A 17-year-old girl is brought to the clinic due to headaches and daytime sleepiness. Six weeks ago, the patient was involved in a motor vehicle collision. She was driving her car when she was hit by another car on the passenger side. The patient hit her head on the window and briefly lost consciousness. She was taken to the emergency department, where CT scan of the head was normal. The patient was diagnosed with a concussion and discharged. She rested at home for 2 days before returning to school. The patient has been eager to participate in class but has a dull headache when reading. The headache is worsened with loud noises. She also has felt sleepy in class and has had difficulty falling asleep at night. The patient has no medical conditions and takes no medications. Temperature is 37.3 C (99.1 F), blood pressure is 115/75 mm Hg, and pulse is 70/min. Pupils are equal and reactive. Cranial nerves II-XII are grossly intact. The neck is supple. Strength, sensations, and reflexes are equal. Gait is normal. Which of the following is the best next step in management of this patient?

Question

A 17-year-old girl is brought to the clinic due to headaches and daytime sleepiness.  Six weeks ago, the patient was involved in a motor vehicle collision.  She was driving her car when she was hit by another car on the passenger side.  The patient hit her head on the window and briefly lost consciousness.  She was taken to the emergency department, where CT scan of the head was normal.  The patient was diagnosed with a concussion and discharged.  She rested at home for 2 days before returning to school.  The patient has been eager to participate in class but has a dull headache when reading.  The headache is worsened with loud noises.  She also has felt sleepy in class and has had difficulty falling asleep at night.  The patient has no medical conditions and takes no medications.  Temperature is 37.3 C (99.1 F), blood pressure is 115/75 mm Hg, and pulse is 70/min.  Pupils are equal and reactive.  Cranial nerves II-XII are grossly intact.  The neck is supple.  Strength, sensations, and reflexes are equal.  Gait is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5c5_f51b_bc81_c331a0a00b49_MD0003_00 This patient has prolonged headaches and sleep disturbance after a concussion, findings suggestive of postconcussion syndrome (PCS). Concussion is a type of mild traumatic brain injury and is characterized by blunt head trauma that causes neurocognitive symptoms without intracranial injury. Most patients who follow a gradual return-to-play protocol after concussion have symptom resolution in <4 weeks. In contrast, PCS is characterized by prolonged (>4 weeks) concussion symptoms. Risk of PCS is increased with a history of multiple concussions. The most common symptom of PCS is headache, which may resemble a tension (ie, bandlike pressure) or migraine (eg, unilateral throbbing) headache; is often triggered by cognitive exertion; and can have associated phonophobia, as seen here. Additional PCS symptoms include dizziness, sleep disturbance (eg, insomnia, daytime sleepiness), mood changes (eg, irritability, anxiety), and poor concentration. Management of PCS is symptomatic care because most patients will improve within 3 months. Interventions may include headache management (eg, amitriptyline), cognitive-behavioral therapy (for insomnia or anxiety), or reassurance alone (if symptom severity is mild). Activity as tolerated should be encouraged. (Choice A) Screening for depression, which may be a symptom of PCS, in an adolescent with sleep disturbance is appropriate. However, this patient expresses interest in school participation, and initiation of a selective serotonin reuptake inhibitor (SSRI) without further evaluation is not indicated. SSRIs are not typically used for PCS headaches. (Choice B) Most posttraumatic seizures occur within 24 hours of injury and are generalized tonic-clonic movements. This patient has no signs of seizure, making electroencephalography unnecessary. (Choice C) Idiopathic intracranial hypertension can present with chronic headaches and is characterized by an elevated opening pressure while performing lumbar puncture. Visual disturbances (eg, obscurations, diplopia) are common, and papilledema or sixth nerve palsy is typically seen on examination. This patient has symptoms temporally related to a head injury and has no ophthalmic signs or symptoms. (Choice E) CT scan of the head may be performed acutely after head trauma to exclude intracranial pathology (eg, hemorrhage). Risk of posttraumatic bleed in a patient with a previously normal study is extremely low, making repeat CT scan unnecessary. In addition, brain MRI is the preferred imaging modality to evaluate for alternate pathology (eg, mass) in a patient with severe, disabling PCS because MRI is more sensitive and avoids radiation exposure. Educational objective: Postconcussion syndrome is characterized by prolonged (>4 weeks) concussion symptoms (eg, headache, sleep disturbance). Management is symptomatic care because most patients improve within 3 months. References: Review of the management of pediatric post-concussion syndrome-a multi-disciplinary, individualized approach. (http://www.ncbi.nlm.nih.gov/pubmed/30758705)

A 17-Year-Old Girl Is Brought to the Clinic Due to Headaches