“What medication should I take after a concussion?”, is possibly not the correct question to ask.
A better question would be “Should I take any medication after a concussion?”

Even then, to answer the question we need to separate the issues of the acute period, say in the first two to four weeks after a concussion episode, from the more chronic presentation when symptoms continue for longer than a few months.

In the acute phase, symptoms such as headache, dizziness or nausea can be strong and debilitating leading to some to seek a script from the doctor for some relief. In the more chronic phases, the frustration of ongoing symptoms and feeling medications might be the cure can also be the driver for medications. Let’s look at what are the important issues for medication use after a concussion.

The Acute Phase

A recent review of the literature on medication use in the acute phase of concussion was reported on in the Journal of the American Medical association (JAMA Neurology).  They reviewed nearly 1400 research articles and concluded that: 

‘This systematic review found a limited number of high-quality, clinically meaningful studies, particularly among children and individuals in the acute stage of injury; therefore, performing an evidence-based analysis that would inform clinical decision-making was not possible.’

In other words, there is not much evidence to support the use of medications in the acute phase of concussion. This is consistent with the Berlin Consensus Statement on sports concussion which concludes the same thing.

What normally happens is, if you go and see a doctor, they will suggest taking some Panadol or Nurofen to ease any pain or discomfort, usually headache-related, in the first few days after the concussion event. These medications can ‘mask’ the symptoms but don’t actually promote any healing in the brain. As much of the rehabilitation from your concussion injury is controlled by your symptom presentation it is important not to mask your symptoms by taking pain-relieving medication for long periods of time or taking too much.

Recommendation 1
If you are still relying on regular medication to get you through the day, three to four days after your concussion, review with your GP to make sure there is nothing sinister going on. Further tests may need to be carried out.
It will also be worthwhile to see a concussion practitioner to start a rehabilitation program, which should help reduce your symptoms.

The Chronic Phase

Ongoing symptoms that last for more than six to eight weeks after a concussion are usually referred to as PCS (Persistent Concussion Symptoms). In these chronic phases of concussion, symptoms might be less intense but more frustrating because they have been continuing for an extended period of time. Hence, just getting some relief from the symptoms can be a huge driver for using medications.
The range of issues in PCS can be quite varied so therefore a range of different medications are often used to give some relief. As with the acute phase, these medications will often just mask the symptoms which can make rehabilitation more difficult. The worst-case scenario is that these medications can sometimes have some other side effects which mimic other concussion symptoms. For example, some medications for dizziness may cause nausea.

Recommendation 2

If you are not doing a serious rehabilitation program for your concussion injury and just using medications to get you through the day, you are not setting yourself up for a good recovery.
Start a rehabilitation program with someone who can guide you through aerobic exercise, a visual/balance program, neck treatment, dietary changes and psychological support. You may need a change of mindset and pull back from other activities to be focused on recovery. This will get you a better long-term recovery.

Recommendation 3

There are occasions where medication is required to help act as a ‘circuit breaker’ to settle symptoms and allow the rehabilitation program to continue more effectively. The healthcare professionals involved in the rehabilitation and medication side of your treatment should be in communication on this process to make effective choices on the best way forward. For example, medications that make you sleepy or fatigued may not be the best choice if you are attempting to exercise on a regular basis. 

In summary, it is most appropriate to see medication as a short term help, not a long term solution.

What is Concussion and PPCS? 

Concussion is defined as a mild to moderate traumatic brain injury, caused by an acceleration/deceleration of the head, which has an impact on the way the nerves in your brain function.

There is no bruising, just inflammation. There is nothing to see on scans or any test, the brain looks normal!

This creates a problem. How do we know if it is a concussion?

What actually happens to the brain?           

