A concussion can be frustrating because the injury is often invisible.
A person may feel dizzy, foggy, irritable, exhausted, or unable to sleep while their CT scan or MRI appears normal. Symptoms may improve within days, but the brain’s metabolic recovery can continue for several weeks.
During this episode of Mind Matters: Navigating Head Injuries and Concussions, legal nurse consultant Kiley Como spoke with Dr. Robert Bashuk about concussion forces, persistent symptoms, headaches, sleep, and the importance of carefully prescribed exercise.
A Concussion Does Not Always Require a Direct Hit
Many people assume a concussion requires a major blow to the head.
However, a concussion may occur when enough force is transmitted through the head, neck, or body to create rapid acceleration and deceleration of the brain.
The person does not necessarily need to lose consciousness or have a visible injury.
Dr. Bashuk explained that concussion-related changes are primarily functional and metabolic rather than structural. These changes may include altered brain chemistry, inflammation, and a temporary drop in cellular energy production.
That is one reason routine scans may not reveal the injury.
Feeling Better Does Not Always Mean Fully Healed
After a concussion, symptoms may begin improving before the brain’s energy system has completely recovered.
Dr. Bashuk compared this to a broken arm.
The intense pain from a fracture may lessen after several days, but the bone still needs time to heal. A person would not immediately return to a contact sport simply because the pain improved.
The same caution may apply to a concussion.
Returning too quickly to activities that create another risk of head injury may expose the brain to another impact before recovery is complete.
This is particularly concerning for athletes, who may feel pressure to return as soon as headaches or dizziness decrease.
Why Some Impacts Cause Concussions and Others Do Not
Not every impact in football, soccer, or daily life causes a concussion.
The amount of force, direction of movement, neck position, preparation for the impact, and individual characteristics may all affect the outcome.
Dr. Bashuk explained that an anticipated impact may affect the body differently from an unexpected one. A person who sees a soccer ball approaching may tighten the neck and prepare for contact. An unexpected hit may create more uncontrolled head movement.
Repeated exposure to lower-force impacts is not the same as suffering a diagnosed concussion, but athletes and parents should still report symptoms honestly.
The absence of a dramatic collision does not automatically mean an injury did not occur.
Women May Experience Concussions Differently
Men experience a greater total number of sports concussions in part because more men participate in certain contact sports.
However, Dr. Bashuk discussed evidence suggesting that women may experience higher concussion rates when comparing athletes in similar sports.
Several possible explanations have been proposed.
Men generally have larger and stronger neck muscles, which may reduce head movement during an impact. Women may also experience hormonal factors that influence injury response and recovery.
Reporting may play a role as well. Some athletes hide symptoms because they do not want to leave the game, disappoint teammates, or lose their position.
Whatever the reason, concussion symptoms should be reported immediately rather than concealed.
Acute Concussion Versus Persistent Symptoms
The early stage of a concussion may include headaches, dizziness, memory problems, fatigue, brain fog, poor concentration, blurred vision, and sleep disruption.
When symptoms continue beyond approximately one month, providers may describe them as persistent post-concussion symptoms.
That does not necessarily mean the original concussion itself remains unchanged.
Persistent symptoms may instead be connected to unresolved problems involving:
- The autonomic nervous system
- Eye movements
- Balance and vestibular function
- The neck
- Sleep
- Nutrition
- Hormonal health
- Anxiety or depression
- Migraine-type headaches
A complete evaluation should examine each symptom rather than treating all ongoing problems as one general concussion complaint.
Every Concussion Has Its Own Pattern
Dr. Bashuk described the importance of identifying each patient’s individual concussion phenotype.
A phenotype is the particular combination of symptoms experienced by that person.
One patient may primarily experience headaches and anxiety. Another may struggle with memory and insomnia. A third may have dizziness, nausea, irritability, headaches, and sleep problems.
These patients may not need the same tests or treatment plan.
Someone without memory concerns may not require the same cognitive evaluation as someone who repeatedly forgets conversations or appointments.
Treating the specific symptom pattern can help providers avoid a one-size-fits-all approach.
