To investigate the relationship between traumatic brain injury (TBI) severity, radiographic imaging findings, and post-traumatic headache (PTH) being reported as the most disabling symptom in a post-TBI clinic cohort.

Post-traumatic headache (PTH) is a common and debilitating condition following TBI, but its mechanisms are unclear. The roles of TBI severity and positive radiographic findings as risk factors for PTH being the primary disabling complaint remain unknown.

Retrospective cohort study of 170 sequential-clinic-TBI patients (09/22-09/25). PTH defined as the patient's self-reported headache being the most disabling symptom and fitting ICHD-3 criteria for acute (<3 months) or chronic (>3 months) PTH. TBI severity classified as mild TBI (mTBI) if GCS ≥13. Radiographic findings “positive” if any intracranial blood or skull fracture on head CT. Multivariable logistic regression, adjusted for covariates: age, sex, mechanism, and time to visit.

Of the 170 patients (mean age 46.88, 43.3% female, 74.9% mTBI, median-evaluation 5 months), 48 reported PTH as their most disabling symptom. Disabling PTH was more common in females (58.3% vs 41.7%, p=0.018), those seen <3 months post-TBI (54.2% vs 45.8%, p=0.028), blunt assault (54.2% vs 45.8%, p=0.019), patients with cervicogenic symptoms (47.9% vs 21.0%, p=0.003), and following mTBI (95.8% vs 4.2%, p<0.001). Multivariable analysis showed that patients with moderate-severe TBI (OR 0.09, 95% CI 0.03-0.25, p<0.001), positive radiographic findings (OR 0.21, CI 0.09-0.0.48, p<0.001), and evaluation >3 months (OR 0.38, CI 0.15-0.91, p=0.03) had lower odds of reporting disabling PTH.

Patients with more severe TBI and those with positive imaging findings paradoxically show lower rates of PTH reported as the most disabling symptom. Disabling headaches are also more common acutely than chronically. These findings suggest that the factors driving headache as the primary disabling complaint differ based on TBI severity. Future studies will explore the role of psychosocial factors.