Postconcussion Syndrome

Javier Cárdenas, MD

Neither Dr. Cárdenas nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Case Vignette

A 19-year-old female soccer player for a division 1 National Collegiate Athletic Association university was referred to the clinic by the team athletic trainer 1 month after sustaining a concussion for persistent headaches. The student-athlete’s initial complaints were headache, insomnia, anxiety, and a decline in academic performance. Headaches were described as a pressure sensation with photophobia but no nausea or vomiting. Frequency was daily with an intolerance to physical and cognitive activity. Headaches were partially relieved with daily ibuprofen. Her cognitive complaints were notable for word-finding and short-term memory problems. Academic adaptations were provided by the institution for note taking and additional time for assignments and tests. She described her insomnia as difficulty falling asleep but not staying asleep. Appropriate sleep hygiene was practiced, but she reported that she could not “shut off my brain.” Her history was notable for premorbid migraine headaches with a frequency of one per month and anxiety. Her examination was normal with the exception of photosensitivity on ophthalmologic examination and imbalance.

The student athlete’s evaluation and treatment plan included noncontrast MRI of the brain with susceptibility imaging, low-dose nortriptyline, physical and vestibular therapy, sports psychology consultation, and neuropsychological (NP) evaluation. MRI results were normal, and NP testing revealed inattention, but otherwise intact cognitive function. Within 1 week of treatment, she reported a decrease in headache frequency and intensity, as well as an improvement in sleep. She was able to tolerate physical and cognitive exertion, and her balance improved with therapy. When symptom free with heavy noncontact physical activity and no longer requiring academic adaptations, she successfully returned to competition. Her anxiety resolved when she returned to physical activity, but she continued sports psychology for treatment of her premorbid anxiety.

Definition

The challenges in defining postconcussion syndrome (PCS) are similar to the challenges in defining concussion. The timeline in which the symptoms of a concussion begin are typically within minutes of the injury but can sometimes take hours and (less commonly) days to develop. The symptoms that patients report in the days and weeks after a concussion are typically referred to as postconcussive symptoms. This is distinguished from postconcussion syndrome, which is defined by the Diagnostic and Statistical Manual IV as physical, behavioral, and cognitive symptoms that “last at least three months.”¹ Although clinicians and researchers fret and debate the definition, patients are equally, if not more confused, often asking, “Do I have a concussion?” when referring to their existing symptomatology regardless of timeframe. For the sake of argument, this chapter refers to postconcussive syndrome and persistent postconcussive symptoms as the physical, behavioral, and cognitive symptoms that persist (or worsen) beyond the typical recovery as defined earlier in the book (Table 27-1). This is particularly relevant when treating student athletes because the timing of intervention is critical to the academic success of the patient.

Generally, symptoms associated with concussion fall into three broad categories: physical, behavioral, and cognitive. Physical symptoms include headaches, dizziness, visual disturbance, and sleep disturbance. Seizures and endocrine disturbances are uncommonly a result of concussion but are addressed later in the chapter because they can be a consequence of moderate and severe traumatic brain injury (TBI). Behavioral symptoms typically include irritability, depression, and anxiety. Less frequently, psychosis can occur after concussion but should be addressed when present. Last, the cognitive symptoms after concussion include problems with focus, short-term
memory, and word finding, although more specific disturbances in cognition have been described in the literature and are elicited by NP evaluation.

TABLE 27-1 Clinical approach to postconcussion syndrome

Domain	Physical	Behavioral	Cognitive
Symptoms	Headache, dizziness, sleep disturbance, vision change, seizures, endocrine abnormalities	Irritability, anxiety, depression, psychosis	Inattention, memory deficit, word-finding difficulty, slow processing speed
Evaluation	Examination, imaging, laboratory testing, electrophysiology	Psychiatric consultation, psychological evaluation	Neuropsychological testing
Treatment	Medications, physical and vestibular therapy, occupational therapy	Medications, behavioral psychology, counseling	Speech and cognitive therapy, medication

While evaluating a patient with PCS (or any TBI, for that matter), it is important to recognize that the symptoms have overlapping influence like that of a Venn diagram. As such, headaches and migraines can negatively affect mood as well as impair cognitive performance.² Additionally, depression and anxiety can influence focus and academic performance and result in a lower threshold for pain.³ The overlap in symptomatology underscores the importance of taking a holistic approach to evaluation and management of patients with persistent postconcussive symptoms. Finally, the most relevant risk factors for developing PCS are the presence of conditions before the concussion. For example, patients with a history of migraine typically have worsening of their headaches after a concussion, and those with attention and learning problems have worsening academic and cognitive performance.⁴ The most at risk for developing long-term symptoms are those with a history of anxiety or depression because psychological disturbance is the most common cause of PCS.⁵

