BACKGROUND: Posttraumatic headaches (PTHs) frequently occur following mild traumatic brain injury and may occasionally present with features of trigeminal autonomic cephalalgias (TACs). PTH-TAC is characterized by unilateral craniofacial pain and autonomic symptoms and can be significantly debilitating. Management of this headache subtype can be particularly challenging as it can be refractory to medical therapies. Currently, there is a paucity of evidence on the optimum medical management for this condition.

OBJECTIVES: This case series evaluated the effectiveness of nerve blocks in managing PTH with TAC features, highlighting their therapeutic potential for this debilitating headache phenotype.

SETTING: In this retrospective study, we identified 4 patients seen at St. Michael’s clinic from January 2021 to December 2023.

METHODS: We identified 4 patients meeting the International Classification of Headache Disorders diagnostic criteria for PTH, presenting with TAC features. They initially failed medical management and later underwent anesthetic nerve block procedures, including occipital, supraorbital, and supratrochlear nerve blocks. Clinical outcomes, including changes in headache frequency, pain intensity using a standard 11-point Numeric Rating Scale (NRS-11), where 0 indicates no pain, and 10 indicates the worst pain imaginable., and autonomic symptoms, were documented over a 2 month follow-up period.

RESULTS: All patients demonstrated significant improvement, with reductions in headache intensity and frequency > 50% in 2 cases and near-complete resolution in 2 cases recorded at the 2 month follow-up. Associated autonomic symptoms, including nasal congestion, tearing, and periorbital pain, also showed marked improvement. No significant adverse effects were reported during or after the procedure.

LIMITATIONS: This is a small case series with a limited follow-up period (2 months).

CONCLUSIONS: Nerve blocks represent a potentially safe and effective intervention for PTH with TAC-like features, providing both rapid and sustained relief for patients with refractory symptoms. However, we need larger prospective cohort studies with extended follow-up periods to confirm the findings of this small case series. Such studies will help standardize evidence-based treatment protocols for this challenging subset of headaches.

KEYWORDS: ICHD-3, International Classification of Headache Disorders 3 criteria, PT-TAC, PTH, TAC, mTBI, mild traumatic brain injury, posttraumatic headache, posttraumatic trigeminal autonomic cephalalgia, trigeminal autonomic cephalalgia