What is the recommended treatment for ear pain associated with a concussion?

Ear Pain with Concussion: Treatment Recommendations

Treat ear pain associated with concussion primarily with acetaminophen or NSAIDs (ibuprofen, naproxen) as first-line analgesics, administered at fixed intervals rather than as-needed during the acute phase. 1

Understanding the Clinical Context

Ear pain is not a typical primary symptom of concussion itself—concussion symptoms typically manifest in physical (headache, neck pain), cognitive, and emotional domains 2. When ear pain occurs alongside concussion, you must determine whether this represents:

• Referred pain from associated head/neck trauma
• Concurrent ear pathology (acute otitis externa, acute otitis media) that requires separate evaluation
• Rare labyrinthine concussion (inner ear injury from the head trauma itself) 3

Initial Assessment: Rule Out Primary Ear Pathology

Perform otoscopy on both ears to distinguish referred pain from true ear disease, as this fundamentally changes your treatment approach 1:

• Normal tympanic membrane and canal: Treat as referred pain with analgesics alone 1
• Canal edema, erythema, debris, or purulent material: Diagnose acute otitis externa and add topical antimicrobial therapy 4, 1
• Bulging tympanic membrane with decreased mobility: Diagnose acute otitis media requiring different management 1
• Perform tragus tenderness and pinna traction test: Positive findings are pathognomonic for acute otitis externa 4, 1

Pain Management Algorithm

For Mild to Moderate Ear Pain

• Acetaminophen or NSAIDs (ibuprofen, naproxen) as monotherapy 1
• NSAIDs may be superior as they reduce both pain and inflammation 5
• Administer at fixed intervals, not PRN, since pain is easier to prevent than treat 1, 5

For Moderate to Severe Ear Pain

• Fixed-combination products containing acetaminophen or ibuprofen with an opioid (oxycodone or hydrocodone) 1
• Limit opioids to 48-72 hour supply to mitigate misuse risk while awaiting improvement 1
• Consider combination therapy with acetaminophen plus an NSAID before escalating to opioids 4

If Acute Otitis Externa Is Diagnosed

Topical antimicrobial therapy is the mainstay, NOT systemic antibiotics 4, 1:

• Ciprofloxacin 0.2% otic solution or ofloxacin otic solution as first-line agents 4
• These cover Pseudomonas aeruginosa and Staphylococcus aureus 1
• Adding a topical steroid may hasten pain relief 4
• Perform aural toilet if canal is obstructed by debris to ensure medication delivery 4

Critical Pitfalls to Avoid

• Do NOT prescribe systemic antibiotics for uncomplicated acute otitis externa—topical therapy is superior 1
• Do NOT use benzocaine otic solution—it is not FDA-approved and may mask disease progression 1
• Do NOT underdose or delay analgesics—pain management should begin immediately at diagnosis 1, 5
• Do NOT assume ear pain is "just part of the concussion" without performing otoscopy to rule out treatable ear pathology 1

Reassessment Timeline

• Patients should show improvement within 48-72 hours of initiating appropriate therapy 4, 1
• Lack of improvement warrants reassessment for treatment failure, misdiagnosis, poor adherence, canal obstruction, or fungal co-infection 1
• Complete resolution may take up to 2 weeks, but improvement should be evident within 72 hours 1

Special Considerations for Concussion Patients

• Most concussion symptoms resolve within the first 3 months, though some may persist longer 2
• Pain and sleep disturbances in the acute phase predict the poorest long-term cognitive and mood outcomes 6
• Customized approaches are indicated for managing concurrent mTBI, pain, and sleep complaints 6