post concussion syndrome

What is post concussion syndrome

Post-concussion syndrome is a complex disorder in which various symptoms such as headaches and dizziness that last for weeks and sometimes months after the head injury that caused the concussion. Concussion also known as minor head injury or mild head injury or minor brain injury. Minor head injury and concussion are generally used interchangeably in the medical literature. Concussion (mild head injury) is a temporary and mild injury to the brain caused by a bump, blow or jolt to the head. Concussion is a common sporting injury, particularly in body contact sports (e.g. football, boxing), and recreational activities where falls are common, such as horse riding, cycling, skiing and diving. Concussion can lead to some or all of the following symptoms: a short period of unconsciousness (15-30 minutes or less) {can have no loss of consciousness], confusion, dizziness, post-traumatic amnesia (generally lasting less than 24 hours), persistent, low-grade headaches. A period of amnesia, or not recalling what has happened, is essential to the diagnosis of concussion. At presentation, the Glasgow Coma Scale (GCS) score ranges from 13-15. However, more recent literature suggests, and many clinicians concur, that a Glasgow Coma Scale score of 14 or 15 denotes an injury with a significantly less chance of intracranial injury on CT scan than a GCS score of 13.

Table 1. Glasgow Coma Scale 

(M) Motor Response(E) Eye Opening(V) Verbal Response
(6) Follows commands(4) Natural(5) Oriented & converses
(5) Localizes to pain(3) To voice(4) Disoriented & converses
(4) Withdrawal to pain(2) To pain(3) Inappropriate words
(3) Decorticate(1) No response(2) Incomprehensible sounds
(2) Decerebrate(1) No response
(1) No response

Your score for each is added up to give a total. A slightly different version of the Glasgow Coma Scale (GCS) is used for children under five years of age.

Table 2. Glasgow Coma Scale scores range from 15 to 3

GCS Total ScoreLevel of Brain Injury
13 to 15Mild Brain Injury
9 to 12Moderate Brain Injury
8 to 3Severe Brain Injury

Most people recover completely from their concussion, with no lasting problems. Sometimes symptoms such as headaches and dizziness, will linger for some weeks. Recovery may take longer for those who have had a previous head injury, the elderly, young children, teens and those with substance abuse problems. Some people may also find that it takes longer to recover if they have another concussion. A small number of people may develop “persistent post-concussive syndrome”, where there are a number of symptoms which last for more than three months.

You don’t have to lose consciousness to get a 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, symptoms occur within the first seven to 10 days and go away within three months. Sometimes, they can persist for a year or more. The goal of treatment after concussion is to effectively manage your symptoms.

Possible post concussion syndrome symptoms include:

  • Headaches
    • Post-concussion headaches can vary and may feel like tension-type headaches or migraines. Most often, they are tension-type headaches. These may be associated with a neck injury that happened at the same time as the head injury.
  • Dizziness
  • Problems with memory or concentration
  • Unsteadiness
  • Depression, anxiety and changes in behavior
  • Fatigue
  • Irritability
  • Anxiety
  • Insomnia
  • Loss of concentration and memory
  • Ringing in the ears
  • Blurry vision
  • Noise and light sensitivity
  • Rarely, decreases in taste and smell

The definition of post concussion syndrome remains controversial muddled by conflicting findings regarding symptom duration, an absence of objective neurologic findings, inconsistencies in presentation, poorly understood etiology, and significant methodologic problems in the literature 1). Depending on the definition and the population examined, 29-90% of patients experience post concussion symptoms shortly after the traumatic insult 2).

Although no universally accepted definition of post concussion syndrome exists, most of the literature defines the syndrome as the development of at least 3 of the following symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light. Confusion exists in the literature, with some authors defining it as symptoms of at least 3 months’ duration, while others define it as symptoms appearing within the first week. Post concussion syndrome is loosely defined as symptom occurrence and persistence within several weeks after the initial insult. In defining persistent post concussive syndrome, most authors use greater than one month, and still others use 6 months or a year. However, it generally applies to ongoing chronic symptoms that continue past expected resolution.

In the Diagnostic and Statistics Manual (DSM 5) 3) postconcussion syndrome is given a diagnosis of either major or mild neurocognitive disorder due to traumatic brain injury.

