The Centers for Disease Control and Prevention estimates there are 1.6 – 3.8 million sports-related concussions every year, with nearly 175,000 children and adolescents treated annually in ERs for sport-related head injuries. The potential long-term consequences of concussions first came to light in former NFL athletes, but concussions can affect all ages of people, athletes and non-athletes alike. With increasing concussion awareness, concussion diagnoses have steadily increased since 2007, as has the need for appropriate treatment.
Current rehabilitation strategies focus on physical and cognitive therapies, but what is the role of nutrition in the treatment of concussion? Are there specific nutrients that may speed up brain healing?
What is a concussion? In simple terms, it’s a mild traumatic brain injury (mTBI) caused by a force or blow that essentially causes the brain to move rapidly inside the skull. For more on the physiology of concussions, check out this ”Explain it to Me” series video with Dr. Sanjay Gupta– you will never look at Jello the same way again! While most commonly associated with sports-related collisions, like in football or soccer, concussions can happen in non-athletes too – in car accidents, crashing on your bike, or even slipping and falling (Coronado et al., 2015).
Most people associate a concussion with losing consciousness, yet fewer than 10% of sport-related concussions involve blacking out or “seeing stars”. The most common immediate symptoms following concussion include headache, nausea, and dizziness, but up to half of concussed individuals do not report feeling ANY symptoms after a concussive blow (Williams et al., 2015).
Longer term symptoms may range from mild to severe, and can persist for weeks or even months, particularly in those with repeated concussions, older age and female gender (Purcell, 2014; Sharp and Jenkins, 2015). These symptoms may include:
- ongoing headaches
- sleep disturbances
- vision problems like seeing double, sensitivity to light
- impaired balance and loss of coordination
- cognitive issues such impaired concentration and memory, slowed reaction time
- behaviour changes including irritability and anger, mood swings, anxiety, depression
Prompt concussion diagnosis and treatment is crucial, yet guidelines for rehabilitation are still developing (Broglio et al., 2014). The first line of treatment is physical and mental rest – typically advised as 1 – 2 weeks. Physical rest is fairly straightforward, but cognitive/mental rest can be a challenge as it includes limiting computer usage and reading, as well as general screen time on computers and TV. Rehab strategies include physical, occupational and cognitive therapies, and also medications, particularly for headaches and sleep (Purcell, 2014).
How does nutrition fit in? As with any injury, proper nutrition is important to support healing and recovery but the precise role of medical nutrition therapy in concussions is still unknown. Most of the research looking at nutrition has been in moderate to severe TBI, requiring hospitalization and nutrition support (Costello et al., 2014) – not really relevant for concussions.
Overall diet. In general, a post-concussion diet would not be terribly different from an overall healthy diet – or so-called an “anti-inflammatory diet” – rich in whole grains, veggies and fruit and lean protein. It’s important to get enough kcalories to support the increased nutrient needs that may accompany mTBI (Foley et al., 2008), so post-concussion is not the time to go on a restrictive diet!
While you will find some internet “experts” touting a ketogenic diet, the research in this area has been limited to animals or pre-clinical studies; a recent review from the Brain Injury Research Center at UCLA (Prins and Matsumoto, 2014) acknowledges the significant side-effects and need for more studies before ketogenic diets can be recommended.
Fluid intake. This one may be obvious but many people are chronically dehydrated – the average water intake in the US is only 3.9 cups per day. Although there are no studies looking at the influence of fluid intake on concussion recovery, increasing fluid intake has been associated with improved outcomes in those with recurrent headaches (Spigt et al., 2012). At minimum, you should aim for 1.5 – 2 L (6 – 8 cups) of plain ol’ water per day, in addition to other fluids and food.
Omega-3 fatty acids. Remember when your mom told you fish is brain food? She was right! The omega-3 fatty acid DHA is crucial for healthy brain development, and plays both structural and functional roles in the adult brain. Results from animal studies suggest DHA supplementation (alone or with the omega-3 EPA) following a concussion may reduce injury-induced cognitive dysfunction (Barrett et al., 2014).
There are a couple of clinical trials currently running (in adults and in adolescents), so we’ll have to wait a few years for results. Keep in mind, both study doses are quite high at 2 grams per day (3 grams is the dose Generally Recognized As Safe), but DHA and EPA have low side effect profiles and the dose found in typical supplement capsules is 300 mg. Or you could just eat 3 ounces of fatty fish like salmon, mackerel or herring per day – that’s about 2 grams DHA/EPA.
Riboflavin. There is good evidence for daily riboflavin in migraine prevention but no research as of yet specifically for those post-concussion (Pringsheim et al., 2012). How is riboflavin effective? Riboflavin is a B-vitamin and is an important co-factor in cellular metabolism – the thought is it may change brain metabolism and reduce neuron excitability (Colombo et al., 2014).
Since persistent headaches are a common complaint in those with post-concussion syndrome, riboflavin may be worth it. Doses seem extremely high at 100 – 400 mg per day (the RDA for riboflavin in only 1.1 – 1.3 mg/day in adults) BUT riboflavin has no tolerable Upper intake Limit, meaning functioning kidneys have no problem clearing out excess.
Branched-chain amino acids (BCAAs). These three essential amino acids – leucine, isoleucine and valine – are so-named because of their chemical structure. Often known for their role in muscle metabolism and exercise performance, BCAAs are often used as a treatment for neurodegenerative disorders like ALS and tardive dyskinesia owing to their role in brain signaling (via chemical messenger GABA).
There is very interesting data from animals – Cole et al. (2010) found concussed mice had reduced brain levels of BCAAs. When given BCAA supplements, the brain levels increased as did cognitive performance. There is currently one clinical trial out of Philadelphia looking at supplementation following concussion with 15 – 60 grams per day of BCAAs vs. placebo, but results will take a few years.
BCAAs are found naturally in protein-rich foods, but BCAA content of food is only about 15% of the total amino acid content – meaning you’d have to eat A LOT of protein to get a therapeutic dose. Supplemental intakes of 15 – 30 grams per day appear to be safe, though a word of caution – BCAA powder tastes TERRIBLE, so capsules (or a pinched nose!) might be the best bet.
Melatonin. Sleep disturbances are extremely common in post-concussion syndrome. While having a good sleep regimen or sleep “hygiene” is important, sleep aids – whether prescribed or over-the-counter – may be of benefit. Researchers are the University of Calgary are currently conducting a clinical trial looking at melatonin supplementation in children and adolescents. In the PLAYGAME study, researchers are comparing placebo for one month with two doses of melatonin: 3 or 10 mg nightly.
Shown to work wonders for jet-lag, melatonin is also being tested as an adjuvant treatment in breast cancer! How does it work? Melatonin is a hormone produced by the brain that maintains your body’s sleep-wake cycle. New research suggests melatonin may have neuroprotective effects, help with anxiety and headaches – all possible concerns after concussion (Barlow et al. 2014).
Dietary sources of melatonin (or melatonin precursors) include tart cherries, sunflower seeds, cardamom and flax, but supplemental doses of 3 – 5 mg nightly are similar to what’s been used in numerous studies and shown to be safe. If your problem is falling asleep, sublingual melatonin is what you want; if you cannot STAY asleep, slow-release might be a better choice.
No Baloney’s advice? Beyond a healthy diet loaded with antioxidants, healthy fats and lean protein there are a few supplements that show significant promise as complementary treatments for concussions BUT we’ll have to wait until at least 2017 for clinical trial results.
Though riboflavin, BCAAs, DHA and melatonin all have low-side effect profiles, you should ALWAYS discuss any new supplement regimen with your healthcare team before starting, particularly if you are taking prescription medication.