Conditions
Post Concussion Syndrome
Post-concussion syndrome or PCS describes the symptoms that can occur following injuries to the head, and are assumed to be associated with a mild traumatic brain injury (mTBI). There are a number of terms that are often used interchangeably such as ‘head injury’, ‘traumatic brain injury’ and ‘concussion’.
Head injury is a broad term that could describe any injury occurring to the scalp (laceration, contusion) skull (contusion, fracture) or brain (including all contents of the cranial vault – brain, internal blood vessels and nerves).
A traumatic brain injury or TBI is a type of ‘acquired brain injury’ caused by an external force. Mild TBI’s may not have any obvious associated external ‘head injury’ and may show normal brain scans. Typical causes are falls, car accidents, sports injuries and physical assaults.
A concussion describes the symptoms that may occur (but don’t always) after a TBI. You can have a TBI without a concussion, but you can’t have a concussion without a TBI. Concussion occupies a difficult space within medicine. There are often no apparent ‘injuries’ and symptoms may take days, and even weeks or months to fully manifest.
In the past these injuries have been heavily stigmatised with sufferers accused of malingering. Too often these may be passed off as ‘psychological’ symptoms, when they may be an adaptive response of the brain to trauma. This has been presumed to be an ongoing ‘inflammation’ but there is another factor that, after initial screening is often overlooked.
PCS must be viewed as a combination of traumatic brain injury and whiplash or neck injury for the following reasons:
- The minimum force required for a concussion has been recorded as 60 G in American football players. Neck tissues can be damaged with as little as 4 G. If there is even a mild concussion it is likely the neck has experienced significant forces, and may have sustained trauma.
- The more severe the head injury, the less common headache is. If the TBI was responsible for the headache, wouldn’t a more severe TBI cause a more severe headache? Could something else like the neck be causing the symptoms?
- Symptoms associated with cervicogenic headache and whiplash can be identical to persistent PCS. i.e. neck problems can cause the same symptoms without a TBI.
- Neck pain, dizziness and headache have been implicated as risk factors for sustaining a concussion.
- A history of migraine is a significant risk factor for developing persistent symptoms post concussion.
This makes a strong case for having an examination of the neck in people with persistent post concussion syndrome using techniques designed to treat brain sensitivity. At present sufferers are left to rest and wait for symptoms to ease, give up careers and activities, and medicate to manage symptoms.
The typical causes of these types of symptoms are after having a concussive event many of which occur at home, at work or after a motor vehicle accident – only 20% relate to sports injury.
Persistent symptoms following whiplash are similar but covered under Whiplash Associated Disorder (WAD).
Post-concussion syndrome is defined by the International Classification of Diseases as the persistence of 3 or more symptoms for 4 weeks following minor head injury. The diagnostic and statistical manual of mental disorders definition required symptoms to be persistent for 3 months.
The overlap with migraine, persistent whiplash and cervicogenic disorders is obvious with symptoms including:
- Headache
- Dizziness
- Neck pain or stiffness
- Balance problems
- Nausea/vomiting
- Impaired memory
- Photophobia
- Phonophobia
and accompanied by difficulty concentrating, insomnia, irritability, pressure in head, fatigue, blurred vision, feeling slowed down, brain fog, confusion, drowsiness, sadness and nervous or anxiousness.
Diagnosis & Symptoms
Post concussion syndrome is defined under the World Health Organisation’s (WHO) International Classification of Diseases and Related Health Problems (10th edition), with the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) actually removing it from their latest edition (5th edition), due to the lack of clarity around the criteria and numbers of misdiagnosis resulting.
The ICD-10 diagnostic criteria describe:
Postconcussional syndrome occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes symptoms such as:
- Headache
- Dizziness
- Fatigue
- Irritability
- Difficulty in concentrating and performing mental tasks
- Impairment of memory
- Insomnia
- Reduced tolerance to stress, emotional excitement, or alcohol
May be accompanied by feelings of depression or anxiety resulting from some loss of self-esteem and fear of permanent brain injury.
Note: We find the presumption here by the American Psychiatric association of why people might be experiencing feelings of depression and anxiety to be overly presumptuous. While these could be the reason, there are a host of other possibilities, the most direct of which is via an irritation of the ‘stress response’ (reticular activating) system – this can lead to symptoms of anxiety and depression as a result of the physiological stress of the TBI, rather than an emotional and behavioural response to the TBI.
Persistent post concussion symptoms:
Influenced by factors other than head injury status, suggesting these symptoms may not be related directly to the TBI.
