Also called: Persistent post-concussion symptoms; post-concussion syndrome; slow recovery from a head knock
Exercise strongly helps
Strength
Stretch
Breathing
Headache, dizziness, fogginess and exhaustion still there weeks after a head knock. Once the brain injury itself has settled, three trainable things usually keep it going - a strained neck, a mis-calibrated inner ear and eye-tracking system, and a stress response that spikes with any exertion.
How common: Up to 3.8 million sports concussions a year in the US; symptoms last past four weeks in about 15-30% of them
What it is
Most concussions resolve in two to four weeks. When symptoms persist beyond that, the cause is usually no longer the original brain injury - it is a set of secondary problems produced by the same impact and by what happened afterwards.
Three account for most of it. The neck was accelerated in the same impact and refers pain and dizziness. The vestibular and visual systems get knocked out of calibration and produce dizziness and fogginess with head and eye movement. And the autonomic system becomes dysregulated so that mild exertion spikes the heart rate and the headache. All three are trainable, and all three are made worse by complete rest.
What it feels like
- Headache that has outlasted the expected recovery
- Dizziness or fogginess, particularly with head movement or in busy visual environments
- Difficulty concentrating and reading, and a screen tolerance that has collapsed
- Heart racing and symptoms spiking with mild exertion
- Exhaustion, poor sleep and irritability
What causes it
Most people have more than one of these at once, and they feed each other. Read the
list looking for the two or three that sound like your week rather than for the one
true answer — the ones that describe you are the ones worth acting on.
- Neck injury from the same impact
- The forces that concussed the brain also accelerated the neck. Upper cervical joints and muscles refer pain into the head and produce dizziness, and neck treatment resolves symptoms in a substantial proportion of persistent cases.
- Vestibular and ocular-motor dysfunction
- The inner ear balance system and eye-tracking control are frequently disturbed. That produces dizziness with head movement, difficulty with reading and screens, and discomfort in visually busy places - all of which respond to specific rehabilitation.
- Autonomic dysregulation
- Heart rate control and blood pressure regulation are affected, so exertion produces disproportionate symptoms. Sub-symptom-threshold aerobic exercise retrains this and is now standard treatment.
- Prolonged complete rest
- Strict rest beyond the first day or two produces worse outcomes than early gentle activity. It deconditions, worsens the autonomic dysregulation, disrupts sleep and increases anxiety.
- Sleep disruption
- Very common after concussion and it worsens headache, cognition, mood and pain sensitivity. It is a treatment target in its own right.
- Anxiety and fear of symptoms
- Being told to avoid anything that provokes symptoms produces avoidance of everything. Fear and vigilance amplify symptom perception and slow recovery.
- Migraine tendency
- A personal or family history of migraine predicts persistent post-concussion headache, probably through a shared sensitisation mechanism.
- Previous concussions
- Each concussion raises the risk of a slower recovery from the next, particularly where returns to activity were rushed.
- Being told to sit in a dark room
- Historically standard advice and now contradicted by the evidence. It remains widely given and it actively prolongs recovery.
Who tends to get it
- Anyone with symptoms persisting more than about a month after a concussion
- People with a personal or family history of migraine
- Anyone with previous concussions
- People who rested completely for weeks after the injury
- Those with pre-existing anxiety, in whom the fear component is larger
What makes it worse, and what settles it
Makes it worse
- Prolonged complete rest, which worsens all three mechanisms
- Avoiding all activity that provokes symptoms, which prevents the adaptation
- Returning to contact sport before full symptom-free recovery
- Poor sleep and irregular routine
- Being told to wait it out with no active treatment
Settles it
- Sub-symptom-threshold aerobic exercise, individually prescribed, which has good trial evidence for speeding recovery
- Cervical spine treatment, which resolves a substantial share of persistent cases
- Vestibular and ocular-motor rehabilitation for the dizziness and visual symptoms
- Gradual reintroduction of screens and cognitive activity rather than avoidance
- Sleep hygiene and a regular routine
What actually helps
The short version: After the brain injury itself has settled, symptoms are often kept going by three things that are trainable: a neck that was strained in the same impact, an inner-ear and eye-tracking system knocked off calibration, and a stress response that makes any exertion raise the heart rate and the headache. Resting completely makes all three worse
Strength work: Neck: Deep Neck Flexors; Neck; Back: Traps: Lower; Shoulders: Serratus Anterior - the neck half of the problem; Walking - 20 minutes daily at an effort that keeps symptoms from rising by more than two points out of ten, adding a little each week
Stretching: Neck; Neck: Suboccipitals; Chest; Back: Mid-Back
Massage: Neck: Suboccipitals; Neck; Back: Upper Back - the headache is often coming from here
Also worth doing: Sleep on a fixed schedule; limit screens rather than banning them; eye-tracking and balance exercises from a vestibular physiotherapist; gradual return to work or school with breaks; a supervised exercise test if symptoms are stuck past a month
What the evidence says: Randomized trials of sub-symptom-threshold aerobic exercise, started within days of injury, speed recovery and cut the rate of persistent symptoms (Leddy), and a randomized trial of cervicovestibular rehabilitation found treated athletes were 3.9 times more likely to be cleared within eight weeks (Schneider). Complete rest beyond the first two days is no longer recommended.
The names above are the Targets qFIT tracks —
the Muscle Guide explains what each one does, and
Quick Add switches on the Exercises you
already have.
The qFIT routine for this
Ready-made routineNeck Relief & Range
qFIT already has this one built. It runs massage first, then stretching, then
strength — the order that works on a body that is already sore — and every
activity in it carries the reason it is there.
The button below opens your Checklist with this routine already selected, so instead
of your whole list you land on just its Categories, Targets
and Exercises, each with its checkbox, ready to tick as you work through
them.
Have more than one problem? Tick yours under My Problems on
My Profile and your Checklist's Routine list gains
Recommended for my problems — every routine for the problems you picked, merged
into one. Your picks stay private; that filter is the only thing they feed.
Get it checked if…
Worsening headache, repeated vomiting, drowsiness, confusion, a seizure, weakness, slurred speech, unequal pupils or clear fluid from the nose or ear - emergency; any new head injury before the last one has cleared - stop all sport
And whatever the body part: chest pain or unusual breathlessness on
exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and
unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or
one calf that is swollen, warm and painful. Any of those, stop and get assessed.
How it usually goes
Most concussions resolve within a month. Where symptoms persist, targeted treatment of the neck, vestibular and autonomic components produces substantial improvement over six to twelve weeks - which is far better than the wait-and-see approach many people are still given. The key change in the evidence is that early gentle activity beats rest. Worsening headache, repeated vomiting, seizures, increasing drowsiness or new neurological signs after a head injury are emergencies.
Prevalence basis: CDC concussion surveillance; persistent post-concussion symptom cohorts
Others the same routine covers
These share the Neck Relief & Range routine, so the work is the same. If one of them also
sounds like you, that is a reason to expect more from it, not less.
This is general information, not a diagnosis, and it cannot examine you.
If it matches you, use it to ask better questions of a clinician rather than to replace one.