What is the best course of treatment for an 18-year-old male experiencing post-concussion headaches three weeks after the injury?

Management of Post-Concussion Headaches at Three Weeks Post-Injury

For an 18-year-old male with post-concussion headaches at three weeks, you should initiate graded sub-symptom threshold aerobic exercise combined with targeted rehabilitation based on specific symptom generators, while providing nonopioid analgesia for headache pain. 1, 2

Immediate Symptom Management

Headache Control

• Offer nonopioid analgesics (ibuprofen or acetaminophen) as first-line treatment for painful headaches, with explicit counseling about analgesic overuse and rebound headache risk 1
• Avoid opioids entirely due to lack of efficacy and dependence risk 1
• If headaches are severe or worsening, evaluate for intracranial complications with neuroimaging 1

Activity Modification at Three Weeks

At this timepoint, complete rest is contraindicated. The patient should be transitioning to active rehabilitation:

• Implement graded physical exercise starting at sub-symptom threshold intensity with gradual increases in complexity and duration 3, 1
• This approach has demonstrated positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 2
• Exercise should be performed minimally 1 time per week for at least 4 weeks 3

Targeted Assessment and Treatment

Identify Specific Symptom Generators

The patient requires evaluation across multiple domains to guide targeted interventions:

Vestibular Assessment 1, 2

• If dizziness, balance problems, or visual disturbances are present, offer vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training 3, 1
• This should be administered at least 1 time per week for 4 weeks minimum 3
• Evidence shows positive effects on physical functioning and return to activities 2

Cervical Spine Evaluation 1, 2

• Assess for neck pain contributing to headaches
• If cervicogenic headache is identified, offer manual therapy (spinal mobilization/manipulation) 3, 1
• This has demonstrated positive effects on pain reduction and readiness to return to activities 2

Visual/Oculomotor Assessment 1, 2

• Screen for vergence, accommodative, or eye movement dysfunction
• If visual symptoms are present, offer oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 3, 1
• While evidence is based primarily on clinical consensus, this shows improvements in visual symptoms, headache, and fatigue 2

Psychological Screening 1, 2

• Evaluate for depression, anxiety, or post-traumatic stress
• If emotional symptoms are present, offer psychological treatment (individual or group therapy) at least 1 hour per week for minimum 4 weeks 3, 1
• This is associated with positive effects on overall symptom burden, emotional symptoms, and quality of life 2

Comprehensive Management Strategy

For persistent symptoms at three weeks, implement interdisciplinary coordinated rehabilitation involving at least two different healthcare disciplines 3, 1, 2

This multidisciplinary approach has shown positive effects on:

• Overall symptom burden 2
• Physical functioning 2
• Emotional symptoms 2
• Quality of life 2

Patient Education

Provide systematic information regarding symptom management, expected recovery course, and self-care strategies 1, 2

• Early patient education has shown positive effects on reducing overall symptom burden and preventing memory problems 2
• Counsel that most symptoms resolve by 3-6 months, but persistent symptoms in a minority may last longer 4, 5

Critical Pitfalls to Avoid

Prolonged Complete Rest Beyond Initial Days 3

• Studies demonstrate that inactivity beyond the first 3 days may worsen self-reported symptoms 3
• At three weeks, the patient should be actively engaged in graduated activity, not resting 3

Analgesic Overuse 1

• Chronic headache after concussion may be multifactorial, with analgesic overuse as a potential contributory factor 1
• Monitor medication use patterns closely

Premature Return to Full Activity 6

• Do not advance activity levels if symptoms worsen 6
• Each progression step should take minimum 24 hours, dropping back if symptoms recur 6

Evidence Quality Context

The recommendations are based on low to moderate certainty evidence, with most being weak recommendations but consistent across multiple guidelines 3, 1, 2. However, the consistency of recommendations and the clear harm of prolonged inactivity support this active rehabilitation approach at the three-week timepoint.