What is the next step for an athlete who develops a headache during a game, 24 hours after completing a full contact practice without symptoms, having previously progressed through the return to play (RTP) concussion protocol?

Management of Headache During Game After Concussion Protocol Completion

The athlete who develops a headache during a game after previously completing the return-to-play protocol should be immediately removed from play and not allowed to return to competition that day. 1

Immediate Actions

• Remove athlete from play immediately
• Perform a sideline evaluation including:
  • Assessment of concussion symptoms
  • Cognitive evaluation
  • Balance testing
  • Neurological examination 1
• Monitor the athlete at 5-minute intervals initially for any deterioration of symptoms 1

Clinical Reasoning

This situation represents a potential recurrence of concussion symptoms. The British Journal of Sports Medicine guidelines emphasize the "When in doubt, sit them out!" principle 1. Even though the athlete successfully completed the return-to-play protocol and was asymptomatic for 24 hours after a full-contact practice, the development of a headache during competition is a significant warning sign that requires immediate attention.

Next Steps in Management

1. Medical Evaluation: The athlete must be evaluated by a healthcare professional trained in concussion management 2, 1

2. Return to Stepwise Protocol: If concussion is confirmed or suspected, the athlete must restart the stepwise return-to-play progression from the beginning 1

   • Step 1: No activity - complete physical and cognitive rest until asymptomatic
   • Step 2: Light aerobic exercise (only when symptom-free for 24 hours)
   • Step 3: Sport-specific exercise
   • Step 4: Non-contact training drills
   • Step 5: Full-contact practice (only after medical clearance)
   • Step 6: Return to competition 2, 1

3. Documentation: Thoroughly document the incident, symptoms, and assessment findings 1

Important Considerations

• Symptom Monitoring: Headache is a key concussion symptom and should never be dismissed as "just a headache" 1
• Conservative Approach: Each step in the return-to-play progression should take at least 24 hours, requiring a minimum of 5 days to return to competition 2
• Performance Impact: Research shows that athletes who continue to play after concussion demonstrate significant performance decreases (36-40% in documented cases) 3
• Risk Factors: Previous concussion history increases risk for subsequent concussions and may require more conservative management 1, 4

Common Pitfalls to Avoid

• Same-day Return: Under no circumstances should the athlete return to play on the same day symptoms develop 2, 1
• Minimizing Symptoms: Allowing an athlete to "play through" a headache can lead to prolonged recovery and increased risk of more severe injury 1, 5
• Inadequate Monitoring: Failure to properly monitor for deteriorating symptoms could miss signs of more serious injury 1
• Premature Return: Returning too early increases risk of prolonged symptoms and potential second-impact syndrome, which can be catastrophic 1

The American Academy of Pediatrics clinical report emphasizes that "no athlete should return to play while still symptomatic at rest or with exertion" 2. This principle applies regardless of whether the athlete previously completed the return-to-play protocol.