Concussion and the headache patient

In my last post I introduced the concept of concussion and the teenager with headaches. I would like to continue this topic by discussing what is helpful for these kids to help avoid disability and too much missed school.

The first step we recommend is for them to see their PCP or even the ED for a basic concussion exam. CT imaging can be useful with a history of more severe trauma, loss of consciousness or amnesia, or general concerns. The mild concussion diagnosis is then made and the usual recommendations of cognitive rest, physical rest, hydration and analgesia can be given.

For the teen with headaches, recent research using fMRI has shown that there is an element of neurogenic inflammation caused by head trauma. Often when the patients call us after concussion has occurred, we have them use a Medrol dose pack (dexamethasone taper), as way to reduce this inflammation. It can be quite helpful, though we really should try to do some research to quantify the results.   It is something to consider for those patients with baseline headache disorders who are very symptomatic.

So time goes by, the usual concussion recovery measures are done, and usually the teens will be feeling much better within 2 weeks. But for my patients with baseline headache disorders, that is not usually how it goes. So often, when one of my patients has a significant (or even not very significant) head bump, the families can go into panic mode. This is because the teen will often have more and prolonged symptoms than would be expected.

The initial symptoms will subside over time, leaving constant headache, and a variety of other complaints consistent with post-concussion syndrome. Besides headache, these symptoms include sleep disruption, moodiness, vision changes, hearing changes, persistent nausea, dizziness, vertigo, and cognitive difficulties, including inability to attend school and learn.  Since every teen and their responses are different, you need to address the issues at hand.  The symptoms that tend to become prolonged are those related to school functioning- trouble with reading, concentration and focus, and trouble related to the school environment –lights, noise, general overstimulation.

The first thing to address is the headache, and to make sure that they are not overusing analgesia. It is OK to use NSAIDS or Tylenol daily for up to 1 week, but much longer than that puts them at risk for developing medication overuse headaches.  So figuring out what they can do to feel better pain-wise is important.  We often talk about strategic use of medications, such as using naproxen during finals or before standardized testing is a smart way to medicate. They need to ensure excellent hydration and could try a little caffeine to help the pain.

For kids with sleep troubles and/or persistent nausea, I have found that a small dose of hydroxyzine (10-25mg) at bedtime can make a big improvement. Melatonin can be helpful for sleep (no more than 5mg), as well as the usual sleep hygiene recommendations (see an earlier post about lifestyle, All about the migraine part 2-3).

School!

There are many challenges for patients with post-concussion syndrome in returning to school. The school environment, with bright fluorescent lights, loud noise, and general commotion and overstimulation (think auditorium assemblies and basketball games in the gym), make school difficult to tolerate. This is true for teens with baseline headache disorders but worse after concussion.

Then there is the challenge of trying to think, focus and learn, especially frustrating for our teens who are natural ‘strivers’; those teens who are place high demands on their achievement. And it is very hard for these students to accept that they need accommodations and that they need to lower the bar of expectations for themselves, at least during recovery. Parents can also have difficulty with this, but they tend to have the maturity to understand what is needed, and can see the big picture. These kids worry me, as they are the ones at risk for becoming disabled, losing hope of ever feeling better, concerned about what the impact of the concussion will have on their future.  They can be unable to come to terms with the need for accommodations and slowing down, start to give up, and begin the slow decline towards disability.

So how can you help?

  • Support and frequent check-ins with the family can be very helpful to keeping them on track.
  • Work with the school on an appropriate re-entry plan, starting with partial days and frequent breaks during the day for cognitive rest. Some schools have special programs to help facilitate this, and can be really helpful. Asking for flexibility with the plan can make it more successful.
  • Enlist your patient to identify the problem areas of his/her day. Is it lunch in the loud cafeteria? Bright lights in English class, flickering lights in the science lab? Loud and hot environment in the gym/PE?   And after identifying the problems spots, work with the student to advocate for what can help them, such as preferential seating, excused from PE class, shutting off the lights, replacing a flickering light bulb, etc. Being able to make these changes can be very empowering and help them stay functional.
  • Cognitive rest is important and there needs to be emphasis on a gradual return to cognitive functioning and demands. They need reinforcement that overtaxing their brain will not help but only hurt them. There are specific accommodations that are helpful and I will attach a link here. Concussion Accommodations
  • For some teens, concentration and focus can be helped by a small dose of stimulant (methylphenidate or amphetamine), being mindful of other issues such as appetite and sleep.
  • Referral to Physical therapy for head and neck stretching. Referral for cognitive rehabilitative therapy (found with occupational or speech language therapy) can help with organization and functional skills post-concussion.  If you have a dedicated concussion center in your area, they will have these resources.
  • Return to physical activity is a slow process and using activity pacing is very useful. It is a difficult subject to explain but there is a series of You Tube videos done by a teenager with chronic pain that helps teens to figure out the concept. She discusses how to assess what is their current activity tolerance, how to set goals and reach them in a sensible measured way.  I put a link to these videos in the resources. YouTube videos on activity pacing
  • Finally, mood issues, irritability, anxiety and depression are a part of post-concussion syndrome. As the headache improves, this can improve also.  But as the duration of the symptoms continues, it is not uncommon for these kids to really get down and feel hopeless, or get very anxious about ever catching up in school and life. The most important thing is to be vigilant and refer to appropriate psychological clinicians as soon as you notice that the teen is having a difficult time. Explaining that feeling down and anxious can be a part of the post-concussion recovery and getting help them keep on the recovery track.

Awareness about the consequences of concussion is becoming much more mainstream. Less familiar is the effect of concussion is for those kids who already have baseline headache disorders. We owe it to our patients to be aware of the impact and support our families through this tough situation.

The Impact of concussion on teens with headache

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.