Peter Attia MD263 ‒ Concussions and head trauma: symptoms, treatment, and recovery | Micky Collins, Ph.D.
CHAPTERS
- 0:00 – 8:39
Micky Collins' Path to Founding the First Concussion Clinic
Peter Attia asks about Micky Collins' background. Collins describes how he drifted into neuroscience, set out to combine brain injury with sports at a time when no concussion field existed, and helped start the UPMC program in 2000. He recounts the 1999 JAMA football study and how the clinic grew to 20,000 visits a year.
- •Collins says no concussion specialty existed when he was in school in the late 1990s
- •Steve Young's concussion coverage on Monday Night Football convinced him this was his calling
- •He and mentors Mark Lovell and Joe Maroon started the UPMC clinic in 2000
- •The 1999 JAMA paper on college football concussion, which he led, was an early landmark
- •The program grew from two or three patients a week to 20,000 visits a year
- 8:39 – 14:07
What a Concussion Is: Energy Crisis and No Biomarker
Collins explains the pathophysiology: the brain shifts in the skull, neuronal membranes stretch, and potassium and calcium fluxes create a mismatch between energy demand and supply. There are no structural changes or cell death, and no blood test or imaging can diagnose it. Attia works through the ion-flux details with him.
- •Concussion is a metabolic mismatch between energy demand and supply at the cell level
- •Potassium leaks out and calcium flows in, causing vasoconstriction and reduced cerebral blood flow
- •Cells are not killed but operate less efficiently, so some brain systems decompensate
- •No biomarker, serum test or imaging currently confirms the diagnosis
- •Attia clarifies that more glucose and ATP are needed to pump potassium back in
- 14:07 – 20:47
Risk Factors, Sex Differences, and Vulnerability After a First Concussion
Collins says concussion affects brain systems rather than specific regions, and that whatever you bring to the table that's weak is affected more. Histories of car sickness, migraine, lazy eye or anxiety raise risk and steer the type of concussion. He discusses why girls are more at risk and how vulnerable someone is while still recovering.
- •Preexisting factors such as car sickness, migraine, strabismus and anxiety mean less force causes injury and predict the pathway
- •Girls are more likely to be concussed, with neck strength and hormones mentioned as factors
- •Collins says 60% of his clinic's patients are female and females have longer outcomes
- •Vulnerability to a repeat injury is higher while still recovering from the first
- •He believes effectively treated concussion does not cause cumulative problems
- 20:47 – 26:52
Symptoms, Predictors of Outcome, and the Cost of Playing Through
Collins lists the signs and symptoms of concussion and reveals that on-field dizziness, not loss of consciousness, is the strongest predictor of a longer recovery. He describes retrospective studies showing that playing on after symptoms adds weeks to recovery, with a dose-response effect.
- •Signs are outwardly observed, while symptoms are patient-reported
- •On-field dizziness is six times more predictive of longer recovery than other symptoms, with fogginess second
- •Kids removed from play recovered in about 18 days versus 44 days for those who played 15 more minutes
- •Each minute of playing through added about seven or eight days of recovery
- •Collins stresses he supports kids playing sports and is not fear-mongering
- 26:52 – 31:51
The Six Types of Concussion and Age and Hormonal Differences
Collins describes how the VOMS exam, ImPACT neurocognitive testing and clinical interview identify six concussion types: cognitive fatigue, vestibular, ocular, migraine, anxiety and neck. He then covers age differences in recovery and early research on hormones and menstruation after head injury.
- •Evaluation combines symptoms, a clinical interview, the VOMS exam and ImPACT testing
- •The six types are cognitive fatigue, vestibular, ocular, migraine, anxiety and neck, and they can overlap
- •Each type has its own treatment, risk factors and return-to-play considerations
- •High schoolers recover slowest, then college athletes, then professionals
- •A JAMA Neurology paper showed menstrual cycles change after head injury, and a women's study is planned
- 31:51 – 34:52
Misinformation, Hysteria, and Why Early Specialist Care Matters
Prompted by Attia's question about the spotlight on CTE and the NFL, Collins says awareness without a solution becomes hysteria and that mismanagement hurts outcomes. He explains that how quickly a patient reaches his clinic was the best predictor of recovery, though chronic cases can still be treated.
- •Awareness without a solution leads to hysteria and misinformation
- •Clinicians unaware of recent advances mismanage concussion
- •Being seen within seven days was the best predictor of getting better
- •Collins says even patients one to three years out can usually be treated effectively
- 34:52 – 43:11
Case Study: A Racecar Driver with a Vestibular Concussion
Collins describes a racecar driver he saw that morning who has suffered for two years after crashes, with daily headaches, dizziness, fogginess and isolation. He explains how the vestibular problem triggers sympathetic arousal, avoidance, anxiety and migraine. Attia shares a similar story of a cyclist.
- •The driver hit the back of the headrest, kept racing, and had a second similar crash
- •Symptoms include headaches up to 8/10, light and noise sensitivity, fogginess and car sickness
- •Vestibular pathways also mediate the sympathetic nervous system, driving fight-or-flight arousal
- •Avoidance, poor sleep and inactivity feed migraine and anxiety
- •Collins says about 80% of his out-of-town patients are this sick
- 43:11 – 43:16
Treatment Plan for the Driver, Medications, and Treating the Root Cause
Collins details the driver's homework: vestibular exercises, a long walk, a rigorous workout, regulated sleep and exposure to busy places, with a follow-up in four weeks. He discusses when medications such as sertraline might be used and agrees with Attia that treating the root cause prevents downstream problems.
