Concussion

Concussion is the sudden but short-lived loss of mental function that occurs after a blow or other injury to the head. It is the most common but least serious type of brain injury.

The medical term for concussion is minor traumatic brain injury.

Symptoms of concussion include brief:

• loss of consciousness after the head injury
• periods of memory loss
• disturbances in vision, such as "seeing stars" or blurry vision
• a period of confusion, a blank expression, or a delay in answering questions immediately after the head injury

If a brain scan is carried out, concussion is only diagnosed if the scan is normal – for example, there is no bleeding or swelling of the brain.

When to seek medical help

Concussion should only be diagnosed by a health professional trained in assessing patients with head injury. They will be able to rule out serious brain injury that needs a brain scan or surgery.

You should visit your nearest accident and emergency (A&E) department if you or someone in your care has a head injury and develops the following signs and symptoms:

• loss of consciousness, however brief
• memory loss, such as not being able to remember what happened before or after the injury
• persistent headaches since the injury
• changes in behaviour, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under five
• confusion
• drowsiness that occurs when you would normally be awake
• loss of balance or problems walking
• difficulties with understanding what people say
• difficulty speaking, such as slurred speech
• problems with reading or writing
• vomiting since the injury
• problems with vision, such as double vision
• loss of power in part of the body, such as weakness in an arm or leg
• clear fluid leaving the nose or ears (this could be cerebrospinal fluid, which surrounds the brain)
• sudden deafness in one or both ears
• any wound to the head or face

Anyone drunk or high on recreational drugs should go to A&E if they have a head injury as it's easy for others around them to miss the signs of a more severe injury.

Phone 999 for an ambulance immediately if the person:

• remains unconscious after the initial injury
• is having a seizure or fit
• is bleeding from one or both ears
• has been vomiting since the injury
• is having difficulty staying awake, speaking, or understanding what people are saying

Certain things make you more vulnerable to the effects of a head injury. These include:

• being aged 65 or older
• having previously had brain surgery
• having a condition that makes you bleed more easily, such as haemophilia
• having a condition that makes your blood more prone to clotting, such as thrombophilia
• taking anticoagulant medication, such as warfarin or aspirin, to prevent blood clots

There are things you can do at home to help relieve concussion symptoms, including:

• apply a cold compress to the injury to reduce swelling – a bag of frozen peas wrapped in a towel will do
• take paracetamol to control any pain – do not use non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, as these can cause bleeding
• avoid drinking alcohol or taking recreational drugs

Read more about how concussion is treated, including information on self care tips and when you can return to playing sport.

Recovery

After experiencing concussion, careful monitoring is needed. This is usually for 48 hours.

This is because the symptoms of concussion could also be symptoms of a more serious condition, such as:

• subdural haematoma – bleeding between the skull and the brain
• subarachnoid haemorrhage – bleeding on the surface of the brain

Outlook

While the medical term "minor traumatic brain injury" can sound serious, the actual extent of damage to the brain is usually minimal and does not cause long-term problems or complications.

There is evidence that repeated episodes of concussion could cause long-term problems with mental abilities and trigger dementia. This type of dementia is known as chronic traumatic encephalopathy (CTE).

However, this seems to only be a significant risk for professional athletes who experience repeated episodes of severe concussion, such as boxers – CTE is sometime nicknamed "boxer's brain".

Post-concussion syndrome (PCS) is a poorly understood condition where symptoms of concussion can last for weeks or months afterwards.

Read more information about PCS as a complication of concussion.

Who's at risk?

Most cases of concussion occur in children and teenagers aged 5 to 14, with the two most common causes being sporting and cycling accidents.

Falls and motor vehicle accidents are a more common cause of concussion in older adults.

People who regularly play competitive team sports such as football and rugby have a higher risk of concussion.

Read more information about the causes of concussion and tips on preventing concussion.

Symptoms of concussion can be mild to severe, and in some cases emergency treatment may be needed.