The DSM-5 criteria for neurocognitive disorder due to traumatic brain injury include the following:

  • 1. Cognitive deficits in attention or memory and;
  • 2.  At least three or more symptoms including;
    • headache,
    • dizziness,
    • fatigue,
    • irritability,
    • apathy,
    • personality change,
    • sleep disturbance,
    • affective disturbance.

To meet the Diagnostic and Statistics Manual criteria for post concussion syndrome, symptoms must be present for three months or greater.

In comparison, the World Health Organization’s International Classification of Diseases (Post Concussion Syndrome ICD-10) defines post concussion syndrome as the presence of three or more of the following symptoms that must be present within the first month post-injury including:

  • Headache,
  • Dizziness,
  • Fatigue,
  • Irritability,
  • Insomnia, and
  • Concentration or memory difficulty.

One of the well acknowledged limitations of the existing definitions of post concussion syndrome is their poor specificity and their inclusion of symptoms that are frequently experienced by patients with other neurological disorders such as depression and migraine as well healthy children and adolescents during everyday life 4). Studies suggest that there is little agreement between these definitions in clinical practice 5) and that the post concussion syndrome ICD-10 definition is six times more sensitive than the DSM definition 6). In addition to these standardized definitions, other non-standardized definitions such as prolonged symptoms or recovery (symptoms lasting greater than 7–28 days) 7), persistent post concussion symptoms 8), and delayed symptom resolution 9) have also been used to describe post concussion syndrome patients. Such descriptions have not only created confusion in the literature but limit comparisons between these studies. Although standardized definitions of post concussion syndrome are important for research purposes, many athletes with symptoms persisting weeks after injury will not meet these post concussion syndrome criteria yet experience significant impairments in quality of life, including feelings of worry and hopelessness regarding the effect of their injury on return to school and sport activities. Importantly, many athletes also begin to experience aerobic deconditioning within 1–2 weeks of inactivity that can also manifest as fatigue, irritability, and sleep disturbance that can be difficult to distinguish from symptoms of post concussion syndrome. Taken together, many athletes will not meet any standardized criteria for post concussion syndrome; however, early active rehabilitation should be considered in those with symptoms persisting beyond 1.5–2 weeks to avoid aerobic deconditioning and help optimize neurological recovery.

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.

Danger Signs in Adults

In rare cases, a person with a concussion may form a dangerous blood clot that crowds the brain against the skull. Contact your health care professional or emergency department right away if you experience these danger signs after a bump, blow, or jolt to your head or body:

  • Headache that gets worse and does not go away.
  • Weakness, numbness or decreased coordination.
  • Repeated vomiting or nausea.
  • Slurred speech.

The people checking on you should take you to an emergency department right away if you:

  • Look very drowsy or cannot wake up.
  • Have one pupil (the black part in the middle of the eye) larger than the other.
  • Have convulsions or seizures.
  • Cannot recognize people or places.
  • Are getting more and more confused, restless, or agitated.
  • Have unusual behavior.
  • Lose consciousness.

Danger Signs in Children

Take your child to the emergency department right away if they received a bump, blow, or jolt to the head or body, and:

  • Have any of the danger signs for adults listed above.
  • Will not stop crying and are inconsolable.
  • Will not nurse or eat.

