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Pain after brain injury

Pain after traumatic brain injury or stroke takes several forms — persistent headache, pain from spastic muscles and affected joints, shoulder pain on a weakened side, and central pain generated by the injured brain itself. Careful assessment separates them, because each is treated differently.

Pain after a brain injury is common, under-reported and frequently overshadowed — attention understandably goes to mobility, speech and cognition, and pain is left to look after itself. But untreated pain quietly undermines everything else: participation in therapy, sleep, mood and behaviour. Treating it well is not an optional extra in brain injury rehabilitation; it is part of it.

Headache is the most common pain after traumatic brain injury, and it is not one thing. Post-traumatic headache can behave like migraine or tension-type headache; headache can also arise from the upper neck — frequently injured in the same event that injured the brain — or from the occipital nerves. The distinction matters because neck-driven headache can be tested with diagnostic blocks and treated at its source, while migraine-type headache follows a different path. Medication overuse headache, from the very medications taken for the pain, is checked for as well.

Spasticity-related pain. Muscles held in constant overactivity ache; joints pulled into fixed positions become painful and eventually contracted. A clenched hand, a flexed elbow, an inverted foot bearing weight badly — each generates pain that resolves only when the underlying tone is treated. Targeted intramuscular injection, splinting and physiotherapy address the cause rather than masking it.

Shoulder pain on the affected side is common after stroke and hemiplegic brain injury: a weakened shoulder's joint and tendons are vulnerable to strain, subluxation and a stiff, frozen pattern. Assessment distinguishes the mechanical contributors, which respond to positioning, handling and targeted injection, from neuropathic contributors.

Central pain. Injury to pain-processing regions of the brain can itself generate pain — often burning, cold or crushing, on the affected side, sometimes emerging months after the injury. It is frequently missed because scans of the painful area are normal; the problem is upstream. Treatment relies on medications matched to central mechanisms and on rehabilitation approaches, with realistic expectations set honestly.

How assessment is adapted. Communication difficulties, memory gaps and fatigue can make standard assessment unreliable, so appointments here accommodate them: information from family and carers is welcomed, observation supplements self-report, and plans are written down clearly for everyone involved. Goals are set with the person and their support network, and reviewed against what actually changes.

Sources: International Association for the Study of Pain; Stroke Foundation — Clinical Guidelines for Stroke Management; Healthdirect Australia.