Primary care doctors are familiar with normal headache presentations, but post-concussive headaches can be multifactorial. Some physicians, usually neurologists, specialize in the medical management of headaches. In addition, the expertise of a multidisciplinary team can provide insights into the potential causes as well as a range of treatment options.

Post-traumatic headache can be a major culprit in delayed recovery, but it is not a diagnostic label. Knowing pre-existing headache causes and frequency will enable you to determine the origin of the patient’s post-traumatic headache. A persistent headache may be unrelated to the mTBI. It could result from a neck injury, for example. Knowing the headache type (cervicogenic pain, occipital neuritis, migraine, tension headache, or vision-related) will help you treat it.

Possible Headache Tx

• Manual therapies to address cervicogenic component.
• Vision rehabilitation (since the headache is unlikely to resolve until visual perception and oculomotor problems are treated).
• Medications.
• Biofeedback relaxation.
• Sleep stabilization.
• Self-management skills.

After three months, if headache pain is chronic without a basic physiological cause, other contributors should be considered, including psychological issues that can trigger or exacerbate headache presentation.

There are multiple types of balance disorders. Some resolve quickly, but others require more time. Balance can be multifactorial, involving:

• The vestibular system.
• Visual perception.
• Postural stability.

Specialists in balance disorders (such as physical therapists, some occupational therapists, and audiologists) may assess and treat complex interactions among sensory, motor, and central processes involved in posture and balance.

Postural stability is less likely to be an issue in young athletes, but should be considered when assessing the patient.

Depending on the etiology (causation), some symptoms respond quickly to treatment. For example, when correctly diagnosed, Benign Paroxysmal Positional Vertigo often resolves in a few sessions of proper treatment. By contrast, central balance (i.e., arising from the brain) or dizziness problems may require weeks of specialized exercises and desensitization therapies.

Frequently, patients with delayed recovery from concussion present with previously undiagnosed visual disturbances. (There are various estimates as to how often.) Head injury sometimes brings such disturbances to light.¹

Ellis et al (2017). Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion. Journal of Neurosurgery, Pediatrics, 19, 38-45

Possible Vision Disturbance Tx

Treatments may involve special lenses and prisms, tinted lenses for contrast sensitivity, and / or binasal occlusion. Appropriate therapy may also include:

• Integration of vision with the balance system.
• Work on depth perception.
• Training in oculomotor coordination and visual tracking.

Knowledge in this area is rapidly evolving. Unusual or atypical disturbances sometimes occur and may warrant further evaluation.

When you assess fatigue, it’s important to determine the type of fatigue the patient is experiencing. Fatigue has two components: physical and mental. Activities that previously took little effort may require great amounts of energy after an mTBI. As a result, the patient may experience an overwhelming sense of tiredness that can be physical, mental, or both.

Fatigue may directly impact a young person’s academic and physical performance by making sustained daily activities, attention, concentration, memory, communication, and emotional control more difficult.

Possible Fatigue Tx

• Improving sleep patterns.
• Decreasing pain.
• Conserving energy.
• Undergoing endurance therapy.
• Practicing pacing techniques.
• Taking medication.

Though it is clear that high-risk activity must be discontinued entirely during recovery, low-level exercise is being shown to have some value for mTBI patients, with a return to activities as soon as is tolerated the new recommendation.²

See: Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann-Demont N, Iverson GL, Hayden A, Makdissi M. Rest and treatment/rehabilitation following sports-related concussion: A systematic review. Br J Sports Med. 2017 Jun;51(12):930-934

Issues with sleep are not the same as issues with fatigue. Sleep is important. It is healing time for the young person recovering from an mTBI. Your patient must not return to his or her previous sleeping pattern if it was insufficient. For example, a teenager’s typical seven hours per night is not enough.



Visit the National Sleep Foundation website for recommended sleep times per age group.

Possible Sleep Issues Tx

There are two major considerations in treating sleep problems.