Head trauma | Headache NewsBlog

Postconcussion symptoms in teens are relieved by CBT

By: Dr. Mauskop

09-04-2017

Alternative Therapies, Head trauma, Psychology of headaches

Postconcussion symptoms can be debilitating and can persist for long periods of time, both in kids and adults. Persistence of headaches, dizziness, difficulty concentrating and with memory is often compounded by depression and anxiety. The usual care consists of mild exercises, sleep medications, antidepressants, and other drugs.

A new study published in Pediatrics shows very promising results from cognitive-behavioral therapy (CBT) in teens with post-concussion symptoms. Children aged 11 to 17 years with persistent symptoms for more than a month after sports-related concussion were randomly assigned to receive collaborative care that included CBT (25 kids) or care as usual (24 kids). The children were assessed before treatment and after 1, 3, and 6 months.

Six months after the baseline evaluation 13% of children who received CBT and 42% of control patients reported high levels of postconcussive symptoms. Depression improved by at least 50% in 78% of the CBT group and 46% of control patients. Anxiety symptoms were at the same level in both groups.

CBT has been shown to be effective in children and adolescents with chronic migraines, so it is not surprising that it would also help with postconcussion headaches and other symptoms. And the effect is quite dramatic.

A major obstacle for wider adoption of CBT is the cost and difficulty in finding a qualified psychologist. In a previous post I mentioned two very effective and scientifically verified online programs, ThisWayUp and moodGYM. These do require persistence and discipline, which in case of teens, parents might be able to provide.

Soccer is not good for your brain, at any age and whether you head the ball or not

By: Dr. Mauskop

08-03-2017

Head trauma, Headaches, Headaches in children

With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period.

The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%.

Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive.

According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any age may be risking brain injury, mostly from heading and unintentional head injuries.

Early return to physical activity after concussion may reduce post-concussive symptoms

By: Dr. Mauskop

05-02-2017

Head trauma

Physical and mental symptoms can persist after a concussion and strangely, mild concussions are more likely to cause persistent symptoms than severe ones. In a previous post, Rest your brain after a head injury I described a study that involved 335 children and young adults. As the title indicates, cognitive rest was associated with a faster recovery.

Another post on concussion and post-concussion headaches mentioned that experts advocate physical rest as well. However, a new study of over 3,000 Canadian children between the ages of 5 and 18 with concussion suggests that the recovery is faster in those who get physically active within the first week of an acute concussion. Of the children who engaged in physical activity within the first week 29% had persistent post-concussive symptoms four weeks later compared to 40% of those who did not engage in any physical activity. This was true whether the child participated only in light aerobic exercise (33% of kids), sport-specific exercise (9%), noncontact drills (6%), full-contact practice (4%), or full competition (17%). I am very surprised that kids were allowed to return to full-contact practice and full competition before complete recovery.

These finding contradict all of the concussion guidelines, which recommend a period of physical and cognitive rest following a concussion until post-concussive symptoms such as dizziness, fatigue, and headaches have resolved. The guidelines also advise to increase the amount of physical activity only if symptoms do not worsen. These guidelines were developed without the benefit of large controlled studies, but rather by a consensus of experts.

The authors also think that children who rest for a long period of time may be unnecessarily deprived of physical activity’s benefits on the growing body. Too much rest may also lead to symptoms such as depression, anxiety, and social isolation.

“We may need to reconsider the current recommendations for strict conservative rest until patients are symptom-free,” study author Roger Zemek, MD, PhD, associate professor and director of research at the University of Ottawa in Canada, said in an interview with Neurology Today. “Patients should be encouraged to participate in some form of active physical rehabilitation following concussion as long as the activity does not put them at risk of re-injury.”

The study authors did caution that “Participation in activities that might introduce risk for collision or falls should remain prohibited until clearance by a health professional to reduce the risk for a potentially more serious second concussion during a period of increased vulnerability.”

Two prominent sports neurologists said that not much will change at their clinics, because programs like the one in the study are already in place. They generally prescribe an early, graduated, return to physical activity for children and adolescents who present with a sports-related concussion. (Phases include light activity like walking, moderate activity like jogging, and moderate-heavy activity like non-contact practice or drills.) Patients may return to full activity within one week, although they may not progress by more than one phase per day. These neurologists also felt that avoidance of all activity can be harmful – not just on physical health, but also on mental health.

They also agreed that kids must not be allowed to immediately return to full-contact sport or high risk activities before complete recovery because of the increased risk of re-injury.

Post-concussion syndrome responds to intravenous magnesium

By: Dr. Mauskop

25-06-2016

Alternative Therapies, Head trauma, Migraine

A new report presented at the last annual scientific meeting of the American Headache Society in San Diego showed that post-concussion symptoms can be helped by an intravenous infusion of magnesium.