Physical Symptoms

Headache

Postconcussive headache is the most common symptom reported by individuals who sustain a concussion. Interestingly, this is a less common feature of those with moderate or severe TBIs.⁶ Postconcussive headaches affect 30% to 90% of athletes after a head injury.⁷ The description of the headaches is most like that of migraine. Specifically, photophobia, phonophobia, nausea, and vomiting are commonly associated with the headache.⁸ In contrast, persistent headaches in PCS have features of chronic daily headache and medication overuse headache.⁹

The evaluation of an individual with persistent headache associated with a concussion includes a detailed history, particularly noting a personal and family history of migraine. Adolescence is the most common time for migraines to present,¹⁰ and concussion can often be the inciting event for those with a strong family history. Worsening of migraine headaches in frequency, intensity, or both is common for those with a personal history of migraine. Modifying factors often include worsening with bright lights, loud noise, physical exertion, and cognitive exertion. Others may also report feeling car sick or bothered by rapid movements. Associated physical symptoms such as dizziness and visual disturbance may exacerbate symptoms. Improvement is commonly associated with sleep, analgesic medication, and avoiding exacerbating environments. Red flags in the history include disturbances in other neurologic function, such as altered mental status, seizures, worsening of vision, and weakness.

The physical examination of a patient with postconcussive headaches is key to determining further treatment and testing. General observation of distress or pain is common with postconcussive headaches, especially under the bright fluorescent lights typically found in a clinical setting. As such, pupillary evaluation and funduscopic examination tend to elicit a negative physical response. It is critically important to perform a complete cranial nerve evaluation because headache may represent an underlying intracranial abnormality. Red flags on neurologic examination in the presence of persistent headache include papilledema, hyperreflexia, and any cranial neuropathy.

Management of postconcussive headaches depends largely on the history and physical examination findings. Those with persistent or worsening headaches warrant neurologic imaging. Although CT scan of the head is valuable in the acute setting, the risks of radiation exposure, especially in a young population, far outweigh the benefit.¹¹ MRI of the brain can provide greater detail of intracranial structures while avoiding unnecessary radiation exposure. MRI studies for trauma do not require contrast enhancement but should include gradient echo sequences.
Gradient echo sequences are readily available sequences and can detect hemosiderin deposition such as those found in shear injury and diffuse axonal injury. A host of emerging techniques and sequences appear to confer greater sensitivity to concussion, but they are not widely commercially available. These include, but are not limited to, susceptibility-weighted imaging, diffusion tensor imaging, and diffusion kurtosis imaging.¹² Lumbar puncture is infrequently indicated but should be considered if headaches worsen or are not responsive to treatment or if funduscopic examination demonstrates papilledema.

Medication treatment of postconcussive headaches can often be a challenging effort of trial and error. Analgesic medications are typically helpful in the early course of injury recovery but can lead to rebound headaches if overused. “Headache prevention” medications are often indicated for those whose headaches fail to improve with time or have an exacerbation of their underlying migraines.¹³ These medications are almost exclusively off label for headache prevention and have other primary indications. Starting doses tend to be fractions of what are used for their primary indications. They are taken on a daily basis to reduce the frequency and intensity of headaches. Common examples of “headache prevention” medications include topiramate, nortriptyline, amitriptyline, valproate, gabapentin, propranolol, and verapamil. Consideration of medication requires a thorough understanding of each medication’s side effect profile and the other symptoms the patient is experiencing. For example, an athlete who is experiencing insomnia in addition to headaches may benefit from a tricyclic antidepressant (TCAs) such as nortriptyline because sleepiness is a common side effect of the medication. Conversely, nortriptyline may exacerbate symptoms in those are experiencing hypersomnia. Tricyclic medications should be avoided in those with a cardiac history because they can cause prolongation of the QT interval. Equally important is a time frame for discontinuation of the medication. There should be an established period of headache freedom before weaning and discontinuing the medication.

Dizziness

Dizziness after a concussion is an often ill-defined descriptor for patients. Therefore, it is imperative that a detailed history of the reported symptomatology be performed. Postural dizziness, or feeling “lightheaded” when changing from a seated (or lying) position to a standing position, is most common. It should be noted that the adolescent population has a high incidence of postural orthostatic tachycardia syndrome (POTS) and typically has low resting blood pressure even in the absence of injury.¹⁴ Dizziness as a result of vestibular dysfunction is present in more than of 80% of athletes after concussion.¹⁵ Athletes often complain of symptoms if trying to track objects or watching television with an excessive amount of movement displayed. Dizziness as a result of posttraumatic vertigo is less common in young athletes but can happen nonetheless. Patients tend to report dizziness with a change in head position, such as rolling over in bed, tilting their heads back (in the shower), and bending over. These descriptions are of dizziness that tends to be intense and episodic, often rendering the patient incapable of movement until the vertigo has resolved.¹⁶ Finally, dizziness can be a component of other symptoms, such as postconcussive headaches. This can occur in the absence of movement and is often accompanied by nausea. These patients also report experiencing motion sickness when traveling in a car.

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