Headaches after Concussion
In my clinical training as a family nurse practitioner, I remember it being pressed upon us that the medical community has largely failed those who had previously suffered brain injury, particularly concussions. I also remember reading that approximately half of all those who are without homes have a history of head injury and we need only to look at retired #football players to see that most die prematurely to recognize that head injuries are in fact, significant long beyond their occurrence for which the medical community has largely been ignorant.
The go to management has been to just take it easy, don't fall asleep, because we aren't going to intervene in an acute head injury unless there is neurological changes anyway. The diagnostic scans in themselves are thought to be unhelpful in acute management, but what we hadn't done is really appreciate the ongoing sequelae of head injuries such as chronic #headaches or #migraines for which it seems I have a number of clients in my own practice.
Fortunately, most concussions resolve for children in under a week, but for others, symptoms persist. What might you need to be aware in the event your own child suffers a head injury or even yourself?
Concussions are a traumatic brain injury and it impacts the way our brain functions. This may occur from a direct blow to the head or even from violent shaking of the head such as in the case of #whiplash. Immediately after the incident, the child may complain of headache, confusion, memory loss, foggy thinking, dizziness, double vision, slurred speech, problems with coordination, or loss of consciousness.
Sometimes they aren't even aware they've suffered a concussion, so it's especially important for parents and coaches to be mindful of signs after a fall or a hit to the head. Any person suspected of a head injury or concussion related to a sporting event should stop playing and be evaluated by a trained professional. Any symptoms should prevent them from playing in the remaining portion of the game, no exceptions.
Certainly bleeding in the brain is a concern and why it is important for a healthcare professional to evaluate anyone who has suffered a headblow, but these problems are quite rare following a single, simple concussion. If a child has prolonged confusion or loss of consciousness, continued vomiting or new symptoms of weakness or change in speech, or worsening of symptoms with time after a concussion, they need to be evaluated emergently by a medical professional.
After critical or emergent issues are rule out however, which rarely require brain scans, then headaches and other symptoms that relate to the concussion can be addressed by the provider. Many times this does present as headaches or migraines, but even mood changes, irritability, dizziness, balance problems, sleeping concerns, sensitivity to light and noise, foggy thinking, confusion, and fatigue can be an issue. If these occur for more than a week after the concussion, or if symptoms worsen rather than getting better, again, further evaluation and management is necessary.
In the acute period, assuming critical concerns are ruled out, the focus becomes on resting. Including limiting exercise, texting, driving, video games, and even limiting school work. Anything that worsens the headache should be avoided as well. Then once all symptoms are gone, children can gradually increase their activity using a step-wise approach, but again, if these symptoms resume, so does rest.
Tylenol can be helpful for headaches, once we have ruled out bleeding, or even Ibuprofen or Naproxen. Resting in a cool, dark, quiet place can lesson headaches and some people find cold packs on the portion of their head that hurts is also helpful. Drink plenty of water, get regular sleep, eat regular meals, decrease or manage stress, and avoid repeat head injury.
Care providers may even offer a "triptan" migraine medication such as sumatriptan to treat severe migraines that don't otherwise respond to ibuprofen or acetaminophen. If the concussion does occur during a sporting event, once the concussions symptoms are gone, they will need to follow a step-wise approach to returning to the activity.
The use of #nutraceuticals is growing once again in the general population. Parents often want a more natural treatment for their child with migraines. Others fail to find relief with conventional therapies or experience undesirable side effects. Many simply prefer a more holistic approach. Nutraceuticals are typically well tolerated and even less expensive which is important in our economy.
Daily supplements of #magnesium, vitamin D3, CoQ10, omega-3 fatty acids, or #riboflavin can be used to decrease headache frequency and severity. There isn't a great deal of research here in the pediatric population, but more so in the teenage group. Magnesium is better supplemented in the soluble forms which makes it easier to absorb, although improved even more when supplemented intravenously. Testing levels via a blood test isn't super helpful as this only identifies about one percent of the total body magnesium. Diarrhea is the primary side effect when supplemented orally, which is avoided when administered intravenously.
Riboflavin or vitamin B2 has the greatest amount of literature in the supplementation of children and adolescents with migraines. It is a cofactor in mitochondrial metabolism, and low levels have been linked to mitochondrial dysfunction and energy metabolism. Supplementation has proven effective in children with mitochondrial disorders. Urine can turn quite bright with riboflavin supplementation, along with diarrhea and frequent urination. The half-life is only two hours, so it would seem frequent supplementation throughout the day would optimize outcomes. An empty stomach is also less able to absorb riboflavin.
Coenzyme Q10 is the only nutrient recommended here already made in the body. It is also a cofactor involved in #mitochondrial metabolism and is known as an antioxidant. When levels are low in the body, it has been associated with abnormal energy metabolism. It has also been shown to be effective in migraine prevention in adults and generally only has the rare side effect. Dosage is generally about 1-3mg per kilogram or 2-6mg per pound which equates to about $30 a month.
Petadolex is a supplement often recommended as well, made with the perennial shrub, #butterbur, grown in Germany. Butterbur holds a substance that inhibits inflammation and serves as an antispasmodic and calcium channel blocker resulting in improvement in migraine symptoms. In its rare form, it can be toxic, but when purified and marketed as Petadolex, it can be used to treat asthma, allergies, and migraines. It can also help maintain muscle tone and blood flow in cerebral blood vessels and reduce spasms and inflammation associated with neurological discomfort. Petadolex is monitored by the German government's Commission E and considered safe by any governmental authority. It is also about $30 a month.
