What is the best treatment approach for a patient with post-concussive syndrome (PCS) and headaches?

Treatment of Post-Concussive Syndrome and Headache

Initiate a structured, active rehabilitation program beginning at 2 weeks post-injury that includes sub-symptom threshold aerobic exercise as the foundation, combined with domain-specific interventions based on systematic assessment of vestibular, cervical, visual, and psychological contributors. 1, 2

Initial Assessment at 2 Weeks Post-Injury

Do not wait for spontaneous recovery—active management at 2 weeks prevents progression to persistent post-concussion syndrome, which affects 15-20% of patients. 2, 3

Systematically evaluate specific symptom domains rather than relying solely on patient self-report: 2

• Vestibular function: Assess for dizziness, balance problems, and motion sensitivity 1
• Cervical spine: Evaluate for neck pain and cervicogenic headache contributions 1
• Visual/oculomotor function: Screen for vergence, accommodation, and eye movement dysfunction causing headache and visual symptoms 1
• Psychological status: Screen for depression, anxiety, and post-traumatic stress 1

Risk factors predicting persistent symptoms include female gender, previous psychiatric history, high early symptom burden (especially headache and fatigue), and multiple prior concussions. 2, 3

Core Treatment Foundation

Patient Education (Grade A Recommendation)

Provide systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period—not generic handouts. 2

This intervention demonstrates positive effects on reducing overall symptom burden and preventing memory problems. 1, 2

Graded Physical Exercise (Primary Intervention)

Implement sub-symptom threshold aerobic exercise immediately with gradual increases in intensity and complexity. 1, 2

• Exercise should be performed below the threshold that exacerbates symptoms 2
• Gradually increase duration and intensity as tolerated 2
• This shows positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1

Critical pitfall: Avoid complete rest beyond the first 24-48 hours, as prolonged rest may have negative implications for recovery and mental/physical wellbeing. 2

Domain-Specific Interventions for Headache

For Headache with Vestibular Symptoms

Initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks. 1, 4

This demonstrates positive effects on physical functioning and readiness to return to activities. 1

For Headache with Neck Pain

Implement spinal manual therapy (mobilization/manipulation) for patients with concurrent neck pain and headache. 1, 4

This shows positive effects on pain reduction and readiness to return to sport/activities. 1

For Headache with Visual Symptoms

Consider oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises. 1, 4

Clinical experience suggests improvements in visual symptoms, headache, and fatigue, though this recommendation is based primarily on clinical consensus rather than controlled trials. 5, 1

For Headache with Emotional Symptoms

Offer psychological treatment (such as cognitive behavioral therapy) as individual or group therapy administered at least 1 hour weekly for minimum 4 weeks. 1, 4

This is associated with positive effects on overall symptom burden, emotional symptoms, and quality of life. 1

Comprehensive Approach for Persistent Symptoms (1-2 Months)

If symptoms persist beyond 4 weeks or are severe, implement interdisciplinary coordinated rehabilitation from at least two different healthcare disciplines (e.g., physical therapy, psychology, occupational therapy). 1, 4

This approach should include at least 2 interventions administered minimally once weekly for 4 weeks and has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 1

Recognize that headaches at 1-2 months may have multiple contributing factors (vestibular, cervical, visual, psychological) requiring targeted interventions. 4

Treatment Algorithm

1. Week 2: Begin systematic assessment of all symptom domains + initiate patient education + start sub-symptom threshold aerobic exercise 1, 2

2. Weeks 2-4: Add domain-specific interventions based on assessment findings:

   • Vestibular rehabilitation if dizziness/balance problems present 1
   • Manual therapy if neck pain/cervicogenic headache present 1
   • Oculomotor therapy if visual symptoms present 1
   • Psychological treatment if emotional symptoms present 1

3. Beyond 4 weeks: If symptoms persist, escalate to interdisciplinary coordinated rehabilitation with at least 2 healthcare disciplines 1, 4

Evidence Quality Considerations

The evidence supporting these interventions ranges from very low to low certainty, with most recommendations being weak but consistent across guidelines. 5, 1

However, the recommendation for early active management over passive rest is strong, and graded physical exercise serves as the foundation for all treatment approaches. 1, 2

Patients may require continued medical care and social assistance with driving support, employment issues, and financial assistance during recovery, as problems can persist for at least 6 months. 2