injury • A. Headache, no typical characteristics known, fulfilling criteria C and D • B. Head trauma with at least one of the following: • 1. Loss of consciousness for > 30 mins • 2. GCS < 13 • 3. Posttraumatic amnesia for > 48 hrs • 4. Imaging demonstration of a traumatic brain lesion (cerebral hematoma, intracerebral and/or • subarachnoid hemorrhage, brain contusion, and/or skull fracture) • C. Headache develops within 7 days after head trauma or after regaining consciousness after head trauma • D. Headache persists for 3 months after head trauma

10. Problems in definition • The concepts of headinjury and braininjuryhavebeenmixed • PTA > 48 hrs – whythislimit?? • ”Imagingdemonstration of a traumaticbrainlesion” – Is skullfracture a brainlesion? Axonalinjuryoroedemaarenotbrainlesions? • ”Within 7 days…” – whatabout PTA > 7 days? • ”Persists for 3 months” – at whichfrequency?

11. And furthercritique… • Whyshould the TBI severitybeincluded in the criteria? • The timelimitsareartificial and donotbase on anyevidence • The role of frequentextracerebralcauses (especiallyconcomitantneckinjury) hasbeenneglected - should the research of posttraumaticheadachereallybebased on thesecriteria?

12. An alternative definition Chronicposttraumaticheadache = Headachethatusuallydevelopswithin 3 monthsafter an injury to the headorneck and is notbetterexplainedwithnon-traumaticcausesafter a thoroughclinicalhistory and examination, includingappropriateimaging and laboratorystudies. Afterdeveloping, the headacheshouldoccur at leastweekly for at least 6 months. A new official definition for clinical and researchpurposesshouldbe made urgently, including the definition for varioussubtypes.

13. How common is chronicposttraumaticheadache? • The figureshavebeenveryvariable, depending on the studypopulation, protocol and headachecriteria • The available data suggest that headache follows head injury in 50 to 80% of patients acutely and continues in 20 to 30% 1 to 2 years later (Couch JR, Lipton RB, Stewart WF, Scher AI. Head or neck injury increases the risk of chronic daily headache. A population-based study. Neurology® 2007;69:1169–1177)

14. Subacutely… • 100 sequential admissions with mild TBI (as defined by American Congress of Rehabilitation Medicine, 1993), and 100 matched minor injury controls with nondeceleration injuries • 15.34% of those with minor head injury continued to complain of persistent posttraumatic headache at 3 months compared to 2.2% of the minor injury controls (Faux S, Sheedy J. A Prospective Controlled Study in the Prevalence of Posttraumatic Headache Following Mild Traumatic Brain Injury. Pain Med 2008, Epub ahead of print)

15. And in the long run… • A Norwegianstudycompared the prevalenceof headache in a cohort with previous hospitalization for head injury (22 yrs earlier) and matched controls • In multivariateconditional regression analysis among 192 responding case/control pairs, there was no evidence of higher odds of headache > 1 day per month (odds ratio, OR 1.04, 95% CI 0.56–1.92, p = 0.90) compared with controls. (Nestvold K, Staven M. Headache 22 Years after Hospitalization for Head Injury Compared with Matched Community Controls. Neuroepidemiology 2007;29:113–120)

16. The type of posttraumaticheadache Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristicsand treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.

17. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristicsand treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.

18. The profile of posttraumaticheadache Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristicsand treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627.

19. Chronicposttraumaticheadache Periodic / daily Episodic Continuous Cervical / occipital Frontal, frontotemporal, ribbon-like, variable Neck-derivedheadache Withcervicalsigns Withoutcervicalsigns No Analgetics≥ 3 days / week Orofacialdysfunction Psychogenic Visual dysfunction Yes Medicationoveruseheadache Idiopathic Hormonalinsufficiency

20. Chronicepisodicposttraumaticheadache • Migrainous (withmigrainouscharacteristics) • Neuritic (withneuralgicsigns and localization)

21. Chronicperiodicposttraumaticheadache • Muscularsource (withmuscularsigns and localization) • Migrainous (withcharacteristics of prolongedmigraine) • Cervical (withcervicalsigns, precipitatingfactors, cervical / frontallocalization)

22. Someimportantnotes… • The spectrum of acute and subacuteposttraumaticheadaches is muchwider • In a minor but significant portion of patients, the clinical history, examination and consultations reveal no clear causes for the persisting headache. • In many of these, the headache clearly accompanies tiredness or fatigue. Treating a sleep problem or fatigue may offer a relief.

23. Someimportantnotes…continued • The often underdiagnosed post-traumatic hormonal insufficiency may also cause headache, and must be kept in mind as a treatable cause. • Cervicogenicheadachesareunderdiagnosed – suggestivefeatures: • rotatoryinjurymechanism • acuteneck pain and restrictedmovements • weakness, numbness or pain in the extremities • cervical pain and impaired mobility persist for weeks after the injury

24. Someimportantnotes…continued Clinicalsigns of cervicogenicheadache: • asymmetrically impaired cervical mobility • pain or tingling produced by rotation or flexion – extension • local tenderness in palpation of the C I-II vertebrae Further evaluation should preferably happen with functional cervical MRI, which is able to show eventual disruptions of the alar or transverse ligaments

25. Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and impact direction in whiplash injuries: associations with MRI-verified lesions of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005 Nov;22(11):1294-302

26. Chronicneck pain after TBI • Is usuallyaccompaniedbyheadache, at leastintermittently • Maystemfrombonyor soft tissueinjuries • The clinicalassessmentshouldincludedetailedinjuryreconstruction, skilledexamination of the cervicalfunction and neurologicalexamination of the cranialnerves and upperextremities

27. Chronicneck pain after TBI • Sensorydisturbances in the upperextremitiesor C I-II regionshouldraise a suspicion of nerverootinjuryorposttraumaticsyringomyelia • Imaging of traumaticlesions in the cervicalspinerequiresexpertise and normalresultsdonotnecessarilymeannormalanatomy • An experiencedphysiotherapistorspecialist in physicalmedicine is invaluable

28. Chronicfacial pain after TBI Mayhavemultipleaetiologies, such as: • Trigeminalinjury • Orofacialdysfunction • Sinus disturbance • Upper cervicallesions • Orbitallesions • Atypicalfacial pain

29. Irritation to structuresinnervatedby the cervical sensory nerves can activate the trigeminal nucleus along with the trigeminovascular system and result in referred pain to the anterior or frontal aspect of the head