The International Classification of Headache Disorders (ICHD-3) only describes the ‘headache’ aspect, which is interesting, and probably due to the fact that the presentation of PCS often looks like migraine. It is defined as Post-traumatic headache which is a secondary headache. That means a headache that is directly caused by another disorder:
Headache attributed to trauma or injury to the head and/or neck.
Under this section are six sub-types:
- Acute headache attributed to traumatic injury to the head (concussion)
- Persistent headache attributed to traumatic injury to the head (concussion)
- Acute headache attributed to whiplash
- Persistent headache attributed to whiplash
- Acute headache attributed to craniotomy (surgical hole drilled in the head)
- Persistent headache attributed to craniotomy (surgical hole drilled in the head)
The delineation of acute versus persistent is symptoms is whether symptoms last beyond three months.
This relates to ‘new headache’ occurring for the first time in close temporal relationship to trauma or injury to the head.
A. Any headache fulfilling criteria C and D
B. Traumatic injury to the head has occurred; (i.e. structural or functional injury resulting from the action of external forces to the head)
C. Headache is reported to have developed within 7 days or after one of the following:
- The injury to the head
- Regaining of consciousness following the injury to the head
- Discontinuation of medication(s) impairing ability to sense or report headache following the injury to the head
D. Either of the following for ‘acute’:
- Headache has resolved within 3 months after its onset
- Headache has not yet resolved but 3 months have not yet passed since its onset.
For Persistent D. reads: Headache persists for > 3 months after its onset
E. Not better accounted for by another ICHD-3 diagnosis.
As you will see below, the requirement for headache to develop within 7 days is problematic.
Epidemiology
0%
90-95% of TBI considered to be mild (< 30 min LOC), disorientation < 24 hours.
Over the first 12 months after concussion injury 71% can expect to suffer headache at some point in time.
- 54% occur within the first week
- 62% with headache at 3 months
- 69% with headache at 6 months
- 58% still suffering headache at 12 months post concussion
- 41% suffer symptoms through all 12 months
- 41% headaches are intermittent
OR 59% of headaches are continuous!!
9% of children suffer
Common Treatments
What happens after concussion?
Rest. Gradual return to activity (walking etc) without making symptoms worse.
Historically, very little else has been done with this group, as over 90% are able to return to symptoms free activity within 30 days. The problem is their brain function isn’t back to baseline. Ground breaking research has demonstrated that while people can pass neuropsychological tests and be symptom free, that they are ‘working harder’ for the same result.
What about the small group who do not recover within 30 days? Often they get passed around from general practitioner, to Ear/Nose/Throat specialist to Neurologist chasing diagnosis that try to fit each symptom – vestibular neuronitis, BPPV,
Without structural damage visible on scans, they are often medicated depending on their predominant symptoms. If symptoms persist – more rest, more medication, maybe do vestibular rehabilitation for dizziness.
Headache medications will be provided based on whether their symptoms look more like a migraine, or more like a tension-type headache.
Beyond this it is , which often fails, and psychology (for persistent anxiety and/or depression symptoms), with some symptomatic management of balance, sleep and gut issues. many also have mild cognitive impairments with memory loss, inability to concentrate and mood disturbance/irritability.
Very little attention is given to the neck post concussion. This is astounding given that:
- The force required to damage tissues in the neck is 4-5kg
- The force to produce a concussion to 10 to 20 times higher at 60-160kg (average 96kg)
This is why when you see an athlete with concussion the first thing they do is to put a hard collar on the neck. However once major structural damage is ruled out (no broken bones or torn ligaments) then neck is all but forgotten about.
This is a mistake, and one that can be rectified, however the method is critical. The symptoms of persistent post concussion syndrome mimic migraine and thats due to the sensitisation of the brainstem that occurs. Treating the neck as a sensitive structure that can decrease this central ‘noise’ in the brainstem, rather than a ‘stiff piece of meat’ to be pummelled into oblivion is a much better option.
Deep tissue work and stretching are thus often provocative. Finding a clinician highly skilled in an approach designed specifically to use the neck to decrease sensitivity in the brain is what is required.
This is exactly what the Watson Headache ® Approach offers, and aside from Dean Watson, there are no more highly skilled practitioners in the country than here at the Melbourne Headache Centre.
Causes
The symptoms of concussion have historically been attributed to a diffuse axonal injury in the brain. In the absence of a focal injury observable on brain imaging, the interpretations are based on animal models of physiological change
stead of a frank brain
Research demonstrates that in people suffering vertigo and eye movement disorders after whiplash have no signs of vestibular dysfunction or injury to the central nervous system. The authors attribute the dysfuncction to the neck injury.
Differential Diagnosis
TBD
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