Post-concussion syndrome can be a persistent problem for people with a head injury, but what are some of those symptoms that one might expect? We have previously explored post-concussion headaches, but in this article we’ll look at another common symptom: dizziness and vertigo.
- Symptoms and diagnosis of dizziness in post-concussion syndrome
- Causes of dizziness after a concussion
- Common triggers of post-concussion dizziness
- Prognosis and outcomes
- Treatment of post-concussion syndrome dizziness and vertigo
- When Dizziness Lingers
- Balance Problems after Traumatic Brain Injury
- What is balance?
- Why is balance important?
- Diagnosing balance problems
- What are common causes of balance problems after traumatic brain injury?
- Treatment options
- How quickly can your balance improve?
- Overview – Severe head injury
Symptoms and diagnosis of dizziness in post-concussion syndrome
Acute dizziness is a commonly-reported problem following concussion, so much so that there are multiple clinical definitions that include it as an identifying sign of post-concussion syndrome.2 However, it can be incredibly difficult to properly diagnose post-traumatic dizziness and vertigo for several reasons, including:
- Latency of symptom onset
- Presence of other dizziness-related side effects
- Difficulty of patients in describing symptoms
- Other causes or conditions of vertigo
Evidence has suggested that up to 80% of those who sustain a concussion frequently report vertigo in the first few days after a head injury, and it can often last up to a week or more. On the other hand, post-concussive dizziness can persist for weeks or months after the trauma, and even become a chronic problem in one out of five patients—with some reporting symptoms for 2 to 5 years or even longer.3
Dizziness is not just limited to the sensation of “spinning” either. Other symptoms and side effects might include: lightheadedness; vertigo; motion sensitivity; balance dysfunction; feeling faint or blacking out; double vision and other eye symptoms after concussion; nausea and vomiting; and more.
Causes of dizziness after a concussion
The symptom of feeling dizzy after head trauma rarely occurs in isolation; instead multiple factors often contribute to the problem.18 There is much question over exactly what are the root causes of post-concussion dizziness, and each patient has unique experiences that must be considered. However, experts agree that the most common reason is benign paroxysmal positional vertigo, which is likely due to damage to the inner ear and may be responsible for 60% of cases.16 However, other causes have emerged, such as:3-5,17
- migraine or vestibular migraine
- central vestibular system damage
- central nervous system dysfunction
- accompanying neck or whiplash injury
- labyrinthine concussion (damage to the inner ear)
Evaluation by a qualified healthcare provider is necessary to determine the cause of the prolonged nature of the symptoms. As with any medical condition, there may be more than one reason that a person experiences dizziness and vertigo.
Common triggers of post-concussion dizziness
Generally speaking, there are a variety of triggers or things that can that can bring about an episode of vertigo and dizziness. Some common triggers include:7,8
- Certain head movements
- Anxiety and/or stress
- Prolonged bed rest
- Certain patterns
- Lights, especially flickering lights
In addition, a recent observational study noted that computer screens and television triggered dizziness in half of adolescents who had endured a sports-related concussion; this is an anecdote that has been reported by numerous patients in clinic and online social communities.13,14 It is thought that these triggers are associated with eye movement and motion sensitivity, and the light from these screens may also lead to the onset of post-concussion symptoms—particularly if migrainous symptoms are prominent after the concussion.
Another study found that younger children with a diagnosis of concussion are more susceptible to visually-induced dizziness.15 These environmental triggers included:
- Completing school work
- Sports participation
- Computer use
- Riding in a car or bus
- Watching TV or cinema movie
- Looking at a striped or moving surface
It is important to speak with your healthcare provider for evaluation of your dizziness or vertigo so that an accurate diagnosis can be made and a list of avoidable triggers can be discussed and developed.
Prognosis and outcomes
Post-concussion syndrome prognosis depends on a variety of factors, however for most people, symptoms resolve within one year of the inciting injury.9 However, as we noted previously, dizziness can last for several years, ultimately disrupting patients’ lives. In fact, dizziness and vertigo have been linked to psychological distress, work-related disability and prolonged recovery duration for those with post-concussion syndrome.6,10,19
Not surprisingly, other chronic symptoms that occur after a concussion (such as headaches or anxiety) have been associated with higher instances of vestibular and balance dysfunction.11 The type of head trauma also makes a difference in the outcomes experienced by patients; specifically, dizziness that stems from blast-induced injuries among military members has been shown to get worse over time.12
Treatment of post-concussion syndrome dizziness and vertigo
It is imperative that patients be evaluated for all symptoms after a concussion, in order to identify other possible causes of dizziness. Some treatment options to better manage post-traumatic vertigo and concussion-related dizziness include:1,9,20
- Physical and cognitive rest
- Anti-vertigo or anti-nausea medications
- Migraine-specific treatments (if migrainous vertigo is also suspected)
- Minimizing other environmental triggers, such as screen time
- Gradual activity increases
- Canalith repositioning procedure- a physical therapy maneuver used in cases where the gravity-sensing ear crystals have been dislodged during the precipitating injury.