Acute sports-related concussion and post concussion syndrome pathophysiology

Basic science and neuroimaging research continues to shape our understanding of the pathophysiological mechanisms that govern clinical symptoms in acute concussion and post concussion syndrome. Historically, the clinical manifestations of concussion were thought to arise primarily as a result of functional disturbances in brain physiology rather than a structural brain injury 10). However, recent research has begun to challenge this assumption. Animal models of concussion and traumatic brain injury suggest that the acute phase of injury is primarily characterized by an increase in cerebral cellular energy demand coupled by insufficient energy substrate delivery resulting in a metabolic energy crisis 11). This metabolic mismatch occurs during a period in which alterations in neuronal depolarization, ion transport, glycolysis, mitochondrial function and excitatory neurotransmitter release are met with reductions in global and regional cerebral blood flow. Although the temporal course of these metabolic processes has been well documented in animal studies, the magnitude and duration of these pathophysiological alterations in humans remain poorly understood. Among the secondary brain injury processes that play an important role in the pathophysiology of moderate, and severe traumatic brain injury is ischemia. Studies suggest that inadequate cerebral blood flow delivery during acute traumatic brain injury is an independent risk factor for poor outcome and death 12) while 90% of fatal traumatic brain injury patients demonstrate histological evidence of ischemia at autopsy 13). That patients often report an exacerbation of concussion symptoms with increased physical and cognitive exercise suggests that a mismatch between cerebral metabolic demand and cerebral blood flow delivery may potentially mediate some of the symptoms of acute sports-related concussion and post concussion syndrome. Recent studies using magnetic resonance imaging (MRI)-based quantitative cerebral blood flow sequences have demonstrated global and regional reductions in resting cerebral blood flow in adolescents and collegiate athletes with sports-related concussion 14). Despite these findings, the relationship between exercise intolerance and cerebral blood flow dysregulation in concussion remains poorly understood but may be mediated by alterations in autonomic nervous system function. Concussion patients have been found to demonstrate physiological markers of increased sympathetic nervous system output such as higher resting heart rates and blood pressure 15). Furthermore, preliminary evidence suggests that concussion is associated with cerebral blood flow dysregulation that is mediated through alterations in carbon dioxide sensitivity 16) and cerebrovascular reactivity 17). Given that mean arterial blood pressure and PaCO2 are important mediators of global and regional cerebral blood flow, it is possible that dysfunction within these systems is responsible for some of the clinical manifestations of acute sports-related concussion and post concussion syndrome.

In addition to functional changes in neurovascular physiology, accumulating studies suggest that acute sports-related concussion may also be associated with microstructural white matter injury. Studies using diffusion tensor imaging (DTI) have detected group differences in several quantitative diffusion tensor imaging (DTI) indices between sports-related concussion patients and healthy controls 18); however, the proportion of sports-related concussion patients who develop these changes remains unclear as does the relationship of these changes to the severity and volume of head injuries, underlying neuropathology, as well as clinical outcomes. Evidence also suggests that concussion and mtraumatic brain injury are associated with the release of proteins such as S100β, glial fibrillary acidic protein, tau, and αII-spectrin N-terminal fragment (SNTF) 19). Although preliminary studies suggest these proteins can be readily detected in the peripheral blood and cerebrospinal fluid of concussion and traumatic brain injury patients, future work is needed to establish the clinical utility of these potential biomarkers in individual patient management.

While these research advances support the notion that acute sports-related concussion is mediated by alterations in brain cellular and cerebrovascular physiology, the extent to which these processes mediate the clinical manifestations of post concussion syndrome remains unclear. Clinically, some symptoms of post concussion syndrome appear reflective of a persistent global metabolic brain injury while others point to isolated dysfunction of neurological sub-systems or co-existing neurological conditions that are multi-factorial in etiology. As such, the initial assessment of the athlete with post concussion syndrome should not be simply aimed at cataloging concussion symptoms, but rather combining elements of the clinical history and physical examination with results of other supplementary tests to elucidate the pathophysiological processes that govern persistent symptoms.

Post concussion syndrome long term effects

The post concussion syndrome symptoms can be divided into the following categories:

  • Cognitive (thinking) symptoms
  • Physical symptoms
  • Emotional and behavioral symptoms

You might experience any number of these symptoms at different times and the effects of a minor head injury are different for everyone.

Cognitive (thinking) symptoms

Cognitive symptoms are thinking difficulties. These symptoms are made worse by worry and stress, so it is important to try not to let the difficulties upset you too much.

Also, it is important to remember that thinking difficulties are experienced by everybody in everyday life. If you are experiencing difficulties after a head injury you might find yourself overestimating your pre-injury abilities and blaming any small errors on your injury. Try to maintain a realistic sense of how you are functioning now compared to before the injury and don’t mislabel normal thinking mistakes as evidence of effects of the injury.

Memory problems

Loss of memory can make everyday life frustrating. You may be able to remember your wedding day, but not where you put your shoes. This can be because you’re having problems concentrating and also because minor head injury disrupts the memory system for a while. Your memory should improve as you recover, but in the meantime there are ways that you can help yourself.

  • Use calendars and diaries to remind you of events
  • Use stick-on labels as reminders, for example, to make sure you lock the back door
  • Carry a notebook to write down new information and things you need to remember
  • Use cooking timers in the kitchen
  • Assign a specific place for everyday items and make sure you keep them there
  • Use calendars on mobile phones and pagers
  • Break down information into small chunks to make it easier to remember
  • Get plenty of sleep and rest. Your memory will work better if you are fresh and rested

Some people might resist using these strategies, claiming that they don’t want to become dependent on them, or that they want their own memory to do the work. This resistance should be discouraged because it is important to use anything that will aid memory. There is no evidence to suggest that using external aids and strategies slows down the natural recovery of memory function.

