Management of Concussion
The recommended management for concussion includes an initial period of relative rest for 24-48 hours followed by a gradual, 5-stage return to activity protocol, with each stage lasting at least 24 hours and progression only if the patient remains asymptomatic. 1
Initial Management (First 24-48 Hours)
Relative rest (NOT strict bed rest) for 24-48 hours after injury 1, 2
- Avoid high-intensity physical activity
- Limit cognitive demands
- Avoid alcohol, illicit drugs, and other substances that might interfere with cognitive function 1
Medication management:
- Acetaminophen is the preferred medication for headache management 1
- Avoid medications beyond acetaminophen unless specifically recommended by a physician 1
- For post-concussion headaches, acetaminophen (1000 mg) or ibuprofen (400 mg) can be used as first-line treatment 1
- Avoid opioids due to high risk of dependency and rebound headaches 1
Return to Activity Protocol
After the initial 24-48 hour rest period, implement a 5-stage graded return to activity protocol 1:
| 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 |
Important rules:
- Each stage must last a minimum of 24 hours 1
- Progress to the next stage only if asymptomatic at the current stage 1
- If symptoms develop during any stage, scale back exertion level to allow maximal activity without triggering symptoms 1
- No same-day return to play for diagnosed concussions 1
Management of Persistent Symptoms (>10 days)
For the 10-15% of patients with persistent symptoms beyond 10 days 3:
Implement a multidisciplinary approach with targeted interventions 1:
- Graded physical exercise
- Vestibular rehabilitation
- Manual therapy
- Psychological treatment
- Vision therapy
- Cognitive rehabilitation
Consider neuropsychological testing to assist with return to play decisions 1
Special Considerations
For young athletes (<18 years):
Athletes with history of concussion:
Return to Play Decision-Making
- Use a team approach involving athletic trainers, physicians, the athlete, and any referral sources 4
- Disqualification criteria:
- Athletes symptomatic at rest and after exertion for at least 20 minutes should not return on the day of injury 4
- Athletes experiencing loss of consciousness or amnesia should be disqualified from further participation on the day of injury 4
- Medical clearance from a licensed healthcare provider trained in concussion management is required before full return to play 1
Warning Signs Requiring Immediate Medical Attention
Instruct patients and families to seek immediate medical attention if symptoms worsen or if there are signs of increased intracranial pressure 1:
- Worsening headache
- Repeated vomiting
- Increasing confusion
- Deteriorating level of consciousness
Common Pitfalls to Avoid
- Prolonged strict rest: Recent evidence suggests that prolonged cognitive and physical rest can be detrimental to recovery 2, 5
- Inconsistent online information: Online resources often provide inconsistent messages about concussion management, which can lead to inappropriate return to play decisions 4
- Overmedication: Avoid prescribing medications beyond acetaminophen without physician guidance 1
- Analgesic overuse: Monitor for analgesic overuse that can lead to rebound headaches 1
By following these evidence-based guidelines, clinicians can optimize recovery, minimize complications, and facilitate safe return to normal activities for patients with concussion.