Post-Concussion Syndrome

What is Post-Concussion Syndrome?

Post-concussion syndrome is a set of physical, thinking and emotional symptoms that continue after a concussion or other mild traumatic brain injury (mTBI). Most people recover within days to weeks. Symptoms that last longer than 3 months are called persistent post-concussive syndrome, which affects a minority of people.^[1] It is a debated diagnosis, because the criteria differ and the symptoms are not specific to concussion.^[2]

Common symptoms

Common symptoms include headache, fatigue, dizziness, balance problems, trouble sleeping, vision changes, difficulty concentrating, and irritability, anxiety or low mood.^[1] Sensitivity to light and noise is also common.^[2]

Causes and risk factors

The syndrome follows a blow to the head or body that shakes the brain, and it is not clear why symptoms last longer in some people.^{[1, 2]} A review of 15 studies of adults found that trouble concentrating soon after injury, a past history of anxiety, depression or sleep disorders, and loss of consciousness or amnesia were linked to more persistent symptoms.^[3] Having had more than one brain injury also raises the risk.^[1]

Later-phase symptoms are strongly influenced by psychological and social factors and are less specific to the brain injury itself.^[2]

How it is diagnosed and treated conventionally

Diagnosis is clinical and starts with a physician ruling out other causes of symptoms. It rests on the history and examination, because there is no single test.^{[1, 2]} Treatment is symptom-based and step-by-step, targeting problems such as depression, anxiety, insomnia, headache, musculoskeletal pain and vertigo, and guided aerobic exercise is beneficial.^[2]

A guideline based on a systematic review found weak support, from very low to low certainty evidence, for common non-drug treatments, including education, graded exercise, vestibular rehabilitation, psychological treatment and coordinated rehabilitation.^[4]

Why Post-Concussion Syndrome calls for a whole-person approach

Post-concussion syndrome rarely has a single cause. The symptoms span physical, thinking and emotional areas, and reviews recommend looking for treatable contributors rather than blaming the brain injury alone.^[2]

That is why a team approach, which can include complementary care alongside medical and rehabilitation care, is reasonable.

Headache

Post-traumatic headache is among the most common and difficult complaints after mild head injury. It often looks like tension-type headache or migraine.^[5] Non-drug and multi-part approaches are often used because medicine options are limited.^[6]

Sleep

Sleep disruption is part of the early symptom picture, and a history of sleep disorders raises the odds of long-lasting symptoms.^{[2, 3]} Poor sleep can in turn worsen headache, mood and concentration.^[2]

Mood, anxiety and stress

Anxiety and depression are risk factors for persistent symptoms, and psychological and social factors shape the late phase.^{[2, 3]} Stress and expectations are among the factors reviewers link to how post-traumatic headache evolves.^[7]

Neck, muscle and balance problems

Neck and musculoskeletal pain and vertigo are listed among the treatable contributors to symptoms.^[2] Manual treatment of the neck and vestibular rehabilitation have been studied, and the guideline gave weak recommendations for both.^[4]

Acupuncture for Post-Concussion Syndrome

What the research shows

Acupuncture may help some post-concussion symptoms, but the evidence is limited and comes from a few small trials. A Cochrane review of acupuncture for traumatic brain injury of all severities found only four trials, with 294 participants, and said their low quality did not allow firm conclusions.^[8]

Newer trials are more encouraging. In a trial of 66 adults after mild TBI, 14 acupuncture sessions over 4 weeks reduced post-concussion symptom scores compared with sham acupuncture and with a waiting list, and the benefit was still seen at 6 to 12 months.^[9] In a small trial of 38 people with chronic post-traumatic headache, 5 or 10 sessions over 5 weeks reduced headache days and pain intensity, without a difference between the two session counts. The study had no sham or untreated group, so the improvement cannot be credited to acupuncture alone.^[10]

In a sham-controlled trial of 60 US veterans with mild TBI and long-lasting sleep problems, most of whom also had PTSD, up to 10 sessions improved sleep scores more than sham needling.^[11] A scoping review of complementary therapies after TBI of any severity included acupuncture among the most studied and found that 97 percent of included studies reported benefit overall, but it called for more rigorous trials.^[12]

How acupuncture may work

How acupuncture might help after concussion is not known. In one trial, brain scans showed improved white matter measures in the acupuncture group, and the change was linked to lasting symptom relief, but this does not prove how acupuncture works.^[9] These are early findings from a single trial.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the head, neck, body, hands and feet, usually left in place for about 20 to 40 minutes. The trials used schedules such as 14 sessions over 4 weeks, and 5 to 10 sessions over 5 weeks.^{[9, 10]} We reassess after a short course of visits.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000.^[13] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Please also tell us about dizziness or fainting, since lying down during treatment may be needed.

