Management of Post-Concussive Syndrome at 3 Weeks
This patient requires immediate discontinuation of NSAIDs, transition to acetaminophen-only analgesia, initiation of a graded aerobic exercise program below symptom threshold, and referral for multidisciplinary assessment given persistent severe symptoms beyond the expected 1-3 week recovery window. 1, 2, 3
Immediate Medication Changes
Stop ibuprofen immediately - NSAIDs should be avoided after head injury due to theoretical risk of intracranial bleeding, and animal studies demonstrate that chronic ibuprofen administration worsens cognitive outcomes after traumatic brain injury. 3 While the FDA label permits ibuprofen use up to 3200mg daily for various conditions 4, this does not apply to post-concussion management where NSAIDs are contraindicated. 2, 3
Continue acetaminophen as the sole analgesic - This is the only recommended first-line medication for post-concussion headache, though it does not shorten recovery time. 2, 3 The patient should use the lowest effective dose. 3
Critical medication principle: Continued need for medication to control symptoms at 3 weeks indicates incomplete recovery and precludes return to normal activities. 2, 3 Before resuming full activity, all medications must be stopped and the patient must remain symptom-free off medication. 3
Activity Modification Protocol
Implement graded aerobic exercise starting immediately - After the initial 24-48 hour acute rest period (which has passed), prolonged complete rest actually worsens outcomes. 5 The patient should begin sub-symptom threshold aerobic exercise performed at least once weekly for a minimum of 4 weeks. 5, 6
The exercise protocol should: 5
- Start below the threshold that exacerbates symptoms (if 8/10 headache worsens with activity, stay well below that intensity)
- Gradually increase intensity and complexity over time
- Progress only if symptoms remain stable or improve
Cognitive rest modifications - Given her reading difficulties and severe symptoms at 3 weeks: 2, 3
- Implement shortened work days with reduced workload
- Provide extra time for tasks requiring concentration
- Avoid video games, excessive computer use, and television
- Consider temporary leave or modified duties if symptoms prevent function
Specialist Referral - Required Now
This patient meets criteria for urgent specialist referral because symptoms have not resolved within the expected 4-6 week timeframe and she demonstrates high-risk features. 1 At 3 weeks with severe persistent symptoms (8-10/10 headache, cognitive impairment, excessive sleep, fatigue), she requires multidisciplinary assessment. 1, 5
Referral should address specific symptom generators: 6, 7
- Vestibular rehabilitation for dizziness (if present beyond what's described)
- Cervical physical therapy for focal frontal and lateral head pain, which may indicate cervicogenic component
- Vision therapy for reading difficulties
- Cognitive behavioral therapy for symptom management and any emerging anxiety/depression
Red Flags Requiring Emergency Evaluation
Monitor for and immediately seek emergency care if she develops: 5
- Repeated vomiting (she has mild nausea but no vomiting currently)
- Worsening headache beyond current 8-10/10 severity
- Confusion or abnormal behavior
- Focal neurologic deficits
- Increased sleepiness beyond her current 10-12 hours
- Loss of consciousness or seizures
Prognostic Counseling
Be direct about timeline: Most concussion symptoms resolve within 1-3 months, but 15-20% of patients develop persistent symptoms. 1, 7 Her risk factors for prolonged recovery include: 1, 7
- Female gender
- High early symptom burden (8-10/10 headache)
- Cognitive impairment at 3 weeks
- Excessive sleep requirements
However, with appropriate treatment including graded exercise and targeted rehabilitation, outcomes improve significantly even in patients with persistent symptoms. 1, 5, 6
Common Pitfalls to Avoid
Do not prescribe muscle relaxants (like cyclobenzaprine) for her frontal/lateral head pain or presumed neck tension - this prevents accurate neurological assessment, masks deteriorating mental status, interferes with symptom reporting, and creates withdrawal symptoms requiring 2-3 week taper if used long-term. 2
Do not continue NSAIDs despite their common use and FDA approval for pain - the post-concussion context changes the risk-benefit calculation. 2, 3
Do not prescribe opioids for headache management due to lack of efficacy and dependence risk. 3
Avoid analgesic overuse - excessive acetaminophen use can lead to rebound headaches, worsening the clinical picture. 3