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Practice Current: "How do you diagnose and treat post-concussive headache?"

While recognizing each case is different, please choose the answer that best reflects your common practice and limit free text to strategies that are not included.

Estimated Time: 2 Minutes

CASE 1
A 25-year-old man presents to clinic with daily headaches 1 month after he slipped on the ice and hit his head on the sidewalk. He did not lose consciousness, but felt dazed following the fall. He did not seek medical attention at time of the fall. About a week after the injury, he developed a holocephalic headache which varies in intensity from mild to severe. The headache is described as a feeling of pressure with occasional throbbing. When the headache is debilitating, it is associated with light and sound sensitivity as well as nausea. The headaches are neither positional nor worse with cough, sneezing, or Valsalva maneuver. The headaches improve following sleep and/or naproxen use. The neurologic exam, including fundoscopic examination, is normal.
1. Would you order imaging for this patient? *This question is required.
What kind of imaging would you order? (Select one. Assume CT imaging can be obtained same day and MRI imaging can be completed in 2 weeks.) *This question is required.
Would you wait for imaging results before starting treatment? (Assume CT imaging can be obtained same day and MRI imaging can be completed in 2 weeks.) *This question is required.
2. Which of the following initial treatment(s) would you recommend? (Check all that apply.) *This question is required.
What daily headache preventative would you start? (Select one.) *This question is required.
3. If the patient in Case 1 were a 14-year-old presenting after a football- or soccer-related concussion without loss of consciousness, would you order imaging? *This question is required.
4. If the patient in Case 1 were a 14-year-old presenting after a football- or soccer-related concussion without loss of consciousness, what initial treatment would you recommend?* (Check all that apply.) *This question is required.
What daily headache preventative would you start? (Select one.) *This question is required.
The 14-year-old patient returns one month later with continued headaches despite following your counseling. The patient would like to take something everyday to treat their headache. What headache preventative would you start? (Select one.) *This question is required.
CASE 2
A 37-year-old woman presents to clinic with headache following a motor vehicle collision which occurred 1 year ago. She was the restrained driver and was parked at a stoplight when another vehicle traveling at 20 mph hit her vehicle from behind. The collision jerked her forwards and backwards, and she hit her head on her seat headrest. She was evaluated in a local ER and was cleared after a CT of the head and cervical spine. The next day she developed bitemporal squeezing headaches not associated with nausea, vomiting, or light or sound sensitivity. The headache will worsen with tasks of concentration. The headache is not positional or worse with cough, sneezing, or Valsalva maneuver. Ibuprofen and sumatriptan lessen her pain but do not abort her headaches. Since the collision she has also had insomnia and endorses depressed mood. 120mg per day of propranolol for 3 months did not reduce her headache frequency. She has been taking topiramate at 50 mg twice a day for 5 months and currently has 20 headache days per month. MRI brain was performed 10 months ago and was normal. Her neurologic exam, including fundoscopic examination, is normal.
5. Would you change the patient’s current headache treatment? *This question is required.
How would you change the patient’s current headache treatment? (Check all that apply.) *This question is required.
6. Would you refer this patient to a mental health professional such as a psychiatrist, psychologist or other behavioral healthcare expert? *This question is required.