What are the recommendations for a patient with headaches and a failed Romberg test 10 days after a concussion?

Management of Headache and Failed Romberg Test 10 Days Post-Concussion

Neuroimaging with CT or MRI is strongly recommended for a patient experiencing headaches and balance issues (failed Romberg test) 10 days after concussion, as these persistent symptoms suggest possible underlying pathology requiring further investigation.

Assessment and Diagnostic Approach

Clinical Significance of Current Symptoms

• Persistent headache and balance problems (failed Romberg test) at 10 days post-concussion are concerning symptoms that warrant further evaluation 1, 2
• A failed Romberg test is independently associated with longer duration of post-concussion symptoms 3
• These symptoms indicate the patient has not yet fully recovered from the concussion and may be developing persistent post-concussive symptoms

Recommended Diagnostic Testing

1. Neuroimaging:

   • Brain CT or MRI is indicated due to:

     • Persistent symptoms beyond the typical recovery window 1
     • Presence of balance dysfunction (failed Romberg test) 2
     • Ongoing headaches that have not resolved 1, 2

   • MRI may be preferable as it offers greater sensitivity for subtle abnormalities not visible on CT 2

   • Neuroimaging should be performed to rule out structural lesions that may be contributing to persistent symptoms 1

2. Comprehensive Neurological Examination:

   • Focus on:
     • Vestibular function assessment
     • Oculomotor testing
     • Cognitive assessment
     • Cervical spine examination 4

3. Neuropsychological Testing:

   • Indicated for persistent symptoms to assess cognitive function 1
   • Should evaluate information processing, planning, memory, and mental flexibility 1
   • Can help determine readiness for return to normal activities 1

Management Recommendations

Immediate Management

1. Activity Restriction:

   • Patient should remain at complete rest (Level 1 in return-to-activity protocol) until asymptomatic 1, 2
   • No return to work, school, or physical activities while symptomatic 1

2. Symptom-Specific Interventions:

   • For headaches:

     • Consider migraine-specific treatment if headache has migrainous features 5, 6
     • Evaluate for medication overuse headache if using analgesics frequently 5

   • For balance issues:

     • Referral for vestibular rehabilitation 1, 2
     • Avoid activities that might lead to falls or further injury 1

3. Psychological Support:

   • Consider psychological treatment as it has shown positive effects on overall burden of post-concussion symptoms 1
   • Address anxiety that may develop related to persistent symptoms 1

Rehabilitation Approach

1. Interdisciplinary Coordinated Rehabilitation:

   • Recommended for persistent symptoms (>10 days) 1
   • Should include professionals from at least two disciplines (e.g., physical therapy, neurology, neuropsychology) 1
   • Has demonstrated positive effects on symptom burden and return to daily activities 1

2. Oculomotor Vision Treatment:

   • Consider if visual symptoms are present alongside headache and balance issues 1
   • Can improve visual symptoms and reduce headache and fatigue 1

3. Gradual Return to Activity Protocol:

   • Only begin once completely asymptomatic 1, 2
   • Progress through these stages (minimum 24 hours at each level):
     1. No activity, complete rest
     2. Light aerobic exercise (walking, stationary cycling)
     3. Sport/activity-specific training
     4. Non-contact training drills
     5. Full contact training (after medical clearance)
     6. Return to full activity 1, 2
   • If symptoms recur at any level, return to previous asymptomatic level 1

Important Considerations and Pitfalls

• Pre-existing conditions: Assess for history of migraine, as it may influence headache presentation and treatment response post-concussion 5, 6
• Multiple co-morbidities: Presence of multiple co-morbidities (anxiety, depression, sleep disorders) may complicate recovery 5
• Avoid premature return to activities: Returning before full symptom resolution risks prolonging recovery or worsening symptoms 1, 2
• Monitor for post-concussive syndrome: Failed Romberg test at this stage increases risk for developing persistent post-concussive syndrome 3
• Medication caution: Be aware that overuse of analgesics for headache may contribute to medication overuse headache 5

By following this structured approach to evaluation and management, you can address both the headache and balance issues while monitoring for complications and promoting optimal recovery from concussion.