Doctors at the department of neurology at UCLA described six patients with a post-concussion syndrome, who were given an infusion of 2 grams of magnesium sulfate. Three out of six had a significant improvement of their headaches and all had improvement in at least one of the following symptoms: concentration, mood, insomnia, memory, and dizziness.

This was a small study, but it is consistent with other studies that show a drop in the magnesium level following a concussion and also studies in animals that show beneficial effects of magnesium following a head trauma.

Our studies have shown that intravenous magnesium can relieve migraine and cluster headaches in a significant proportion of patients.

Considering how safe intravenous magnesium is and how devastating the effect of a concussion can be, it makes sense to give all patients with a post-concussion syndrome if not an intravenous infusion, at least an oral supplement. I usually recommend 400 mg of magnesium glycinate, which should be taken with food. For faster and more reliable effect, we routinely give patients with migraines, cluster, and post-concussion headaches an infusion of magnesium. Patients who do not absorb or do not tolerate (it can cause diarrhea) oral magnesium, come in to for monthly infusions.

Pre-Concussion Psychological Symptoms Can Delay Recovery from a Concussion

By: Dr. Mauskop

23-05-2016

Head trauma, Psychology of headaches

Post-concussion symptoms have long been thought to be more severe and prolonged in people who have pre-existing psychological problems. This has been shown to be the case in the military personnel. A new study confirmed this observation in the first prospective study. Over 2,000 high school and college athletes in Wisconsin were asked to answer 18 questions (Brief Symptom Inventory-18, or BSI-18) and then were followed for three years. The 18 questions, which are listed below, addressed the presence of anxiety, panic attacks, depression, and somatization (excessive bodily sensations). In the ensuing three years, 127 athletes sustained a concussion. The concussion had to be diagnosed by a licensed athletic trainer according to the Department of Defence definition, which includes alteration of mental status with associated headache, nausea, vomiting, balance difficulties, dizziness, cognitive difficulties, and other. These athletes were again evaluated two and six weeks later. Eighty percent of concussed athletes were men. The mean duration of symptoms was five days. Ninety five percent of them recovered completely within a month. High somatization score on the BSI-18 questionnaire predicted prolonged duration of symptoms, while no correlation was found with the years of playing a sport, the type of sport (most played football), number of prior concussions, migraines, ADHD, or the grade point average. Another factor that delayed recovery was the initial symptom severity after the concussion. Most of the concussions were mild with less than 10% of athletes losing consciousness.

An interesting and unexplained fact, not examined in this study, is that milder concussions tend to cause more severe symptoms than severe ones.

This was a very thorough study, but it was relatively small, so it is possible that other pre-concussion factors may also delay recovery. One such factor is pre-existing migraines. I see many patients, adults and children, who suffered from migraines and after a concussion have worsening of their migraines or new daily persistent headaches. If they themselves have never suffered from migraines, often their mother or siblings have a history of migraines, suggesting genetic predisposition to migraines.

Treatment of post-concussion symptoms, include typical therapies employed in migraine sufferers, including aerobic exercise, biofeedback, magnesium supplementation, Botox injections, and a variety of medications.

Brief Symptom Inventory-18

The Somatization dimension
01. Faintness or dizziness
04. Pains in heart or chest
07. Nausea or upset stomach
10. Trouble getting your breath
13. Numbness or tingling in parts of your body
16. Feeling weak in parts of your body
The depression dimension
02. Feeling no interest in things
05. Feeling lonely
08. Feeling blue
11. Feeling of worthlessness
14. Feeling hopeless about the future
17. Thoughts of ending your life
General anxiety
03. Nervousness or shakiness inside
06. Feeling tense or keyed up
15. Feeling so restless you couldn’t sit still
Panic
09. Suddenly scared for no reason
12. Spells of terror or panic
18. Feeling fearful

Treating concussion in children

By: Dr. Mauskop

22-06-2015

Alternative Therapies, Botox, Chronic migraine, Head trauma

Several presentations at the annual meeting of the American Headache Society held in Washington DC last weekend discussed the treatment of post-concussion symptoms in children (everything below also applies to adults). Among many topics, the speakers addressed the question of aerobic exercise after the concussion. Most experts agree that starting physical exercise too early can worsen the symptoms and delay recovery. At the same time, because aerobic exercise has so many benefits for the brain, it is prudent to begin aerobic exercise 2 to 4 weeks after the concussion. The child should begin exercising for short periods of time and at low intensity. Exercise should be stopped as soon as symptoms, such as headache or dizziness worsen. Brisk walking could be the first activity to be tried. The ideal duration is about 30 minutes and when this goal is achieved, the intensity of exercise can be gradually increased.