- Exercise-based vestibular rehabilitation
Vestibular Migraine: The Effects of Migraine Vertigo and Dizziness
Post-Concussion Syndrome Headaches
7 Common Eye Symptoms after Concussion
1Willer, B and Leddy, JJ. Management of Concussion and Post-Concussion Syndrome (2006) Current Treatment Options in Neurology 2006, 8:415–426.
3Sharp, DJ., and Jenkins, PO. Concussion is confusing us all. (2015) Pract Neurol. 2015 Jun; 15(3): 172–186.
4Fife, TD., and Giza, C. Posttraumatic vertigo and dizziness. (2013) Semin Neurol. 2013 Jul;33(3):238-43.
5Lee, SC., Vestibular System Anatomy (2016, June 27). Retrieved from https://emedicine.medscape.com/article/883956-overview.
7Avoiding Vertigo Triggers. (2017, May 15) Retrieved from https://di-vertigo.com/2017/05/avoiding-vertigo-triggers/
15Pavlou M, Whitney SL, Alkathiry AA, et al. Visually Induced Dizziness in Children and Validation of the Pediatric Visually Induced Dizziness Questionnaire. Frontiers in Neurology. 2017;8:656. doi:10.3389/fneur.2017.00656.
16Davies RA, Luxon LM. Dizziness following head injury: a neuro-otological study. J Neurol. 1995 Mar;242(4):222-30.
20Chamelian L, Feinstein A. Outcome after mild to moderate traumatic brain injury: the role of dizziness. Arch Phys Med Rehabil. 2004 Oct;85(10):1662-6.
When Dizziness Lingers
Care providers advised Mary to be patient and to allow her dizziness, along with her other post-concussion symptoms, to resolve over time. After nine months, Mary’s cognitive-communication impairment improves significantly—but her dizziness does not.
As audiologists and SLPs, we are in a unique position to note whether a patient has lingering dizziness. We often interact with TBI patients throughout their recovery as part of a multidisciplinary team. But to best help these patients, we need to do more than that: We need to be alert to the possibility that dizziness in a patient like Mary is something other than post-concussion syndrome. It could be due to other causes, such as an underlying peripheral vestibular pathology.
The overlooked symptom
Mary is one of almost 2 million Americans who suffer and survive a TBI each year. Defined as a sudden, traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force, TBI is a complex condition with symptoms that vary considerably from person to person. The most common symptoms include cognitive-communication difficulties involving attention, memory, executive function, processing speed and language.
Additionally, physical impairments such as hearing loss, headaches, seizures, nausea, incoordination, visual disturbances, paralysis, paresis and dysphagia also are quite common. Because such a wide spectrum of symptoms is associated with TBI, a multidisciplinary team typically identifies and manages these patients. Despite the benefits of a multidisciplinary approach, some TBI symptoms may fail to receive the attention they deserve, primarily because they fall under the post-concussion syndrome umbrella. One often-overlooked symptom is dizziness.
According to reports, the incidence of dizziness and disequilibrium associated with TBI ranges from 40 to 60 percent in adults. In most cases, dizziness following TBI can be attributed to post-concussion syndrome. However, underlying peripheral vestibular dysfunction following TBI—such as benign paroxysmal positional vertigo, unilateral vestibular weakness, perilymph fistula or superior canal dehiscence—may also produce dizziness, vertigo and imbalance. A vestibular evaluation completed by an audiologist can identify concurrent or mitigating vestibular dysfunction or, conversely, confirm normal vestibular function. Using a wait-and-see approach, as noted with Mary, may result in prolonged discomfort as well as diminished functional abilities.
Electronystagmography, videonystagmography and rotary-chair testing are valid, well-established tools for vestibular evaluation. An audiologist can use these tests to identify any underlying peripheral vestibular dysfunction associated with TBI. It can be difficult to distinguish post-concussion syndrome from vestibular dysfunction, especially from the presentation of symptoms alone. But identifying a potential vestibular lesion may be critical to the patient’s overall management and recovery, as there are often evidence-based treatment options with the potential to resolve or mitigate symptoms.
