What is the management protocol for an athlete who develops a headache during competition after being cleared to play following a concussion?

Management of an Athlete with Headache During Competition After Concussion Recovery

An athlete who develops a headache during competition after being cleared to play following a concussion should be immediately removed from play and not allowed to return to competition that day.1, 2

Immediate Assessment Protocol

When an athlete who has previously recovered from a concussion develops a headache during competition:

1. Immediate removal from play - The athlete must be removed from competition immediately

2. Sideline evaluation by a healthcare professional, including:

   • Assessment of all concussion symptoms using a standardized checklist
   • Cognitive evaluation (orientation, memory, concentration)
   • Balance testing
   • Neurological examination

3. Monitoring for deterioration - The athlete should be monitored at 5-minute intervals initially 1

Clinical Reasoning

The development of a headache during competition in an athlete with a recent concussion history raises significant concerns:

• Headache is one of the most common symptoms of concussion 1, 3
• The symptom may indicate incomplete recovery from the previous concussion
• There is risk of second impact syndrome if the athlete continues to play while symptomatic 2
• The Vienna consensus statement is clear: "When in doubt, sit them out!" 1

Return to Play Decision Making

After the initial assessment:

• Same-day return to play is prohibited - The athlete must not return to competition on the same day, regardless of whether symptoms resolve quickly 1, 2
• Medical evaluation - The athlete must be evaluated by a healthcare provider with experience in concussion management 2
• Restart the return-to-play protocol - The athlete must restart the stepwise return-to-play progression from the beginning 1, 2

Return to Play Protocol Restart

The athlete must follow the established stepwise progression:

1. No activity, complete rest until asymptomatic for 24 hours
2. Light aerobic exercise (walking, swimming, stationary cycling)
3. Sport-specific training (running drills in soccer, skating in hockey)
4. Non-contact training drills
5. Full-contact practice after medical clearance
6. Return to competition

Each step requires a minimum of 24 hours, and if symptoms recur, the athlete must return to the previous asymptomatic level 1, 2

Special Considerations

• Previous concussion history increases risk for subsequent concussions and may require more conservative management 1, 2
• Younger athletes may require longer recovery times and more conservative approaches 2
• Athletes with multiple concussions may need consideration for temporary or permanent disqualification from contact sports 1, 2

Common Pitfalls to Avoid

1. Allowing same-day return to play - This is explicitly prohibited by current guidelines 1, 2
2. Minimizing the significance of a headache - Headache is a key concussion symptom and should never be dismissed as "just a headache" 1, 3
3. Relying solely on athlete self-report - Athletes may underreport symptoms to continue playing 4
4. Failing to document the incident - Thorough documentation is essential for tracking recovery and making future decisions 1
5. Inadequate monitoring - The athlete should be monitored for deteriorating symptoms that could indicate a more serious injury 1, 2

Remember that postconcussive vulnerability is supported by both animal and human studies, showing that a second impact before complete recovery can result in worsening metabolic changes within the brain 4.