- •The driver gets vestibular exercises twice daily, a 45-minute walk and a workout of 45 to 60 minutes
- •Exercises such as ball throws against a wall, planks with head turns, lateral shuffles and burpees target the vestibulo-ocular reflex
- •Collins avoids medication initially and tries behavioral treatment first
- •Possible medications mentioned include sertraline, Wellbutrin, Effexor and escitalopram
- •Treating the root cause prevents downstream hormonal and other issues
- 43:16 – 56:44
Why Vestibular Problems Dominate and the Rest Myth
Collins says treatment is the opposite of rest: active, targeted, exposure-based therapy. Attia asks whether the brain looks normal at the cellular level, and they discuss why vestibular problems seem to amplify the others, though anxiety is the most common profile in Collins' data.
- •Collins says rest makes things worse; vestibular problems are treated by retraining
- •Exercise, regulated sleep and exposure to busy environments are central
- •Collins suspects the brain looks normal structurally and physiologically years later
- •Anxiety is the most common profile, followed by migraine, vestibular, ocular and fatigue
- •Collins's gut feeling is that vestibular problems often kick off the cascade
- 56:44 – 1:02:47
Hyperbaric Oxygen, Synthetic Ketones, and Sports Concussion Rates
Attia asks about hyperbaric oxygen and synthetic ketones. Collins is not a believer in hyperbarics, citing no supporting data and the risk of feeding anxiety, while the ketone idea has not been studied by his group. They then discuss which sports carry the highest concussion risk.
- •Collins will not have patients do hyperbaric treatment and sees no compelling data
- •Attia raises opportunity cost, and both note hyperbaric sessions invite rumination
- •Collins finds the synthetic ketone idea theoretically interesting but knows of no research
- •Football leads in incidence, and equestrian sports have the highest lifetime rate at 90%
- •He cites 1.8 to 3.6 million sports and recreation concussions per year
- 1:02:47 – 1:11:22
Natural History, Dementia Risk, and CTE
Collins says nobody knows what share of concussions become chronic, though many kids recover on their own. On dementia and CTE, he cites studies showing no proclivity toward neurodegeneration, describes a controlled UPMC study of former NFL players, and warns about patients wrongly convinced they have CTE.
- •No one has determined the denominator of how many concussions become chronic
- •Collins cites Grant Iverson's group, which found no proclivity toward dementia but some increase in anxiety
- •UPMC is running a three-day evaluation of former NFL players against controls
- •He says the science on CTE is not definitive and brain-donation studies have selection bias
- •Some patients who fear they have CTE improve with treatment, and suicidality is a serious concern
- 1:11:22 – 1:17:42
Advice for Parents: When and Where to Seek Care
Attia asks what parents should do when a child may have a concussion. Collins recommends specialty concussion clinics, notes access has expanded, names several programs, and advises seeing a specialist within a week once an intracranial bleed is ruled out. He also says adults with no symptoms generally need not be evaluated.
- •Specialty concussion clinics are better equipped than a general pediatrician
- •Collins names INOVA, Boston Children's and clinics in Houston, Phoenix and California, and notes telemedicine
- •First rule out an intracranial bleed, then seek specialty care within a week
- •It's never too early or too late to seek help
- •An adult with no symptoms may not need evaluation, though weekend warriors should get checked before playing again
- 1:17:42 – 1:18:42
APOE4 and Concussion Susceptibility
Attia asks whether the APOE4 genotype raises susceptibility to concussion or traumatic brain injury. Collins says it has been looked at but there is no compelling data that it increases risk.
- •APOE has been studied in concussion without compelling findings
- •There is no evidence of an augmentative effect of APOE4 plus concussion
- •Collins raised the question in his 1999 JAMA paper
- •Research is neither definitive nor comprehensive
- 1:18:42 – 1:23:34
Concussion in Older Adults: The 90-Year-Old Patient
Attia asks about falls in older people, and Collins offers reasons for greater vulnerability: atrophy, unprotected falls, syncope and less cerebrospinal fluid. He describes a 90-year-old patient with a fall-related concussion and untreated positional vertigo, and how active vestibular therapy and family coaching can help.
- •Older adults suffer more unprotected falls, syncope, less motor control and less cerebrospinal fluid protection
- •Collins calls this an understudied area and is doing early geriatric concussion research
- •The 90-year-old fell after a syncopal episode and had a facial fracture, small subdural and concussion
- •Family overprotection and inactivity worsened the vestibular problem
- •Treatment includes vestibular therapy, balance exercises, walking, busy environments and coaching the family
- 1:23:34 – 1:29:46
Research Funding, Specialist Training, and Closing Thoughts
Collins lists funding sources for his research, including NIH, the NFL, the CDC and the Chuck Noll Foundation. He stresses that neurologists and neurosurgeons are not trained in concussion in medical school, so a specialist matters, and says there are about 10 to 15 fellowship programs. Attia closes optimistic about recovery prospects.
- •Funding comes from NIH, the NFL, the CDC and the Chuck Noll Foundation
- •The Steelers were the first team to do baseline testing
- •Concussion is not in the medical school curriculum, so neurologists may not know it
- •Roughly 10 to 15 fellowship programs train concussion specialists
- •Attia ends far more optimistic about recovery even for long-standing cases