Ayurvedic medicine for Post-Concussion Syndrome

The Ayurvedic view

Ayurveda has no classical diagnosis that matches post-concussion syndrome. Head injury is traditionally described as trauma to the head, with lasting headache, dizziness, poor sleep and poor concentration viewed as aggravated Vata, the principle said to govern movement and the nervous system, sometimes with a disturbed mind. This is a traditional framework used to choose treatment, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals, steady sleep hours and limited stimulation
• Gentle warm oil massage of the head, neck and shoulders, as tolerated
• Breathing practices as a general support for stress and rest
• Herbs prescribed individually by a qualified practitioner, as covered below

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before a physician has assessed a recent head injury and ruled out danger. Strong or depleting procedures are not appropriate in this condition. Reviews list sleep problems, stress and neck muscle pain as treatable contributors to symptoms, which is what the routine and massage above are meant to address, although these Ayurvedic methods have not themselves been tested.^[2]

What the research shows

There are no clinical trials of Ayurvedic medicine or Panchakarma for post-concussion syndrome. A PubMed search for concussion and brain injury with Ayurveda, Panchakarma, curcumin, ashwagandha and Bacopa found only laboratory studies and general reviews, and no clinical trials. Any benefit is unknown. Ayurvedic care is offered here for relaxation and general support, not as a treatment shown to work.

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic, so sourcing matters.^[14]

Herbal medicine for Post-Concussion Syndrome

Herbs and formulas that have been studied

Research on herbs after brain injury covers herbal medicine used alone or alongside standard care in traumatic brain injury of all severities. No herb or formula has been studied specifically in well-designed trials of post-concussion syndrome.^[15] Transdermal medication therapy, in which herbal preparations are applied to the skin, may also be discussed, but we know of no trial of it for this condition.

What the research shows

The evidence is limited and of low quality. A systematic review of 37 randomized trials (3,374 participants) in traumatic brain injury found that herbal medicine, alone or added to usual care, improved the clinical response rate, and subgroup results favored herbs for post-concussion syndrome, dizziness and headache. The authors still concluded there was insufficient evidence to recommend herbal medicine for brain injury, because most trials had a high risk of bias and the quality of evidence was very low to moderate.^[15] Laboratory research on herbs such as curcumin has not been confirmed in people with concussion.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. A review of reported interactions describes bleeding when warfarin was combined with danshen or ginkgo, and serotonin syndrome when St John's wort was combined with SSRI antidepressants.^[16] Tell us about every medicine you take, including pain relievers, sleep aids and antidepressants.

Herbal and dietary supplements are a growing cause of liver injury.^[17] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine would describe lasting symptoms after a head blow as blood stasis in the head with disturbed flow of qi. Ayurveda would describe aggravated Vata. Researchers study things that loosely parallel these ideas, such as microscopic changes in the brain's white matter, sleep and stress-system disruption, and tension in the neck muscles.^{[2, 9]}

No study has shown that a dosha or a Chinese pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for post-concussion syndrome is complementary. Keep your physician and your rehabilitation team, and do not stop or change prescribed medicines or therapies without your prescriber. We do not diagnose the cause of symptoms after a head injury, so a new or worsening symptom should be evaluated by a physician first.

Please bring your diagnosis, the date and details of the injury, any imaging reports, a full list of medicines and supplements, and notes from your treating team.

When to seek urgent medical care

Some symptoms after a head injury can signal bleeding or another serious problem, and a physician should assess a head injury before any complementary care begins.

• A headache that is getting steadily worse or is sudden and severe
• Repeated vomiting, a seizure, or increasing drowsiness or confusion
• Weakness, numbness, slurred speech, or vision changes that are new
• Clear fluid or blood from the nose or ears, or unequal pupils
• A new blow to the head while you are still recovering
• Fainting, or being unable to wake normally

If any of these occur, call 911 or go to the nearest emergency department.