Introduction

Concussions have recently become a hot subject and are discussed particularly in sports. But, have you heard about post-concussion syndrome? Post-concussion syndrome (PCS) refers to a recognisable set of symptoms that typically develop following a minor head injury, lasting for months or even years after the initial injury, and individuals who have had more than one brain injury are more likely to develop it.¹

Concussions are very common, but specialists struggle to measure how many individuals suffer from them each year. One of the reasons is that there are different criteria for diagnosing PCS, which change over time. Many people who suffer from concussions do not seek medical attention.²  

Young people assigned male at birth (AMAB) and older individuals assigned female at birth (AFAB) are most likely to have concussions. People AFAB represent most of the affected cases, making up 64% of those over 65 years old, but there is an overall predominance in those AMAB. The most prevalent causes of injury are assault, falls, and road traffic crashes, with falls affecting the majority of the young (<15 years) and elderly (>65 years) populations.³

If a person has been diagnosed with a concussion and then attains another head injury before the first concussion heals completely, they may be at risk of PCS. Providing medical assistance after the initial concussion is critical to avoiding this dangerous condition.⁴

Common symptoms of post-concussion syndrome

PCS symptoms often fall into four groups:

Blood dysregulation symptoms:

• Headache - the most common symptom (15.3% of patients with PCS) and varies from one person to the other⁵ 
• Tiredness
• Feeling sick
• Disturbed sleep 
• Persistent neck pain

Cognitive-related symptoms: 

• Poor concentration
• Brain fogginess 
• Difficulty reading 
• Memory problems (amnesia) 
• Difficulty finding objects

Sensory-related symptoms: 

• Visual blurring
• Double vision (diplopia)
• Light or sound sensitivity
• Nausea
• Taste or smell change
• Vertigo
• Ringing in the ears

Psychological (behavioural) symptoms:

• Depressive mood
• Anxiety
• Agitation
• Being irritable
• Lack of energy or motivation
• Some personality changes

Not everyone with PCS will experience all of the symptoms listed above. These symptoms may last up to a few weeks. However, for some individuals, they can last longer.⁶

Possible complications include:

• Excessive usage of pain medications
• Memory loss
• Trouble working or inability to work at all
• Long-term sleep disturbances
• Problems with everyday routine such as housework, bathing, grooming, and dressing
• Behavioural changes including aggressiveness, anxiety, and sadness
• Self-harm and suicidal ideation

Diagnosis and assessment

Diagnosis of PCS is challenging since the symptoms are unclear, difficult to prove, and can be attributed to other disorders. There are no standard diagnostic PCS criteria. 

According to the International Classification of Diseases (ICD), the diagnosis of PCS includes a history of concussion in addition to the presence of 3 or more criteria of the following:⁷

• Headache
• Feeling dizzy
• Feeling tired
• Irritable mood
• Difficulty sleeping
• Affected concentration
• Memory impairment
• Unable to cope with stress, anxiety, or alcohol

Patients with symptoms associated with PCS require extensive physical and neurological testing. If there is a considerable risk of brain bleeding, a CT scan should be conducted. However, other imaging techniques such as MRI, SPECT, and MEG are more efficient at diagnosing PCS.

If your healthcare practitioner believes you have PCS, they will arrange follow-up appointments to monitor any changes in your symptoms. They may perform several tests or ask you the same questions at each follow-up visit. They do this to monitor your symptoms and search for any changes, no matter how slight, that indicate a shift in your status.

Treatment of post-concussion syndrome

Sadly, there is no specific treatment for PCS. Instead, there are treatment plans that facilitate recovery. In other words, individuals need time to recover and symptom-targeted treatment is done to alleviate some of their symptoms.

• Headaches - Treated using medications for depression or seizures. However, overuse of these medications can lead to the persistence of headaches
• Memory and cognitive symptoms - These symptoms typically resolve over time. Some individuals may need occupational therapy. Moreover, stress can be decreased by relaxation techniques
• Depression and anxiety - Psychotherapy and antidepressants are utilised according to each individual’s case
• Sensory symptoms - Vestibular physical therapy, vision therapy, and other treatments may help to restore balance and alleviate these symptoms

It is worth knowing that, previously, individuals with PCS were advised to rest. On the contrary, recent research proved that low-level activity can help the healing process. It should not involve heavy weights or sports activities.⁸

FAQs

Why do some people have PCS while others don't?

According to the Concussion Legacy Foundation, being AFAB and at advanced age are risk factors for PCS. Moreover, if an individual suffered from a concussion due to a severe blow, had an increased duration of initial concussion symptoms, major visual symptoms after concussion, or decreased neck strength they would be more likely to develop PCS.

Post-concussion syndrome versus symptoms after concussion

The main difference between concussion and PCS is the duration of symptoms after head trauma. In concussions, symptoms occur right after the head trauma and fade or resolve, while PCS symptoms happen in the first few weeks after head trauma. They have a similar range of symptoms and severity may increase over time.

What medications are used to treat post-concussion headaches?

Amitriptyline has been studied for treating PCS headaches and was successful in many patients, 90% made an excellent or good recovery. Furthermore, its calming properties can benefit people suffering from sleep disturbances following a concussion, in addition to relieving headaches.⁹

Summary

Post-concussion syndrome emerges after a head injury, persisting for months to years, with symptoms including headache, fatigue, visual changes, and more. Typically, young people AMAB and older individuals AFAB (often from falls or accidents) are most susceptible. Early symptom recognition is vital to prevent prolonged issues, especially as subsequent head injuries increase the risk.

Diagnosing PCS poses difficulties due to vague symptoms and no standardised criteria. Overall, PCS treatment focuses on alleviating symptoms and promoting healing, underscored by regular follow-up appointments for symptom monitoring and treatment adjustment.