What is the recommended management for a patient with a concussion?

Management of Concussion

The recommended management for concussion includes an initial period of relative rest for 24-48 hours followed by a gradual return to activities using a structured 5-stage protocol, with acetaminophen as the preferred medication for headache management. 1

Initial Management (First 24-48 Hours)

• Implement relative rest for 24-48 hours after injury 1, 2

  • Avoid strict bed rest which can be detrimental 1, 3
  • Avoid high-intensity physical activity 1
  • Avoid alcohol, illicit drugs, and substances that interfere with cognitive function 1

• For headache management:

  • Use acetaminophen (1000 mg) as first-line treatment 1
  • Ibuprofen (400 mg) may be considered as an alternative 1
  • Avoid opioids due to high risk of dependency and rebound headaches 1
  • Monitor for analgesic overuse which can lead to rebound headaches 1

Comprehensive Assessment

Evaluate all five concussion subtypes to guide appropriate management 1:

1. Cognitive symptoms
2. Ocular-motor symptoms
3. Headache/migraine symptoms
4. Vestibular symptoms
5. Anxiety/mood symptoms

Additionally, assess for associated conditions like sleep disturbance 1

Return to Activity Protocol

After the initial rest period, implement a structured 5-stage return 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, scale back exertion level to allow maximal activity without triggering symptoms 1
• No same-day return to play/activity for diagnosed concussions 1
• Medical clearance from a licensed healthcare provider trained in concussion management is required before full return to play 1

Management of Persistent Symptoms (>10 days)

For the 10-15% of patients who experience persistent symptoms 4:

• Implement targeted interventions through an interdisciplinary approach 1:

  • Graded physical exercise
  • Vestibular rehabilitation
  • Manual therapy
  • Psychological treatment
  • Vision therapy
  • Cognitive rehabilitation

• Consider additional investigations:

  • Formal neuropsychological testing 1
  • Conventional neuroimaging to exclude structural pathology 4

Special Considerations

• Young athletes (<18 years): Manage more conservatively due to longer recovery times and risk of second-impact syndrome 1
• Athletes with history of concussion: Treat more conservatively; consider temporary or permanent disqualification from contact sports for those with three or more concussions and slowed recovery 1

Patient Education

Instruct patients and families to seek immediate medical attention if symptoms worsen or if there are signs of increased intracranial pressure, such as 1:

• Worsening headache
• Repeated vomiting
• Increasing confusion

Common Pitfalls to Avoid

1. Prolonged complete rest: Evidence shows that prolonged cognitive and physical rest can be detrimental to recovery 2, 5, 3
2. Premature return to full activity: Returning before symptoms resolve increases risk of prolonged recovery 1
3. Overuse of analgesics: Can lead to rebound headaches 1
4. Ignoring psychological aspects: Anxiety and depression can develop during recovery and require specific management 1, 3
5. One-size-fits-all approach: Different concussion subtypes require targeted interventions 1, 6

The evidence strongly supports a balanced approach that avoids both extremes of complete inactivity and premature return to full activity. The structured, gradual return protocol provides the optimal framework for concussion management.