The most common symptoms of concussion are:

• confusion, such as being unaware of your surroundings, a delay in answering questions, or having a blank expression 
• headache
• dizziness
• nausea
• loss of balance
• feeling stunned or dazed
• disturbances with vision, such as double vision, blurred vision or "seeing stars" or flashing lights
• difficulties with memory

Difficulties with memory can mean:

• you are unable to remember events that occurred before the concussion happened (this usually only affects the minutes immediately leading up to the concussion) – retrograde amnesia  
• you are unable to remember any new information or events after the concussion happened – anterograde amnesia

Both types of memory loss usually improve within a few hours.

Less common symptoms

Less common symptoms include:

• loss of consciousness
• slurred speech
• changes in behaviour, such as feeling unusually irritable
• inappropriate emotional responses, such as suddenly bursting into laughter or tears

When to seek medical advice

As a precaution, it is recommended that you visit your nearest accident and emergency (A&E) department if you or someone in your care has a head injury resulting in concussion and then develops any of the following signs and symptoms:

• loss of consciousness from which the person then recovers
• amnesia (memory loss), such as not being able to remember what happened before or after the injury
• persistent headaches since the injury
• changes in behaviour, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under the age of five
• confusion
• drowsiness that goes on for longer than an hour when you would normally be awake
• a large bruise or wound to the head or face
• prolonged vision problems, such as double vision
• reading or writing problems
• balance problems or difficulty walking
• loss of power in part of the body, such as weakness in an arm or leg
• clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)
• a black eye with no other damage around the eye
• sudden deafness in one or both ears

Anyone taking warfarin should seek medical assistance after a head injury, even if they feel well. 

Anyone who is drunk or high on recreational drugs should also go to A&E if they have a head injury. It's often easy for others around them to miss signs of a more severe head injury.

Certain things make you more vulnerable to the effects of a head injury, such as:

• being aged 65 or older
• a previous history of brain surgery
• having a condition that makes you bleed more easily, such as haemophilia, or having a condition that makes your blood more prone to clotting, such as thrombophilia
• taking anticoagulant medication (such as warfarin) to prevent blood clots, or taking low-dose aspirin

When to seek emergency medical treatment

You should phone 999 for an ambulance immediately if the person:

• remains unconscious after the initial injury
• is having difficulty staying awake, speaking or understanding what people are saying
• is having a seizure or fit
• has been vomiting since the injury
• is bleeding from one or both ears

Concussion occurs when a blow or impact to the head causes a sudden disruption to part of the brain known as the reticular activating system (RAS).

The RAS is located in the middle of your brain, and helps regulate your sense of awareness and consciousness. It also acts as a filter that allows you to ignore unimportant information by focusing on details you need.

For example, your RAS helps you to:

• fall asleep and wake up as required
• suddenly hear when your flight is being called in a noisy airport
• notice news items that interest you when you are quickly scanning a newspaper or news website

During a head injury severe enough to cause concussion, your brain is moved out of its normal position for a short time. This rotation disrupts the electrical activities of brain cells that make up the RAS, which in turn triggers symptoms associated with concussion, such as:

• loss of memory 
• a brief period of unconsciousness
• mental confusion

Increased risk

The three main causes of concussion are:

• being involved in a road accident
• an accidental trip or fall
• taking part in sporting or other recreational activities

Activities known to have a higher-than-average risk of concussion include:

• rugby
• football
• cycling
• boxing
• martial arts, such as karate or judo

Most doctors would argue that the physical benefits of regularly taking part in these sports outweigh any potential risks associated with concussion.

But this is only if you (or your child) wear appropriate equipment, such as a helmet, and are supervised by a suitably trained referee, umpire or trainer with experience of diagnosing and treating concussion.

The exception to this is boxing, as most doctors – especially those who treat head injuries – have stated that the risks of serious brain injury associated with boxing are unacceptably high and the sport should be made illegal.

Because of the nature of concussion, most diagnoses are either made at an accident and emergency (A&E) department, by a paramedic at the scene of an accident, or by a trained official at a sporting event.

The person making the diagnosis will perform a careful physical examination to check if there are any noticeable signs and symptoms of a more serious brain injury, such as bleeding from the ears, while making sure breathing is unaffected.

If you are conscious, you will be questioned so your state of mind (particularly your memory) can be assessed.