The brain undergoes a sheering force during the injury process, which places a stretching load on the nerves. This leads to an initial burst of over-activity in the nerves, which affects body function. For example, the body becomes rigid, you can hear ‘bells’ or see ‘stars’ 

This burst of activity in the brain then causes an energy deficit in the brain – FATIGUE. It’s like the nerves have done a 400m sprint, then collapse. This fatigue of the nerves, in the brain, can take a few minutes to two days to manifest in a range of symptoms such as headaches, dizziness, fatigue, nausea and brain fog. Our brain is a high energy structure – 2% of body weight but uses 20% of our blood supply due to high energy needs. This is why the process of fatigue impacts us so much!

“Concussion in Sport Australia Position Statement Feb 2019” 

With a day or two rest, and then a graduated return to mental and physical activity (best directed by a health professional who understands the process), 80% of people will return to normal function in two to four weeks. For some, symptoms persist and this can create a disruption to normal work/school activities, often leading to anxiety as to how long the problem will last. This is a problem called Persistent Post Concussion Symptoms (PPCS).

In the USA, it’s estimated  that each year 1.17% of population will incur a concussion. If Australia has a similar number this means 282k of the population will experience a concussion every year. if 20% develop PPCS, 56 000 will have symptoms longer than 4-6 weeks, some will experience symptoms that will last years.

If you have a family history of migraine your genetics might mean you are more likely to develop PPCS.

Persistent Post-Concussion Symptoms (PPCS)

Persistent symptoms following a concussion can be a complicated issue and difficult to address. A group of specialists was convened in Australia in 2019 to give some direction for the treatment approach to concussion in Australia. Here is what they said about PPCS.

According to the position statement, there are four areas that need to be addressed in PPCS. With my experience as a headache practitioner, I believe a fifth category should be added: Diet. Diet can have a huge impact on the way the brain functions. Therefore, the five areas requiring attention are: 

1. Physiological processes with exercise
   2. The Cervical spine (neck)
   3. Vestibular/Visual function and balance
   4. Psychological support
   5. Diet

It’s important to understand that no two concussions present the same – there is always individual variation. As a consequence, everyone’s rehab will be different, with emphasis on the problematic areas. That’s why guidance is often the key to an effective rehab program. Treatment in the five areas generally involve the following features:

1. Physiological processes with exercise

Sub-symptom aerobic exercise is often a vital ingredient to restore normal brain function. A Buffalo Concussion Treadmill Test is used to determine your required heart rate for exercise that won’t aggravate symptoms but will help restore brain function.

 2. The Cervical spine (neck) 

The upper neck is very often injured during a concussion. A concussion injury requires 70-120G’s of force on the brain but an upper neck ‘whiplash’ type injury can occur with as little as 4G’s of force. The upper neck can often be a source of headaches, nausea, dizziness and several other symptoms common in concussion as well. A skilled assessment of the upper neck is often a key aspect of dealing with PPCS effectively.

 3. Vestibular/Visual function and balance

A concussion can disrupt the normal functioning of the vestibular and visual systems. These problems, along with the neck, can have an impact on balance and equilibrium i.e. the challenge of staying upright in this world.
Visual problems, on their own, can make it difficult to read and concentrate affecting the ability to work or attend school for many people. Specific exercises and treatment can be used to target these issues and help a person experiencing PPCS to return to normal activities, both physical and mental/cognitive.

4. Psychological support 

Persistent symptoms after a concussion can be so disrupting to a person, they can lead to significant anxiety. A previous history of a mental health disorder can make this even more likely to occur. Support and encouragement from friends and family is paramount if someone with PPCS is going to navigate their road to recovery.
Concussion is often called an invisible injury as people can look normal whilst suffering these debilitating. Psychological support can make the difference between a successful rehab program or failure.

5. Diet

The Gut-Brain interface is becoming a key area of health research in more recent times. Poor dietary choices such high sugar diets and or excessive alcohol can definitely aggravate the effect of a concussion on the brain.

Summary

Persistent Post-Concussion Symptoms (PPCS) can definitely be a debilitating problem but can also be treated effectively. Although complex, when assessed by competent health professionals, an effective program can be put together that will help overcome your PPCS problem.