What are the symptoms and treatment of a concussion?

Concussion Symptoms and Treatment

Concussion Symptoms

Concussion presents with a constellation of symptoms across four distinct domains—physical, cognitive, emotional, and sleep-related—with headache being the most frequently reported symptom occurring in the majority of cases. 1

Physical Symptoms

• Headache is the most common symptom overall, occurring in the majority of concussion cases 1
• Dizziness and balance problems are frequently reported physical manifestations 1
• Nausea and vomiting commonly occur, with repeated vomiting representing a red flag requiring emergency evaluation 1
• Fatigue and drowsiness are typical physical complaints 1
• Light sensitivity (photophobia) and noise sensitivity (phonophobia) are characteristic sensory disturbances 1
• Visual problems including blurred vision and double vision are common 1
• Numbness may be present 1

Cognitive Symptoms

• Difficulty concentrating and remembering are hallmark cognitive impairments 1
• Mental fogginess or feeling "slow" may predict slower recovery 1
• Confusion and amnesia (both retrograde and anterograde) are important indicators, with amnesia serving as a marker of more serious injury requiring systematic assessment 1

Emotional and Behavioral Symptoms

• Irritability, sadness, nervousness, and heightened emotionality are common emotional changes 1
• Anxiety and depression frequently occur and may persist 1

Sleep Disturbances

• Trouble falling asleep, excessive sleep, loss of sleep, and drowsiness are common sleep-related symptoms 1

Critical Red Flags Requiring Emergency Evaluation

• Loss of consciousness occurs in less than 10% of concussions but warrants immediate emergency evaluation 1
• Repeated vomiting, altered mental status, seizure activity, and signs of skull fracture mandate emergency medical services activation 1
• Worsening headache, confusion, focal neurologic deficits, abnormal behavior, and increased sleepiness require immediate medical attention 2

Temporal Pattern

• Symptoms may present immediately or evolve over minutes to hours following injury and can be delayed in onset 1
• Resolution typically follows a sequential course with most symptoms resolving within the first 3 months 1
• 15-20% of patients develop persistent symptoms beyond 3 months, which may result in long-term cognitive and physical impairment, adverse mental health conditions, and decreased quality of life 3

Important Clinical Considerations

• The symptoms are nonspecific and cannot be explained by drug, alcohol, medication use, cervical injuries, peripheral vestibular dysfunction, or other comorbidities, requiring careful differential diagnosis 1
• Symptoms result from a neurometabolic cascade triggered by biomechanical forces, increasing local energy demand amid decreased cerebral blood flow and mitochondrial dysfunction 1
• Any child with a single symptom or sign of head injury must be immediately removed from activity and not return that day, regardless of symptom resolution, following the "when in doubt, sit them out" principle 1

---

Treatment of Concussion

Complete physical and cognitive rest for the first 24-48 hours after concussion is essential, followed by a gradual, structured return to activity rather than prolonged complete rest, which may actually worsen outcomes. 2, 4

Initial Management (First 24-48 Hours)

• Complete physical and cognitive rest is mandatory for the first 24-48 hours to allow initial recovery during the acute neurometabolic cascade when energy deficit and vulnerability are highest 4
• No return to play on the day of injury under any circumstances 4
• Monitor for warning signs including repeated vomiting, worsening headache, confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, loss of consciousness, or seizures 2
• Avoid all medications except acetaminophen immediately after injury, and only as recommended by a physician 4

Structured Return-to-Activity Protocol (After 24-48 Hours)

After the initial rest period, implement a gradual return to activity rather than prolonged complete rest, which may worsen outcomes. 2

• Each step takes a minimum of 24 hours before advancing to the next level 2, 4
• Exercise should be performed below symptom exacerbation threshold and gradually increased in intensity 2, 4
• Progression follows these steps: light aerobic exercise → sport-specific training → non-contact training drills → full contact practice → return to normal activity 2
• If any symptoms recur, immediately return to the previous asymptomatic level and rest for 24 hours before attempting to progress again 4

Academic Accommodations

• Return to school protocols should be customized based on symptom severity, with gradual increases in duration and intensity of academic activities as tolerated 2
• Temporary academic accommodations include shortened school days, reduced workloads, extended time for assignments and tests, and postponement of standardized testing 2, 4
• Educational supports should be adjusted on an ongoing basis until the student's academic performance returns to pre-injury levels 2

Management of Persistent Symptoms (Beyond 10 Days)

Symptoms persisting beyond 10 days require multidisciplinary management, as 15-20% of patients develop persisting symptoms. 4

• Graded physical exercise should be implemented for patients with persistent symptoms, performed at least once weekly for a minimum of 4 weeks, below symptom exacerbation threshold 2
• Vestibular rehabilitation is recommended for patients with persistent vestibular dysfunction, including otolith manipulating procedures, habituation exercises, adaptation exercises, and balance training 2
• Manual therapy for the neck and spine should be considered for persistent symptoms, especially when neck pain is present 2
• Referral to a specialist in traumatic brain injury is recommended if symptoms persist beyond 3 weeks 2

Medication Management

• Never allow return to play while taking any medications for concussion symptoms, including pain relievers, anti-nausea medications, or sleep aids 4
• Avoid all medications except acetaminophen as recommended by a physician 4

Critical Pitfalls to Avoid

• Returning to activity too soon before symptoms have resolved is the most common error and can significantly worsen outcomes or prolong recovery 2, 4
• Inadequate rest during the acute 24-48 hour phase compromises initial recovery 4
• Ignoring symptoms or lack of proper medical evaluation delays appropriate care 2, 4
• Underestimating recovery time or relying solely on patient-reported symptoms without objective assessment 2

Special Populations

• Younger athletes generally require longer recovery times and more conservative management with stricter return-to-play guidelines 4
• Multiple concussions increase risk of long-term difficulties with memory, concentration, chronic fatigue, persistent headaches, depression, and other neurological sequelae 4
• Preexisting mood disorder and high symptom load immediately after injury are the most consistent predictors of persisting symptoms in youth athletes 3