Postconcussion Syndrome

Aka: Postconcussion Syndrome, Post-Concussion Syndrome, Post-Traumatic Headache, Postconcussive Symptoms

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II. Definitions

  1. Postconcussion Syndrome
    1. Persistent Concussion-related symptoms beyond 3 months and beyond resolution of initial Concussion
  2. Mild Traumatic Brain Injury (MTBI)
    1. Preferred term to Postconcussion Syndrome
    2. Postconcussion Syndrome is a subjective term with symptoms that may be altered by Secondary Gain and other external factors

III. Epidemiology

  1. Incidence 5-20% of Concussions (or MTBI)
    1. Some estimates are as high as postconcussive syndrome in 38-80% of Concussions

IV. Risk Factors

  1. Female gender
  2. Children and older age
  3. Inadequate social support
  4. Lower baseline functional status or socioeconomic status
  5. Pre-existing conditions
    1. Major Depression
    2. Anxiety Disorder
    3. Attention Deficit Disorder
    4. Migraine Headaches
    5. Post-Traumatic Stress Disorder (PTSD)
    6. Substance Abuse
  6. Head Injury related findings
    1. Glasgow Coma Scale <15
    2. Loss of consciousness
    3. Acute Intoxication

V. Symptoms

  1. Common Symptoms
    1. Headache (most common)
    2. Dizziness
  2. Cognitive Symptoms
    1. Impaired attention and memory
    2. Difficult Executive Function (e.g. organization, planning, reasoning)
  3. Behavioral Symptoms
    1. Irritability
    2. Altered mood
    3. Insomnia
    4. Fatigue
  4. Other Symptoms
    1. Blurred Vision
    2. Photosensitivity
    3. Neck Pain
    4. Tinnitus
    5. Balance difficulty
    6. Hearing Loss
    7. Loss of Taste or smell sense
  5. Exacerbating Factors
    1. Physical Activity (most common)
    2. Cognitive activity

VI. Diagnostics

  1. Chronic Headaches after Concussion (esp. severe or progressive Headache without prior head imaging)
    1. Head CT or Head MRI
  2. Persistent Dizziness after Concussion
    1. Electronystagmography (ENG)
    2. Fistula Test
    3. Posturography
  3. Persistent neurologic or behavioral changes
    1. Neuropsychological Testing (including computerized Neuropsychological Testing)
  4. Activity provoked symptoms
    1. Graded aerobic treadmill test may reproduce Concussion symptoms

VII. Precautions: Red Flags

  1. See Concussion Red Flags

VIII. Prognosis

  1. See Cognitive Deficit following Concussion
  2. Prolonged course risk factors
    1. See Risk Factors above

IX. Management: Targeted symptom management

  1. Cognitive deficit
    1. See Cognitive Deficit following Concussion
    2. Consider Neuropsychological Testing
    3. Consider brain imaging
    4. Assess for comorbid conditions
      1. Major Depression
      2. Anxiety Disorder
      3. Insomnia
  2. Mood Disorder
    1. Major Depression Management
    2. Anxiety Management
    3. Consider Selective Serotonin Reuptake Inhibitor (SSRI)
  3. Headaches
    1. Consider Migraine Prophylaxis
  4. Vertigo
    1. See Vertigo Management
  5. Sleep Disturbance
    1. See Disorder of Initiating and Maintaining Sleep (Insomnia)
    2. See Sleep Hygiene
  6. Sports
    1. See Return to Play after Concussion
    2. No sports participation until initial Concussion symptoms resolve
    3. If Exercise-induced symptoms after initial Concussion symptoms have resolved
      1. Submaximal Exercise Prescription
      2. Example: 80% of maximal tolerated Heart Rate for 20 min/day, 5 days per week
  7. Other symptom management
    1. Fatigue management
    2. Insomnia management
  8. Consultations to consider
    1. Physical therapy
      1. Consider if persistent Headache, Dizziness, cervical Neck Pain at >10 days after injury
      2. Cervicovestibular Rehabilitation and balance therapy
      3. Neck rehabilitation
    2. Other specialists
      1. Consider if persistent symptoms >4 weeks after injury
      2. Occupational Therapy
        1. Functional therapy on specific tasks
      3. Speech Therapy
      4. Neuropsychology
      5. Mental Health

X. Complications

  1. See Cognitive Deficit following Concussion

XI. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Bengtzen, Novak and Chesnutt (2016) Crit Dec Emerg Med 30(5): 3-10
  3. Jotwani (2010) Curr Sports Med Rep 9(1): 21-26 [PubMed]
  4. Kushner (2001) Am Fam Physician 64:1007-14 [PubMed]
  5. Mott (2012) Am Fam Physician 86(11): 1045-51 [PubMed]
  6. Patricious (2022) Br J Sports Med 57(11): 695-711 [PubMed]
  7. Valente (2023) Ann Emerg Med 81(5): e63-105 [PubMed]

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