October 3, 2023
Treatment ApproachDescription
Analgesic Treatment– Phenotypically guided treatment shows a 64% response rate
– “SKIP protocol” for severe acute pain: saline infusion, ketorolac, and anti-emetic
– Avoid triptans in the first few weeks post-concussion
– Occipital nerve blocks can provide long-term benefit, especially for cervicogenic or occipital neuralgia-like pain
– Caution against overusing analgesics and encourage limited use for headache exacerbations
– Nonpharmacological strategies (e.g., cold cloths, short rest periods) are effective in children
– Facet joint injections (C2 or C3) in collaboration with radiology colleagues for suspected facet-related pain
Chronic and Preventative Treatment– Choice of prophylactic agents based on comorbidities
– Amitriptyline or nortriptyline for sedation or better tolerability
– Propranolol if pain worsened by exercise, indomethacin if purely exercise-induced
– Caution with topiramate due to cognitive complaints, but may be considered for overweight patients without depression
– Flunarizine as an option for children under 10 or 11 years
– Melatonin (1-10 mg) being tested in an RCT
– Nutraceutical agents (magnesium, folate) may have limited efficacy
– Neck physiotherapy recommended for cervicogenic component
– Psychological management as an adjunct to medical therapy, including cognitive-behavioral therapy (CBT)
– Biofeedback as a nonpharmacological alternative
– Repetitive transcranial magnetic stimulation may be

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