December 29


Concussion Headaches with Iyad Salloum

By Wil Seto

December 29, 2023


Mark: Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. And we're talking about concussion headaches. How are you doing, Iyad? 

Iyad: Doing great. Let's get into it. 

Mark: So I would assume that every concussion has headaches afterwards. Is that true? 

Iyad: You'd be surprised. I mean, it's one symptom for sure. And it's definitely like, I would call it a major presentation after concussion, but I wouldn't necessarily say that all concussions have headaches. That's a bit of a sweeping statement, even though concussions and injuries to the head, to the brain. 

But it tends to be one of the things that, I think one of my clients described it best as, you know, I'm seeing you not because of the pain. It's just because I can no longer deal with the pain kind of thing. So it tends to be like an issue of management and also treatment because they're kind of lost. They'll try certain medication, which seems to help temporarily, but then they seem to recur with most people for different reasons. 

And I think really the biggest thing that we try to do in the clinic is try to figure out what kind of, A) what kind of a headache are we dealing with what's contributing to it? Because often people get given one reason and in my experience with concussion and we learn new stuff every day. It's never just one thing. 

So I think that multimodal approach is so key in concussion treatment and especially when assessment. Because it's kind of lazy of us to blame everything on Oh, you are sensitive to light. And that's what's causing your headaches because sometimes the headaches make you sensitive to light. 

So it's hard for us to draw that causal. This cause this or just cause that. And there's lots of contributors. So that's one of the things that we would do in our first first few visits in the clinic, because it's really hard to assess everything you need for a concussion in one session. Otherwise the person would be just completely wiped and hate you forever for flaring them up so much. 

Mark: Right. So we typically think that concussion happens from contact sports, football, hockey. There's growing awareness of, you know, heading the soccer ball is a problem, rugby, but I think it happens a lot more than people think. 

Iyad: We now know that you don't need to hit your head to get a concussion. And I think like, that's one of the main things we have a brand new consensus statement that came out in June and now the definition of concussions changed to any direct or indirect hit to the head. So that means you can have a blow to the body that causes some of this movement in the brain. 

And even the definition of what's necessary. So like you'll see old videos of your brain hitting the skull inside the skull itself. We now know that it's not just that that seems to affect it because even just the movement could cause some injury there. So I think that's one factor. 

The other thing that tends to be really neglected is Most of the concussions I see are actually after motor vehicle accidents too. And people come in, they're like, I just think, I think it's my neck. And I think it's my neck. And yes, it usually is the neck. Because what we're finding is the force needed to experience case of whiplash is much smaller than that needed to develop, you know, symptoms after a concussion and actually get a concussion. 

So typically what we see is that, yeah, they do go hand in hand, but also to blame everything on the neck is also probably a little leaves the person kind of a bit shorthanded. So that's definitely one of the things we would assess. So I would kind of go into some major kind of big picture stuff. 

Some people have just really poor exercise tolerance, though they will find that when they do any cardiovascular exercise, I'm talking spinning on a bike, which you would think nothing's moving in a crazy way. All I'm doing is just spiking my heart rate up. Even if I have no resistance on my leg, even if I'm not leaning forward on the handlebars, they can get symptoms. 

So that's one of the things that we would try to assess. In the clinic we have a very good set of tests that we do. We could do it on a bike or on a treadmill. We would want to do a neck exam because the neck definitely, we can get cervicogenic headaches. And those are very hard. It's hard for you to kind of sometimes say this is my neck or this is just a headache. 

And they can also come with a host of other symptoms like sensitivity to sound and light, you know, like I said, it's a bit more involved. And sometimes we can have some, this is a bit controversial in some areas, I guess, where does this condition exist or not? We know that there are some reports of it. 

It's called cervicogenic dizziness. So that's dizziness from following a neck injury. And we have some good rehab tools for that too. And then, you know, there are people who develop migraines, and then we would kind of want to work well with our physicians, colleagues, and trying to tackle this from both ways, because if there is a confirmed you know, like, onset of migraines, those can also have a whole host of other symptoms, such as you have something called a vestibular migraine which can cause vertigo after a migraine. 

And we'd want to deal with that, and then deal with some of the symptoms. Let's say the sequelae of dizziness and whatever happens. So this is kind of like why it's a little kind of, for me, a bit premature to say it's one cause because I could see so many different things usually in clients of ours. And the way I look at it, I'm like, your brain does so many different jobs. 

