FAQ

Herbal medicine consists of the use of herbs to treat certain conditions and improve overall health. There is some evidence that herbal medicine may serve as a safe alternative to improve post-concussion symptoms. However, at the moment there is not enough literature supporting the efficacy of herbal medicine for the treatment of concussion. Our review has identified one systematic review with meta-analysis supporting its efficacy as a monotherapy or adjunctive therapy to conventional treatment for TBI in comparison to conventional treatment alone. However, authors state that there is insufficient evidence for its use in clinical practice, as most identified studies were of low quality and highly heterogeneous. Additionally, the expert panel expressed the following concerns with this review.
  • Though this review lists specific herbal medicines identified in the included studies, no standardized recommendations are made for specific herbs effective in the treatment of concussion
  • This review did not analyze concussion populations alone, challenging the generalization to our guideline
Though the panel does not recommend herbal medicine, the evidence should be considered at the physician’s discretion.
  1. Gau BS, Yang HL, Huang SJ, Lou MF. The use of complementary and alternative medicine for patients with traumatic brain injury in Taiwan. BMC Complement Altern Med. 2012;12:211. Published 2012 Nov 6.
  2. Lee B, Leem J, Kim H, Jo HG, Kwon CY. Herbal Medicine for Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Limitations. Front Neurol. 2020;11:772.

There is emerging evidence supporting the efficacy of neuromodulatory modalities for the treatment of some prolonged symptoms following concussion. For example, repetitive transcranial magnetic stimulation may be particularly effective for the treatment of post-concussive depression and headache. However, though the expert panel expresses that this may be a useful tool, it is largely inaccessible in a clinical setting and evidence remains exploratory.
  1. Buhagiar, F., Fitzgerald, M., Bell, J., Allanson, F., & Pestell, C. Neuromodulation for Mild Traumatic Brain Injury Rehabilitation: A Systematic Review. Frontiers in human neuroscience. 2020;14, 598208.
  2. Mollica, A., Safavifar, F., Fralick, M., Giacobbe, P., Lipsman, N., & Burke, M. J. Transcranial Magnetic Stimulation for the Treatment of Concussion: A Systematic Review. Neuromodulation:Technology at the Neural Interface. 2021;24(5), 803–812.
  3. Argyriou AA, Mitsikostas DD, Mantovani E, Litsardopoulos P, Panagiotopoulos V, Tamburin S. An updated brief overview on  post-traumatic headache and a systematic review of the non-pharmacological interventions for its management. Expert Rev Neurother. 2021;21(4):475-490.
  4. Heslot C, Azouvi P, Perdrieau V, Granger A, Lefèvre-Dognin C, Cogné M. A Systematic Review of Treatments of Post-Concussion Symptoms. J Clin Med. 2022;11(20):6224.

There is currently insufficient evidence that prescribing cannabis alleviates prolonged symptoms following concussion or improves recovery following an acute injury. As literature pertaining to this topic in our review was lacking, more research is necessary to potentially consider implementing cannabis use therapeutically for concussion.

Evidence suggests that TBI may be a potential risk factor for dementia, particularly when TBI’s are severe or cumulative. Even one severe TBI has been associated with hyperphosphorylated tau pathology, which has been considered a potential sign of neurodegenerative disease. There is some evidence suggesting that individuals with mild TBI, even when presenting without loss of consciousness, may be two times as likely to later develop dementia. However, risk increases with severity of injury. Communities should be informed about concussion prevention and potential related future consequences for disease prevention.
  1. Barnes DE, Byers AL, Gardner RC, Seal KH, Boscardin WJ, Yaffe K. Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in US Military Veterans. JAMA Neurol. 2018;75(9):1055-1061.
  2. Goedert M, Masuda-Suzukake M, Falcon B. Like prions: the propagation of aggregated tau and α-synuclein in neurodegeneration. Brain. 2017;140(2):266-278.
  3. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413-446.
  4. Zanier ER, Bertani I, Sammali E, et al. Induction of a transmissible tau pathology by traumatic brain injury. Brain. 2018;141(9):2685-2699.

