Motor & Sensory

Date Published: September 21, 2020

Pain Disorders

Overview

Definition

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage…” (p.210); 1 the relationship between pain and tissue damage is not constant or uniform.

Acute pain is usually associated with defined tissue damage or a pathological process, and although it usually occurs at the time of injury as a one-time event, it may reoccur as a series of time limited events. 4

Chronic pain is usually defined as pain that continues for more than three to six months and is often not as well associated with tissue damage or a pathological process.

While the pain an individual with an ABI experiences can vary, there are several defined pain syndromes that are common post ABI. Defining the pain someone experiences as a specific pain syndrome can be valuable in determining the ideal treatment method.

Prevalence

Pain

One study reports chronic pain in 52% of those with moderate to severe TBI sampled. 11 Hoffman et al., 12 found 74% of participants reported experiencing pain and 55% of those reported that pain interfered with a variety of daily activities.

Post-Traumatic Headaches

In a survey of 485 individuals, Hoffman and colleagues found the prevalence of headaches during the first year of recovery post TBI was 40%, regardless of the severity of injury. 13 Lucas found that almost 60% of respondents who reported experiencing headaches, also reported experiencing migraines or probable migraines. 14 Studies have found that PTH often resolves itself within the first 6 to 12 months of injury; however, in 18-33% of the TBI population headaches persist longer than one year. 15,16

Etiology

General Pain

The etiology includes associated injuries at time of trauma and complications associated with traumatic brain injury.

  • Orthopedic injury
  • Burns
  • Abrasions
  • Wounds
  • Spasticity
  • Deep venous thromboembolism
  • Heterotopic ossification
  • IVs/tracheostomies/gastrostomy tubes
  • Constipation
  • Organ injury
  • Other noxious stimuli
  • Neuropathic pain
    • Central (usually damage to thalamus) injury
    • Peripheral nervous system injury

Post-Traumatic Headaches

PTH may be the consequence of injuries to the following structures

  • Dura
  • Venous sinuses
  • Cranial cavities (sinuses, ears, nasal cavities, orbits)
  • Cervical spine injury (disc, facet joints, ligamentous structures, fracture)
  • Cervical myofascial tissue

Risk Factors

Pain

  • Lower Functional Independence Measures scores
  • Presence of depressive symptoms or depression
  • Lower scores on the Community Integration Scale

Post-Traumatic Headaches

  • Cervical spine injury
  • Chronic and diffuse muscle strain (including whiplash injuries)
  • Chronic muscle contraction
  • Anxiety 18
  • Visual or vestibular system complications

Clinical Features

Pain SyndromeDescription and Clinical Presentation
Neuropathic painCaused by primary damage or dysfunction to the peripheral nervous system. Can result in chronic symptoms in the form of pain, often burning, associated with numbness or tingling. Pain can change in intensity and frequency from day to day. 5
Central pain syndromeCaused by damage to or dysfunction of the central nervous system and is usually chronic. Common symptoms include burning pain and numbness, which can become more severe with touch or colder temperatures. Central pain syndromes may impact large areas of the body, or small areas, such as only the hands and feet. Numbness and occasional sharp pains may also occur. 6
Post-traumatic headaches (PTH)PTH is the most commonly reported physical complaint following an ABI 7 and can develop up to months following the primary injury. 8 PTH should not be viewed as a singular condition, rather it be regarded as something that may be generated through multiple sources. 9 The primary types of PTH are tension-type, migrainous, cluster like, and cervicogenic. 10 PTH do not necessarily indicate a serious underlying issue and are often considered an expected part of recovery. However, if PTH are accompanied by other significant symptoms further investigation is warranted.

Subtypes of Headaches

Cervicogenic (musculoskeletal) headache

  • Due to injury to cervical spine (facets, discs, ligamentous structures) or myofascial pain
  • Unilateral head pain usually suboccipital initially and then spreads
  • C2 and C3 facet dysfunction in particular radiates to the head
  • Band or cap like discomfort
  • Relieved by local heat, cold or massage

Neuritic head pain

  • May be due to local blunt trauma, penetrating injury or surgical excision.
  • Involves small nerves innervating the scalp.
  • Patient may report numbness or dysesthesias.