Difficulties with attention and concentration

The ability to concentrate and attend to things is very often significantly reduced by minor head injury, particularly in the first few days. The problem usually takes two forms.

Firstly, it may be difficult to concentrate on more than one task, or to concentrate when there are distractions, such as when children are playing or the TV is on. You may find it difficult to cope in large groups of people when several conversations are going on at once.

Secondly, the concentration span can be reduced so you may find it difficult to concentrate on one thing for as long as usual. This can be particularly disruptive to work and study.

Some suggestions for dealing with attention and concentration problems are as follows:

  • Start a task when you are feeling fresh, then stop as your attention begins to fade
  • Cut out background noise
  • Try to carry out important or complex tasks in a quiet area
  • Do one task at a time
  • Break down tasks into manageable chunks
  • Concentration depends on being alert, so if you are tired and can’t concentrate, have a rest

Difficulties with planning and organizing

You may find it difficult to plan and organize. This can be frustrating, especially if these skills are needed for your job, and even everyday tasks such as preparing meals can become difficult. Some suggestions to help compensate for these difficulties are:

  • Try to stick to a daily routine
  • If your job requires high levels of planning and organization, consider returning on part-time hours and taking on lighter duties until you feel better
  • Try to stick to simple meal plans – follow set recipes from cookery books and, if possible, get someone to help
  • Make ‘to do’ lists
  • Set realistic goals for each day and don’t be too disheartened if you don’t always achieve them
  • Use external aids, such as mobile phones, pagers, electronic watches or tablets, to provide reminders of tasks
  • Use a diary, journal or online calendar (e.g. Google Calendar)
  • Do one task at a time
  • Try to plan and carry out tasks in a quiet area
  • Get plenty of rest

Physical symptoms

Headaches

Headaches are a common complaint after minor head injury, particularly in the early stages. Remember, if the headache is severe, persistent and unrelieved by ordinary painkillers in the few days after injury then it can be a sign of complications and you should return to the emergency department.

In the later stages, headaches are often caused by other difficulties. For example, if you are fatigued, stressed, physically tense, or struggling with your concentration, you may get headaches.

At this stage the following suggestions may help:

  • Write down when you get headaches – you may be able to see if there is a time or place that causes them and plan for that
  • Try relaxation techniques – often headaches are due to muscle tension and techniques such as meditation and even moderate exercise could help
  • Try not to take too many painkillers (especially ones containing codeine) as these can become addictive and can actually make headaches worse in the long run

You should discuss these issues with your doctor or other healthcare professional.

Dizziness, balance and co-ordination problems

Minor head injury often disrupts the balance organs in the ears, so it is common in the first few days after injury to experience vertigo, where the world seems to spin around you. The slowing of information processing caused by the injury can also lead to a feeling of unreality, disorientation and a sense of ‘floating’. Symptoms which are closely related to dizziness are problems with balance and co-ordination. You may feel wobbly and unsteady on your feet because of the dizziness. You may also drop things or bump into people and objects due to your brain processing information less efficiently than usual.

You can be assured that these problems are common and usually settle within a few days or weeks and then disappear entirely. Take greater care in situations which could be dangerous, such as crossing the road, and don’t drive until the symptoms have gone. If the symptoms are very problematic or persistent then see your doctor as there are some therapeutic techniques which may help.

Visual problems

It is important to remember that if you experience blurred or double vision in the first few days after the injury you should return to the emergency department. If you still experience double vision in the longer term then legally you must not drive and should consult your doctor about this. Some other problems with vision that are common after minor head injury are photophobia (sensitivity to light) and loss of depth perception.

These symptoms are usually mild and should clear up within a week or two. However, if they persist or are very debilitating then see your doctor.

Be extra careful in situations where clear, accurate vision is required and avoid driving until the symptoms have cleared. If your depth perception is affected, be very careful when crossing the road.

Sensitivity to light is one of the most common visual problems after minor head injury. This can even be triggered by indoor lighting, especially fluorescent lights and it helps to wear sunglasses, even indoors. This problem can remain when other symptoms have cleared, meaning sometimes people have to carry on wearing dark glasses, even when they have otherwise recovered.