As far as the very common cognitive problems after a concussion, the experts also agreed that complete cognitive rest is not helpful. Just like with physical exercise, it is best to begin mild activities, such as reading for pleasure, and then slowly increase the load, as tolerated.

Several scientific presentations reported that the most common type of headaches that occurs after a concussion is migraine. When these post-concussion migraines last for more than 3 months and occur on more than 15 days each month, they are considered to be chronic migraines.

The treatment of post-concussion chronic migraines is the same as the treatment of chronic migraines that occur without a concussion. These treatments may include cognitive behavioral therapy, biofeedback, magnesium and other supplements (magnesium deficiency is found in up to 50% of migraine sufferers and magnesium is depleted by trauma), various preventive medications, and Botox injections.

Although the FDA has not yet approved Botox injections for the treatment of chronic migraines in children, Botox is safer than most drugs. We know about the safety of Botox in children because it has been widely used even in very young children who suffer from cerebral palsy and are unable to walk unless their stiff leg muscles are relaxed by Botox. Botox was approved by the FDA 26 years ago and some kids have been getting injections for over 20 years and so far there have been no long-term side effects observed.

Post-concussion symptoms could be due to PTSD

By: Dr. Mauskop

06-08-2014

Head trauma

Post-concussion syndrome, which often includes headaches, can persist for many months especially after a minor injury (yes, mild injury is more likely to cause post-concussion syndrome than a severe one).
However, little is known about prognosis after the injury. The symptoms fall into three categories – cognitive (such as memory, concentration difficulties), somatic (headaches, dizziness, etc), and emotional (irritability, anxiety, depression). A study by French physicians recently published in JAMA Psychiatry, also took into account the fact that injuries are often sustained during psychologically distressing events (car accidents, assaults, falls) and looked for symptoms of post-traumatic stress disorder (PTSD) in those patients.

The authors conducted a study of patients seen at an emergency department for a mild head injury. They checked on these patients for persistent symptoms three months after the concussion. The study included 534 patients with head injury and 827 control patients with non-head injuries.

The study showed that three months after the injury, 21.2 percent of head-injured and 16.3 percent of nonhead-injured patients had post-concussion syndrome, while 8.8 percent of head-injured patients met the criteria for PTSD compared with only 2.2 percent of control patients.

Their conclusion was that it is important to differentiate post-concussion syndrome from PTSD because it has important consequences, in terms of treatment, insurance resource allocation and advice provided to patients and their families. They also stressed the importance of considering PTSD in all patients with mild traumatic brain injury who suffer persistent symptoms.

Rest your brain after a head injury.

By: Dr. Mauskop

07-01-2014

Head trauma

Strenuous mental activity seems to delay recovery after a head injury, according to a new study published in Pediatrics .

Doctors have always recommended rest after a head injury, but it has never been clear how much to limit activities, what kind to limit (physical, mental, or both), and for how long.

Dr. William P. Meehan III, director of the Micheli Center for Sports Injury Prevention in Waltham, Massachusetts and his colleagues studied 335 patients (62% were males), aged 8 to 23 who came to a sports concussion clinic within three weeks of their injury between 2009 and 2011. Most of the concussions were sustained while playing ice hockey, football, basketball or soccer. The researchers asked them about their symptoms and how often they were reading, doing homework or playing games at each of their appointments.

Those with minimal cognitive activity were not reading or doing homework, and spent less than 20 minutes on the Internet or playing video games each day. They could have watched TV or movies or listened to music. Those with moderate or significant cognitive activity did some reading and some homework, but less than usual. Others had not limited their cognitive activities at all since their last clinic visit.

On average, patients took 43 days to fully recover from their concussions. Those with more minor concussions tended to get over their symptoms faster. So did those who did less with their brains while recovering.

Results showed that only those engaging in the highest levels of cognitive activity had a substantial increase in their symptom duration, while those at all lower activity levels seemed to recover at about the same pace.

According to Dr. Meehan, “This would suggest that while vigorous cognitive exertion is detrimental to recovery, milder levels of cognitive exertion do not seem to prolong recovery substantially”

In general, Meehan said, doctors recommend almost complete brain rest for three to five days after a concussion, followed by a gradual return to normal activities.

Athletes suspected of having a concussion should be seen by the most immediately available medical personnel, like an athletic trainer or team doctor, he said, with a follow-up visit to their primary care doctor.

I would also emphasize the importance of physical rest and complete avoidance of any activities that could result in another head injury before completely recovering from the first one. Complete recovery means no symptoms at all, including headaches, dizziness, mental fog, fatigue, difficulty concentrating, insomnia, anxiety, depression, and other. Taking a magnesium supplement can also help since animal studies show magnesium depletion following an injury. If rest alone does not lead to a complete recovery, cognitive behavioral therapy, medications (for anxiety, depression, and irritability), and Botox injections (for persistent headaches) are sometimes needed.