Headache and Dizziness Provoked by Mental Imagery in Patients With Persistent Postconcussive Symptoms: A Case Series

To document and characterize headache and dizziness provocation during mental imagery of real-life symptom-provoking movements in patients with persistent postconcussive symptoms (PPCS).

Outpatient rehabilitation department at Reuth Rehabilitation Hospital, Tel Aviv, Israel.

Thirteen adults (7 females; mean age 34.3 ± 12.6 years) undergoing multidisciplinary rehabilitation for PPCS with functional decline after mild traumatic brain injury. All were ≥3 months postinjury, reported both headache and dizziness, and had a known real-life symptom trigger (eg, movements, activity). Patients with cognitive, linguistic, or psychiatric impairments were excluded.

Case series.

The primary outcome was the result of mental imagery testing of symptom-provoking movements for headache and dizziness, routinely performed as part of vestibular evaluation protocol at the facility. Secondary outcomes included demographics, medical history, clinical trajectory, imaging results, current medications, symptom questionnaires scores (Brief Pain Inventory, Dizziness Handicap Inventory), and vestibular bedside assessments findings.

Headache was provoked in 9 out of 13 patients (69.2%), and dizziness in 11 out of 13 patients (84.6%) during mental imagery of real-life symptom-provoking movements. Five of the 13 patients (38.5%) had oculomotor and vestibular abnormalities (eg, benign paroxysmal positional vertigo, vestibular asymmetry, oculomotor deficits). Symptom reproduction occurred regardless of vestibular pathology in 3 out of 5 cases with oculomotor or vestibular abnormalities. All patients reported additional symptoms, such as musculoskeletal pain, fatigue, and sleep disturbances.

This case series identifies a novel clinical phenomenon in patients with PPCS, where mental imagery of symptom-provoking movements provokes headache and dizziness. These findings suggest a potential link between mental imagery and symptom exacerbation, supporting the notion that PPCS may reflect functional rather than structural mechanisms. This perspective underscores the need for further research to elucidate underlying mechanisms and explore potential therapeutic interventions.