Hearing problems

Hearing problems usually take the following forms:

  • Mild deafness
  • Sensitivity to loud noise
  • Tinnitus – the perception of sound without external cause. This can take the form of ringing, buzzing, humming, whistling, whining or other noises

Any deafness could be caused by damage to the inner ear or nerves in the brain and should be reported to a doctor to rule these possibilities out. Alternatively, you may only notice the deafness when you are in an environment such as a party, when many conversations are going on at once. In this case the deafness may be caused by impaired attention and concentration and should get better as information processing ability gets back to normal.

Sensitivity to loud noise is common after minor head injury, because coping with loud noise requires lots of energy and concentration. As with other symptoms this will go away in time, but until it does the only real strategy is to avoid noisy atmospheres that you find distressing. Tell family and friends about the problem and ask them to respect your need for a quiet environment.

Avoiding noisy situations can lead to avoiding environments that you would usually enjoy, such as parties and football matches. Talk to family and friends about this and try to organize enjoyable, social occasions where you can control the noise levels. For example, ask a select few friends around for a quiet dinner.

Tinnitus is not one of the most common effects of minor head injury but can be extremely distressing when it occurs. See a doctor for an examination to rule out possible treatable causes and ask about referral to an ear specialist.

Communication problems

You may find it difficult to express yourself in an accurate way. You may not be able to find the right words, or you might muddle sentences. The following suggestions may help:

  • Be patient with yourself
  • Take the time to find the right words
  • Prepare what you want to say by thinking of key words or making lists
  • Explain to people that they need to be patient with you

You can also ask your doctor to refer you to a Speech and Language Pathologist who could be able to help.

Sleep problems

People tend to need more sleep than usual for a while after a minor head injury. Getting enough sleep and maintaining good sleep habits are essential to a good recovery. Lack of sleep leads to fatigue, which can worsen a lot of the other problems, such as difficulty concentrating, headaches and irritability.

The following dos and don’ts should help you to maintain good sleep habits:

DO

  • Do establish a regular routine by going to bed and getting up at the same times each day
  • Do take ‘power naps’ during the day but try to avoid doing so after 4pm, as this may disrupt your sleep/wake cycle
  • Do use an alarm clock to wake you from naps to ensure you don’t sleep too long
  • Do use your bed for sleeping only – don’t watch TV in bed
  • Do develop rituals before bedtime to wind down and relax; for example, taking a bath or listening to gentle music
  • Do get regular exposure to the outdoors and natural light
  • Do exercise regularly
  • Do create a calm bedroom that is cool, dark and quiet – earplugs and blackout blinds can help
  • Do avoid stress and worry at bedtime
  • Do use relaxation techniques

DON’T

  • Don’t push yourself to stay awake and don’t worry about ‘giving in’ to tiredness
  • Don’t eat heavy meals late in the evening
  • Don’t look at the time when you wake up as this may make it difficult to get back to sleep
  • Don’t have too much caffeine, nicotine or alcohol in the evening

As you recover you will find that you need less sleep. However, you may find that you can’t get to sleep, or wake during the night. Typically, this can be made worse by:

  • Stress – This may be caused by frustration with your rate of recovery, or by other people expecting you to recover sooner. Financial or family problems may also contribute, particularly if you are still absent from work.
  • Changes in your sleep cycle – If you don’t have regular times for getting up and going to bed then your sleep might be affected.

At this stage there are a number of strategies that can help:

  • Relaxation training. Ask your doctor about techniques such as meditation and yoga. You could also ask about referral to a counselor who can teach relaxation techniques.
  • If you have specific worries that are affecting your sleep try to resolve them. Talk the matter through with a close friend or family member, or ask your doctor about referral to a counselor.
  • If you have cut out your daytime nap and are feeling more tired you could try taking naps again and then gradually phasing them out. If you are still taking daytime naps and are having trouble getting to sleep at night try cutting out the naps.

Fatigue

This is one of the most common effects of minor head injury and it is also the most important symptom to control, as being tired affects everything you do. You may get tired more quickly than before and even simple actions, like dressing or cooking, can make you feel exhausted.