Mig99 is a specially processed and standardized form of #feverfew from Germany and has been found effective for reducing the incidence of migraines by 3.4 times, but has not been studied in children. Feverfew is the medieval aspirin or the aspirin of the 18th century. People who are sensitive to ragweed and related plants may experience allergic reactions to feverfew. It should also not be taken if pregnant because it may affect uterine contractions.
A number of studies reveal the benefits of supplementing vitamin D and migraines, and even for general pain conditions. Deficiency is associated with many diseases and many adults, adolescents and children are deficient. The best source of vitamin D is 15 to 20 minutes of daily direct sunlight during the midday. Fish can provide a limited source, along with breastfeeding (if mom has sufficient stores herself). Typically an additional supplement needs to be taken. Vitamin D3 is a gene regulator which improves immune function, mood conditions and many additional disorders.
Physical therapy, massage, biofeedback therapy, and acupuncture are additional remedies which may prove beneficial. When headaches persist for more than a few weeks, it may reasonable to consider beginning low-impact aerobic exercises such as walking, slow swimming, yoga, slow stationary biking that doesn't make headaches and other symptoms worse. Interestingly, there is concern that long periods of complete rest may eventually worsen rather than improve symptoms. This does not mean "return to play," but merely to start moving.
Fortunately, if resolution doesn't happen in the first few weeks after concussion, most are better within three months and almost all are better within a year after injury. Interestingly though, I do have a few athletes in my practice who presented with headaches or migraines but hadn't remembered their initial head injury. Others do remember, but the injury was more than a decade ago. Others have had multiple concussions, and after one, subsequent concussions are much more likely with longer and longer recovery periods.
Here's the thing though, ongoing migraines is typically the result of having not adequately treated the concussion earlier. While the integrative therapies may prove somewhat helpful above, the key to recovery is active rehabilitation so the underlying issue can be resolved. Not only can headache and migraine result without proper treatment, but so might hormone dysregulation, car sickness, anxiety, blood pressure issues, change in taste or smell, low energy or motivation, delayed responses to questions, nausea, noise sensitivity, occasional heartbeat irregularities, depression, difficulty concentrating, difficulting finding things, persistent neck pain, ringing in the ears, short-term memory issues, sleep disturbances, feeling of overwhelm, tired eyes, getting lost and the list goes on even more.
Symptoms range from cognitive to physical to emotional. Contrary to popular belief, loss of consciousness doesn't increase your likelihood of having persistent symptoms. A sports related concussion isn't necessarily less severe than a vehicle-related injury. What can seem like a minor head injury at the time can still have long lasting effects. The good news is that even after many years, cognitive function can improve with treatment.
A regular MRI scan cannot detect post-concussion syndrome; it can only detect structural damage to the brain. The damage caused by concussions is not shown with a standard structural MRI, but there are tests that can detect post-concussion syndrome such as a functional neurocognitive image or fNCI. This is a kind of functional MRI that looks at oxygenated and deoxygenated hemoglobin in the brain as it is accomplishing different cognitive tasks. By comparing blood flow in regions of your brain to a database of brains of people who haven't had any injury and are functioning normally, the areas of the brain affected can be pinpointed, and a customized treatment protocol developed.
Some people experience for longer time periods largely because of an inflammatory response. The affected part of the brain during a concussion experience a temporary breakdown of tiny structures in and around the injured cells. As a consequence, those cells fail to get the oxygen they need to power the signaling your brain normally requires. When you try to do something those cells govern - like remembering where you put your keys - they won't be able to accomplish the task. Other neural pathways will then attempt to complete the process, even though its a less efficient path for that information to take.
Most will return to normal function within three to six weeks of the original head trauma, but for post-concussion syndrome, that brain damage never heals on its own; the traffic jam is never relieved. In those cases, the brain keeps less efficient pathways to complete tasks even after the inflammation has resolved. This suboptimal signaling is what results in long-lasting concussion symptoms.
Neuroplasticity is Remarkable
The cool thing is that we can relearn better signaling pathways with a combination of physical and cognitive therapy. This post-concussion syndrome treatment requires a multidisciplinary approach meaning that most practitioners cannot offer a comprehensive rehabilitation program so medication becomes the primary tool in their toolbelt.
When I talk with clients about neuroplasticity, often this is with those suffering from trauma. We fail to consider that although if we use our quadriceps in the gym for squats they will mold differently, growing with increased mass, as do our biceps with curls, that potentially this is true too of our brains. We know those with chronic stress have larger amygdalas which causes them to be super efficient at identifying threats, sometimes to their detriment making them anxious and overly triggered. Consider though if we apply this understanding to concussion therapy.
A combination of physical and cognitive therapy designed to stress the brain enough that the brain will return to more optimal neural pathways is the key. A clinical neuropsychologist, a neuroradiologist, maybe even a neurosurgeon in partnership with a clinical psychologist, neuromuscular therapists, neurocognitive therapists, occupational therapists and #DynaVision specialists are all experts which may compose a comprehensive concussion team.
Physical therapy, vestibular therapy, speech therapy, occupational therapy, vision therapy, music therapy, and massage therapy are among those therapies which might be utilized. Aerobic exercise will even play into treatment. Neuromuscular therapy and scheduled rest, along with cardio exercise, will help the autonomic nervous system calm, since it too can be impacted by head injuries as well. Our practice can be of significant support here as we utilize #yoga, mindfulness, polyvagal theories, limbic healing exercises, and additional therapies to impact the autonomic nervous system. At least two to three hours of therapy a week is typical.
If you're told to simple rest in a dark room following a concussion, connect. Let us help you better advocate for yourself.