What is the immediate management and treatment for a concussion?

Immediate Management of Concussion

Remove the individual from activity immediately when concussion is suspected—this is non-negotiable—and activate emergency medical services if any warning signs are present, including loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp swelling/deformities. 1, 2

Immediate On-Field Actions

• Stop play immediately when concussion is suspected; the rule is "when in doubt, sit them out" 3, 4
• Never allow same-day return to play after diagnosed concussion—this is absolute regardless of symptom resolution 2, 4
• Activate EMS immediately for any severe warning signs: loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp deformities 1, 2
• Monitor continuously for neurological deterioration while awaiting advanced care 1, 4

First 24-48 Hours: Strict Rest Period

• Implement complete physical and cognitive rest for 24-48 hours after injury—this initial rest period is essential to allow the neurometabolic cascade to stabilize 2, 3, 5
• Limit all concentration-demanding activities: reading, video games, computer use, television, loud music, and bright lights 2, 5
• Avoid all medications except acetaminophen, and only as recommended by a physician 2, 5
• Prohibit alcohol, illicit drugs, or any substances interfering with cognitive function 2

Critical Warning: The Danger of Prolonged Rest

• Do not extend strict rest beyond 48-72 hours—excessive rest beyond this period worsens outcomes and prolongs recovery 3, 5, 6
• Prolonged activity restriction contributes to physical deconditioning, psychological consequences, and persistent post-concussive symptoms 6

After 48 Hours: Gradual Return to Activity

Once the initial 24-48 hour rest period is complete and the patient is asymptomatic at rest, begin the stepwise return-to-activity protocol:

Six-Step Protocol (Minimum 24 Hours Per Step)

1. No activity: Complete rest until asymptomatic at rest 2, 3
2. Light aerobic exercise: Walking, swimming, stationary cycling—below symptom threshold 2, 3, 5
3. Sport-specific exercise: Skating drills, running drills without contact 2, 3
4. Non-contact training drills: Passing drills, resistance training 2, 3
5. Full-contact practice: Only after medical clearance 2, 3
6. Return to competition: Full unrestricted play 2, 3

Protocol Rules

• Each step requires minimum 24 hours before advancing 2, 3, 5
• If any symptoms recur at any stage, drop back to the previous asymptomatic level and rest 24 hours before attempting progression again 2, 3, 5
• Supervised, sub-threshold aerobic exercise is particularly beneficial for adolescents with acute concussion 1, 5
• Never return to play while taking any medications for concussion symptoms—this indicates incomplete recovery 2, 3

Academic Accommodations

• Implement temporary academic modifications: shortened school days, reduced workloads, extended time for assignments, postponement of standardized testing 2, 3
• Gradually increase duration and intensity of academic activities as tolerated 3

Medication Management

• Acetaminophen only for symptom management, and only as recommended by a physician 2, 5
• Avoid NSAIDs and aspirin due to theoretical bleeding risk 5
• Never use vestibular suppressants (meclizine, antihistamines, benzodiazepines) for concussion—these provide no benefit and may interfere with recovery mechanisms 5

Management of Persistent Symptoms (Beyond 10 Days)

Symptoms persisting beyond 10 days affect 15-20% of concussion patients and require multidisciplinary management: 2, 3, 5

• Graded physical exercise under professional guidance 2, 5
• Vestibular rehabilitation for balance and dizziness symptoms 2, 5
• Manual therapy of the neck and spine for cervical pain 2, 5
• Formal neuropsychological assessment for persistent cognitive symptoms 2, 3
• Cognitive behavioral therapy for psychological symptoms 5
• Vision therapy for oculomotor dysfunction 5

Special Population Considerations

Younger Athletes (Under 18 Years)

• Manage more conservatively with stricter return-to-play guidelines—damage to the maturing brain can be catastrophic 2, 3
• Recovery typically takes longer in younger athletes compared to older ones 3, 5
• Never underestimate recovery time in this population 2

Athletes with Multiple Prior Concussions

• Athletes with three or more prior concussions who experience slowed recovery may require temporary or permanent disqualification from contact sports 2
• History of concussion increases risk of sustaining another concussion 4

Critical Pitfalls to Avoid

• Allowing return to play too soon—this is the most dangerous mistake, risking worsened outcomes, prolonged recovery, or second-impact syndrome 2, 3
• Immediate removal from activity is protective: athletes removed immediately miss approximately 3 fewer days from sport and have less severe acute symptoms 7
• Skipping steps in the return-to-play protocol 2
• Prescribing excessive prolonged rest beyond 48-72 hours 2, 3, 6
• Relying solely on patient-reported symptoms without objective assessment 2, 3
• Failing to identify and manage persistent symptoms beyond 10 days 2

Team-Based Decision Making

• Return-to-play decisions require a team approach involving athletic trainer, physician, athlete, and any referral sources 2
• Consider physical examination, imaging studies (when indicated), objective tests, and exertional efforts 2, 4
• Medical clearance from a licensed healthcare provider trained in concussion management is mandatory before return to play 3, 4