Post-Concussion Headache

Headache

Overview

Post-concussion headache (PCH) is a primary headache disorder that develops within 7 days following a concussion or mild traumatic brain injury and persists for weeks to months. It represents one of the most common sequelae of concussion, affecting 30-90% of patients, and significantly impacts functional recovery and quality of life. The headache often coexists with other post-concussion symptoms including dizziness, cognitive impairment, and mood changes, requiring a comprehensive biopsychosocial management approach.

Pathophysiology

Post-concussion headache results from multiple interconnected mechanisms including central sensitization of pain pathways, dysfunction of descending pain inhibitory systems, neuroinflammation, and altered neurotransmitter balance (serotonin, dopamine, norepinephrine). The initial traumatic force causes axonal injury and disruption of neuronal membrane integrity, triggering a cascade of metabolic and ionic disturbances. Cervical dysfunction commonly coexists due to rapid acceleration-deceleration forces during injury, creating a peripheral contribution through myofascial tension and cervical joint dysfunction. Vestibular system involvement, autonomic nervous system dysregulation, and post-traumatic stress responses perpetuate the headache cycle. Maladaptive neuroplasticity and pain chronification may develop with prolonged symptoms and fear-avoidance behaviors.

Typical Presentation

Site

Typically bilateral, frontal-temporal, or occipital regions; may be diffuse and non-localized; often cervicogenic component with upper neck and base of skull involvement

Quality

Pressurizing, throbbing, aching, or tension-like quality; may be sharp or stabbing; often described as heavy or vice-like; frequently changes in character throughout the day

Intensity

Mild to moderate intensity (4-7/10), though can be severe; typically fluctuates throughout the day; often worse with cognitive exertion, physical activity, or sustained postures

Aggravating

Cognitive activity and mental exertion; physical activity and exercise; sustained screen time or reading; neck movement and postural strain; bright light and noise sensitivity; stress and emotional triggers; poor sleep; rapid head movements; changes in weather or barometric pressure

Relieving

Rest and mental disengagement; quiet dark environments; neck stretching and gentle movement; stress reduction techniques; sleep; application of heat or ice; caffeine (sometimes); lying down with head supported

Associated

Cervical stiffness and neck pain; dizziness and vertigo; visual disturbances and photophobia; sound sensitivity (hyperacusis); fatigue and sleep disturbance; cognitive difficulties (brain fog, memory impairment, concentration issues); mood changes (irritability, anxiety, depression); balance impairment; vestibular dysfunction signs; nausea; temporal mandibular dysfunction

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Cervical Flexion-Rotation Test

Procedure

Patient lying on their back. Fully flex the neck passively, then rotate the head to each side until firm resistance or pain, and compare the range.

Positive Finding

Rotation clearly reduced to one side with a firm end-feel, or the familiar headache reproduced.

Interpretation

Suggests the upper neck (C1–C2) may be contributing to the headache. Before upper cervical techniques, screen for cervical arterial dysfunction (dizziness, double vision, difficulty speaking or swallowing, drop attacks, numbness, nystagmus) and for instability (recent trauma, rheumatoid arthritis, Down syndrome). The figure previously stored came from studies of cervicogenic headache, not post-concussion headache. In Hall 2010 (60 people), rotation was most restricted in cervicogenic headache and least in migraine; no study of the test after concussion was found in this search (Europe PMC, October 2026), so no figure is shown. A positive test after concussion suggests the upper neck may be contributing. The figure previously stored came from studies of cervicogenic headache, not post-concussion headache. In Hall 2010 (60 people), rotation was most restricted in cervicogenic headache and least in migraine; no study of the test after concussion was found in this search (Europe PMC, October 2026), so no figure is shown. A positive test after concussion suggests the upper neck may be contributing.

Sources

Questionnaire

Dizziness Handicap Inventory (DHI)

Procedure

The patient completes a 25-item questionnaire about the physical, emotional and functional effects of dizziness, scored from 0 to 100.

Positive Finding

A higher score means more impact from dizziness.

Reference: Jacobson & Newman, 1990, American Journal of Otology

Interpretation

Measures how much dizziness affects daily life and tracks change with treatment. It does not show the cause of the dizziness.

Sources

No accuracy study

Cervical Range of Motion Assessment

Procedure

Once fracture has been ruled out after recent trauma (for example with the Canadian C-Spine Rule), measure active neck movement in all directions, comparing sides and noting headache, dizziness or neck pain.

Positive Finding

Reduced or painful movement, or headache or dizziness brought on by neck movement.

Interpretation

The neck is often injured at the same time as the head, and neck problems can drive ongoing headache and dizziness after concussion. After a head injury, a worsening headache, repeated vomiting, drowsiness, confusion, a seizure, weakness, slurred speech or unequal pupils needs emergency care.

