Concussion Evaluation:

Not all Headaches are Created Equal


Concussions have become more frequently identified as awareness has increased over the past several years, as reflected in reported concussion numbers and emergency room visits.

In the realm of concussions, headaches are a pervasive issue that require careful consideration. It is all too common to assume that a patient experiencing a headache after a blow to the head is conclusive evidence of a concussion. This line of thinking can lead to over diagnosis and over treatment of a concussion that may have already resolved, or in cases where a concussion may not have occurred at all. Managing concussions involves numerous scenarios involving headaches: the reported headaches may not be specific to concussions, pre-existing headaches might be present, the character of the headache may change, or multiple types of headaches may coexist in the same patient.

And to aid in the management of concussion related headaches, it is useful to remember the mnemonic “HEADACHE.”

Headaches other (Migraine, Tension): Migraine, headaches are vascular headaches, characterized by a neurologic prodrome, often involving ocular symptoms, followed by a severe unilateral throbbing headache. These headaches may be triggered by trauma such as a concussion and commonly occur in females, often around puberty coinciding with increased participation in organize sports. Tension, headaches, similar to cervical headaches, are muscular headaches described as a squeezing sensation in a band-like pattern around the head. They can be secondary to various causes, including emotional stress, eyestrain, and neck strain.

Eye (Oculomotor) headache: The oculomotor system is one of the most commonly affected processes in a concussion. As force is transmitted to the brain, strain often occurs in areas involving the visual system. Screening tests, such as the well documented VOMS oculomotor tests, can detect deficits in this domain. Typically, these deficits result in headaches induced by visual stimuli, such as focusing and tracking, and are often felt in the frontal region.

Axial spine (Cervical) headache: The mechanics of a concussion involve forces transmitted to the brain through acceleration/deceleration. To move the cranium, the cervical structures are also involved. Violent motions of the cervical structures could lead to muscular and fascial injuries, less commonly, bony injuries. Headaches resulting from cervical injuries typically originate in the posterior cranial region and wrap around towards the temples. They are generally described as squeezing in nature, and are often experienced upon waking in the morning.

Drug (Rebound) headache: Many concussion patients are given over-the-counter medications for pain and headaches. Prolonged use of these medications can lead to medication induced dependence. Headaches associated with this rebound effect occur when the medication is not taken, and typically subside when the medication is resumed. These headaches are generally experienced globally.

Anxiety contributions to headaches: Mental health issues significantly complicate concussion management. Depression and anxiety are commonly diagnosed in teenagers, and their symptoms can worsen following a concussion. In some cases, anxiety and depression may arise as a result of the concussion experience, which encompasses not only the physical injury, but also the lifestyle consequences that accompany it. These patients may fixate on, or amplify their symptoms, including headaches.

Concussion headache: This is a commonly experienced headache associated with concussion. It is thought to result from an energy deficit in the brain following the injury. Exertion and cognitive activity can tax the brain enough to trigger a headache in this “impaired state.” These headaches typically have a global/vertex distribution and are exacerbated by cognitive tasks and sensory stimulation. They may also indicate a disturbance in normal brain function, as the brain lacks pain receptors and may interpret changes in function as global pain.

Hemorrhage: Fortunately, these headaches are uncommon in sports-related head injuries, but they are potentially life-threatening, and must be identified rapidly. These severe headaches typically worsen over time and can be accompanied by declining neurologic function. Symptoms may include repeated vomiting, slurred speech, and obtundation. Hemorrhagic headaches can include epidural hematomas, subdural hematomas, and inter-parenchymal hemorrhages. Immediate medical attention is required in these cases.


Hormonal: following a head injury, hypopituitarism, with growth hormone deficiency being the most common, can occur. Low growth hormone levels can mimic many symptoms of a concussion, particularly memory loss and decreased energy.

Extra-cranial headache: These headaches result from injury outside the skull and include tension and cervical headaches. They are associated with soft tissue injuries directly related to the location of the head impact. Acute cases may present with lacerations or bruises, with more insidious cases can develop due to scar tissue and potential involvement of superficial nerves. These headaches are palpable at the site of the injury and are often described as sharp and stabbing in nature.

It is important to recognize the multitude of headache types that may be present when evaluating patients with head injuries. Not all headaches can be attributed to concussions, and understanding the different types of headaches allows for more effective patient care. Treatment plans can vary significantly depending on the specific type of headache. For example, oculomotor headaches and cervical headaches often respond well to appropriate therapies, while anxiety related headaches may require psychotherapy as part of the treatment plan.

At Comprehensive Sports Medicine, we have extensive experience in distinguishing between various headache types associated with concussions and implementing appropriate treatment plans.