Post-traumatic Headache: What to Do When Nutraceutical Therapy Has Not Worked
When post-traumatic headache persists despite a preventive nutraceutical and supplement trial, a structured next step is needed. This protocol addresses patients who have not reached the target headache reduction following that initial approach.
An initial course of preventive nutraceutical/supplement therapy — riboflavin, magnesium, and melatonin where clinically indicated — did not achieve the target: reduction or resolution of headache at the 2-week reassessment, or across the full 6–8 week preventive trial.
When nutraceuticals have not been sufficient, prescription preventive therapy — selected case-by-case based on headache phenotype and tolerability — together with non-pharmacologic interventions, forms the basis of the next step; the complete selection criteria and further options for persistent or refractory cases are detailed in the full protocol.
At least 50% reduction in headache frequency (headache days).
References
DOI: 10.1111/head.14795DigitalPrescription preventive therapies (e.g., amitriptyline, topiramate, or propranolol) should be chosen on a case-by-case basis considering side-effects and headache phenotype, starting 4–6 weeks post-injury if headaches are not improving and are occurring more than 1–2 days/week, impact function, or both.
Additional therapies including onabotulinumtoxinA and CGRP-targeted therapies do not have direct evidence in children with PTH but based on experience of our group may be considered in youth with refractory PPTH.
Non-pharmacologic interventions including cervico-vestibular therapy and behavioral interventions, such as CBT, should be considered in PTH management based on clinical assessment.
Assessed HA outcomes when amitriptyline was started 1-month post-injury and continued for median of 4 months; 82% reported >50% reduction in number of HA days and side-effects (primarily sedation) were reported in 33%.
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