There is much evidence and information in the literature about the general effect of concussion on kids and teens. Most pediatric practices and schools use specific protocols for concussion recovery and these plans generally work well. Unfortunately, for patients with headache, the story of recovery can be quite different. In this post, I would like to discuss the impact of concussion/mild head trauma on patients with a headache history.
A concussion happens when there is an impact injury to the skull that mildly damages the brain tissue, causing bruising and swelling. Immediate symptoms of a concussion can include a loss of consciousness, confusion, amnesia, nausea, vomiting, headache or dizziness. Some signs of a concussion may not appear for several hours after the injury and may persist for several days or weeks.
Post-concussion symptoms are caused by both physiologic and psychological factors from the effect of brain trauma. Physically, symptoms can be caused by structural damage to the brain or disruption of the neurological messaging system, triggered by impact. Psychological factors can be involved, since many of the symptoms, including headache, dizziness and sleep disruption, can also be attributed to depression, anxiety or PTSD.
Healthy teens generally recover from their concussions within a reasonable amount of time, especially if they follow the usual post-concussion guidelines, instituting cognitive and physical rest for a period of time. Depending on the severity of the injury, recovery can be complete within 3-4 weeks, with a gradual return to function.
Unfortunately, teens with a headache history (migraine, tension-type, new daily persistent headache) have a much more difficult time with their recovery. In fact, migraine is a risk factor for prolonged concussion recovery. Even when the head blow is quite mild, kids with headache tend to be much more symptomatic, diagnosed with a concussion. Whether it is a true ‘concussion’ or not, these patients have significant symptoms consistent with concussion. And they are much more at risk for developing post-concussion syndrome.
Post-concussion syndrome (PCS) is a condition in which the symptoms of a concussion persist for weeks, months or years. Symptoms of PCS include:
- Headache: recurrent or constant mild to severe headache pain
- Sleep: disruption, insomnia, daytime fatigue.
- Mood: anxiety, irritability, depression, confusion
- Sensory Alterations: blurred or double vision, slurred speech, altered sense of smell or taste, tinnitus or hearing loss, photophobia and phonophobia
- GI complaints: nausea, vomiting, decreased appetite
- Balance issues: unsteadiness, lightheadedness, dizziness or vertigo
- Cognition: forgetfulness, misplacing common items, difficulty concentration and focus, comprehension and reading
After concussion, migraineurs tend to have more frequent and severe migraine episodes. The migraines become more difficult to treat with their usual rescue medications. For patients with TTH, there can also be more severe symptoms, often related to muscle spasms and tightness, especially if there was a whiplash injury. For NDPH patients, their overall baseline headache pain is increased with more frequent headache spikes and other symptoms.
Overall, having a mild head trauma can cause considerable symptoms and even the development of disability in your usually well-functioning teenager with headaches. For primary care providers, awareness of the likelihood of prolonged recovery for these patients is key. Realistic expectations can be set with the patient and family. PCPs can assist in obtaining accommodations for school and academic demands, as well as supportive therapies to foster recovery. Emotional support is very important, as the results of these types of unexpected injuries can really test the resilience of the any family unit.
It’s important to remember that these types of injuries are not just sports-related. One of the most prolonged and symptomatic PCS patient in my practice was a teenage girl with migraine who slipped and hit her head on the side of a bathroom sink. She was out of school for months and suffered greatly from this injury, requiring a lot of support and intervention to get back to functioning. And then she fell and hit her head on the ice the following winter! She made a full recovery but….. oh my goodness.
In my next post, I will talk about care and treatment of the patient with headache and concussion.