Post-Concussion Syndrome Treatment Guidelines

What is post-concussion syndrome?

Post-concussion syndrome (PCS) is a complex disorder that can occur following a mild traumatic brain injury (mTBI), such as a concussion. It is characterized by the persistence of concussion symptoms for weeks, months, or even longer after the initial head injury has healed. PCS is not considered a distinct diagnosis; instead, it refers to patients who experience ongoing symptoms after a concussion (Leddy et al., 2012). While most individuals recover from a concussion within a few days or weeks, a subset of patients experience persistent symptoms that significantly impact their quality of life.

PCS typically follows mild traumatic brain injuries, but the exact cause of persistent symptoms remains unclear. Notably, the severity of the initial head trauma does not necessarily predict the onset of PCS. Instead, factors such as age, sex, a history of prior concussions, and pre-existing mental health conditions (e.g., anxiety or depression) are key post-concussion risk factors (Teshome et al., 2022; Varriano et al., 2018). These factors may exacerbate the risk and prolong recovery.

Post-concussion symptoms can be broad, encompassing both physical and cognitive domains, and they tend to mirror the acute concussion symptoms. Common post-concussion syndrome symptoms include (NHS Inform, 2024; Permenter & Sherman, 2020):

• Cognitive symptoms: Problems with memory, attention, and executive functioning are often reported. Patients may describe difficulty concentrating, mental fog, or slowed thinking.
• Physical symptoms: Persistent headaches, dizziness, fatigue, and visual disturbances are common, as well as heightened sensitivity to light and noise. Symptoms may worsen with exertion or stress.
• Emotional and behavioral symptoms: Anxiety, irritability, and depression can arise or worsen after the injury, often contributing to the overall burden of PCS.
• Sleep disturbances: Insomnia or fragmented sleep can exacerbate other symptoms and slow the recovery process.

Imaging studies, such as MRI or CT scans, are generally unremarkable in PCS patients, as the underlying pathophysiology is often not detectable through standard imaging.

Treatment of post-concussion syndrome

The goal of PCS treatment is to address both the physical and emotional symptoms that persist after the initial injury, promoting full concussion recovery. Here are some possible treatment options for post-concussion syndrome:

Cognitive therapy

Cognitive therapy plays a crucial role in managing the mental fog, memory issues, and difficulty with concentration that are common in PCS. This therapy helps patients regain cognitive function and develop strategies to cope with deficits, ultimately aiding in their recovery (Concussion Legacy Foundation, n.d.).

Vision therapy

Patients often experience visual disturbances as part of their PCS symptoms, such as blurred vision or difficulty tracking objects. Vision therapy can be an effective intervention, targeting eye coordination, focusing issues, and visual processing to alleviate these symptoms.

Non-contact aerobic exercises

Non-contact aerobic exercise as part of an occupational therapy regimen may be beneficial for individuals experiencing prolonged recovery or PCS. According to Graham et al. (2014), engaging in light aerobic activity without additional impacts during the window of vulnerability can support recovery, particularly in youth recovering from sports-related concussions. Research by McCrea et al. (2009) suggests that exercise, when carefully monitored, does not negatively affect recovery and may, in fact, aid in symptom improvement.

Pharmacological interventions

Managing post-traumatic headaches, a common symptom of PCS often requires a combination of medications and therapeutic strategies. Key pharmacological options include:

• Amitriptyline: This tricyclic antidepressant is effective in treating post-traumatic headaches by inhibiting the reuptake of serotonin and norepinephrine, which helps reduce pain and improve sleep quality (Hurwitz et al., 2020).
• Intravenous dihydroergotamine (DHE): Primarily used for acute migraine relief, DHE may also benefit severe PCS-related headaches. It works as a vasoconstrictor, reducing cranial blood vessel inflammation and alleviating pain (McBeath & Nanda, 1994).
• Metoclopramide: An antiemetic commonly used to manage concussion-related symptoms such as nausea and vomiting.
• Propranolol: A non-selective beta-blocker that helps prevent migraines and can also be useful in managing post-concussion anxiety.
• Indomethacin: A non-steroidal anti-inflammatory drug (NSAID) that may be considered for headache relief when other treatments prove ineffective.

How to use our treatment guidelines handout template?

Carepatron has created a Post-Concussion Syndrome Treatment Guidelines handout you can use as a reference when formulating a treatment plan for patients with PCS. This handout lays out recommendations for cognitive therapy, vision therapy, exercises, pharmacological interventions, and more, helping you provide a comprehensive and tailored approach to managing the symptoms of PCS.  

