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Appendix 1 POSTTRAUMATIC HEADACHE h Arnold P. Friedman, M.D. and H. Mikropolous, M.D. A. INTRODUCTION Chronic headache as a sequela of head injury may follow all types and degrees of head trauma. The incidence of headaches following head in- juries varies in the literature from 28 percent to 65 percent. As emphasized by Denny-Brown (36) and his associate (1), it is evident that the complaints of the patient following head injury will vary not only with the manner and degree of injury but with the personality structure, compensation factors, and the environmental status. The present report is based on a series of 169 patients with posttraumatic headache seen at the Montefiore Hospital as a part of the follow-up study. More than one-half of the patients were of Latin and Semitic extractions, and less than 1 percent (only 1) was Negro. The family histories were not significant in their psychiatric aspects. Only five (3 percent) gave a history of any mental illness. From our inquiries, 146 patients (75 percent) had no neurotic or habit disturbances in infancy or childhood; enuresis and nail biting were reported by 12 patients (7 percent). One hundred and thirty-five patients (80 percent) were in active combat at the time of trauma, and 22 (13 percent) were in a combat area. During the first week following injury, 71 patients (42 percent) had no complaints, 17 (10 percent) were torpid, 9 (5 percent) were confused, and 5 (3 percent) were stuporous. Some 152 patients (90 percent) had fair or good school adjustment. Of this group, 44 (26 percent) were high school graduates, 59 (35 percent) had 1 or 2 years of high school, 20 (12 percent) had 1 or more years of college, and 11 (7 percent) had professional training. In this series it was found that 159 patients (94 percent) were headache- free prior to injury. Of the 10 (6 percent) who had pretraumatic head- aches, 7 (4 percent) were classified as suffering from tension headaches. The onset of headaches was immediate in 25 patients, within 1 week in another 25, and within 1 month following injury in another, a total of 93 men (55 percent). Ten percent of the total group developed headache between 1 and 6 months and 13 percent after the sixth month and up to the fifth year. In the others, the time of onset is unknown. In over 50 percent of the patients (86), the onset of headache was abrupt. 165

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In 118 patients (70 percent) the duration of posttraumatic headache was over 5 years. In eight (5 percent) it was less than 2 months. In 85 (50 percent) severity of headache was indicated as moderate, in 42 (25 percent) it was severe, and in the remaining 25 percent it was variable. Thirty-four patients (20 percent) had generalized headaches, 56 (33 percent) had localized polar headaches (bifrental, bitemporal, etc.), 56 (33 percent) had localized unilateral headaches, while the others were variously located. The most predominant quality was "dull and pressing," but the headaches varied from patient to patient and in each patient, and were described as sharp, pressing, stabbing, aching, burning, etc. Fifty-one (30 percent) had pain localized to the site of scalp injury. One hundred and thirty-five patients (80 percent) reported no spread of their headache, while 15 percent reported spread to the head, neck, or upper face. B. DURATION AND FREQUENCY In 12 patients (7 percent) the headaches were constant, and of the remaining 157 (93 percent) with periodic headaches, 51 (30 percent of the entire group) complained of one or more attacks per day, and 90 (53 per- cent) reported a minimum of 1 to 4 attacks per month. In the remaining group (10 percent) the attacks occurred approximately three times a year. In those patients with periodic headaches, attacks lasted from 30 minutes to 4 hours in approximately half of the patients, and less than 30 minutes in 10 percent. C. PRODROMATA No prodromata were noted in 159 patients (94 percent). In the remain- ing 10 the most common complaints were visual (i.e., scotoma, photo- phobia, blurring), gastric (nausea and anorexia), and emotional (difficulty in concentration, irritability, etc.). D. ASSOCIATED MANIFESTATIONS During an attack of headache the most common associated manfesta- tion was photophobia, which was noted by 37 patients (22 percent). Thirty-four (20 percent) complained of gastric disturbances, i.e., anorexia or nausea, and of this group 12 (7 percent) had vomiting. Neurological complaints as associated manifestations were not noteworthy; a few com- plained of tinnitus. Twenty-five (15 percent) complained of vasomotor phenomena, which included chilly feelings, sweating, coldness, warmth, etc. Fifty-four (32 percent) did not have any associated mental or emo- tional symptoms with their headaches. Of the remaining 115, 106 re- ported irritability, 52 had difficulty in concentration, and 35 reported anxiety with depression. Of the group, 110 men (65 percent) had dizziness without true vertigo associated with the headache or as part of the post- traumatic syndrome. Such feelings were described as "unsteadiness" by a majority of the patients, but attacks of dizziness did not consistently occur with the headache, even in these men. Thirty percent of the patients were free of such symptoms and 5 percent had both dizziness and vertigo. Other associated manifestations were not particularly significant except that 34 (20 percent) reported general weakness and hypersensitivity to noise. 1M

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E. TERMINATION OF ATTACKS One hundred and fifty-six patients (92 percent) reported that they had no symptoms accompanying the end of the headaches. The remaining 13 (8 percent) had a variety of complaints, including sleepiness, frequency of urination, etc. F. CONTRIBUTING FACTORS One hundred and one patients (60 percent) reported that mental or physical effort or fatigue precipitated the headache. Change in tempera- ture and weather was a predominant physical factor which the patients said was responsible for precipitating their attacks. In one-half of the patients emotional disturbances alone were responsible for producing an attack. One hundred and eight patients (64 percent) reported that rest and quiet would relieve their attacks, and 60 (15 percent) reported that lying down gave relief. In a small number of patients relief was reported after eating, mental effort, or application of heat. One-third of the patients reported that no specific maneuver helped their headaches. In one-half of the patients, headaches were aggravated by movement of the head. G. RESPONSE TO TREATMENT Only 22 patients (13 percent) received psychotherapy as prophylactic treatment for their headaches. Fifteen failed to respond, and 7 had mod- erate success. Symptomatic Treatment Coal tar derivatives were moderately effective in approximately 60 per- cent of the patients. Opiates, used in a few patients, gave good results. Sedatives, which were used in a very small number of patients, were effec- tive in only one-third. There are no data available on the use of com- binations of sedatives and coal tar derivatives. Data on prophylactic treat- ment by pharmacological methods were not available. 167

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