A 7-year-old girl is brought to clinic due to a diffuse headache. She first developed pain while working on a math assignment today. The headache was exacerbated by the sound of her classmates yelling at recess. She was permitted to lie down in a dark, quiet room, which helped. The patient had just returned to school today after a vacation, during which she hit her head on the passenger door when her mother's car collided with another car. The patient did not lose consciousness and was taken to the emergency department, where head imaging was normal. Since the incident, she has been more irritable at times. Vital signs are normal. The patient has a normal affect and can easily recall details of the accident. Examination shows return of headache when asked to move her eyes left and right rapidly between 2 points held a short distance away. Neurologic examination is otherwise normal. Which of the following is the most likely cause of this patient's symptoms?
Concussion | |
Clinical features |
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Management |
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TBI = traumatic brain injury. | |
This patient's headache is most likely due to a concussion from the recent motor vehicle collision. Concussion is a mild traumatic brain injury caused by axonal shearing from rapid rotational acceleration of the brain during a fall or strike to the head. The injury results in neurologic disturbance but no structural intracranial injury.
The predominant finding in patients with concussions is headache, which typically develops shortly after the head trauma and may be triggered by physical or cognitive exertion, as well as visual tasks (eg, rapid eye movement between two points), as seen in this patient. Light and/or noise sensitivity is also common and may worsen the headache. Other symptoms can include cognitive impairment (eg, confusion, difficulty concentrating), emotional changes (eg irritability), and sleep disturbances.
Diagnosis of concussion is typically based on clinical symptoms in the context of a normal physical examination. Although neuroimaging is not required for diagnosis, focal neurologic abnormalities should prompt investigation (eg, CT head without contrast) for structural brain injury. Treatment of a concussion involves symptomatic management (eg, nonsteroidal anti-inflammatory drugs for headache), as well as physical and cognitive rest, followed by a gradual return to activity.
(Choice A) Although a motor vehicle collision can precipitate acute stress disorder, patients generally experience intrusive thoughts and nightmares, not headache. This patient easily recalls the accident without distress.
(Choice C) Migraine headache is classically described as a unilateral throbbing and may be associated with photophobia and/or phonophobia. This patient's diffuse headache triggered by a visual task after known head trauma is more consistent with concussion.
(Choice D) Perilymphatic fistula, a rare complication of head trauma, is characterized by fluid leakage from the cochlea and semicircular canals. Unlike in this patient, the presentation involves hearing loss and vertigo triggered by the Valsalva maneuver; riding in an elevator; or sudden, loud sounds.
(Choice E) Tension headache is a common cause of bilateral headache. In contrast to a concussion, tension headaches are not typically associated with light or noise sensitivity and are not provoked by visual tasks.
Educational objective:
Concussion is caused by rapid rotational acceleration of the brain during head trauma. Diagnosis is based on clinical findings of neurologic disturbance (eg, headache, noise sensitivity, emotional changes) without evidence of structural intracranial injury. Treatment is physical and cognitive rest followed by a gradual return to activity.