Although dizziness resulting from TBI can resolve over time, for many people like Mary, it does not. But she is lucky. Her SLP decides not to wait any longer to see whether Mary’s dizziness improves on its own. Instead, she consults with an audiologist who specializes in vestibular evaluation. The audiologist’s vestibular evaluation reveals Mary has a bilateral, multi-canal, benign paroxysmal positional vertigo. Mary’s reported motion-provoked symptoms are also consistent with benign paroxysmal positional vertigo. After four visits consisting of canalith repositioning—Epley and log-roll maneuvers—over five weeks, Mary is free of dizziness and well on her way to recovery from her TBI. She has returned to her normal schedule of driving, assisting her husband in his business and managing a busy household.
The chart online highlights the differences in symptoms, duration and onset, and treatment methodologies for dizziness from post-concussion syndrome, as opposed to peripheral vestibular dysfunction. In cases of prolonged dizziness following a brain injury and symptoms indicative of peripheral vestibular dysfunction, consideration of a vestibular evaluation by a qualified audiologist may be warranted. For patients like Mary, it can work out beautifully.
The author’s email address is [email protected]
If your child suffers a concussion, whether while playing sports or from a fall or other accident, keep a close watch for symptoms of more severe brain trauma.
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“Parents should be concerned about a series of things we call red-flag issues,” says neurologist Andrew Russman, DO. “These are symptoms that warrant a prompt evaluation because they could signal something more worrisome than just a concussion.”
Watch for these 10 red-flag symptoms
If you see any of the following symptoms after a concussion, go to an Emergency Department immediately for a medical evaluation:
- Severe or worsening headache or ringing in the ears
- Neck pain
- Increasing confusion or dizziness (Some patients exhibit sadness about the injury, unusual or irritable behavior or the inability to recognize people or places.)
- Fainting, drowsiness, significant decline in alertness, inability to waken from sleep, any prolonged loss of consciousness
- Slurred speech
- Weakness or numbness in arms or legs
- Clear, watery discharge from the nose or ears, or bloody discharge from the ears
- Pupils that are unequal in size
Of these, Dr. Russman says, the most common are headache, neck pain, and fogginess or dizziness.
“The basic concern is to know to identify the concussion symptoms and seek medical attention appropriately,” he says. “If there are some of these red flags, an ER evaluation is important.”
How to handle a less serious concussion
Dr. Russman addresses two common misconceptions about concussions.
First, if a child suffers a concussion, he or she does not necessarily need a CT scan, he says.
“Few patients with concussions will benefit from any type of brain imaging in their early evaluation,” he says. “In fact, ERs have a whole list of criteria for requiring a CT scan, so the patient would have to have at least one of the red-flag symptoms.”
Second, you don’t have to keep the child awake if he or she is not showing any of the red-flag symptoms, he says.
“As long as the child has remained awake and alert, there’s no reason that you have to wake them if they fall asleep at a normal time,” he says.
Again, if the child’s condition worsens or he exhibits any of the red-flag symptoms, take him or her immediately to the ER.
What usually happens when a child athlete gets a concussion?
Typically, if your child gets a concussion during an organized athletic event, one or more members of a team of trained medical professionals will examine him or her immediately. This usually starts with a team physician or athletic trainer on the sidelines. A physical therapist, pediatrician or neurologist may examine your child later.
After that initial evaluation, the medical professional will help decide whether the child should go to the office for a follow-up evaluation, to the ER for immediate medical attention, or whether he or she is well enough for parental observation at home.
“They should never return to the sport on the same day they have had the injury,” says Dr. Russman. “Next, they need to go through a graded program of physical recovery under the direction of a licensed healthcare professional.”
The goal for athletes
While most patients may not need an ER evaluation, they all need to carefully follow a set of guidelines that will return them to the classroom first, and then return them to their athletic activities, Dr. Russman says.
“The point person on the sidelines, the team physician and the athletic trainers, as well as the other medical professionals involved, will follow up and continue to evaluate and eventually help the child return to learn and return to play,” he says.
Balance Problems after Traumatic Brain Injury
People with traumatic brain injury (TBI) commonly report problems with balance. Between 30% and 65% of people with TBI suffer from dizziness and disequilibrium (lack of balance while sitting or standing) at some point in their recovery. Dizziness includes symptoms such as lightheadedness, vertigo (the sensation that you or your surroundings are moving), and imbalance.
How bad your balance problem is depends on many factors:
- How serious your brain injury is.