Following the suggestions on sleep problems should help you to manage your fatigue and there are a number of other things you could try:

  • Set a daily routine – prioritise and set realistic targets to achieve each day
  • Pace your workload by taking lots of short breaks during tasks
  • Think about when you are most tired – try to do your more difficult and demanding tasks at times when you are most awake
  • Identify the triggers to your fatigue – if you can recognize the activities and situations that are most tiring you can plan for them in your daily routine
  • Build rest times into your day
  • Don’t overdo it, but try to build activities up slowly over time
  • Explain to other people that you get tired – it can be difficult to recognize the signs of fatigue after a head injury, so ask family and friends to let you know when you appear fatigued and the signs they notice
  • If going back to work, start with fewer hours and build up gradually

Don’t push yourself or you may get into a cycle where you don’t get enough rest. In the space of a few days you could become completely exhausted and all other symptoms may get worse. This is referred to as ‘boom and bust’ and you should take care to avoid it. Your fatigue will decrease as you start to feel better but can return, along with other symptoms, if you try to do too much too soon.

Changes to taste or smell

Following a minor head injury some people report that their senses of taste and/or smell have been affected. The senses of taste and smell are linked so if the sense of smell is lost then the sense of taste will be affected.

Changes to the senses of taste and smell can be extremely distressing and sadly there are no cures available. Recovery often occurs spontaneously after minor head injury, often within the first three months.

In the meantime, there are strategies you can use to compensate:

  • Fit a smoke alarm, have electrical appliances regularly serviced, unplug appliances when not in use and use an alarm to remind you of food cooking in the oven.
  • Have gas appliances regularly serviced and fit a gas detector. You might want to consider fitting an electric cooker and fire.
  • Always eat or throw out food by its ‘use by’ date. If in doubt, throw it out. Clear out the fridge and cupboards regularly.
  • Try to keep products such as drinks, bleach, cleaning chemicals and solvents in their original bottles/packets. Make sure they are clearly labelled.
  • Empty rubbish bins regularly and keep toilets and kitchen appliances clean to avoid health risks.
  • Be aware of the need to wash yourself, your clothes and bed-sheets regularly. Use an antiperspirant deodorant and perhaps a shoe deodoriser too. You could ask a close friend or family member to advise on hygiene problems.
  • It is important to keep your mouth clean and brush teeth regularly and thoroughly, including brushing your tongue as well. Using mouthwash and dental floss helps. It is important to pay regular visits to the dentist.
  • Take precautions and follow manufacturer’s advice when using products such as paint, cleaning chemicals and solvents. Wear a protective mask, ensure rooms are well ventilated and don’t smoke.

It is also important to remember to maintain a healthy, balanced diet, as loss of taste and smell can affect eating habits.

Sexual problems

You may find that you have little or no sexual urge, or the complete opposite. In some cases this can continue longer than other symptoms and can be a major factor in preventing a return to a full life.

If you have a partner it is important to speak to them about this, as it can make relationships difficult. If you don’t have a partner it is also important to discuss this with someone, as it can affect the way you feel about yourself and can lead to problems with depression.

The problems may be caused by several factors. They may be the direct result of injury to the brain, but after a minor head injury they are more likely to be a result of the psychological effects of other symptoms.

Alternatively, sexual problems can be a result of damage to the pituitary gland, which is situated at the base of the brain and controls hormone secretion in the body.

The following suggestions may help:

  • Seek advice from your doctor
  • Seek referral to a clinical psychologist or neuropsychologist who specializes in sexual difficulties after head injury
  • Speak to a sex therapist or a specialist organization, who deals with sex and relationship issues
  • If there are possible hormonal problems then discuss it with your doctor and ask about referral to an endocrinologist

Nausea

It is common to experience a sensation of nausea after a minor head injury, especially in the first few days. If the nausea is severe or accompanied by vomiting, then it is important to seek medical advice. However, although it can be very unpleasant, usually the symptom isn’t serious, is relatively mild and goes away in time. Nausea may be a result of the injury itself or could be caused by medication you’re taking. As with other symptoms, if the problem persists it would be a good idea to discuss it with a doctor.

Emotional and behavioral symptoms

Irritability and anger

Things that wouldn’t bother you before your head injury may anger or irritate you. You might lose your temper for no reason or snap at family and friends. This happens because self-control and calmness require the brain to be fresh and working well. As you recover the problem should improve, but it can be very upsetting to you and those around you, so it is important to try to manage it.

