What are the next steps for an athlete who developed a headache during a full-contact game after returning to play following a concussion diagnosis?

Management of Athlete with Recurrent Headache During Return to Play After Concussion

The athlete should be immediately removed from play, evaluated by a healthcare professional, and the return-to-play protocol must be restarted from the beginning. 1

Immediate Actions Required

• Immediate removal from the game/competition
• Complete rest (both physical and cognitive) until symptoms resolve
• Medical re-evaluation by a healthcare professional with concussion management experience
• No return to any physical activity until completely asymptomatic at rest

Why This Is Critical

The development of a headache during competition after a recent concussion represents a significant warning sign that the athlete's brain has not fully recovered. The American Academy of Neurosurgery emphasizes that any symptom recurrence during the return-to-play progression requires a return to the previous asymptomatic stage 1. In this case, the athlete has demonstrated that they are not ready for full contact play.

Analysis of Protocol Violation

This athlete's return-to-play progression contained several critical errors:

1. Premature progression through protocol stages: Each step should take a minimum of 24 hours, meaning the full protocol requires at least 5 days after becoming asymptomatic 2. This athlete progressed through multiple stages in just 6 days after diagnosis.

2. Failure to report symptoms: The athlete should have been instructed to immediately report any recurrence of symptoms during the protocol 1.

3. Continued play despite symptoms: Continuing to play with a headache puts the athlete at risk for:

   • Decreased cognitive ability and reaction time
   • Increased risk of subsequent injury
   • Prolonged recovery time
   • Potential for more serious brain injury 1

Correct Return-to-Play Protocol

The athlete must now restart the following stepwise progression, with each step taking a minimum of 24 hours 2, 1:

1. No activity: Complete physical and cognitive rest until asymptomatic
2. Light aerobic exercise: Only when completely symptom-free for 24 hours (walking, swimming, stationary cycling at 70% maximum heart rate)
3. Sport-specific exercise: Running drills, no head impact activities
4. Non-contact training drills: More complex drills, may start light resistance training
5. Full-contact practice: Only after medical clearance
6. Return to competition: Only after completing all previous steps without symptoms

Important Considerations

• The athlete must be completely asymptomatic at each stage before progressing to the next 1
• If symptoms return at any stage, the athlete must return to the previous asymptomatic stage 1
• Younger athletes typically require longer recovery periods compared to college-aged or professional athletes 2, 1
• Medical clearance from a licensed healthcare provider trained in concussion management is mandatory before returning to contact sports 1, 3

Potential Complications to Monitor

• Athletes with multiple concussions or prolonged symptoms may require a more conservative approach 1
• If symptoms persist beyond the expected recovery period (typically 7-10 days), referral to a specialist with expertise in sport-related concussion is recommended 2
• For athletes with multiple concussions, consideration for temporary or permanent disqualification from contact sports may be necessary 1

The athlete's health and safety must be the primary concern, and a cautious approach to return-to-play following concussion is essential to prevent potential long-term consequences.