- Where in your brain you were injured.
- Other injuries you had along with your brain injury. For example, in a motor vehicle crash, you could suffer a TBI, cervical spine injury, and rib and leg fractures. All of these injuries will affect your ability to maintain your balance.
- Some medications used to manage the medical issues connected with the traumatic event or accident.
What is balance?
Balance is the ability to keep your body centered over your feet. The ability to maintain your balance is determined by many factors, including your physical strength and coordination, your senses, and your cognitive (thinking) ability.
Most people can control their body movement within certain limits before losing their balance and needing to adjust their posture or take a step to keep from falling. Adjusting your posture or taking a step to maintain your balance before, during, and after movement is a complex process that is often affected after brain injury.
Why is balance important?
When you have poor balance you have a high risk of falling and having another brain injury or broken bone. Maintaining balance while sitting and standing is important for all of our daily activities, including self care and walking. Poor balance can keep you from taking part in many types of activities, such as sports, driving, and work.
Diagnosing balance problems
Many different kinds of health care providers may be involved in diagnosing and treating balance problems, including physiatrists (physical medicine or rehabilitation doctor), neurologists, otolaryngologists (ENT), and neuro-ophthalmologists. The first place to start is by having your physician review your medications, since this is a common cause of balance problems. Physical and occupational therapists may also help identify and treat balance problems.
Two commonly used tests for identifying balance problems are the Berg Balance Scale and the Dynamic Gait Index. Both of these tests can be used to track your progress as your balance improves with therapy and to provide information about potential risk of falls.
What are common causes of balance problems after traumatic brain injury?
Medications: A number of commonly used medications can cause dizziness, lightheadedness and decreased balance. These include some blood pressure medications, antibiotics, tranquilizers, heart medications, and anti-seizure medications. Ask your doctor if any of the medications you are taking may be causing dizziness or balance problems. A change in medications or dosages may improve the problem.
A drop in blood pressure when standing or sitting up suddenly (called postural hypotension) can make you feel lightheaded and dizzy. It may occur when you get up quickly from sitting on the toilet or a chair, or getting out of bed. Having your blood pressure taken while in a lying, sitting and standing position may also help diagnose blood pressure-related balance problems.
Problems with eyesight (vision impairments): Eyesight is one of the key senses you need to keep your balance. Eyesight problems such as double vision, visual instability, partial loss of vision, and problems with depth perception can make your balance worse.
Inner ear problems (vestibular impairments): Your inner ear contains many tiny organs that help you keep your balance (called the vestibular system/labyrinth). Your inner ear has three loop-shaped structures (semicircular canals) that contain fluid and have fine, hair-like sensors that monitor the rotation of your head. It also has other structures (otolith organs) that monitor linear movements of your head. These otolith organs contain crystals that make you sensitive to movement and gravity. If your vestibular system is damaged from your head injury, you may have problems with balance, dizziness, or a sudden sensation that you?re spinning or that your head is spinning. Three types of vestibular impairments are:
- Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo. With trauma, the crystals in the inner ear can be moved out of place, making you sensitive to changes in gravity. BPPV is characterized by brief episodes of mild to intense vertigo. Symptoms are triggered by specific changes in head position, such as tipping your head up or down, and by lying down, turning over or sitting up in bed. You may also feel out of balance when standing or walking.
- Labyrinthine concussion or injury to the nerve to the vestibular system are also causes of vertigo and imbalance after brain injury.
- Traumatic endolymphatic hydrops occurs when there is a disruption of the fluid balance within the inner ear. When this happens, you may have periods of vertigo, imbalance and ringing in your ears that last for hours to days.
Problems with your ability to sense things (sensory impairments): For example, nerves in your feet send messages to your brain that help you keep your balance. If these nerves are damaged from your brain injury, your brain may not get the messages it needs. The brain may need to rely more on your eyesight and inner ear to keep your balance.
Brainstem injury: A traumatic injury to the brainstem and cerebellum (parts of the brain that control movement) can make it hard for you to walk and maintain your balance.
Leakage of inner ear fluid into the middle ear (called perilymph fistula) sometimes occurs after head injury. It can cause dizziness, nausea, and unsteadiness when walking or standing. It can get worse when you are more active and may get better with rest.
Mental health issues: Sometimes people with brain injuries have anxiety, depression or a fear of falling. These conditions can cause or increase balance problems. Doctors call this psychogenic dizziness.
Balance problems can have many different causes, each one requiring a different treatment. Your doctor, physical and occupational therapists and/or other health care providers will work with you to understand and treat all the different causes.