Sources

No accuracy study

Cervical Segmental Palpation

Procedure

Assess each cervical level from C0 to C7 with gentle accessory glides and palpation, comparing sides and asking whether the familiar headache or dizziness is reproduced.

Positive Finding

Painful or stiff levels that reproduce the familiar headache.

Interpretation

Identifies cervical levels that may be contributing and guides treatment. Agreement between examiners is only moderate.

Sources

No accuracy study

Oculomotor Screening (Smooth Pursuit & Saccade Testing)

Procedure

With the head still, ask the patient to follow a slowly moving target, then look quickly between two targets, then focus on a target moving closer (convergence). Ask about headache, dizziness, nausea or fogginess after each part (as in the VOMS screen).

Positive Finding

Jerky eye movements, poor convergence, or symptoms brought on by the eye movements.

Interpretation

Suggests the visual and vestibular systems are contributing, and points towards vestibular and oculomotor rehabilitation. New double vision or unequal pupils need urgent medical review.

Sources

Questionnaire

Neck Disability Index (NDI)

Procedure

The patient completes a 10-item questionnaire about how neck pain affects daily activities, scored from 0 to 50.

Positive Finding

A higher score means more neck-related disability.

Reference: Vernon & Mior, 1991, Journal of Manipulative and Physiological Therapeutics

Interpretation

Measures neck-related disability and tracks change with treatment. It does not diagnose the source of the headache.

Sources

⚠ Red Flags

  • •Signs of increasing intracranial pressure: progressively worsening headache, vomiting, altered consciousness, seizures
  • •Focal neurological deficits: weakness, sensory loss, speech difficulties, coordination problems
  • •Loss of consciousness or prolonged confusion following the initial injury
  • •Cerebrospinal fluid leakage (clear fluid from nose or ears)
  • •Persistent or progressive neurological symptoms beyond expected post-concussion timeline
  • •Signs of concurrent spinal cord injury: bilateral symptoms, bladder/bowel dysfunction, respiratory compromise
  • •High-impact mechanism with severe initial symptoms despite mild clinical presentation
  • •Immunocompromised status with fever and headache suggesting meningitis
  • •Anticoagulation use with any head injury mechanism
  • •Repeated concussions within short timeframes suggesting cumulative brain injury

⚡ Yellow Flags

  • •High pain catastrophizing and fear-avoidance behaviors limiting participation in recovery
  • •Significant mood disturbance including depression or anxiety predating or worsening post-injury
  • •Excessive focus on symptoms with health anxiety or illness preoccupation
  • •Lack of social support or poor family understanding of post-concussion condition
  • •Secondary gain factors or ongoing litigation related to the injury
  • •Pre-existing chronic pain or psychiatric conditions complicating recovery trajectory
  • •Maladaptive coping strategies including substance use or social withdrawal
  • •High baseline stress levels or recent significant life stressors
  • •Poor sleep hygiene and sleep disturbance perpetuating symptom cycle
  • •Unrealistic expectations regarding recovery timeline and functional restoration

Osteopathic Techniques

Neck symptoms are common after concussion, and early neck pain raises the risk of lasting symptoms. For neck pain, headache or dizziness lasting more than 10 days, cervicovestibular rehabilitation is recommended; in one trial it sped up return to sport.

Safety: Before treating the neck, screen for vascular causes of headache and neck pain, such as artery dissection. Suboccipital release is not used with an acute neck fracture, suspected neurovascular compromise or a new focal neurological deficit.

Region

Cervical paraspinals, upper trapezius and levator scapulae

Technique

Soft tissue, neck and shoulder girdle
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of soft tissue on its own after concussion. Neck and vestibular rehab as a package helped return to sport.

Rationale

Eases neck muscle tension within cervical and vestibular rehab, once serious injury is ruled out. Untested on its own.

How it's done & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) across or along the cervical paraspinals, upper trapezius and levator scapulae, usually with the patient supine.

Evidence in Post-Concussion Headache

Searched 24 Oct 2026: no trials of neck soft tissue technique on its own after concussion. In a 2014 trial, cervical and vestibular rehabilitation as a package made medical clearance by 8 weeks about 4 times more likely; the abstract does not say which neck techniques were used.

Region

Cervical spine (C1–C4)

Technique

Articulation, cervical
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of neck mobilisation on its own after concussion. Neck and vestibular rehab as a package helped return to sport.

Rationale

Gentle, graded neck mobilisation within a cervicovestibular rehab program. Untested on its own.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of a restricted cervical segment within its passive range, with no thrust. Usually done with the patient supine and the head supported; the amplitude can vary.