Concussion Symptoms Are Not Specific
Headaches, fatigue, poor concentration, and irritability can occur after a concussion, but they can also result from several other conditions.
Similar symptoms may appear with:
- Whiplash
- Migraine
- Sleep deprivation
- Anxiety
- Depression
- Post-traumatic stress
- Medication effects
- Chronic pain
A provider must determine whether the symptoms are caused by the concussion, another injury, an existing condition, or a combination of factors.
For example, a person may continue experiencing headaches because of a neck injury even after the early metabolic effects of the concussion have improved.
This overlap is why concussion treatment often requires several types of evaluation.
Post-Traumatic Headaches Often Resemble Migraines
Headaches are among the most common symptoms reported after a concussion.
Dr. Bashuk explained that many post-traumatic headaches have migraine-like features, including nausea, light sensitivity, sound sensitivity, and severe throbbing pain.
He discussed anti-CGRP medications, which are commonly used to treat migraines.
CGRP stands for calcitonin gene-related peptide, a protein involved in migraine pain and inflammation. Dr. Bashuk stated that he sometimes uses medications targeting CGRP for post-traumatic headaches.
These medications are not specifically approved to treat concussions, so their use in this context may be considered off-label.
Medication decisions should be made by a qualified provider who understands the patient’s symptoms, medical history, and possible risks.
Headaches and Poor Sleep Can Create a Cycle
A severe headache can make sleep difficult.
Poor sleep may then increase fatigue, irritability, brain fog, and sensitivity to pain. Those symptoms may make the headache feel even worse the following day.
Dr. Bashuk connected this cycle to the glymphatic system, the brain’s waste-clearance system.
Much of the glymphatic system’s work occurs during deep sleep. When sleep is disrupted, the brain may be less effective at removing metabolic waste.
A concussion may also interfere with normal glymphatic function.
The result may be a cycle of poor sleep, inflammation, headaches, cognitive symptoms, and additional sleep disruption.
Rest and Sleep Are Not the Same
Dr. Bashuk made an important distinction between resting and sleeping.
Remaining inactive on a couch throughout the day does not provide the same benefit as entering deep, restorative sleep.
Sleep supports the brain’s natural recovery and waste-removal processes.
Rest may still be appropriate during the first days after an injury, especially when symptoms are severe. However, prolonged inactivity should not be confused with healthy sleep or a complete treatment plan.
Improving sleep may involve addressing headaches, stress, exercise tolerance, medication, daily routines, and other contributing factors.
Why Exercise Must Be Prescribed Carefully
Exercise is now an important part of many concussion treatment plans.
That does not mean a patient should immediately begin running several miles or completing a high-intensity workout.
Dr. Bashuk discussed the Buffalo Concussion Treadmill Test and Buffalo Concussion Bike Test. These tests help identify the heart-rate range at which exercise can be completed without causing a major increase in symptoms.
The patient may then exercise within a controlled zone for a specific period.
The purpose is to support blood flow, autonomic nervous system function, sleep, and gradual tolerance to activity.
Exercise that is too intense may make symptoms worse.
For that reason, concussion exercise should begin under appropriate medical guidance rather than through trial and error.
Stationary Equipment May Be Safer
Walking can be used as part of a concussion exercise plan, but it may be difficult to control consistently.
Weather, hills, traffic, animals, and interruptions can affect pace and heart rate.
A treadmill or stationary bike allows the patient and provider to control the environment more carefully.
A stationary bike also reduces the risk of falling compared with riding outdoors.
The best option depends on the patient’s balance, mobility, fitness, access to equipment, and medical condition.
Concussion Recovery Requires More Than Waiting
Persistent symptoms should not automatically be treated with more rest.
The patient may need evaluation for headaches, neck injuries, vestibular problems, vision changes, sleep disruption, nutritional concerns, or autonomic nervous system dysfunction.
The appropriate treatment may include controlled exercise, medication, therapy, education, sleep support, and rehabilitation.
A concussion may be invisible on imaging, but its effects can significantly disrupt a person’s life.
Recognizing the injury, reporting symptoms honestly, and addressing each part of the patient’s unique symptom pattern can help create a safer and more effective path toward recovery.
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