Concussion Diagnosis and Management Guidelines
A comprehensive concussion assessment should evaluate all five concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) as well as associated conditions like sleep disturbance to properly characterize the injury and guide appropriate management. 1
Diagnosis
Clinical Assessment
- Concussion is a clinical diagnosis based on:
Key Diagnostic Tools
- Graded symptom checklists to assess and track symptom severity 3
- Standardized assessment tools for structured evaluation 2
- Cognitive evaluation including:
- Orientation
- Past and immediate memory
- New learning and concentration
- Balance testing (specific but not sensitive indicator) 3
Neuroimaging
- Reserve imaging only for suspected intracranial bleeding 3
- Consider emergent neuroimaging for:
- Acutely worsening headache
- Severe headache with other risk factors
- Headache interfering with sleep
- New neurological symptoms 2
Management
Immediate Management
- Remove from play/activity immediately if concussion is suspected 3
- No same-day return to play for diagnosed concussions 3
- Monitor for deteriorating physical or mental status 3
Rest and Activity Progression
- Initial period of relative rest for 24-48 hours 2
- Avoid strict bed rest and high-intensity physical activity 2
- Implement 5-stage graded return to activity protocol:
| Stage | Activity | Duration |
|---|---|---|
| 1 | Symptom-limited activity | ≥24 hours |
| 2 | Light aerobic exercise | ≥24 hours |
| 3 | Sport-specific exercise | ≥24 hours |
| 4 | Non-contact training drills | ≥24 hours |
| 5 | Full-contact practice | ≥24 hours |
- Progress only if asymptomatic at current stage 2
- If symptoms occur, halt progression and restart at preceding symptom-free step 3
Symptom Management
- For post-concussion headaches:
- First-line treatment: acetaminophen (1000mg) or ibuprofen (400mg) 2
- Monitor for analgesic overuse (limit to ≤15 days/month) 2
- Avoid opioids due to dependency risk and rebound headaches 2
- Consider headache pattern (migraine-like, tension-type, cervicogenic) 2
- For migraine-like headaches: consider NSAIDs and triptans if persistent 2
- For cervicogenic component: consider physical therapy 2
Special Considerations
- Cognitive rest and academic accommodations for students 3
- For symptoms persisting >10 days, implement multidisciplinary management 2
- Address sleep disturbances as they may exacerbate headaches 2
Return to Play/Activity
- Require medical clearance from a licensed healthcare provider trained in concussion management before full return to play 2, 3
- Consider neuropsychological testing to assist return to play decisions 3
- Neuropsychological testing should:
Prevention of Complications
- Provide clear discharge instructions about warning signs requiring emergency care 2
- Seek immediate medical attention for:
- Worsening headache
- Repeated vomiting
- Increasing confusion 2
- For post-concussion syndrome, implement targeted interventions:
- Graded physical exercise
- Vestibular rehabilitation
- Manual therapy
- Psychological treatment
- Vision therapy
- Cognitive rehabilitation 2
Risk Factors for Prolonged Recovery
- History of previous concussion 3
- Greater number, severity, and duration of symptoms 3
- Female gender in sports with similar playing rules 3
- Youth athletes 3
- Pre-injury mood disorders, learning disorders, attention-deficit disorders, and migraine headaches 3
Concussion management requires careful assessment of all five subtypes and associated conditions, followed by a structured return to activity protocol that prioritizes symptom resolution before advancing activity levels. The approach should address specific symptom domains while monitoring for potential complications.