Evidence in Post-Concussion Headache

Searched 24 Oct 2026: no trials of cervical mobilisation on its own after concussion. In a 2014 trial, cervical and vestibular rehabilitation as a package made medical clearance by 8 weeks about 4 times more likely; the abstract does not say which neck techniques were used.

Region

Suboccipital muscles (below the occipital ridge)

Technique

Suboccipital release
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials after concussion. A reference chapter lists it for tension and migraine headache.

Rationale

Gentle sustained hold under the base of the skull for upper-neck tension. Untested after concussion.

How it's done, cautions & evidence

How it's done

Patient lies supine and flat. Sitting at the head of the table, cup the head in both hands, find the occipital ridge and slide just below it onto the suboccipital muscles. Curl the fingertips up into the muscles and hold for 3–5 minutes or until the tension releases, then re-check symptoms.

Cautions

Do not use with an acute neck fracture, suspected neurovascular compromise or a focal neurological deficit. The commonest reactions are a passing headache, tiredness or nausea; worse pain or nerve compression are rarer risks.

Evidence in Post-Concussion Headache

Searched 24 Oct 2026: no trials of suboccipital release after concussion. StatPearls lists tension and migraine headache as indications, which is indirect.

Region

Upper thoracic spine (T1–T4)

Technique

Muscle energy, thoracic
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials after concussion. Indirect: neck and vestibular rehab is recommended for lingering neck symptoms.

Rationale

Low-force and patient-powered, for a stiff upper back. Untested after concussion.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Post-Concussion Headache

Searched 24 Oct 2026: no trials of upper thoracic MET after concussion. A 2023 review recommends cervicovestibular rehabilitation for neck pain, headache or dizziness lasting more than 10 days, which is indirect.

Region

Cranial base and cervical fascia

Technique

Myofascial release
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials after concussion. Indirect: myofascial release eased pain in other headache types.

Rationale

Gentle sustained release of the upper neck fascia. Untested after concussion.

How it's done, cautions & evidence

How it's done

Passive. Direct: the fascia is loaded into its restriction and a steady force is held at the barrier until the tissue releases, then the next barrier is taken up. Indirect (for example unwinding): the hands follow the tissue toward ease and let it lead, without adding force. Re-check afterward.

Cautions

Reconsider with a healing fracture, severe osteoporosis, advanced diabetes, rheumatoid arthritis, malignancy or an aneurysm. Get informed consent and protect privacy, especially for pelvic floor work.

Evidence in Post-Concussion Headache

Searched 24 Oct 2026: no trials of myofascial release after concussion. A 2024 meta-analysis found it reduced pain in tension-type, cervicogenic and migraine headache, which is indirect.

Rehabilitation Exercises

Gentle Cervical Rotation in Neutral

Range of MotionBeginner

Cervical Flexion-Extension Pendulum (Supported)

Range of MotionBeginner

Upper Trapezius Stretch (Modified)

StretchingBeginner

Suboccipital Myofascial Release (Self-Massage)

StretchingBeginner

Cervical Isometric Stabilization (Multi-Planar)

StrengtheningIntermediate

Deep Cervical Flexor Activation (Supine Chin Tuck)

StrengtheningIntermediate

Postural Awareness and Correction (Desk Posture)

PosturalBeginner

Gaze Stabilization Exercises (Vestibulo-Ocular Reflex)

BalanceIntermediate

Graduated Aerobic Activity (Walking Program)

CardiovascularBeginner

Scapular Stabilization and Retraction Exercises

PosturalIntermediate

Thoracic Spine Mobilization (Supported Extension)

Range of MotionBeginner

Proprioceptive Training (Dynamic Stability Progression)

BalanceAdvanced

Referral Criteria

  • •Headache showing progressive worsening despite 4-6 weeks of appropriate conservative management
  • •Any red flag symptoms requiring urgent neurological evaluation and imaging
  • •Persistent cognitive impairment, memory problems, or concentration difficulties beyond expected timeline
  • •Significant mood disturbance including depression or anxiety requiring psychological intervention
  • •Vestibular dysfunction with persistent dizziness or vertigo requiring specialized vestibular rehabilitation
  • •Suspected cervical spine pathology requiring advanced imaging (MRI) or orthopedic evaluation
  • •Trigeminal neuralgia or other primary headache disorder suspected
  • •Chronic pain development with significant functional disability and psychosocial factors requiring pain management specialist
  • •Sleep disorders significantly impacting recovery requiring sleep medicine consultation
  • •Substance use or dependency issues requiring addiction medicine support
  • •Unresponsiveness to multimodal conservative approach after 8-12 weeks suggesting need for neurologist re-evaluation
  • •Suspected post-traumatic stress disorder or complex emotional sequelae requiring mental health intervention