Should a patient with post-concussion syndrome and migraines stop school and work activities?

Management of Post-Concussion Syndrome with Migraines

Patients with post-concussion syndrome and migraines should not completely stop school and work activities, but rather gradually increase participation with appropriate accommodations to avoid symptom exacerbation. 1

Initial Management Approach

• Complete physical and cognitive rest is only recommended for the first 24-48 hours after concussion, as prolonged inactivity beyond this period may actually worsen symptoms 2, 1
• After the initial rest period, a gradual return to cognitive activities should be implemented with modifications based on symptom severity 1
• Continuing complete cessation of school or work activities beyond the acute phase can be detrimental to recovery and may worsen self-reported symptoms 1

Structured Return to School/Work Protocol

• Return-to-school/work protocols should be customized based on the severity of post-concussion symptoms as determined jointly by medical and school/workplace teams 1
• The process should involve gradually increasing the duration and intensity of academic/work activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms 1
• Specific accommodations may include:
  • Shortened school/work days 1, 2
  • Reduced workloads 1
  • Extended time for assignments and tests 1, 2
  • Breaks during the day when symptoms worsen 1
  • Limiting activities requiring intense concentration 1

Managing Migraine Symptoms

• Post-concussion migraines often have features similar to pre-existing migraine conditions and should be managed accordingly 3
• Consider medication for prolonged symptoms such as migraines, but note that continued medication use to control symptoms indicates incomplete recovery 1
• Medications should be stopped before considering full return to normal activities, and the patient must remain symptom-free off medication 1
• Environmental modifications may help manage migraine symptoms:
  • Avoiding bright lights (consider sunglasses for photophobia) 1
  • Minimizing exposure to loud noises or music 1
  • Limiting screen time that may trigger symptoms 1

Monitoring and Progression

• Postconcussion symptoms and academic/work progress should be monitored collaboratively by the patient, family, healthcare professionals, and school/workplace teams 1
• Educational and workplace supports should be adjusted on an ongoing basis until performance has returned to pre-injury levels 1
• For students/workers who demonstrate prolonged symptoms and difficulties despite accommodations, referral to a specialist in mild traumatic brain injury is recommended 1

Common Pitfalls to Avoid

• Complete cessation of activities beyond the acute phase (first few days) may actually prolong recovery 1, 4
• Returning to full activities too quickly without appropriate accommodations can exacerbate symptoms 2, 5
• Underestimating the cognitive effects of concussion by teachers, employers, or family members due to normal physical appearance 1
• Failure to recognize that post-concussion syndrome is heterogeneous and requires individualized symptom management 4, 5

Special Considerations for Persistent Symptoms

• For symptoms persisting beyond 4 weeks, physical exercise performed below symptom exacerbation threshold may actually help reduce post-concussive symptoms 1, 5
• Social support is a key element in recovery and should be emphasized to caregivers, educators, and employers 1
• For persistent migraines, a targeted treatment approach may be needed, with evidence showing that triptan medications can be effective in many cases 3