  • Fatigue and lack of sleep can cause irritability – if you are feeling very tired follow the suggestions in the ‘Sleep problems’ and ‘Fatigue’ sections (see above).
  • A daily routine will make the causes of irritability easier to recognize – try to spot what activities contribute to irritability and anger and what times of day the problem is at its worst
  • Find alternative, healthy outlets for anger, for example, exercising at the gym
  • Try relaxation techniques such as meditation, or just make sure you make time in your day to relax in whatever way you find most comfortable, such as listening to music, reading or having a long bath
  • If you find yourself in a situation where you recognize yourself about to lose control, take time out by leaving the room and taking some deep breaths.

Depression and anxiety

These problems are common after minor head injury and are often caused by other difficulties, such as:

  • Tiredness
  • Concentration problems
  • Difficulty controlling emotions
  • Symptoms persisting longer than expected
  • Financial concerns
  • Family and relationship problems

Worrying about your health can be very stressful and this may be the longest period you have ever felt ill. If the symptoms don’t clear up as quickly as you had hoped then depression and anxiety can become more of an issue.

One factor that can lead to depression is a lack of information on your condition, which makes some people think they are ‘going mad’. Be assured that your symptoms are perfectly normal and should clear even if it takes longer than you expect.

Some important things to remember in order to help yourself are:

  • Try to maintain good sleep habits – depression and anxiety lead to interrupted sleep and the resulting tiredness makes the problems worse
  • Try relaxation techniques such as meditation
  • Write down your worries and work through them one at a time
  • Try to think positively and don’t dwell too much on negative things – maintaining a positive outlook can significantly improve your rate of recovery
  • Talk through your worries with family, friends, support group or doctor

If your problems persist and you are worried about your state of mind see your doctor. Make sure the doctor understands that your depression stems from your injury and its effects and ask about referral to a neuropsychologist or a counselor who specializes in depression after head injury. It is particularly important to seek professional advice if you have a history of depression from before the injury, as this may make it more likely that you will experience depression now.

Lack of insight

After minor head injury, many people are unable to accurately judge their own actions and may behave inappropriately without realizing it.

This is fairly common in the first few days after injury when people may be uncharacteristically reckless and deny that they have any problems. Often people will insist on returning to work or to driving before they are ready. Usually, after a week or two, people will suddenly realize what they have been doing and find it difficult to believe they could have acted that way.

On occasions, the lack of insight might persist for longer and may result in denial of problems at home or at work, or in socially unacceptable behaviour. This can be very distressing for friends, family and workmates and is a very difficult problem to deal with.

Generally the problem will resolve itself in time, but there are some things that family and friends can do to help:

  • Provide verbal feedback on behavior – tell the person when they have behaved inappropriately, but do so in a discrete and non-confrontational way
  • Meet others in a similar position

Other issues

Alcohol

Don’t expect to be able to deal with alcohol in the usual way. A head injury can greatly reduce tolerance to alcohol so you should abstain as much as possible until you have fully recovered. Avoid alcohol completely in the first few days after injury.

Driving

Driving is a complex skill which we usually take for granted, but the effects of a minor head injury can make it very dangerous. Try to avoid driving until your concentration and reactions are good enough, then start carefully and avoid long, stressful journeys and heavy traffic. In some cases it may be necessary to inform the licensing authority in your area.

How long does post concussion syndrome last

True prognosis is difficult to define given that many patients with minor symptoms may not enter the health care system and those that participate in research appear to have more significant symptoms at baseline. In addition, a wide heterogeneity exists in patients enrolled in studies.

Most patients recover fully in less than 3 months, although some small studies suggest persistence of minor cognitive defects for asymptomatic minor traumatic brain injury patients 20).

Approximately 15% of patients complain of problems more than 12 months after injury. This group is likely to experience persistent and intrusive symptoms that may be refractory to treatment and impose a lifelong disability.

At least one study found the persistence of dizziness as a symptom seemed to portend a longer and more significant symptom complex 21). Other studies found the depression, pain, and symptom invalidity were correlated with longer and worse symptoms 22). Another found patients with early clinical symptoms, such as headache, dizziness, and intracranial lesions were more likely to have persistent post concussion syndrome.

Post concussion syndrome is commonly associated with multiple concussions, but in one series, 23.1% of patients experienced post concussion syndrome after only 1 concussion (average was 3.3 concussions). Median duration of symptoms in this series was 7 months 23).