So why shouldn't we try to like try to address that in as a holistic way as possible instead of just saying no, no, no, it's just going to be just this thing because this is the loudest guy in the room, you know, and it tends to be a little bit of column A, B and C in those cases. 

Mark: So what's the typical treatment look like? 

Iyad: Again, it depends on what's contributing to it. So we would want to do a very thorough amount of testing. Obviously the testing is informed by the symptoms. So our first thing we do is we do a few questionnaires which the clients will do on their own.. We would want to get a really good history of what triggers the headaches. What triggers the symptoms. What are the symptoms beyond headaches, if there are any. 

And then we would go through a very systematic kind of approach. If it's my first time ever seeing this client and they've never seen a physician or anybody else who's had a good look at them, I would do a bit more screening for red flags to make sure everything's okay. And then we can kind of dive in and we can look at a few things. 

We can look at some of the things called oculomotor function to look at how the eye's moving and attending to different stimulation, and then we would assess the neck. We also want to do some form of exercise testing because that's really, really important. That tends to be the one that's usually neglected because it's very time consuming. 

However, we tend to see that that actually is a really, really big piece. And we would do this exercise testing in a very controlled environment. I've been mostly using the stationary bike because I find that it provides less noise in testing. So I can really pick out, can this person actually get their heart rate up? Can they tolerate it? And how long and how much intensity they could do it at? And then I'm monitoring a lot of other variables like heart rate and a few other things and exertion. And then based on that I can give a very nice prescription for that client to go and start moving again and get their rehab on track. 

And obviously a lot of it comes down to education about managing your own resources. We can't just kind of go all out every time. We have to kind of really pace ourselves in the recovery and we want to see some form of graded exposure there. We don't want to just go to absolute rest. Rest is really useful in the first 2 to 3 days. And then after that, we want to start stimulating the body just a bit. 

Even if it's going out for a walk, even if it's just like reading a single page, depending on the person's goals, if you want to get them back to school, it would be one approach, want to get them back to work, one approach, want to get them back to sports, another approach. So that's where the nuance happens. And that's where it's a little more vague. Because if I want to get back to a soccer field versus reading a whole textbook, I need different things to be considered in my rehab. 

Mark: Of course. And typical, I guess it's this again depends on the acuteness of the injury, how long does it take to fix it? 

Iyad: I can tell you that there's no consensus on this because so many things are like the variables at play are when did the concussion happen versus when did we start dealing with this? How aware are we that we are actually dealing with a concussion versus not? How many other systems are involved? How much severity is there from the beginning? 

So all of those factors can dictate how long it takes. So I cannot give a singular like, oh, yeah, it's about 4 to 6 weeks. And then, you know, you'll be back in no time. This is just not one of those conditions that we can kind of just give a very good, clear definition on because there's just so much variety in that same case. 

But I think the way I kind of will structure that prognosis piece is like, how well, how long is I will see how they're developing in the 1st, 1 to 2 weeks. And based on that we can decide, do we push more aggressively or do we need to hold back? 

So I think like, again, there's so much individual differences here that I'm loathe to give a one size fits all piece of advice and also set people with the wrong expectation or, you know, because some people might need to be pushed on faster. And some people might need to be held back a bit more. 

Mark: Would it be wrong to say that if this is someone's third or fourth concussion, that it's going to take longer? 

Iyad: It just makes sense if you've had multiples that the recovery is a little more complicated because it's just more history there. And it depends also how well they recovered from the previous ones and where they were at. But the good news is we do see people recover. 

My last client had 7 concussions by the age of 19, which is, you know, it sounds like a lot, but she just returned to her sports. So I think like it's all possible. We obviously try to provide as much education as possible to the athlete or to the client, and then they can make the best informed decision themselves. Like, it's never just like, yeah, I think you should go back to sports. It's more like, here's what's going to happen. Here's where the potential pathways are in front of us. And based on this, then you have more information, how do you want to proceed? 

Mark: If you're having a concussion syndrome of any kind, especially headaches, the guys to see in North Burnaby are Insync Physiotherapy. You can reach them at to book your appointment. Or you can call them in North Burnaby at (604) 298-4878 to book your appointment. Thanks so much, Iyad. 

Iyad: Thank you.

Wil Seto

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