Post-concussion syndrome

Definition

Post-concussion syndrome is a complex disorder in which a variable combination of post-concussion symptoms — such as headaches and dizziness — last for weeks and sometimes months after the injury that caused the concussion.

Concussion is a mild traumatic brain injury, usually occurring after a blow to the head. Loss of consciousness isn't required for a diagnosis of concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome doesn't appear to be associated with the severity of the initial injury.

In most people, post-concussion syndrome symptoms occur within the first seven to 10 days and go away within three months, though they can persist for a year or more. Post-concussion syndrome treatments are aimed at easing specific symptoms.

Symptoms

Post-concussion symptoms include:

• Headaches
• Dizziness
• Fatigue
• Irritability
• Anxiety
• Insomnia
• Loss of concentration and memory
• Noise and light sensitivity

Headaches that occur after a concussion can vary and may feel like tension-type headaches or migraine headaches. Most, however, are tension-type headaches, which may be associated with a neck injury that happened at the same time as the head injury. In some cases, people experience behavior or emotional changes after a mild traumatic brain injury. Family members may notice that the person has become more irritable, suspicious, argumentative or stubborn.

When to see a doctor
See a doctor if you experience a head injury severe enough to cause confusion or amnesia — even if you never lost consciousness. If a concussion occurs while you're playing a sport, don't go back in the game. Seek medical attention so that you don't risk worsening your injury.

Causes

Some experts believe post-concussion symptoms are caused by structural damage to the brain or disruption of neurotransmitter systems, resulting from the impact that caused the concussion. Others believe post-concussion symptoms are related to psychological factors, especially since the most common symptoms — headache, dizziness and sleep problems — are similar to those often experienced by people diagnosed with depression, anxiety or post-traumatic stress disorder. In many cases, both physiological effects of brain trauma and emotional reactions to these effects play a role in the development of symptoms.

Researchers haven't determined why some people who've had concussions develop persistent post-concussion symptoms while others do not. No proven correlation between the severity of the injury and the likelihood of developing persistent post-concussion symptoms exists.

Risk factors

Risk factors for developing post-concussion syndrome include:

• Age. Studies have found increasing age to be a risk factor for post-concussion syndrome.
• Sex. Women are more likely to be diagnosed with post-concussion syndrome, but this may be because women are generally more likely to seek medical care.
• Trauma. Concussions resulting from car collisions, falls, assaults and sports injuries are commonly associated with post-concussion syndrome.

Preparing for your appointment

An emergency room doctor often makes the initial diagnosis of a concussion. Once discharged, you may seek care from your family doctor or general practitioner. However, he or she may refer you to a doctor who specializes in brain and nervous system disorders (neurologist) or a brain rehabilitation specialist (physiatrist).

If you are referred to a specialist, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and know what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements that you're taking.
• Ask a family member or friend to go with you, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your appointment. List your questions from most important to least important in case time runs out. For post-concussion syndrome, some basic questions to ask your doctor include:

• Why are these symptoms still occurring?
• How long will they continue?
• Do I need any additional tests? Do these tests require any special preparation?
• Are there any treatments available, and which do you recommend?
• Are there any activity restrictions that I need to follow?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
• When can I return to work?
• When can I drive again?
• Is it safe to drink alcohol?
• Is it OK to take my medications that were prescribed before the injury?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• How did the initial injury occur?
• Have your symptoms been constant or do they come and go?
• What symptoms are you currently experiencing?
• How often do your symptoms occur?
• Does anything seem to improve your symptoms?
• What, if anything, makes your symptoms worse?
• Are your symptoms getting worse, staying the same or improving?

Tests and diagnosis

No single test will prove you have post-concussion syndrome. Your doctor may want to order a scan of your brain to check for other potential problems that could be causing your symptoms. Computed tomography (CT) imaging is generally the preferred test for detecting brain abnormalities.

If you're experiencing a lot of dizziness, you may be referred to a doctor who specializes in ear, nose and throat complaints. A referral to a psychologist or psychiatrist may be in order if your symptoms include anxiety or depression, or if you're having problems with memory or problem solving.

Treatments and drugs

There is no specific treatment for post-concussion syndrome. Instead, your doctor will treat the individual symptoms you're experiencing. The types of symptoms and their frequency are unique to each person.

Headaches
Medications commonly used for migraines or tension headaches, including some antidepressants, appear to be effective when these types of headaches are associated with post-concussion syndrome. Examples include:

• Amitriptyline. This medication has been widely used for post-traumatic injuries, as well as for symptoms commonly associated with post-concussion syndrome, such as irritability, dizziness and depression.
• Dihydroergotamine (D.H.E. 45) combined with metoclopramide (Reglan). These medications may provide relief for chronic headaches, but they must be administered intravenously in the hospital.

Keep in mind that the overuse of over-the-counter and prescription pain relievers may contribute to persistent post-concussion headaches.

Memory and thinking problems
No medications are currently recommended specifically for the treatment of cognitive problems after mild traumatic brain injury. Time may be the best therapy for post-concussion syndrome if you have cognitive problems, as most of them go away on their own in the weeks to months following the injury.

Certain forms of cognitive therapy may be helpful, including focused rehabilitation that provides training in how to use a pocket calendar, electronic organizer or other techniques to work around memory deficits and attention skills. Relaxation therapy may also help.

Depression and anxiety
The symptoms of post-concussion syndrome often improve after the affected person learns that there is a cause for his or her symptoms, and that they will likely improve with time. Education about the disorder can ease a person's fears and help provide peace of mind. If you're experiencing new or increasing depression or anxiety after a concussion, some treatment options include:

• Psychotherapy. It may be helpful to discuss your concerns with a psychologist or psychiatrist who has experience in working with people with brain injury.
• Medication. To combat anxiety or depression, antidepressants or anti-anxiety medications may be prescribed.

Prevention

The only known way to prevent post-concussion syndrome is to avoid the head injury in the first place.

Avoiding head injuries
Although you can't prepare for every potential situation, here are some tips for avoiding common causes of head injuries:

• Fasten your seat belt whenever you're traveling in a car, and be sure children are in age-appropriate safety seats. Children under 13 are safest riding in the back seat, especially if your car has air bags.
• Use helmets whenever you or your children are bicycling, roller-skating, in-line skating, ice-skating, skiing, snowboarding, playing football, batting or running the bases in softball or baseball, skateboarding, or horseback riding. Wear a helmet when riding a motorcycle.
• Take steps around the house to prevent falls, such as removing small area rugs, improving lighting and installing handrails.