Follow the steps to use the handout:

Step 1: Access the treatment guidelines

Choose "Use Template" to access the Post-Concussion Syndrome Treatment Guidelines via the Carepatron app. Click "Download" for a PDF copy.

Step 2: Assess your patient

Conduct a thorough assessment of your patient’s symptoms, history, and specific needs. Take note of any particular challenges they may be facing, which will help you tailor the treatment plan to their individual circumstances.

Step 3: Formulate the treatment plan

Using the information from the guidelines, develop a personalized treatment plan that incorporates relevant recommendations. Consider integrating a mix of therapies, exercises, and pharmacological interventions based on your patient’s assessment results.

Step 4: Save and share

Save the handout for easy access during future patient assessments and treatment planning. You can also share the PDF copy with colleagues or other healthcare professionals involved in your patient's care to ensure everyone is on the same page regarding treatment approaches and recommendations.

Benefits of using this handout

Using the Post-Concussion Syndrome Treatment Guidelines handout offers several key advantages for you and your patients:

Fully digital

You and your patients can access the handout from any device, including computers, tablets, or smartphones, making it available anytime and anywhere, whether in a clinic or during a telehealth consultation.

Contains research-backed recommendations

The handout is built upon evidence-based studies, ensuring that the treatment recommendations are scientifically backed and grounded in research. This is crucial for providing effective and reliable care for post-concussion syndrome.

Improved patient outcomes

Our reference handout is designed to guide healthcare professionals in creating structured, evidence-based treatment plans for PCS. By providing targeted interventions, the handout assists in managing the wide range of PCS symptoms. Additionally, it promotes the development of individualized care plans tailored to each patient’s specific symptoms and needs, ensuring personalized and effective treatment.

Better patient education

Another key benefit is enhanced patient education, as the handout serves as a useful tool for explaining the treatment process, helping patients better understand their condition and actively participate in their recovery journey.

References

Graham, R., Rivara, F. P., Ford, M. A., Carol Mason Spicer, Youth, in, Board, Institute of Medicine, & National Research Council. (2014, February 4). Treatment and management of prolonged symptoms and post-concussion syndrome. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK185342/

Hurwitz, M., Lucas, S., Bell, K. R., Temkin, N., Dikmen, S., & Hoffman, J. (2020). Use of amitriptyline in the treatment of headache after traumatic brain injury: Lessons learned from a clinical trial. Headache: The Journal of Head and Face Pain, 60(4), 713–723. https://doi.org/10.1111/head.13748

Leddy, J. J., Sandhu, H., Sodhi, V., Baker, J. G., & Willer, B. (2012). Rehabilitation of concussion and post-concussion syndrome. Sports Health: A Multidisciplinary Approach, 4(2), 147–154. https://doi.org/10.1177/1941738111433673

McBeath, J. G., & Nanda, A. (1994). Use of dihydroergotamine in patients with postconcussion syndrome. Headache: The Journal of Head and Face Pain, 34(3), 148–151. https://doi.org/10.1111/j.1526-4610.1994.hed3403148.x

McCrea, M., Guskiewicz, K., Randolph, C., Barr, W. B., Hammeke, T. A., Marshall, S. W., & Kelly, J. P. (2009). Effects of a symptom‐free waiting period on clinical outcome and risk of reinjury after sport‐related concussion. Neurosurgery, 65(5), 876–883. https://doi.org/10.1227/01.neu.0000350155.89800.00

NHS Inform. (2024, May 16). Post-concussion syndrome | NHS inform. https://www.nhsinform.scot/illnesses-and-conditions/injuries/head-and-neck-injuries/post-concussion-syndrome-pcs/

Permenter, C. M., & Sherman, A. l. (2020). Postconcussive syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534786/

Teshome, A. A., Ayehu, G. W., Yitbark, G. Y., Abebe, E. C., Mengstie, M. A., Seid, M. A., Molla, Y. M., Baye, N. D., Amare, T. J., Abate, A. W., Yazie, T. S., & Setargew, K. H. (2022). Prevalence of post-concussion syndrome and associated factors among patients with traumatic brain injury at Debre Tabor Comprehensive Hospital, North Central Ethiopia. Frontiers in Neurology, 13. https://doi.org/10.3389/fneur.2022.1056298

Varriano, B., Tomlinson, G., Tarazi, A., Wennberg, R., Tator, C., & Tartaglia, M. C. (2018). Age, gender and mechanism of injury interactions in post-concussion syndrome. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques, 45(6), 636–642. https://doi.org/10.1017/cjn.2018.322