Marshall C. Freeman, MD, FAHS
Head injury is common and may cause neurological impairment. Head injury results from falls, motor vehicle accidents (MVA), sports injuries, and military traumatic brain injuries. According to the Centers for Disease Control and Prevention (CDC), from 2006-2010, falls were the most common cause of traumatic brain injury (40.5%). Other common causes included motor vehicle accidents (14.3%) and assaults (10.7%). Falls impact individuals at the extremes of age, with seniors and children/adolescents disproportionately affected. More than half (55%) of all traumatic brain injuries in children (0-14 years old) were caused by falls, while the large majority (81%) of head injury in seniors were due to falls.
In 2010 alone, there were approximately 2.5 million emergency room visits, hospitalizations, or deaths related to traumatic brain injury (TBI). The CDC reports TBI was associated with over 50,000 deaths. From 2001-2010 the rates of TBI-related emergency room visits increased by 70%. Sports-related concussion and head injury have also dramatically increased, with nearly 250,000 children diagnosed in the emergency room setting (2009).
Traumatic brain injury can range from mild to severe. Concussion is considered a subtype of TBI. A universal definition of concussion does not exist, but most medical organizations recognize that concussion is a brain injury induced by biomechanical forces leading to the impairment of neurological function. While loss of consciousness is common in concussion, it is not required to occur by definition.
Concussion can occur due to direct blunt-force trauma, such as hitting your head against the ground during a fall, or due to rotational or acceleration-deceleration injury, as might happen during an automobile accident. In the latter situation, an individual who is wearing a seat-belt may be thrown or rotated in one direction and back, but may not actually hit their head inside the vehicle. These mechanical forces cause damage not only to brain tissue alone (blunt-force) but perhaps even more significantly to more delicate supporting neuronal tissues and pathways (so-called shearing injuries).
In the mildest forms of concussion only a brief impairment of consciousness or concentration may occur and the individual usually recovers rapidly and completely. In the majority of situations, recovery from concussion will occur after 7-10 days. In more moderate or severe cases of concussion, more persistent and obtrusive symptoms may result. Concussion may cause loss of consciousness, memory difficulties, concentration difficulties, amnesia, mood and personality changes, learning difficulties, task-completion difficulties, sleeping problems, balance disorders, dizziness, and headache.
The evaluation of concussion usually includes brain imaging such as computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the head. In the majority of cases such imaging will be normal. The current standard available imaging rarely identifies shearing injuries, and often times such brain changes may not even develop until somewhat later in the course of the injury (i.e. days or weeks). Brain imaging is useful, however, in identifying the presence of skull fractures or traumatic intracerebral bleeding.
A basic neurological examination should be performed. This includes testing of the level of attention and wakefulness, cranial nerve examination, basic sensory examination, reflexes, and motor examination. If acute neck trauma can be safely excluded, then the individual should have gait (walking) and balance testing.
Cognitive evaluation of the injured individual is mandatory. Initial testing at the time of the accident is desired in order to obtain immediate post-injury cognitive status. This testing should include the individual recollection of events of the accident, simple item memory testing, and number or digit recall. If cognitive changes are present, serial testing over time should be performed to determine improvement. In moderate or severe cases of head trauma, formal neurocognitive and neuropsychological testing will be helpful to better identify specific areas of impaired functioning.
Headaches are a common feature of concussion or TBI. Many individuals will continue to experience headache pain even after most other symptoms of concussion have resolved. In my practice, it is not uncommon to see individuals suffering from post-concussive or post-traumatic headaches for months or even years after the original injury. By current definition from the International Classification of Headache Disorders, 3rd revision beta (ICHD-3b), post-traumatic headache should begin within seven days of the original injury, while chronic status is defined by persistence of the headaches after 3 months. Many of the chronic post-traumatic headaches eventually develop features of migraine or tension-type headache.
As a result of the above, many of the treatments used to treat post-traumatic headache are borrowed from the migraine or tension-type headache class. Daily preventative medication is an important part of therapy and many post-traumatic headaches will respond to medications from the blood pressure, anti-depressant, or anti-seizure groups. Physical therapy is occasionally helpful and some patients have responded favorably to acupuncture. For patients who continue to experience concentration or multi-tasking difficulties, formal cognitive behavioral therapy is useful.
In a later article I will discuss the background and challenges of sports-related injuries, another common cause of concussion and traumatic brain injury.
Marshall C. Freeman, MD, FAHS is the director of Headache Wellness Center (HWC) in Greensboro, NC. He is a board-certified neurologist in Adult Neurology, Neuromuscular Medicine, and Electrodiagnostic Medicine. He is a Fellow of the American Headache Society and holds specialty certification in Headache Medicine by the United Council of Neurological Subspecialties. HWC is the oldest and longest continuously operating headache specialty practice in North Carolina, serving the headache population since 1990. HWC is actively accepting new adult and pediatric patients. Please contact our office if you are interested in our current migraine studies. Visit www.HeadacheWellnessCenter.com or call 336-574-8000.