Ways you can improve your balance:
- Increasing your strength and flexibility will help your balance. Specific exercises include stretches for your ankle and hip muscles or strengthening activities for your legs, such as mini-squats, toe- raisers, or standing leg lifts. Go to www.nia.nih.gov/Go4Life for more information about these exercises, or talk to your doctor or physical therapist.
- Find your limits in balance by moving your body over your feet as far as you can without lifting your feet. This will help you develop balance strategies to prevent losing your balance. You can also practice movements that allow you to transition from one position to another, such as going from sitting to standing, reaching above your head to get something off a shelf, or picking up something off the ground.
- Practice standing or walking in different conditions. For example, you can practice standing with your eyes closed to decrease your dependency on vision for balance or stand on a pillow to improve your ability to use vision for balance. Change how far apart your feet are and work on balance by bringing them closer together, in front of one another or even stand on one leg.
- Practice activities that will improve your balance while walking, such as walking longer distances; walking and keeping up with someone else while carrying on a conversation; walking over different surfaces, such as on grass and sidewalks; and walking in crowded places such as the grocery store.
- Be cautious when working on your balance, and make sure you work at an appropriate level to avoid falling when no one is around. A physical or occupational therapist can help design a program that is safe for you to practice at home.
- BPPV is treated by using movements to relocate the crystals in your inner ear back to where they belong. To learn more about the treatment of BPPV, go to http://www.tchain.com/otoneurology/disorders/bppv/bppv.html.
How quickly can your balance improve?
How quickly your balance problems improve depends on the extent of injury and your health status before your injury. A condition such as BPPV can be treated effectively in one or two treatment sessions. Injuries that involve many types of impairments can take weeks, months or years.
- Most people with TBI are able to walk independently within three months of injury. Although most can return to walking, many continue to have problems with moving quickly and with balance needed to return to high-level activities such as running or sports.
- With hard work, people with TBI can continue to improve their balance for many years after injury but balance problems are still identified more frequently in people with TBI than in people without TBI.
Katz DI, et al. Recovery of ambulation after traumatic brain injury. Arch Phys Med Rehabil. 2004; 85(6):865-9.
McFayden BJ, et al. Modality-specific, multitask locomotor deficits persist despite good recovery after a traumatic brain injury. Arch Phys Med Rehabil. 2009; 90(9):1596-606.
Maskell F, Chiarelli P, Isles R. Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj. 2006;20(3):293-305.
Patla AE, Shumway-Cook A. Dimensions of mobility: defining the complexity and difficulty associated with community mobility. J Aging Phys Activity. 1999: 7: 7-19.
Williams GP, Schache AG. Evaluation of a conceptual framework for retraining high-level mobility following traumatic brain injury: two case reports. J Head Trauma Rehabil. 2010: 25(3): 164-72.
This information is not meant to replace the advice from a medical professional. You should consult your health care provider regarding specific medical concerns or treatment.
Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the TBI Model System directors.
Balance Problems after TBI was developed by Michelle Peterson, PT, DPT, NCS, and Brian D. Greenwald, MD, in collaboration with the Model Systems Knowledge Translation Center.
Severe head injury
Severe head injury
Severe head injuries require immediate medical attention because there’s a risk of serious brain damage.
These pages focus on severe head injury.
Find out more about minor head injuries
Symptoms of a severe head injury can include:
- unconsciousness – where a person has collapsed and is unresponsive, even for a brief period of time
- concussion – a sudden but short-lived loss of mental function that occurs after a blow or another injury to the head; a person with concussion may have a glazed look or appear confused, but won’t necessarily be unconscious
- fits or seizures
- difficulty speaking or staying awake
- problems with the senses – such as hearing loss or double vision
- repeated episodes of vomiting
- blood or clear fluid coming from the ears or nose
- memory loss (amnesia)
- sudden swelling or bruising around both eyes or behind the ear
- difficulty with walking or co-ordination
Dial 999 immediately to request an ambulance if you’re with someone who experiences any of these symptoms after a head injury.
Alternatively, take them immediately to your nearest A&E department.
You should also go to A&E if someone has injured their head and:
- the injury was caused by a forceful blow to the head at speed, such as being hit by a car or falling 1 metre or more
- the person previously had brain surgery
- the person previously has had problems with uncontrollable bleeding or a blood clotting disorder, or is taking medication that may cause bleeding problems, such as warfarin
- the person has been drinking alcohol or has taken drugs
- the injury wasn’t accidental – for example, you deliberately hurt yourself or someone else hurt you on purpose