What treatment is recommended for a 20-year-old patient one week post-concussion with photophobia, dizziness, headache, and nausea unrelieved by acetaminophen (Tylenol)?

Treatment for Post-Concussion Syndrome at One Week

This 20-year-old patient requires immediate initiation of graded physical activity (sub-symptom threshold aerobic exercise) combined with targeted symptom management, cognitive rest modifications, and specialist referral if symptoms persist beyond 3 weeks. 1

Immediate Management Approach

Physical Activity Protocol

• Begin sub-symptom threshold aerobic exercise immediately rather than strict rest, as complete rest beyond 2-3 days may actually delay recovery 1
• Start with light aerobic activity (walking, stationary cycling) at 60-70% of maximum heart rate for 15-20 minutes daily 1
• If symptoms worsen during activity, reduce intensity but do not stop completely; the goal is to stay just below the threshold that exacerbates symptoms 1
• Gradually increase activity duration and intensity as tolerated over subsequent days 1

Cognitive Rest Modifications

• Implement partial cognitive rest rather than complete avoidance of all mental activity 1
• Reduce screen time (phones, computers, television) to 30-minute intervals with breaks 1
• Limit reading, especially for academic purposes, to short periods 1
• If employed or in school, consider shortened work/school days with reduced workload and extended time for assignments 1
• Avoid standardized testing until symptom-free 1

Symptom-Specific Treatment

For Headache Management

• Continue acetaminophen as first-line, but optimize dosing (650-1000mg every 6 hours as needed, maximum 4000mg/24 hours) 1
• Add an NSAID if acetaminophen alone is insufficient: ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily 1
• Critical warning: There is no evidence supporting NSAID efficacy specifically for post-concussion headache, and one animal study suggested ibuprofen may worsen cognitive outcomes after traumatic brain injury 1
• However, the theoretical risk of intracranial bleeding from NSAIDs after concussion has not been documented in sport-related concussion studies 1
• Do not use opioids or butalbital-containing medications as these are contraindicated and may worsen outcomes 1

For Photophobia (Light Sensitivity)

• Recommend FL-41 tinted glasses (rose-colored lenses specifically designed for photophobia) which have demonstrated efficacy in post-concussion light sensitivity 2
• Reduce exposure to bright lights and screens, using dimmer settings and blue light filters 2
• Photophobia is the second most common concussion symptom and may persist for months, requiring specific intervention 2

For Dizziness and Nausea

• Refer for vestibular physical therapy evaluation as dizziness is frequently due to treatable peripheral vestibular dysfunction (benign paroxysmal positional vertigo occurs in up to 30% of post-concussion patients) 3
• Consider meclizine 12.5-25mg three times daily for acute symptom relief, though this should not replace vestibular therapy 3
• Avoid prolonged use of vestibular suppressants as they may delay central compensation 3

Red Flags Requiring Immediate ED Return

Instruct the patient to return immediately if any of the following develop: 1

• Repeated vomiting (more than 2-3 episodes)
• Worsening or severe headache unrelieved by medication
• Increasing confusion or problems with memory
• Focal neurologic deficits (weakness, numbness, vision changes)
• Abnormal behavior or personality changes
• Increased sleepiness or difficulty staying awake
• Seizures

Specialist Referral Criteria

Refer to a concussion specialist or sports medicine physician if: 1

• Symptoms persist beyond 3 weeks 1
• Symptoms significantly worsen despite conservative management 1
• Patient plans to return to contact sports (requires medical clearance) 1
• Multiple concussion history 1

Multidisciplinary Treatment Considerations

Based on symptom profile, consider referrals to: 1, 4

• Vestibular physical therapy for dizziness and balance problems 1, 4, 3
• Cervical physical therapy if neck pain or occipital headaches are present 1, 4
• Vision therapy/neuro-optometry for photophobia, convergence insufficiency, or visual tracking problems 1, 4
• Cognitive behavioral therapy if anxiety, depression, or sleep disturbance develops 1, 4

Prognosis and Timeline

• Most patients (80-85%) recover completely within 3 months 1, 5
• At one week post-injury, this patient is in the typical recovery window 1
• Persistent symptoms beyond 3 months occur in 15-20% of patients and constitute post-concussion syndrome 1, 5, 6
• Risk factors for prolonged recovery include: female gender, age >40 years, prior concussion history, high initial symptom burden, and pre-existing mood disorders 1, 5

Critical Pitfalls to Avoid

• Do not prescribe strict bed rest or complete activity restriction beyond the first 48-72 hours, as this may prolong recovery 1
• Do not use medications to mask symptoms to allow premature return to activities - any medication used to control symptoms indicates incomplete recovery 1
• Do not discharge without written instructions at a 6th-7th grade reading level given to both patient and caregiver 1
• Do not overlook medication overuse headache risk - counsel that using headache medications >10-15 days per month can cause rebound headaches 1