24-06-2025
Many With Posttraumatic Headache Go Undiagnosed, Untreated
MINNEAPOLIS — Posttraumatic headache (PTH) is frequently misdiagnosed and undertreated in nonspecialist settings, highlighting a critical gap in diagnostic accuracy, treatment access, and integrated care for this complex condition, new research showed.
Investigators found that patients with the condition are frequently misdiagnosed and undertreated in nonspecialist settings. Further, most are only correctly diagnosed with a migraine phenotype after evaluation by a headache specialist.
'A central message of our work is that the diagnosis of 'headache' is too often treated as a monolith — an endpoint rather than the beginning of a diagnostic journey,' study investigator Natalia Murinova, MD, clinical professor of neurology, and director of the headache clinic at the University of Washington (UW), Seattle, told Medscape Medical News .
The results of the retrospective analysis were presented at the American Headache Society (AHS) Annual Meeting 2025.
Precision in Diagnosis Essential
Chronic PTH is a secondary headache disorder caused by a primary condition such as head injury. The condition is also characterized by comorbidities that include psychiatric and sleep disorders, which can worsen headache symptoms. Further, chronic PTH can mimic other primary headache disorders such as chronic migraine and chronic tension-type headache.
'For patients with posttraumatic headache, particularly those whose symptoms persist and evolve into a chronic phenotype, it is imperative to move beyond the nonspecific label of 'headache' and identify the precise headache disorder using ICHD [International Classification of Headache Disorders]-3 criteria,' Murinova said.
The retrospective analysis included 2552 patients diagnosed with chronic PTH at the UW Medical Center. Researchers identified a subset of 728 patients and 1817 who were seen in non-headache clinics.
In both groups, they assessed the prevalence of comorbid migraine and headache phenotypes, psychiatric disorders — including major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder — and sleep disorders such as insomnia and obstructive sleep apnea.
They also analyzed the use of preventive medications, including beta-blockers, antiepileptic drugs (AEDs), calcitonin gene-related peptide (CGRP) monoclonal antibodies, preventive gepants, serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCAs), and memantine.
Results showed that 662 patients (90.94%) at the headache clinic and 599 patients (33.96%) at the non-headache clinic were diagnosed with episodic migraine. In addition, 598 patients (82.14%) at the headache clinic and 285 patients (15.69%) at the non-headache clinic were diagnosed with chronic migraine.
Compared with patients at the non-headache clinic, their counterparts attending the headache clinic were also more likely to be diagnosed with chronic PTH phenotypes such as medication overuse headache (25.55% vs 4.46%), chronic tension headache (10.58% vs 5.89%), episodic tension headache (7.97% vs 5.94%), cluster headache (1.92% vs 1.43%), hemicrania continua (1.37% vs 0.50%), and headaches related to cerebrospinal fluid leak (0.55% vs 0.72%).
The most common psychiatric and sleep-related comorbidities were depression (27.50%), anxiety (25.74%), insomnia (9.25%), posttraumatic stress disorder (8.06%), and obstructive sleep apnea (2.62%).
Missed Therapeutic Opportunities
More than 50% of patients at the non-headache clinic received no other headache diagnosis, while very few patients at the headache clinic had no additional headache diagnosis (58.94% vs 5.36%).
'This likely reflects a combination of factors: Gaps in access to headache-trained clinicians, underrecognition of chronic posttraumatic headache as a treatable neurological disorder, and a fragmented approach to posttrauma care,' Murinova explained.
'It's also possible that some patients received nonpharmacologic interventions such as physical therapy, behavioral therapy, or complementary modalities, but these were not consistently documented in the EMR [electronic health record].'
'Nonetheless, the underutilization of preventive pharmacotherapy underscores a broader issue of missed therapeutic opportunities, especially in patients with treatable phenotypes,' she added.
Most patients (71.11%) at the non-headache clinic were not taking preventative medications, but among those who were, beta-blockers (9.19%), TCAs (9.36%), SNRIs (9.41%), AEDs (8.26%), and memantine (4.73%) were the most commonly prescribed medications.
Patients in the non-headache clinic were also taking antihypertensive medications (4.68%), CGRP inhibitors, preventive gepants (2.04%), cyproheptadine (0.06%), and onabotulinumtoxinA (1.10%).
At the headache clinic, patients were less likely to be prescribed TCAs (3.43%) and more likely to be prescribed memantine (40.80%), CGRP inhibitors (17.17%), and onabotulinumtoxinA (11.40%) than patients at the non-headache clinic.
Why Headache Classification Matters
The distinction between headache types is not academic. It directly informs treatment eligibility,' said Murinova.
If a patient is diagnosed with chronic migraine as a phenotype of PTH, they may be eligible to receive treatments like onabotulinumtoxinA or anti-CGRP monoclonal antibodies, while patients with a more ambiguous diagnosis may not have access to these therapies, she explained.
'Diagnostic specificity is both a clinical and systems-level imperative,' Murinova said.
In an ideal scenario, patients with chronic PTH would be treated by an interdisciplinary team — including a neurologist, rehabilitation medicine specialist, physical therapist, and behavioral health provider — who would evaluate the headache phenotype and address comorbidities such as sleep disturbances, mood symptoms, and autonomic dysregulation, Murinova said.
'By establishing structured care pathways and triage algorithms, institutions can streamline referrals and reduce diagnostic delays,' she added.
More than 50% of patients at the non-headache clinic received no other headache diagnosis, while very few patients at the headache clinic had no additional headache diagnosis (58.94% vs 5.36%).
Need for Collaboration, Network Building
Commenting on the research, Hope O'Brien, MD, MBA, founder and chief executive officer of the Headache Center of Hope in Cincinnati, who was not involved in the research, said the results of the study were not surprising.
Despite efforts from specialists to educate providers treating patients with chronic conditions, chronic PTH remains undiagnosed and undertreated,' O'Brien told Medscape Medical News .
Previous research has shown that an accurate diagnosis is more likely with a headache specialist than a non-headache specialist, despite diagnostic tools to provide that diagnosis, O'Brien noted.
'It's very simple, but unfortunately most providers who see patients with headaches are unaware that these exist, or they believe that it takes too much time to use the tools to make these diagnoses,' she added.
Also commenting for Medscape Medical News , Amaal J. Starling, MD, associate professor of neurology at the Mayo Clinic in Phoenix, who was not involved in the study, noted that treating PTH is particularly challenging, as the FDA has not approved any treatments specifically for the condition due to a lack of supporting evidence.
While headache specialists have expertise in managing conditions like PTH, the limited number of specialists makes it impractical for them to treat all patients. Instead, they can play a collaborative role in managing more complex cases, Starling noted. 'However,' she added, 'I do agree that creating standardized evaluation protocols and flow charts for the management of PTH may be helpful for the non-headache clinicians.'
Comorbidities such as depression, anxiety, posttraumatic stress disorder, and insomnia 'not only complicate the clinical picture, but they can also perpetuate or exacerbate headache symptoms, and it can contribute to the chronicity and functional impairment of patients,' O'Brien noted.
Both experts emphasized that effective management of concussion and PTH requires a multidisciplinary, patient-centered approach. Starling highlighted the importance of building collaborative networks with specialists in areas such as sleep and psychiatry to ensure coordinated care.
O'Brien underscored that the high rate of underdiagnosis and complex comorbidities among patients with PTH further reinforces the need for integrative care models that support long-term recovery.
'We need to learn to adopt a patient-centered approach, and as clinicians and providers who see these patients, we need to better manage them and recognize that they're complex with their comorbid conditions. Ultimately, we need to have a more sustainable, meaningful plan to encourage recovery,' said O'Brien.