Possible questions include:

• Where are we?
• What were you doing before the concussion?
• Can you repeat the months of the year in reverse order?

You may be asked to try what is known as the "finger-nose-finger" test. The person running the test will hold one of their fingers in front of you. You are asked to touch their finger and then touch the tip of your nose as quickly as possible.

This test is a good way of assessing what effect the concussion has had on your balance and co-ordination.

If you are unconscious, as a precaution it is assumed that you have a serious neck or spinal injury until proved otherwise. You should therefore not be moved until a specialist brace can be fitted around your neck and spine to protect it.

Similarly, if you see a person who is unconscious, make no attempt to move them unless they are in immediate physical danger. Instead, dial 999 for an ambulance and wait with them until paramedics arrive.

Further testing

In some circumstances, further testing may be recommended if there are any signs or symptoms that suggest a more serious injury to your brain. The most widely used test for suspected brain injury is a computerised tomography (CT) scan. 

However, if it is thought you may have damaged the bones in your neck, an X-ray may be used to assess the damage quickly. CT scans are avoided on children under 10 where possible, but may be necessary in some cases.

A CT scan takes a series of X-rays of the inside of your skull and puts them together using a computer. The image that is created forms a cross-section of the inside of your skull and brain.

Adults

A CT scan is usually recommended in adults who:

• have persistent problems in speaking, carrying out instructions or opening their eyes
• have signs and symptoms that suggest the base of the skull is fractured, such as clear fluid running from the nose or ears, or very dark blotches above and below the eyes ("panda eyes")
• have a seizure or fit after the injury
• have vomited more than once since the injury
• are unable to remember events more than 30 minutes before the injury
• have any signs of neurological problems, such as loss of feeling in certain parts of the body, problems with balance and walking, and persistent changes in eyesight

A CT scan is also recommended for adults who have experienced some loss of consciousness or memory since the injury and who:

• are aged 65 or over
• have a problem that makes them prone to uncontrollable bleeding, such as a blood clotting disorder (for example, haemophilia) or are taking the anticoagulant medication warfarin
• were injured in a particularly serious accident, such as a road accident or falling from a height of more than one metre

Children

A CT scan may be recommended in children who:

• lost consciousness for more than five minutes
• are unable to remember what happened before or after the injury and this has lasted more than five minutes
• are unusually drowsy
• have been sick three times or more since the injury
• had a seizure or fit after the injury
• have signs and symptoms that suggest the base of the skull is fractured, such as "panda eyes"
• have memory loss
• have a large bruise or wound to the face or head

A CT scan is also usually recommended for babies less than a year old who have a bruise, swelling or cut on the head bigger than 5cm (2 inches).

There are some self care techniques you can use to relieve mild concussion symptoms. If more serious symptoms start to develop, you should seek immediate medical treatment.

Some self care techniques for mild symptoms of concussion are:

• if concussion has resulted from playing sport, you should stop playing immediately
• apply a cold compress to the injury to reduce swelling – a bag of frozen vegetables wrapped in a towel could be used, but never place ice directly on the skin as it's too cold; apply the compress every 2 to 4 hours and leave it in place for 20 to 30 minutes
• take paracetamol to control pain – do not use non-steroidal anti-inflammatory drug (NSAID) painkillers like ibuprofen or aspirin as these can sometimes cause bleeding at the site of the injury
• get plenty of rest and avoid stressful situations where possible
• avoid drinking any alcohol or taking recreational drugs
• undertake a step by step return to work, college, school and sport – you can read more about this in the return to sports section
• only drive a car or ride a bike when you feel you have completely recovered
• do not play any contact sports for at least 3 weeks – this includes sports like football and rugby
• make sure you have someone to stay with you for the first 24 hours after the injury in case you experience more serious follow-up symptoms

When to seek follow-up advice

Sometimes the symptoms of a more serious brain injury do not occur for several hours, or possibly days, after the initial injury has taken place. This means it's important that you remain alert for signs and symptoms that could suggest a more serious injury has occurred.

Returning to sports

You should rest for at least 24 to 48 hours after a concussion.

