What is the appropriate evaluation and management for hyperacusis following a concussion?

Hyperacusis Following Concussion: Evaluation and Management

Patients with hyperacusis after concussion should receive early education and counseling within the first 4 weeks, followed by a multimodal treatment approach including graded physical exercise, vestibular rehabilitation if vestibular dysfunction is present, manual therapy for cervical involvement, and psychological treatment, with consideration of cognitive sound exposure therapy for persistent symptoms.

Initial Evaluation

Timing and Assessment

• Evaluate within the first 4 weeks post-concussion to identify hyperacusis as part of the broader persistent postconcussion symptom (PPCS) complex 1
• Assess for co-occurring symptoms including headache, dizziness, vestibular dysfunction, cervical pain, tinnitus, and cognitive/emotional symptoms, as hyperacusis rarely occurs in isolation after concussion 1
• Distinguish hyperacusis from related conditions: hyperacusis involves physical discomfort/pain at sound levels tolerable to most people, distinct from misophonia (emotional reactions to specific sounds), noise sensitivity (general environmental discomfort), or phonophobia (anticipatory fear of sound) 2
• Document baseline sound tolerance using Loudness Discomfort Levels and validated questionnaires like the Hyperacusis Questionnaire (HQ) 3, 4

Key Clinical Pitfalls

• Do not assume hyperacusis is purely an auditory problem—it is typically part of a broader postconcussion syndrome requiring comprehensive assessment 1
• Avoid ordering standard structural neuroimaging, as concussion-related hyperacusis reflects functional rather than structural disturbance 1, 5

Early Management (First 4 Weeks)

Systematic Education and Counseling

Provide early information and advice within the first 4 weeks post-injury, delivered individually or in groups by healthcare professionals using oral and written materials 1

This intervention should include:

• Education about postconcussion symptoms, including hyperacusis as a common and typically self-limited symptom 1
• Symptom management strategies and self-care guidance 1
• Reassurance about expected recovery trajectory to reduce anxiety and catastrophizing 1

The evidence shows this reduces overall symptom burden at 2 weeks post-intervention and decreases the number of patients experiencing memory problems and functional impairment, though the certainty of evidence is very low 1

Activity Modification

• Avoid strict rest, as evidence shows detrimental effects from complete activity restriction 5
• Avoid high-intensity physical activity in the acute phase, as this also shows harmful effects 5
• Implement gradual return to normal sound environments rather than complete sound avoidance, which can worsen hyperacusis 6, 3

Treatment for Persistent Symptoms (Beyond 4 Weeks)

Graded Physical Exercise

Initiate graded physical exercise at least once weekly for a minimum of 4 weeks if symptoms persist beyond the acute phase 1

• Exercise should involve gradual increases in intensity and complexity over time, including general physiotherapy, sensorimotor training, and aerobic/anaerobic training 1
• This intervention shows positive effects on overall symptom burden, physical functioning, behavioral reactions, emotional symptoms, and quality of life 1
• Strong recommendation for adolescents specifically, where evidence is most robust 5

Vestibular Rehabilitation

Provide vestibular rehabilitation if vestibular dysfunction is documented, administered at least once weekly for 4 weeks 1

Components include:

• Otolith manipulating procedures 1
• Habituation and adaptation exercises 1
• Substitution training and balance training 1

This addresses the common co-occurrence of vestibular symptoms with hyperacusis in postconcussion syndrome 1

Cervical Manual Therapy

Consider manual treatment of the neck and spine if cervical involvement is present, typically performed by physiotherapists or chiropractors 1

• Cervical dysfunction commonly accompanies hyperacusis after concussion due to the mechanism of injury 7
• Manual therapy includes hands-on mobilization and/or manipulation of the spine or other joints 1

Psychological Treatment

Implement psychological interventions for patients with significant distress or comorbid psychiatric symptoms 1

• Hyperacusis-related distress often involves anxiety, avoidance behaviors, and mood changes requiring specific psychological support 6, 8
• Cognitive behavioral therapy (CBT) approaches are commonly used, though evidence quality is low 8, 4

Specific Hyperacusis-Directed Therapy

Cognitive Sound Exposure Therapy (CSET)

For persistent hyperacusis, consider cognitive sound exposure therapy combining psychoeducation, gradual sound exposure, and counseling 3, 2

Recent evidence (2024) shows:

• Biweekly sessions (mean 6 sessions, range 4-8) with gradual sound exposure up to 70-80 dB SPL 3
• Integration of breathing and relaxation strategies from acceptance and commitment therapy and CBT 3
• Significant improvements: mean increase in tolerable sound level of +23.7 dB, decrease in Hyperacusis Questionnaire scores of -9.8 points, with sustained benefits at 6 months 3
• Benefits transfer from therapy sounds to everyday environmental sounds 3

Sound Desensitization Principles

• Gradual and systematic sound desensitization is the cornerstone of hyperacusis-specific treatment 2, 4
• Avoid complete sound isolation, as this worsens sensitivity over time 6, 3
• Patients must learn to structure daily life and plan activities to balance sound exposure with recovery periods 6

Coordinated Care Approach

Interdisciplinary Rehabilitation

Consider interdisciplinary coordinated rehabilitative treatment for complex or refractory cases 1, 9, 7

• Approximately 30% of concussion patients have longer-lasting symptoms requiring multidisciplinary involvement 7
• The general practitioner plays a central role in diagnosis, referral, and care coordination, particularly for complex cases with repeated concussions, vestibular dysfunction, cervical involvement, severe pain, or psychological concerns 7
• The Australian and New Zealand guidelines (2026) emphasize multidisciplinary concussion teams for persistent symptoms 9, 7

Monitoring and Follow-up

• Reassess at regular intervals using the Hyperacusis Questionnaire and functional outcome measures 3, 4
• Monitor for comorbid conditions including tinnitus (which co-occurs in many cases), depression, anxiety, and quality of life impairment 6, 8, 10
• Consider audiological assessment if symptoms persist, though peripheral hearing is typically normal in concussion-related hyperacusis 10

Evidence Quality Considerations

The evidence base for hyperacusis management after concussion is limited:

• Most recommendations for postconcussion symptom management are based on very low to low certainty evidence 1
• Hyperacusis-specific interventions are typically evaluated in mixed populations or as secondary outcomes 4
• The most recent evidence for cognitive sound exposure therapy (2024) shows promise but requires further validation in larger trials 3
• No pharmacological or surgical interventions have established efficacy for postconcussion hyperacusis 4