What are the management and treatment options for post-concussion syndrome?

Workup and Management of Post-Concussion Syndrome

The management of post-concussion syndrome requires a structured, stepwise approach focusing on identifying specific symptom generators and implementing targeted interventions including sub-symptom threshold aerobic exercise, vestibular rehabilitation, cognitive therapy, and appropriate medication management. 1

Initial Assessment and Rest Period

• Initial management should include complete physical rest for the first 24-48 hours after concussion, followed by a gradual return to activity when the patient becomes asymptomatic at rest 2
• Cognitive rest is essential during the early recovery phase, especially in the first 24-48 hours, limiting activities requiring concentration such as reading, video games, computer use, television viewing, and exposure to loud music or bright lights 2
• The phrase "When in doubt, sit them out!" should guide initial management decisions, with no return to play on the same day of injury 3, 2

Symptom-Based Management Approach

Physical Symptoms

• Headaches should be assessed for specific type (migraine, tension, cervicogenic) and treated accordingly with appropriate medications and non-pharmacological approaches 4
• Vestibular-ocular dysfunction requires specific evaluation and targeted vestibular rehabilitation therapy 5
• Cervical spine therapy should be considered for patients with neck pain or cervicogenic headaches 1
• Dizziness and balance problems may benefit from specialized vestibular therapy exercises 4

Cognitive Symptoms

• Temporary academic accommodations should be implemented, including shortened school days, reduced workloads, extended time for assignments and tests, and postponement of standardized testing 2
• Cognitive rehabilitation therapy may be beneficial for persistent attention, memory, or executive function deficits 1
• Neuropsychological testing can assist in identifying specific cognitive deficits and guiding return to activity decisions 3

Sleep Disturbances

• Address sleep hygiene practices and consider short-term medication for insomnia if non-pharmacological approaches are ineffective 4
• Maintain consistent sleep-wake cycles to support recovery 3

Emotional/Psychological Symptoms

• Cognitive behavioral therapy (CBT) is recommended for managing anxiety, depression, and irritability associated with post-concussion syndrome 5
• Consider psychiatric referral for patients with severe or persistent emotional symptoms 4

Graded Return to Activity Protocol

• Implement a stepwise return to activity protocol following the 24-48 hour rest period 2:

  1. No activity, complete rest until asymptomatic
  2. Light aerobic exercise (walking, swimming, stationary cycling)
  3. Sport-specific training exercises
  4. Non-contact training drills
  5. Full contact training after medical clearance
  6. Return to normal activity/play

• Each step should take a minimum of 24 hours; if symptoms recur, return to the previous asymptomatic level and try to progress again after 24 hours of rest 2

• Sub-symptom threshold aerobic exercise (exercise that doesn't provoke symptoms) has shown benefit for both early and persistent post-concussion symptoms 4

Medication Management

• Avoid medications except acetaminophen immediately after injury, and only as recommended by a physician 2
• Do not return to play while taking any medications for concussion symptoms 2
• For persistent symptoms, targeted pharmacotherapy may be considered:
  • Headaches: appropriate analgesics, triptans for migrainous features 4
  • Sleep disturbances: short-term sleep aids 4
  • Mood symptoms: antidepressants for persistent depression or anxiety 5

Special Considerations for Persistent Symptoms (>10 days)

• Symptoms persisting beyond 10 days require multidisciplinary management 3
• Persisting symptoms affect 15-20% of concussion patients but may be higher according to objective cognitive assessments 3
• Risk factors for developing persistent symptoms include high early symptom burden, history of multiple concussions, pre-existing psychiatric conditions, longer duration of unconsciousness/amnesia, and younger age 4
• Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 2

Warning Signs Requiring Immediate Medical Attention

• Loss of consciousness
• Severe or worsening headache
• Repeated vomiting
• Altered mental status
• Seizures
• Visual changes
• Swelling or deformities of the scalp 2

Common Pitfalls to Avoid

• Returning to activity too soon, which can worsen outcomes or prolong recovery 2
• Inadequate rest during the acute phase 3
• Ignoring symptoms or lack of proper medical evaluation 2
• Underestimating recovery time, which varies between individuals 2
• Relying solely on patient-reported symptoms without objective assessment 3
• Failing to identify and address comorbid conditions that may mimic or exacerbate post-concussion symptoms 4

Long-term Monitoring

• Monitor for persistent symptoms beyond the typical recovery period (4-6 weeks) 5
• Be aware that repeated concussions may lead to long-term difficulties with memory, concentration, fatigue, headache, and other neurological issues 2
• Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 3