Neuralgic head pain

  • Larger peripheral nerves involved include occipital, supraorbital, infraorbital and facial nerves.
  • Stabbing and/or burning pain.

Post-traumatic migraine

  • Throbbing, sometimes unilateral, exacerbated by coughing, bright lights, noise and activity.
  • May present with associated nausea or vomiting if severe.

Post-traumatic tension headaches

  • Tension headache is most common non-traumatic cause of headaches
  • Characterized by bilateral, viselike discomfort and associated with cervical or musculoskeletal etiology.

Assessment

History

Pain is a subjective experience and is often not accompanied by objective findings. The history is therefore very important in the assessment.

Pain

  • Premorbid history of pain conditions
  • Nature of the pain (burning, aching, stabbing, onset, location, duration, severity, frequency)
  • Severity of pain on Visual Analogue Scale
  • Aggravating and alleviating factors
  • Coping strategies (i.e. activity levels, adjustment, pacing, anxiety and catastrophizing)
  • Depression and anxiety screen
  • Impact of pain on lifestyle

PTH

  • Premorbid history of headaches
  • Mechanism of head injury
  • Assess for acceleration/deceleration forces at injury
  • Neurosurgical intervention
  • Complete description of pain: character, onset, location, duration, exacerbating factors, relieving factors, severity, frequency
  • Associated symptoms (photophobia, aura, nausea, vomiting)

Physical Exam

INESSS-ONF Clinical Practice Guideline Recommendations

Pain should always be considered if a person with traumatic brain injury presents with agitation and has cognitive/communication issues, non-verbal psychomotor restlessness or worsening spasticity, with particular attention paid to non-verbal signs of pain (e.g., grimacing).19

Pain

  • Palpate for localized tenderness
  • Assess movement of involved or adjacent joints
  • Neurological examination

Headache

  • Neurologic exam
  • Cervical range of motion
  • Palpation of cranial/cervical musculature
  • Palpation of temporomandibular joints
  • Provocative maneuvers of cervical spine (Spurling maneuver, distraction test, compression test)

Screening

Pain itself is both complex and subjective; thus, self-reports are vital to any treatment plan. Descriptive details related to the intensity, the length of time the pain is felt, the location, and what exacerbates or relieves the pain are vital in developing an individualized treatment strategy. 20 There are a number of tools and assessments used by physicians and therapists to assist in diagnosing and measuring pain. Amongst these are the:

  • Visual analog scale (pain)
  • Numeric rating scale
  • McGill pain questionnaire
  • Headache disability inventory
  • Headache diary

Diagnostic Testing

  • Radiographs of affected area
  • Electromyogram/nerve conduction study for peripheral nerve lesions/radiculopathy
  • Consider triple phase bone scan for heterotopic ossification, complex regional pain syndrome or occult fractures
  • Consider duplex Doppler ultrasound of affected limb to evaluate DVT
  • Consider CT scan for lumbosacral spine or MRI for cervical spine as appropriate

Laboratory Investigations

Laboratory tests are rarely helpful in diagnosis of pain after traumatic brain injury.

Diagnosis

In individuals who have sustained a moderate or severe TBI, the diagnosis of pain is often made through the combination of symptoms described by the patient and information provided by family members, physical examination to help localize the pain and in some cases diagnostic testing and imaging.

Diagnostic Criteria

For diagnostic criteria, please refer to the International Classification of Headache Disorders.

International Classification of Headache Disorders

Differential Diagnosis

  • Degenerative or mechanical spinal pain (present pre-accident).
  • Fibromyalgia (present pre-accident).