Following this, you can gradually return to normal life and then sport using a step by step approach. In the first 24 to 48 hours you can continue to do things like reading and walking.

You should carefully and slowly return to normal life to lower the risk of:

• making your symptoms worse or
• causing new symptoms.

You should only move to the next step if the activity isn't making symptoms worse or causing new symptoms. If the activity makes your symptoms worse, then you should rest and try again the next day if you feel ready.

After the initial rest period, doing some light physical activity can be good for your recovery. You should aim to return to normal daily activities like work and education, before you return to sport.

Current UK concussion guidelines for non-elite (Grassroots) sports recommend these steps:

1. Relative rest for 24 to 48 hours – minimise screen time and do some gentle exercise.
2. Gradually introduce daily activities like reading and some light physical activity like walking.
3. Increase study or work-related activities with rest periods, increase the intensity of exercise.
4. Part time return to study or work and sports training – you should not take part in any activities that risks impact to your head.
5. If you're not experiencing symptoms after resting for 14 days, you can consider returning to full sports training.
6. After 21 days, you can consider competitive sports again, as long as you're symptom free after 14 days of rest and during training in stage 5.

You should stop experiencing symptoms after about 2 to 4 weeks. Sometimes it can take longer. Everyone's recovery is different. It's important to gradually return to your normal activities to reduce the risk of a further brain injury or longer-term problems.

Children and teenagers might take longer to recover than adults.

If you've like to read more about the step by step return to sport, you can read the full guidance on the Sport Scotland website. 

Post-concussion syndrome (PCS) is the term used to describe a collection of symptoms that can last for several weeks or months after the concussion.

The exact cause of PCS is not known. One theory is that PCS is the result of a chemical imbalance in the brain triggered by the initial injury that caused the concussion. Another theory suggests PCS may be caused by damage to nerve cells in the brain.

Symptoms of PCS

The symptoms of PCS fall into three main categories:

• physical
• psychological
• cognitive (affecting a person's thinking ability)

Physical symptoms of PCS can include:

• headaches – often described as similar to migraines in that they cause a throbbing pain on one side or the front of the head
• dizziness
• feeling sick (nausea)
• sensitivity to bright lights
• sensitivity to loud noises
• ringing in the ears – the medical term for this is tinnitus
• double or blurred vision
• fatigue
• lost, changed or reduced sense of smell and taste

Psychological symptoms of PCS can include:

• depression
• anxiety 
• irritability
• lack of energy and interest in the world around you
• having problems sleeping
• changes in appetite
• sudden and inappropriate outbursts of emotion, such as having fits of laughter or crying for no apparent reason

Cognitive symptoms of PCS include:

• decreased concentration
• forgetfulness
• difficulty remembering things or learning new information
• difficulties with reasoning (working out problems)

Treating PCS

There is no specific treatment for the symptoms of PCS, though many medications used to treat migraines have also proved effective in treating the headaches caused by PCS.

Antidepressants and talking treatments such as psychotherapy may help control the psychological symptoms, such as depression and anxiety.

Most cases of PCS will resolve within three to six months, and only 1 in 10 people will still have symptoms after a year.

There are a number of commonsense precautions you can take to reduce your risk of concussion.

These precautions include:

• always wearing the recommended equipment when taking part in a contact sport such as rugby or boxing
• making sure any contact sport you or your child are taking part in is supervised by a properly qualified and trained person
• always wearing a seat belt when driving
• wearing a motorcycle helmet – this is a legal requirement if you are riding a motorcycle in Scotland
• wearing a cycle helmet – this is not a legal requirement, but cycle helmets have been recommended by several leading organisations, such as the Royal Society for the Prevention of Accidents

It is also easy to underestimate how many cases of concussion occur as the result of a fall or slip at home or in the garden, especially in older people. Following some or all of the suggestions below will help keep your home and garden as safe as possible.

• keep stairways clear so you do not trip over anything
• use appropriate safety equipment if you're doing any kind of DIY
• use appropriate equipment to change a light bulb, such as a stepladder
• clean up spillages to prevent someone slipping

For more information, visit the Royal Society for the Prevention of Accidents website.