What are the next steps for a patient with worsening headache and blurred vision in both eyes 9 weeks after a concussion?

Urgent Neuroimaging and Specialist Evaluation Required

This patient requires immediate head CT imaging and urgent ophthalmology consultation due to worsening symptoms 9 weeks post-concussion, particularly the progression from unilateral to bilateral vision changes, which raises concern for evolving intracranial pathology or orbital complications. 1

Immediate Red Flag Assessment

This presentation contains concerning features that warrant urgent evaluation:

• Worsening headache at 9 weeks post-injury is atypical for standard concussion recovery, where 80-85% of patients recover completely within 3 months 1
• Progressive visual symptoms (unilateral to bilateral blurred vision) suggest possible evolving pathology rather than typical post-concussive symptoms 2, 1
• Occipital location of pain combined with bilateral vision changes requires exclusion of posterior fossa pathology, venous sinus thrombosis, or delayed intracranial hemorrhage 1

Urgent Diagnostic Workup

Neuroimaging

• Obtain non-contrast head CT immediately to exclude delayed intracranial hemorrhage, subdural hematoma, or other structural lesions 1
• If CT is negative but symptoms persist, consider MRI brain with venography to evaluate for venous sinus thrombosis, which can present with delayed worsening headache and visual symptoms 1

Ophthalmologic Evaluation

• Urgent ophthalmology referral is indicated for bilateral vision changes to assess for:
  • Papilledema (suggesting increased intracranial pressure) 2
  • Traumatic optic neuropathy 2
  • Oculomotor dysfunction or cranial nerve palsies 2
  • Retinal or vitreous pathology 2
• Complete ophthalmologic examination should include visual acuity, pupillary examination, intraocular pressure, confrontational visual fields, fundoscopic examination, and detailed sensorimotor assessment 2

If Imaging is Negative: Post-Concussion Syndrome Management

Assuming dangerous pathology is excluded, this patient has persistent post-concussion symptoms requiring specialized management:

Immediate Specialist Referral

• Refer to concussion specialist or sports medicine physician because symptoms persisting beyond 6-8 weeks require specialized multidisciplinary management 1, 3
• This is particularly important given the cognitive symptoms and visual disturbances, which may benefit from targeted interventions 1

Specific Treatment Interventions

For Visual Symptoms:

• Oculomotor vision therapy should be offered for persistent visual symptoms, as clinical evidence shows improvement in visual symptoms and reduction in associated headache and fatigue 2
• Vision therapy has demonstrated positive effects even without control group studies in post-concussion patients 2

For Headache Management:

• Recognize this as the migraine-type concussion subtype, characterized by photophobia, phonophobia, and nausea 4
• Treat with migraine-specific therapies including triptans, preventive medications if headaches are frequent, and lifestyle modifications 4, 5

For Overall Recovery:

• Begin sub-symptom threshold aerobic exercise at 60-70% maximum heart rate for 15-20 minutes daily, gradually increasing as tolerated 1
• Avoid strict rest beyond 48-72 hours, as complete rest may delay recovery 1
• Implement partial cognitive rest with screen time limited to 30-minute intervals with breaks 1

Interdisciplinary Coordinated Care

• Recommend interdisciplinary coordinated rehabilitative treatment involving at least 2 disciplines (physiotherapy, occupational therapy, neuropsychology) administered minimally once weekly for at least 4 weeks 2
• This approach shows positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 2

Prognosis and Monitoring

• This patient falls into the 15-20% who develop persistent symptoms beyond 3 months, constituting post-concussion syndrome 1, 6
• Risk factors for prolonged recovery include high initial symptom burden and worsening symptoms (both present in this case) 1, 6
• Provide written instructions to return immediately for: repeated vomiting, severe worsening headache, increasing confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, loss of consciousness, or seizures 1

Critical Pitfall to Avoid

Do not attribute worsening symptoms at 9 weeks to "normal concussion recovery" - the natural history of concussion shows improvement over time, not deterioration 2, 6. Progressive worsening mandates exclusion of structural pathology before proceeding with post-concussion syndrome management 1.