The panel does not at this time recommend hyperbaric oxygen for concussion treatment in adults. Evidence suggests that there may be some cognitive benefits such as improvements in verbal memory; however, literature is lacking in this area. The overall evidence from our review suggests that hyperbaric oxygen is not more effective than placebo for post-concussion symptoms, PTSD or quality of life outcomes. Refer to recommendation 5.8 in the management of prolonged symptoms guideline section, along with the supporting associated evidence.
  1. Dong Y, Hu X, Wu T, Wang T. Effect of hyperbaric oxygenation therapy on post-concussion syndrome [published correction appears in Exp Ther Med. 2018 Dec;16(6):4918]. Exp Ther Med. 2018;16(3):2193-2202.
  2. Hart BB, Weaver LK, Gupta A, et al. Hyperbaric oxygen for mTBI-associated PCS and PTSD: Pooled analysis of results from Department of Defense and other published studies. Undersea Hyperb Med. 2019;46(3):353-383.

There is evidence suggesting that biomarkers may improve diagnostic accuracy for traumatic brain injury. The use of biomarkers for clinical decision making in concussion is suspected to reduce healthcare costs. Various biomarkers have been identified to potentially facilitate the identification of concussion. For example, blood biomarker S100 calcium binding protein B (S100B) may now be able to differentiate complicated vs. uncomplicated mTBI patients. Also, plasma concentration of glial fibrillary acidic protein (GFAP) may be the most promising biomarker as evidence suggests that it may be able to distinguish between healthy controls, uncomplicated mTBI, and complicated mTBI. GFAP has also been found to have good sensitivity and specificity in identifying MRI findings among patients with negative CT. Although research is emerging, the expert panel cautions that the evidence is currently not strong enough to change current clinical practice, and these methods may not be feasible or widely available in the emergency room.
  1. Gill J, Latour L, Diaz-Arrastia R, et al. Glial fibrillary acidic protein elevations relate to neuroimaging abnormalities after mild TBI. Neurology. 2018;91(15):e1385-e1389.
  2. Giza CC, McCrea M, Huber D, et al. Assessment of Blood Biomarker Profile After Acute Concussion During Combative Training Among US Military Cadets: A Prospective Study From the NCAA and US Department of Defense CARE Consortium. JAMA Netw Open. 2021;4(2):e2037731.
  3. Mondello S, Sorinola A, Czeiter E, et al. Blood-Based Protein Biomarkers for the Management of Traumatic Brain Injuries in Adults Presenting to Emergency Departments with Mild Brain Injury: A Living Systematic Review and Meta-Analysis. J Neurotrauma. 2021;38(8):1086-1106.
  4. Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma. 2019;36(13):2083-2091.
  5. Yue JK, Yuh EL, Korley FK, et al. Association between plasma GFAP concentrations and MRI abnormalities in patients with CT-negative traumatic brain injury in the TRACK-TBI cohort: a prospective multicentre study. Lancet Neurol. 2019;18(10):953-961.

Concussions may not be defined as more or less severe. Though symptom number, frequency and duration may differ, this does not signify a worse concussion.

Recent research has shown that some nutritional therapies may be helpful following a concussion. For example, some research has found omega-3 fatty acids may heal the brain and help people feel better following a concussion.1, 2

Omega-3 fatty acids are found naturally in foods such as fish (e.g., mackerel, salmon, and tuna), nuts and seeds (e.g., flaxseed, chia seeds, and walnuts), and can be found in dietary supplements such as fish oil.3, 5 The three main omega-3 fatty acids are alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA).5 ALA is an essential fatty acid, meaning your body cannot make it on its own and must obtain it from food. 5 ALA is then converted into EPA and DHA in the body.5 Omega-3s play a key role in the functioning of cell membranes, especially in the brain.3, 5 DHA is an important component of neuronal cell membranes, regulating a variety of neurological processes such as synaptogenesis and myelination.4 EPA is found in lower concentrations in the brain but is thought to reduce inflammation in the brain following injury.4

Less is known about the use of other nutritional interventions in the treatment of concussion. Although the evidence is growing for the use of omega-3 fatty acids post-concussion, there is insufficient evidence for our experts to make a recommendation at this time.

