Concussion Management

Michael Reardon, M.D.April 24,2016

Objectives

• Understand what a concussion is• Know how to recognize it • Understand the differential diagnosis• Know how to manage and treat symptoms • Know when to refer for more comprehensive

evaluation

What is a Concussion?

• Trauma to the head– Does not have to be direct blow to head

• Pathophysiological Changes– Neuro-metabolic cascade

• Clinical Syndrome– Signs and symptoms

What Causes a Concussion?

• Impact or acceleration/deceleration forces

• Helmets do not prevent concussions

What is a Concussion?

• Pathophysiological Changes– Neuro-metabolic cascade

Clinical Syndrome

• Observable Signs– Loss of consciousness (only 10-15%)– Amnesia or confusion– “Dazed”, slowed down, sluggish, sleepy– Mood or Behavioral changes– Balance problems– Vomiting

Clinical Syndrome• Subjective symptoms

– Headache or “pressure” in head– Vision changes: blurry, fuzzy, spots/stars– Nausea– Sensitivity to light and noise– Dizziness– Feeling slowed down, like in a fog– Trouble remembering and concentrating– Irritable, anxious, or depressed mood– Sleepy or trouble sleeping

Common Features of Concussion

• Onset relatively immediate, though may go unrecognized

• Tends to improve with rest, and worsen with exertion or over-stimulation

• With good management, usually resolves over days to weeks

Differential Diagnosis

• Moderate to severe TBI• Non-TBI causes of symptoms

– Dehydration, heat exhaustion, migraine

• Side effects or complications of treatment– Deconditioning, anxiety, somnolence or altered circadian

rhythm

• Psychological disorders

How to differentiate concussion from more severe TBI

• GCS >13• Amnesia/disorientation resolves within 1-2

hours• No focal deficits• Able to walk independently• Normal Head CT or MRI

Features suggesting some other problem

• Significant delay in onset of symptoms/signs• Displaying profound memory impairment• Continued somatic complaints after several

weeks• Very specific or peculiar triggers for symptoms• Significant emotional or behavioral symptoms

Management of Concussion

• Immediately remove from game/event• Never return to sport/activity on same day• Medical evaluation prior to return to sports or

high-risk activities• Gradual, step-wise return to sports after

symptoms and signs have resolved

Management of Concussion

• Avoid repeat injury• Education• Treatment of symptoms• Relative rest• Gradual return to activities as tolerated

Management of Concussion• Education

– Full recovery can range from days to several weeks; cannot be predicted at onset

– Repeat head trauma before full recovery can damage the brain; highest risk in first 1-2 weeks

– Light exercise as tolerated will NOT harm the brain, and will likely help– Attempting cognitive/academic activities as tolerated will NOT harm

the brain– Treating headaches and other symptoms is helpful for recovery; not

just “masking” symptoms

Treatment of Symptoms

• Headaches• Nausea• Dizziness• Sleep disorder• Anxiety or depressed/irritable mood• Cognitive impairment

Treatment of Headaches

• First line– Naproxen 15mg/kg/day divided BID– Magnesium 250-500mg BID

– May add benedryl + phenergan 0.5-1 mg/kg/dose q 6-8 hr as needed

– May add imitrex 25-50mg q 8 hr x 2-3 days

Treatment of Headaches

• Second line– Cyproheptadine 4-12mg qhs; may add smaller dose in AM

as toleratedor– Amitriptyline 25-50mg qhs

– Consider hospitalization for IV meds if severe and not improving

Treatment of other Symptoms

• Nausea– Phenergan, compazine, or reglan better than zofran for

migraine

• Dizziness– No medication works for dizziness (including Meclizine)– Time, rest, gradual increase in movement– Vestibular Therapy when not improving

Treatment of other Symptoms• Sleep disorder

– Sleep hygiene; maintain normal circadian rhythm; exercise– Melatonin 3-6mg; up to 12-15 if helpful; benedryl 25-50 mg– Cyproheptadine, amitriptyline, or gabapentin (esp if headaches)

• Anxiety or depressed/irritable mood– Psychotherapy – Consider SSRI and/or psychiatry

• Cognitive impairment– Omega 3: fish oil 1000-3000mg/day; or Vayarin 2 capsules/day

Management of Concussion• Relative rest, as tolerated

– At least one day at home; a few days if needed; plan to return to school with adjustments

– Encourage light, relaxing activities as tolerated– Encourage short trials of school work as tolerated– Return to school when tolerating moderate

activities without significant worsening of symptoms

Management of Concussion• Recommended School Adjustments

– Encourage flexibility based on symptoms– Avoid noisy, crowded environments

• Bus, cafeteria, gym; change classes before bell rings

– Reduce the amount of work; allow more time– Delay testing or adjust tests

• Shorter tests; multiple choice or open note

– Allow rest breaks and extra time

Management of Concussion• Gradual return to exercise

– Start very light, low impact exercise, even if still having symptoms; walking or stationary bike

– Find pace that does not cause worsening of symptoms; suggest 5-15 minutes

– Gradually increase pace and/or duration over several days as tolerated

– When symptoms have cleared, can advance to more strenuous, higher impact exercise

Management of Concussion• When to clear for full return to sports

– All symptoms have cleared, without medication, and with full participation in school and vigorous non-contact exercise

– School performance is back to baseline– Neurological exam is normal– If pre-injury baseline tests were performed, post-

injury scores are within range of baseline

Management of Concussion• When to refer for further evaluation

– Complex past history• Multiple concussions; other neuro issues

– Unusual symptoms or signs– Severe headaches or other symptoms– Symptoms are not improving in 1-2 weeks with

first-line management

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