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.

 

 

Tension-type headache strategies

I have reviewed factors contributing to tension-type headaches, as well as some preventive strategies.  In this post I will cover appropriate rescue medications, and talk about treatment for underlying anxiety, which often needs to be addressed for kids with tension-type headaches.

Analgesia is a key part of a rescue strategy for TTH. Non-steroidal anti-inflammatory drugs (NSAIDS) are the mainstay of headache analgesia. The side effects are GI, such as gastric distress, nausea, ulcer, hematologic, such as bleeding disorder or platelet dysfunction, or related to allergic reaction.  Any of the NSAIDS can be effective in treating a tension-type headache.  Treating a TTH  as soon as possible is the key to success.  I talked about this class of medications more in depth in the blog post “migraine medications to the rescue…analgesia”.  Ibuprofen and naproxen are the most commonly used NSAIDS and are effective for those who can take them.  Some people will also use diclofenac, sulindac and even ketorolac.

For patients who cannot take NSAIDS, acetaminophen (Tylenol) is useful and usually well tolerated, with adult dosing for teens of 650-1000mg q4-6h, weight- appropriate dosing for younger kids. There are many formulations- suspension, chewable tabs, dissolve tabs, regular tablets and extra strength tablets.

Aspirin can also be used, but should be used in a limited fashion due to the risk of Reye’s syndrome.  Another Excedrin product, Excedrin Tension Headache, similar to Excedrin migraine, but does not contain aspirin can be used as well.  Each coated tablet contains 500 mg of acetaminophen and 65mg of caffeine. Of course you wouldn’t want to use this in the evening.

For all analgesia, patients should not take them for more than 2-3 days/week to avoid medication overuse headaches.

Other medications: there are a few other medications that can be used for treating other symptoms associated with tension-type headaches. These would include anti-emetics like ondansetron for nausea or an antihistamine, like Benadryl or hydroxyzine, for dizziness. A muscle relaxant could also be a rescue medication, such as tizanidine, but quite apt to make them sleepy.

Complementary rescue strategies:  In addition to the medications we have talked about, there are a number of complementary interventions that can really help resolve a tension-type headache.  In addition, reiki, acupuncture and other complementary therapies can certainly play a role in reducing stress and anxiety, which often trigger tension-type headaches. For some patients, doing these strategies can treat a TTH, and they do not need to take any medication.

  • Aromatherapy: using an essential oil, such as peppermint, lavender, or ginger used topically, gently massaged on the temples or behind the ears
  • Ice/cold (or heat) applied to the forehead or the neck
  • Gentle massage to the neck and occiput or frontal/temples
  • Anything that activates the relaxation response, such as a CBT or biofeedback exercise, or breathing technique, using a relaxation/meditation app, soothing music. My favorite is the Insight Timer app, so many options and free.

Stress and anxiety are frequent triggers of tension-type or stress headaches. Many of us carry our cares and worries in our neck and shoulders. During stressful times, the trapezius and paracervical muscles (which encompass our head) tense up around our heads, squeezing the occipital nerve in particular bilaterally, and triggering headache.  Relieving the pain involves getting these muscles to relax. I refer you to my blog post “stress and migraines” for more information about this and appropriate strategies.

When I have a patient who demonstrates or reports having significant anxiety, I know that this needs to be addressed in order for the teen to start having less frequent TTH. This is not always a welcome message, especially when I encourage them to get some professional help. It is not always easy to bring up, but so necessary.  There are many ways to intervene, including medications, but having a good counselor to talk to and learn CBT skills from is the best intervention, from my point of view. Kids and teens actually do very well with CBT (Cognitive behavioral therapy), especially if they do their ‘homework’ and if there is buy-in and support from the family.

Unfortunately, there can be significant barriers to getting into counseling, including lack of local providers, insurance barriers, time constraints and general lack of commitment to the process.  I think finding an appropriate therapist (psychologist, LICSW) is the biggest hurdle.  The PCP can help by knowing the network of child psychology providers in the area. The website, www.psychologytoday.com, has a search feature which can help with that; just enter the zip code, and narrow the search (child/teen, CBT), and a list of local providers comes up.  I have found this to be a very valuable resource, especially when I see patients who are not from my area. I also refer families to their insurance carrier, to find providers who are in network.  I encourage families to understand that finding a therapist is a process, which may involve many phone calls and leaving messages. It can be quite frustrating.

Concerning medications, I have an informal rule that I will not start an anxiolytic medication unless there is counseling set up or actively being pursued.  I think it is important to send the message that there is work to be done to manage anxiety, and the more work the patient is willing to do, the less medication (and side effects) is needed.  Also SSRI/SNRI medications are not without risk, including the black box warning of suicidality in the young and teenage population.

There are definitely times when both counseling and medication is needed, but in my opinion, the therapy is most important. Why? Because therapy/CBT can help our young patients develop the skills and resilience to face the challenges of life. Kids and teens need to develop their inner resources to deal with their quickly changing environments, without becoming overwhelmed or despondent, or falling into other unhealthy coping strategies, such as addiction. As providers, we owe it to them to steer in the right direction as best we can, to speak up when we think psychological help is needed, and to support our families in their healing journeys.

Off the soapbox now……………

My next posts will be about another primary headache, new daily persistent headache (NDPH), a very challenging headache diagnosis. Stay tuned………