  1. Feinberg C, Dickerson Mayes K, Jarvis RC, Carr C, Mannix R. Nutritional supplement and dietary interventions as a prophylaxis or treatment of sub-concussive repetitive head impact and mild traumatic brain injury: A systematic review. Journal of Neurotrauma. 2023;40(15-16):1557-1566. doi:10.1089/neu.2022.0498
  2. Finnegan E, Daly E, Pearce AJ, Ryan L. Nutritional interventions to support acute mtbi recovery. Frontiers in Nutrition. 2022;9. doi:10.3389/fnut.2022.977728
  3. Heileson JL, Anzalone AJ, Carbuhn AF, et al. The effect of omega-3 fatty acids on a biomarker of head trauma in NCAA football athletes: A multi-site, non-randomized study. Journal of the International Society of Sports Nutrition. 2021;18(1).
  4. Mullins VA, Graham S, Cummings D, et al. Effects of fish oil on biomarkers of axonal injury and inflammation in American football players: A placebo-controlled randomized controlled trial. Nutrients. 2022;14(10):2139. doi:10.3390/nu14102139
  5. Office of dietary supplements - omega-3 fatty acids. NIH Office of Dietary Supplements. Accessed October 19, 2023. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer/.

Common methods of biofeedback include neurofeedback and heart rate variability biofeedback. Neurofeedback provides patients with real-time feedback on electroencephalogram (EEG) activity to change poor brain functioning.1 This method trains patients to decrease certain types of brain activity and increase others.1 Heart rate variability biofeedback involves monitoring the length of time between heart beats. The variability can be changed by using certain breathing techniques (e.g., using the diaphragm, paced breathing) which then improves functioning of different brain areas.2

There is a growing body of research supporting biofeedback methods in the treatment of post-concussion symptoms. Individual studies have found positive outcomes for the treatment of headache, sleep, cognitive difficulties, pain, and stress.1-6 Although more research seems to be supporting the use of biofeedback methods, there is still not enough evidence for a recommendation to be made. Of the studies currently available there are only a small number of randomized controlled trials,1-4, 6 all of which lack statistical power due to their small sample sizes.

  1. Chen P-Y, Su I-C, Shih C-Y, et al. Effects of neurofeedback on cognitive function, productive activity, and quality of life in patients with traumatic brain injury: A randomized controlled trial. Neurorehabilitation and Neural Repair. 2023;37(5):277-287. doi:10.1177/15459683231170539
  2. Lu HC, Gevirtz R, Yang CC, Hauson AO. Heart rate variability biofeedback for mild traumatic brain injury: A randomized-controlled study. Applied Psychophysiology and Biofeedback. 2023;48(4):405-421. doi:10.1007/s10484-023-09592-4
  3. Polich G, Gray S, Tran D, Morales-Quezada L, Glenn M. Comparing focused attention meditation to meditation with mobile neurofeedback for persistent symptoms after mild-moderate traumatic brain injury: a pilot study. Brain Injury. 2020;34(10):1408-1415. doi:10.1080/02699052.2020.1802781
  4. Stevens AW, Trotter K. Book excerpt: Neurofeedback, biofeedback, and concussions: Level 3 – probably efficacious. Biofeedback. 2023;51(1):7-10. doi:10.5298/1081-5937-50.04.07
  5. Wallace T, Morris JT, Glickstein R, Anderson RK, Gore RK. Implementation of a Mobile Technology–Supported Diaphragmatic Breathing Intervention in Military mTBI With PTSD. Journal of Head Trauma Rehabilitation. 2022;37(3):152-161. doi:10.1097/htr.0000000000000774
  6. Campbell KR, Peterka RJ, Fino PC, et al. The effects of augmenting traditional rehabilitation with audio biofeedback in people with persistent imbalance following mild traumatic brain injury. Frontiers in Neurology. 2022;13. doi:10.3389/fneur.2022.926691