What are the best treatment options for persistent post-traumatic headaches when first line agents like TCAs have failed?

Would treat post-traumatic headache according to the primary headache disorder phenotype.

Post-traumatic headaches statistically most often have a migraine disorder phenotype. So if one does not respond to TCA as a preventative medication then I would consider other migraine disorder preventative medications such as topiramate, beta-blockers, venlafaxine, CGRP antagonists, Botox, etc. Would use triptans and/or NSAIDs as abortive treatment. Abortive treatments should be limited to 10-15 days per m...

To my 20 years of experience, you treat most of them like migraine.

It seems to me different pills we know, with different side effects are 60-70% effective. I prefer TCA and sometimes Beta blockers if they have sympathetic overdrive.

Monthly shots CGRP Inhibitors are 80-85% effective.

Botox every 3 months is 90-95% effective if injected in proper ways.

You also have to address their neuropsychiatric symptoms or secondary gains if they have no good response to the above treatments.

Agree with all the above.

Adding screen also for occipital neuralgia and consider blocks. Most importantly it is best to work on a holistic approach that educates on the importance of lifestyle modifications- hydration, exercise, behavioral health support, and medical therapy.

We remind all those that experience pain that it's a Marathon, not a sprint.

Take care.

Agree that most have a pattern of migraine and with a careful history, often there is a prior history of headache disorder (usually undiagnosed). Those individuals tend to have lingering headaches and will require treating the headache based on characteristics. I will say that I have had post-traumatic headaches present as both cluster and TACs with no prior history of such headaches.