Complications

Pain post TBI can evolve from episodic pain to daily pain with an increasing negative impact over time, as pain ultimately impacts participation in rehabilitation and thereby slows recovery. 3

  • Delay in cognitive recovery
  • Sleep disorders
  • Fatigue
  • Elevated levels of anxiety, depression and post-traumatic stress disorder

12,21

Management

INESSS-ONF Clinical Practice Guideline Recommendations

Rehabilitation programs for individuals with traumatic brain injury should have pain management protocols in place, which include:

  • Regular review and adjustment mechanisms
  • Handling, support and pain relief modalities appropriate to the person’s needs
  • Education of healthcare professionals and caregivers about appropriate handling of paretic upper limbs during transfers, hypersensitivity and neurogenic pain

When treating pain post TBI, it is important for clinicians to identify the causes of pain, not just the symptoms. 20 To reduce the impact on cognitive recovery, treatment plans should take into consideration the medications the patient is already receiving, as well as the location, type, and frequency of the pain. It should be acknowledged that in many cases the pain generator persists in which case pain can only be managed. Treatment for pain often involves an interdisciplinary approach.3 To increase the likelihood of compliance with treatments, a good working relationship between physicians and the patient is needed. Overall, more research is needed to assess the effectiveness and efficacy of these treatments in the TBI population.

Non-pharmacological Interventions

Non-pharmacological interventions for both chronic pain and PTH may include: biofeedback, cold and heat packs, massage therapy, acupuncture, and exercise. 22

Biofeedback, relaxation, meditation, and CBT are considered the gold standard of behavioural treatments for pain. 3

Cognitive Behavioral therapy (CBT) considered a diverse set of problem-specific interventions and incorporates physical, psychological, and behavioural approaches to managing pain. 23 With CBT the individual is taught to use self-regulation and self-control, and to take responsibility for one’s lifestyle. 24 This therapy has been used to help patients cope with the pain, depression, and anxiety associated with chronic headaches. 25,26

A variety of other non-pharmacological interventions have been explored to reduce pain and headaches following an ABI. They are biofeedback, relaxation training, acupuncture, cryotherapy, yoga and mindfulness. Unfortunately, all of these interventions have very limited evidence to support their efficacy in those with an ABI specifically. Although their use may be appropriate in specific cases for individuals with ABI they should be considered on a case by case basis.

Pharmacological Interventions

It has also been noted that the use of anticonvulsant medication seems to produce fewer adverse events. 4 Anticonvulsants currently used to treat pain include carbamazepine, oxcarbamazepine, lamotrigine, gabapentin, pregabalin, and topiramate, however, there are limited studies investigating their effectiveness either in isolation or in combination with other medications.

Unfortunately, there are limited recommendations for the management of pain and post-traumatic headache following an ABI. Pregabalin is the only pharmacological agent supported by the Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe TBI. 27

InterventionEffectLevel of Evidence

Anticonvulsants

  • Valporic acid
  • Divalproex sodium
  • Pregabalin
  • Gabapentin
  • Carbamazepine
  • Oxcarbazepine
  • Lamotrigine
  • Topiramate
Reduction in pain intensity, may improve sleep and reduce anxiety.

Gabapentin and Pregabalin are considered first line. Lack of evidence in ABI research.

Works best for neuropathic pain or fibromyalgia but not musculoskeletal pain.

Antidepressants
  • Amitriptyline
  • Venlafaxine
  • Duloxetine
Treatment of comorbid depression and sleep disturbance and reduction of pain intensity.

Duloxetine and Venlafaxine considered first unless for sleep or neuropathic pain. Lack of evidence in ABI research.

Amitriptyline works better for neuropathic pain but has significant side effects.

Topical analgesicsCapascasin or Lidocaine creams

Lack of evidence in ABI research.

May work in some patients.

OpioidsPrimary role in moderate to severe acute pain. Very restricted role in chronic pain.

Use lowest possible dose and aim for time limited use. Lack of evidence in ABI research.

Effective in acute pain. Last resort in chronic pain because of dependency and addiction issues.

CannabinoidsIncreasing role especially CBD. Treatment of sleep, pain and anxiety.

Oil taken orally or inhalation. Lack of evidence in ABI research.

Role not fully established.