Hiploylee et al 24) found that time to recovery often depended on the number of initial symptoms reported, with each symptom reducing recovery rate by about 20%. They also found that post concussion syndrome may be permanent if recovery hasn’t occurred within 3 years. Those who did not recover were more likely to be noncompliant regarding the recommendation to not return to play.

Post concussion syndrome causes

Some experts believe post-concussion symptoms are caused by structural damage to the brain or disruption of the messaging system within the nerves, caused by 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. There’s no proven connection between the severity of the injury and the likelihood of developing persistent post-concussion symptoms.

However, some research shows that certain factors are more common in people who develop post-concussion syndrome compared with those who don’t develop the syndrome. These factors include a history of depression, anxiety, post-traumatic stress disorder, significant life stressors, a poor social support system and lack of coping skills.

More research is still needed to better understand how and why post-concussion syndrome happens after some injuries and not others.

Risk factors for developing post-concussion syndrome

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.

Post concussion syndrome 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 12 are safest riding in the back seat, especially if your car has air bags.
  • All children aged 12 and under should ride in the back seat. Airbags can kill young children riding in the front seat. Never place a rear-facing car seat in the front seat or in front of an air bag.
  • Never driving while under the influence of alcohol or drugs.
  • 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 action at home to prevent falls, such as removing small area rugs, improving lighting and installing handrails.

Post concussion syndrome symptoms

Post-concussion symptoms include:

  • Headaches
  • Dizziness
  • Fatigue
  • Irritability
  • Anxiety
  • Insomnia
  • Loss of concentration and memory
  • Ringing in the ears
  • Blurry vision
  • Noise and light sensitivity
  • Rarely, decreases in taste and smell

Post-concussion headaches can vary and may feel like tension-type headaches or migraines. Most often, they are tension-type headaches. These may be associated with a neck injury that happened at the same time as the head injury.

Table 3. Post concussion syndrome symptoms categories

Thinking/
Remembering
PhysicalEmotional/
Mood
Sleep
Difficulty thinking clearlyHeadache

Fuzzy or blurry vision

IrritabilitySleeping more than usual
Feeling slowed downNausea or vomiting
(early on)Dizziness
SadnessSleep less than usual
Difficulty concentratingSensitivity to noise or light

Balance problems

More emotionalTrouble falling asleep
Difficulty remembering new informationFeeling tired, having no energyNervousness or anxiety

Some of these symptoms may appear right away. Others may not be noticed for days or months after the injury, or until the person resumes their everyday life. Sometimes, people do not recognize or admit that they are having problems. Others may not understand their problems and how the symptoms they are experiencing impact their daily activities.

The signs and symptoms of a concussion can be difficult to sort out. Early on, problems may be overlooked by the person with the concussion, family members, or doctors. People may look fine even though they are acting or feeling differently.

Post concussion syndrome 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. A computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be performed to detect structural 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 licensed counselor may be in order if your symptoms include anxiety or depression, or if you’re having problems with memory or problem-solving.

Post concussion syndrome treatment

No treatments have been proven effective, though neurotherapy or quantitative EEG biofeedback is a modality that has been shown in recent studies to improve symptoms of post concussion syndrome. More controlled studies are needed at this point. Your doctor will treat the individual symptoms you’re experiencing. The types of symptoms and their frequency are different for everyone.

A neurologist, physical medicine specialist, primary care physician, or psychologist specializing in these disorders usually coordinates treatment.

Headaches

Medications commonly used for migraines or tension-type headaches, including some antidepressants, antihypertensive agents and anti-epileptic agents, appear to be effective when these types of headaches are associated with post-concussion syndrome. Medications are usually specific to the individual, so you and your doctor will discuss which are most appropriate for you.

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 after the injury.

Certain forms of cognitive therapy may be helpful, including focused rehabilitation that provides training in the specific areas that you need to strengthen. Some people may need occupational or speech therapy. Stress can increase intensity of cognitive symptoms and learning stress management strategies can be helpful to decrease cognitive symptoms. Relaxation therapy also may 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.

Playing sports

If you have had a minor head injury and play contact sports, make sure you seek medical advice before continuing to play. Repeated minor head injuries can have cumulative effects and it is dangerous to expose yourself to the risk of a second injury whilst still recovering from the first one. Sports such as rugby have a compulsory rest period, followed by a gradual return to play, but other sports, such as football, have less rigorous rules. Consult your doctor and don’t feel rushed to return to contact sport until you are ready.

References   [ + ]

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