By Andrew Russman, DO

After a concussion, patients want to know when they can get back to “normal” — whether that means school, work, sports or social activities. The answer is rarely simple. The following case study illustrates the need for collaboration and comprehensive management options in the face of seemingly intractable symptoms.

Presentation

In September 2013, a 13-year-old female suffered a concussion during a soccer game after her head was hit by a kicked ball and she subsequently fell. She lost consciousness for a couple of minutes, was disoriented, suffered immediate headaches, and had pupils of differing sizes. EMS transported her to a Cleveland Clinic regional hospital for further assessment and a CT scan, which showed normal results. The patient was discharged with educational materials and instructions to follow up with a primary care provider.

She saw her physician six days later. Her parents were concerned by her symptoms — particularly her severe headaches — and wanted to know when she could return to school, ballet, soccer, cheerleading and other activities.

Evaluation

During the primary care visit, the patient reported headaches, irritability and emotional concerns, nausea, and difficulty concentrating. She was referred to Cleveland Clinic’s Concussion Center.

When the patient was first assessed by the Concussion Center team (including me, an athletic trainer and others), she was highly sensitive to light and sound, so evaluations took place in a darkened, quiet room. Initial assessment included completion of a graded concussion symptom checklist. History-taking about the present illness was complicated by the patient’s amnesia for the event. She could remember the ambulance ride but not the on-field incident or its immediate aftermath. Her parents detailed her initial symptoms and the concerns that prompted her emergency department evaluation. She had been unable to tolerate a return to the classroom and was struggling with focus and concentration. She felt “foggy” in her thinking and struggled with headache severity, neck pain, dizziness, nausea, and light and sound sensitivity.

Physical and neurologic examination revealed the following:

• Light-headedness and positional orthostatic tachycardia when transitioning from lying to sitting to standing
• Abnormally near point of convergence
• Pupillary dilation
• Increased horizontal gaze saccadization
• Slowed finger-nose-finger and rapid alternating movements
• Upper cervical and occipital nerve tenderness
• Discomfort with neck rotation, flexion and extension
• Unsteady tandem gait

Using the Cleveland Clinic Concussion (C3) App, we assessed symptom severity, reaction time, balance function, concentration and processing speed. Symptom severity was high, concentration was impaired, and both processing speed and reaction time were slowed.

Our clinical impression was of a concussion of high symptomatic severity, with sequelae including acute post-traumatic headache, convergence insufficiency, cervicalgia, occipital neuralgia, vestibulopathy, cognitive impairment and orthostatic tachycardia.

Initial treatment

Initial treatment was supportive and conservative, consisting of naproxen sodium (with food) for headaches, avoidance of activities that worsened symptoms, lower extremity exercises and increased salt intake for treating orthostatic tachycardia, and melatonin for sleep normalization and headache.

At one-week follow-up, symptom severity remained high. Convergence insufficiency had improved. She was referred for vestibular rehabilitation through physical therapy. By her third visit, the patient’s light-headedness, orthostatic tachycardia and vestibulopathy were improving, but the severe headaches, cervicalgia, occipital neuralgia and other symptoms persisted. She had significant difficulty tolerating the headache symptoms during school and absorbing new academic material. School accommodation — including allowance for rest breaks, symptom reduction and return to the classroom — was tried without success. Academic material was brought home and a recommendation was made for home tutoring.

Further evaluation and treatment

We obtained a 3-tesla MRI to evaluate for structural abnormalities that might explain the cognitive difficulties and continued symptom severity, but it showed no evidence of imaging sequelae of traumatic brain injury. Concurrently, we started prescription medication for headache prevention, performed bilateral greater occipital nerve blocks, and referred the patient for cognitive behavioral therapy and biofeedback therapy, as well as acupuncture and additional physical therapies through Cleveland Clinic Children’s Hospital for Rehabilitation. The patient also increased her physical activity by riding a stationary bike for 30 minutes per day.

Despite this intensive outpatient management, the patient continued to struggle with high symptom severity at 90 days post-injury. In January 2014, she entered Cleveland Clinic Children’s intensive three-week Pediatric Pain Rehabilitation Program under the care of pediatric physiatrist Benjamin Katholi, MD. A comprehensive mix of physical therapy, cognitive behavioral therapy, biofeedback, group therapy sessions, pain management and other techniques, this program helped her finally return to school in a limited capacity. Following the intensive portion of the program, she continued outpatient therapy and added work with a speech therapist to improve memory and cognitive skills. In spring 2014, she began receiving botulinum toxin injections for the intractable migraine headaches resulting from her concussion, and significant improvement followed.

Finding the appropriate therapies took time, as did finding the right pharmacologic and nonpharmacologic approaches. For example, whereas amitriptyline, cyclobenzaprine, propranolol and gabapentin were not beneficial when the headaches evolved from a predominantly tension-type pattern into an intractable migraine pattern in March 2014, topiramate eventually proved helpful. Bilateral greater occipital nerve blocks have been helpful as an adjunctive therapy when the patient’s occipital neuralgia has flared.

Case concluded: Ongoing progress, return to most activities

The patient’s headaches persisted throughout 2014 but have been better managed since 2015. She receives the greatest benefit from botulinum toxin injections every 90 days, with topiramate (100 mg daily) as an added preventative. With school accommodations, her academic performance has improved. Managing headaches in the presence of life stressors has been a continued challenge marked by peaks and valleys. Ongoing work on coping mechanisms and strategies with an experienced pediatric psychologist has been essential.

She has resumed noncontact sports, once again participates in dance and is active on the drill team. However, due to the severity of her post-concussion syndrome, we recommended against contact sports such as soccer and stunt-based cheerleading.

Discussion: Takeaways for concussion management

When I see this patient now, it feels like a successful journey, although we remain prepared to manage symptom relapses. Progress toward clinical recovery for this patient involved a tremendous amount of time and collaborative care.

This case highlights several important factors for any clinicians who treat patients with concussions:

• Neurological assessment is complicated. The initial providers in the emergency department and the primary care physician would have had little reason to suspect how complicated this case would become, which underscores the need for referrals to appropriate specialists.
• Setting expectations is critical. This patient — and her parents — prioritized returning to school and after-school activities. However, the complexity of her case and compounding symptoms meant we had to set and manage reasonable goals as her condition worsened.
• We must offer a menu of care options. In this case, no single therapy helped the patient turn the corner in what appeared to be an intractable case — a variety of strategies did. It’s worth noting those strategies included a full range of medication, therapeutic (behavioral and physical), pain management and alternative options.

Dr. Russman, Co-Medical Director of Cleveland Clinic’s Concussion Center, is a vascular neurologist and brain injury medicine specialist.