Antiepileptic Medications to Treat Pain Post TBI 4,20,28

Antiepileptic MedicationTypical Dose; Dose RangeAdverse Events (partial list)
Carbamazepine (Tegretol®)200mg q 8hr; 100-1600mg/dayDrowsiness, bone marrow suppression, kidney stones
Valproic acid (Depekene®)250mg q 8hr; 600-2400mg/dayDrowsiness, headache, sleepiness, agitation, mood swings, memory loss
Phenytoin (Dilantin®)250mg q 8hr; 600-2400mg/dayDouble vision, imbalance, slurred speech
Gabapentine (Neurontin)600mg q 8hr; 200-3600mg/dayDrowsiness, dizziness
Clonazepam (Klonopin®)0.5mg q 8 hr; 2-7mg/dayDrowsiness, disequilibrium, abnormal behaviour
Oxcarbazepine (Tripeptal®)300-600mg q 12hr; 150-1800mg/dayDrowsiness, lightheadedness, dizziness
Lamotrigine (Lamictal®)50-100mg q 12hr; 50-200mg/dayRash, fatigue, stomach upset
Topiramate25mg q 12hr; 200-400mg/dayAtaxia, impaired concentration, confusion, dizziness, fatigue, speech disturbances, language problems.
Pregabalin (Lyrica®)300-450mg/day; 150-600mg/dayDrowsiness, dizziness
Levetiracetam (Keppra®)250-500mg q 12hr; 250-1500mg/dayDrowsiness, dizziness


Antidepressants to Treat Pain Post ABI 4,20

AntidepressantsTypical Dose; Dose RangeAdverse Events
Amitriptyline (Elavil®)75mg qhs; 10-150mg/dayDrowsiness, dry mouth, weight gain, constipation, seizures, cardiac toxicity, urinary retention
Venlafaxine (Effexor®)37.5mg od; 150-225mg/dayHigh blood pressure, weight loss, dry mouth, impotence, tremor
Nortriptyline (Pamelor®)75mg qhs; 10-150mg/dayDrowsiness, dry mouth, weight gain, constipation, seizures, cardiac toxicity, urinary retention
Desipramine (Norpramin®)75mg qhs; 50-200mg/dayDrowsiness, dry mouth, weight gain, constipation, seizures, cardiac toxicity, urinary retention
Duloxetine (Cymbalta®)60mg qd; 3-120mg/dayInsomnia, nausea, dizziness, fatigue, constipation
Fluoxetine (Prozac®)20mg qd; 5-60mg/dayAnxiety, nervousness, insomnia, tremor, chest pain, diarrhea
Paroxetine (Paxil®)20-40mg qd; 20-50mg/dayDrowsiness, dizziness, insomnia, headache

Topical Anesthetics to Treat Pain Post TBI 4

MedicationTypical DoseAdverse Events
Capsaicin (Zostrix®, Axsain®)0.025-0.075% 3-4 times dailyBurning, skin irritation
Lidocaine 5% (Lidoderm®)1-4 patches 12 hours per daySkin irritation

Surgical Interventions

Not relevant.

Algorithm

Treatment for Sub-acute/Chronic Pain Post Traumatic Brain Injury

Resources

ERABI Module

ERABI Guidebook

INESSS-ONF Clinical Practice Guidelines

Other

References

1. International Association for the Study of Pain. Part III Pain Terms: A Current List with Definitions and Notes on Usage. In: Merskey H, Bogduk N, eds. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2 ed. Seattle: IASP Press; 1994.

2. Theeler BJ, Erickson JC. Posttraumatic headache in military personnel and veterans of the iraq and afghanistan conflicts. Current treatment options in neurology. 2012;14(1):36-49.

3. Branca B, Lake AE. Psychological and neuropsychological integration in multidisciplinary pain management after TBI. The Journal of Head Trauma Rehabilitation. 2004;19(1):40-57.

4. Gould HJI. Pain Defined Understanding Pain: What it is, Why it happens and How it’s managed. In: LM S, ed. American Academy of Neurology. 1 ed.2007:1-8.

5. Zasler ND, Martelli, M. F., Nicholson, K., Horn, L. Post-traumatic Pain Disorders: Medical Assessment and Management. In: Zasler ND, Katz, D.I. & Zafonte, R.D, ed. Brain Injury Medicine. 2nd ed. New York: Demos Medical Publishing; 2013:954-971.

