What is the appropriate treatment and assessment for a 27-year-old female with pre-syncope (pre-syncopal episode), dizziness, photophobia (light sensitivity), and headache after a head strike, with no initial neuroimaging (e.g. computed tomography (CT) scan) performed in the emergency department (ED)?

Assessment and Treatment of Post-Head Strike Symptoms with Pre-Syncope

Immediate Assessment Priority

This patient requires urgent evaluation for post-concussion syndrome, not routine syncope workup, because the head strike preceded the symptoms and she now has the classic post-concussive triad of headache, dizziness, and photophobia. 1, 2

The pre-syncopal episode was likely the precipitating event that caused the head strike, but the current symptom complex (headache, dizziness, light sensitivity) occurring after documented head trauma represents a distinct clinical entity requiring concussion-specific management rather than syncope evaluation. 1, 2

Critical Clinical Decision Point: Does This Patient Need Neuroimaging Now?

No routine head CT is indicated at this point unless specific high-risk features develop. 3, 4

Indications that WOULD require urgent CT imaging:

• Focal neurological deficits on examination 3, 4
• Worsening or severe headache 2
• Repeated vomiting 2
• Altered mental status or confusion lasting >15 minutes 2
• Seizure activity 4
• Signs of skull fracture or significant external trauma 3

Why imaging was appropriately deferred in the ED:

• Studies demonstrate only 5-6.4% of syncope patients have acute CT abnormalities, and nearly all had external evidence of significant head trauma or focal neurological deficits 3
• Brain imaging in uncomplicated presentations does not improve outcomes but significantly increases costs and hospitalization rates 4
• The symptom triad of headache, dizziness, and photophobia represents expected post-concussive symptoms rather than indicators of intracranial pathology 1, 2

Required Assessment Components NOW

Detailed History Elements:

• Timing sequence: Did pre-syncope cause the fall, or did head strike cause the symptoms? 5, 6
• Pre-syncopal prodrome: Lightheadedness, tunnel vision, nausea, warmth, sweating suggest reflex syncope 3, 6
• Position and activity: Was she standing, sitting, or supine when pre-syncope occurred? 3, 6
• Cardiac red flags: Exertional symptoms, palpitations, chest pain, family history of sudden cardiac death <30 years 5
• Loss of consciousness duration: <30 seconds favors syncope over seizure 5
• Post-event symptoms: Immediate recovery suggests syncope; prolonged confusion suggests seizure 4

Physical Examination Must Include:

• Orthostatic vital signs: Blood pressure and heart rate supine, after 1 minute standing, and after 3 minutes standing to detect orthostatic hypotension 3, 6
• Complete neurological examination: Assess for focal deficits, cranial nerve abnormalities, coordination, gait 3, 4
• Cardiac examination: Murmurs suggesting structural heart disease, irregular rhythm 6
• Vestibular testing: Dix-Hallpike maneuver if vertigo component present 7, 8
• Assessment for nystagmus: Spontaneous nystagmus suggests vestibular pathology 8

Mandatory Testing:

• 12-lead ECG: Required in ALL patients with syncope/pre-syncope to screen for long QT, Brugada pattern, delta waves (WPW), bundle branch blocks 5, 4

Treatment Algorithm

For Post-Concussion Symptoms (Primary Issue):

Immediate management:

• Cognitive and physical rest for 24-48 hours: Limit screen time, reading, bright lights 2
• Symptomatic headache treatment: Acetaminophen preferred initially; avoid NSAIDs in first 24 hours due to theoretical bleeding risk 2
• Photophobia management: Sunglasses, dim lighting, gradual light exposure 1, 2
• Sleep hygiene: Address insomnia early as it predicts prolonged recovery 2

Graduated return to activity (after 24-48 hours if improving):

• Light aerobic exercise is beneficial and should be prescribed early for both early and late-phase post-concussive disorders 2
• Avoid contact sports or risk of re-injury until symptom-free 2

For Pre-Syncope (Secondary Issue):

If vasovagal syncope suspected (most likely in 27-year-old female):

• Hydration: Increase fluid intake to 2-3 liters daily 3
• Salt supplementation: 6-10 grams daily if no contraindications 3
• Counter-pressure maneuvers: Leg crossing, muscle tensing when prodrome occurs 3
• Avoid triggers: Prolonged standing, dehydration, heat exposure 5

If orthostatic hypotension detected:

• Review medications for culprits (antihypertensives, diuretics, alpha-blockers) 3, 6
• Compression stockings: Waist-high, 30-40 mmHg 3
• Slow positional changes: Sit before standing, dangle legs 3

Risk Stratification for Cardiac Causes

This patient is LOW RISK for cardiac syncope based on:

• Young age (27 years) 5
• Female gender 5
• Pre-syncopal episode (not exertional) 5

However, ECG is still mandatory to exclude:

• Long QT syndrome (can present with emotional stress triggers) 5
• Wolff-Parkinson-White syndrome (delta wave) 5
• Brugada syndrome (ST elevation V1-V2) 5

Proceed to cardiology referral and echocardiogram ONLY if:

• Abnormal ECG findings 5, 4
• Syncope during exertion or swimming 5
• Family history of sudden cardiac death <30 years 5
• Syncope without prodrome or while supine 5
• Palpitations or chest pain preceding event 5

Follow-Up Plan

Reassess in 24-48 hours:

• Most post-concussive symptoms resolve within days to weeks 1, 2
• Worsening symptoms require urgent re-evaluation and consideration of imaging 2

Red flags requiring immediate return:

• Worsening headache despite treatment 2
• Repeated vomiting 2
• Increasing confusion or altered mental status 2
• Focal neurological symptoms (weakness, numbness, vision changes) 4
• Seizure activity 4
• Recurrent syncope 5

If symptoms persist beyond 2 weeks:

• Consider referral to concussion specialist or sports medicine 2
• Evaluate for comorbid conditions: depression, anxiety, sleep disorders 2
• Implement hierarchic treatment approach targeting most disabling symptoms first 2

Critical Pitfalls to Avoid

• Do not assume benign vasovagal syncope without obtaining ECG 5
• Do not order brain CT/MRI without specific neurological indications—this represents wasteful testing 3, 4
• Do not dismiss pre-syncope as less serious than syncope—they have identical 30-day serious outcomes 3, 5
• Do not prescribe prolonged complete rest—early guided aerobic exercise improves outcomes 2
• Do not attribute all symptoms to concussion if cardiac red flags present—obtain ECG and consider cardiology evaluation 5
• Do not rely on age alone as indication for imaging—clinical features determine need 3, 4