What is the next step if an athlete develops a headache after progressing to full contact practice in the concussion protocol?

Management of Headache During Concussion Return-to-Play Protocol

If an athlete develops a headache after progressing to full contact practice in the concussion protocol, they must stop immediately and return to the previous asymptomatic level of activity for at least 24 hours before attempting to progress again. 1, 2

Immediate Response to Symptom Recurrence

When an athlete develops any symptom, including headache, during the return-to-play protocol:

• Immediately stop all physical activity
• Remove the athlete from practice/competition
• Document the recurrence of symptoms
• Assess for any worsening or additional symptoms

Return-to-Play Progression After Symptom Recurrence

The stepwise approach after symptom recurrence follows this algorithm:

1. Complete rest until asymptomatic for at least 24 hours
2. Once asymptomatic for 24 hours, return to the previous step in the protocol where the athlete was last asymptomatic
3. Progress through each subsequent step with a minimum of 24 hours at each level
4. Contact healthcare provider if symptoms recur again

Evidence-Based Rationale

The American Academy of Pediatrics guidelines clearly state: "If symptoms return while on the protocol, once the athlete is asymptomatic again for 24 hours, the previous step may be attempted again." 1 This approach is consistently supported across concussion management guidelines.

The Praxis Medical Insights summary reinforces that "if concussion is confirmed or suspected, the athlete must restart the stepwise return-to-play progression from the beginning" and emphasizes that "each step in the return-to-play progression should take at least 24 hours." 2

Common Pitfalls to Avoid

• Same-day return: Never allow an athlete to return to play on the same day symptoms recur, regardless of how quickly symptoms resolve 2
• Skipping steps: Do not allow athletes to skip steps in the progression or accelerate through steps faster than 24 hours each
• Ignoring mild symptoms: Even mild headaches should be taken seriously as they indicate incomplete recovery
• Inadequate monitoring: Athletes should be closely monitored for any worsening of symptoms which could indicate a more serious injury

Special Considerations

• Multiple symptom recurrences: Athletes who experience repeated symptom recurrences during the protocol may require:

  • More conservative management
  • Longer rest periods between progression attempts
  • Evaluation by a concussion specialist
  • Consideration of temporary or permanent disqualification from contact sports if symptoms persist 2

• Age considerations: Younger athletes typically require longer recovery times and more conservative approaches 2

• Previous concussion history: Athletes with prior concussions may need more cautious management 2

The Vienna consensus statement's principle of "When in doubt, sit them out!" remains paramount in concussion management 1, 2. The primary goal is to ensure complete recovery before returning to play to prevent cumulative brain damage and potential second-impact syndrome.