6. National Institute of Neurological Disorders and Stroke. Central Pain Syndrome Information Page. National Institute of Health. https://www.ninds.nih.gov/disorders/all-disorders/central-pain-syndrome-information-page. Published 2019. Accessed2019.

7. Yamaguchi M. Incidence of headache and severity of head injury. Headache. 1992;32(9):427-431.

8. Young WB, Packard, R.C. & Ramadan. Headaches associated with head trauma. In: Silverstein SD, Lipton, R.B. & Dalessio, D.J., ed. Wolfe’s Headache and other Head Pain. 7 ed.2001:325-348.

9. Horn LJ, Siebert B, Patel N, Zasler ND. Post-traumatic Headache. In: Zasler ND, Katz, D.I. & Zafonte, R.D, ed. Brain Injury Medicine. 2nd ed. New York: Demos Medical Publishing; 2013:932-953.

10. Defrin R. Chronic post-traumatic headache: clinical findings and possible mechanisms. The Journal of Manual and Manipulative Therapy. 2014;22(1):36-44.

11. Lahz S, Bryant RA. Incidence of chronic pain following traumatic brain injury. Archives of physical medicine and rehabilitation. 1996;77(9):889-891.

12. Hoffman JM, Pagulayan KF, Zawaideh N, Dikmen S, Temkin N, Bell KR. Understanding pain after traumatic brain injury: impact on community participation. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2007;86(12):962-969.

13. Hoffman JM, Lucas S, Dikmen S, et al. Natural history of headache after traumatic brain injury. Journal of Neurotrauma. 2011;28(9):1719-1725.

14. Lucas S. Headache management in concussion and mild traumatic brain injury. PM & R : the journal of injury, function, and rehabilitation. 2011;3(10 Suppl 2):S406-412.

15. Seifert TD, Evans RW. Posttraumatic headache: a review. Current pain and headache reports. 2010;14(4):292-298.

16. Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2006;85(7):619-627.

17. Gellman H, Keenan MAE, Botte MJ. Recognition and Management of Upper Extremity Pain Syndromes in the Patient with Brain Injury. The Journal of Head Trauma Rehabilitation. 1996;11(4):23-30.

18. Hillier SL, Sharpe MH, Metzer J. Outcomes 5 years post-traumatic brain injury (with further reference to neurophysical impairment and disability). Brain injury : [BI]. 1997;11(9):661-675.

19. ONF-INESSS. Clinical Practice Guideline for the Rehabilitation of Adults with Modarate to Severe TBI. 2016.

20. Zasler ND, Martelli MF, Nicholson K. Chronic Pain. In: Silver JM MT, Yudofsky SC, ed. Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, Inc; 2011:375-396.

21. Dobscha SK, Clark ME, Morasco BJ, Freeman M, Campbell R, Helfand M. Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain medicine (Malden, Mass). 2009;10(7):1200-1217.

22. Medina JL. Efficacy of an individualized outpatient program in the treatment of chronic post-traumatic headache. Headache. 1992;32(4):180-183.

23. Roth AD, Pilling S. Using an Evidence-Based Methodology to Identify the Competences Required to Deliver Effective Cognitive and Behavioural Therapy for Depression and Anxiety Disorders. Behavioural and Cognitive Psychotherapy. 2008;36(2):129-147.

24. Martelli MF, Nicholson, K., & Zasler N.D. Psychological Assessment and Management of Port Traumatic Pain. In: Zasler ND, Katz, D.I. & Zafonte, R.D, ed. Brain Injury Medicine: Principles and Practice. 2 ed.2012:974-987.

25. Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain. 2011;152(9):2098-2107.

26. Gurr B, Coetzer BR. The effectiveness of cognitive-behavioural therapy for post-traumatic headaches. Brain injury. 2005;19(7):481-491.

27. INESSS-ONF. Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe TBI. Ontario: Ontario Neurotrauma Foundation;2015.

28. Guay DR. Oxcarbazepine, topiramate, zonisamide, and levetiracetam: potential use in neuropathic pain. The American journal of geriatric pharmacotherapy. 2003;1(1):18-37.