Post-concussion symptoms and differential diagnosis

SymptomDifferentialCommentsTipsInvestigation and therapy
Dizziness and vertigoNon-specific post- traumatic dizziness v benign paroxysmal positional vertigo (BPPV)Whiplash often causes dizziness. BPPV occurs after mild as well as severe head injuryBPPV is induced by head movement, particularly lying down, turning, or sitting up in bedDix-Hallpike manoeuvre diagnostic. Treat with particle repositioning manoeuvre
Blank spellsConcentration lapses (ie day dreaming) v epilepsyPost-traumatic epilepsy is rare after mild head injuryConcentration lapses occur when tired or unstimulated, the person can be “snapped” out of lapses and there is no post-ictal confusionInvestigation is usually unnecessary. EEG if high index of suspicion. A negative EEG is not informative
Temper outburstsBehavioural change v epilepsyPost-traumatic epilepsy is rare after mild head injuryThere is a “trigger”, often trivial, to behavioural outbursts. They are usually directed (eg targeted at a partner or family member). Seizures are not usually triggered or directed and are stereotyped
Fatigue and tirednessPost-traumatic fatigue v depressionPost-traumatic fatigue is very common. Rarely traumatic hypopituitarism is the causeFatigue associated with depression tends to be the same throughout the day whereas post-traumatic fatigue gets worse through the dayConsider checking pituitary function. Limit physical activity and mental demands. Consider psychiatric or neuropsychological assessment. Treat with antidepressants when appropriate
HeadachesPost-traumatic migraine v other headache typesHeadaches are a very common part of the post concussion symptom complex. Post-traumatic migraine can arise in the absence of any prior history of migraineFeatures suggesting migraine are unilateral location, throbbing, photophobia, and vomiting along with intermittency. Post-traumatic migraine is frequently bilateral. Post-traumatic tension headache or chronic daily headache is bilateral, constant, non- throbbing and usually daily, worse through the day. Note that some nausea and photophobia can be presentTreat migrainous headaches with usual antimigraine prophylactic preparations (table 3), and acute migraine headache with analgesia and/or a triptan. Treat tension type headaches with amitriptyline or valproate prophylaxis and avoid regular daily analgesics
Sleep disordersInsomnia v excessive daytime somnolence v depressionInsomnia and daytime hypersomnolence frequently coincidePeople with sleep problems are more likely to also experience fatigueNocturnal hypnotics (table 3). Consider stimulants (eg methylphenidate) for debilitating daytime somnolence, and antidepressants where depression identified
Poor memory and concentrationPost-traumatic cognitive impairment v depression, early dementia, fugue states, malingeringDepressed people complain of forgetfulness, but those with dementia and the organically impaired tend not to recognise it. Depression amplifies amnesia. Depressive pseudodementia usually has a definable onset whereas dementia does not