Treating post concussion syndrome: matching care to your symptoms

When the room spins as you roll over

Brief spinning when you lie down, roll over or tip your head back may point to benign paroxysmal positional vertigo, or BPPV. The Canadian guideline says to suspect BPPV when symptoms come with position changes and to test for it once the neck has been checked [3].

The usual fix is a set of guided head movements called a repositioning maneuver. It earns an A rating in the Canadian guideline [3] and a strong recommendation in a 2017 U.S. ear, nose and throat guideline [9]. That guideline advises against routine scans for typical BPPV and against routine use of medicines that dull the balance system [9]. It also says you do not need to limit head positions after the treatment [9].

After a head injury, BPPV can be stubborn. The U.S. guideline reports that up to 67 percent of trauma related cases need repeat treatment, compared with 14 percent of other cases, and that both ears may be involved [9]. If one to three tries fail, the Canadian guideline suggests an ear, nose and throat specialist or a clinician certified in vestibular rehabilitation [3].

Dizziness and poor balance that linger

Vestibular means the inner ear balance system. Vestibular rehabilitation is a program of exercises for dizziness and balance, taught by a trained clinician. Canada’s guideline recommends it, with an A rating, for dizziness that limits daily life [3]. The military and veterans guideline gives a milder “suggest” for a trial of these exercises [5].

A 2022 review looked at 7 trials covering 266 patients between 9 and 67 years old. In the three trials that used the same dizziness scale, scores dropped more with vestibular therapy, at least in the short term. The trials were small and varied, so the best amount and timing are still unclear [10].

Neck pain after whiplash

A crash can strain the neck as well as jolt the brain. A 2020 physical therapy guideline sorts concussion problems into four areas: the neck, inner ear and eye movement, exercise tolerance, and movement control [11]. The 2022 Amsterdam consensus on sport concussion recommends combined neck and balance therapy, known as cervicovestibular rehabilitation, if headaches, dizziness or neck pain persist past 10 days [12]. That advice comes from athletes, so it may not fit every crash survivor exactly.

Blur, eye strain and reading trouble

A 2022 statement from eye care groups focuses on children and teens. Right after a concussion, up to 40 percent of young people report blurry vision, double vision or light sensitivity [13]. Most recover on their own within 4 weeks [13]. Early on, the statement advises cutting back on reading and other close visual work, then building back up [13].

When vision problems limit your day past a month, the Canadian guideline suggests a professional trained in vision assessment, such as an optometrist or ophthalmologist [3]. Double vision or complex symptoms may call for a neuro ophthalmologist [3].

Be careful with vision therapy sold as a cure. The eye care statement says it has been widely promoted for concussion, but a close look finds too little evidence that it works [13]. The VA/DoD guideline also found too little evidence to favor or reject any particular vision treatment [5]. Temporary prism glasses for close work can ease blur and double vision in some cases [13].