What are the symptoms and management of a mild concussion in a patient?

Symptoms of Mild Concussion

Mild concussion presents with a constellation of physical, cognitive, and emotional symptoms that typically resolve within 3 months in 80-85% of patients, but 15-20% develop persistent post-concussion syndrome requiring specialist referral and active rehabilitation.

Acute Symptom Presentation

Physical Symptoms

The most common physical manifestations include:

• Headache (the most frequently reported symptom) 1
• Dizziness and balance problems 1
• Nausea and vomiting 1
• Fatigue and feeling tired all the time 1
• Sleep disturbances 1
• Vision problems and blurred vision 1
• Increased sensitivity to noise and/or light 1

Cognitive Symptoms

Patients commonly experience:

• Memory problems and difficulty with short-term memory 1
• Difficulty concentrating or paying attention 1
• Confusion 1
• Problems with decision making 2

Emotional/Behavioral Symptoms

The affective domain includes:

• Irritability 1
• Anxiety 1
• Depression or mood swings 1
• Emotional lability 1

Risk Stratification for Persistent Symptoms

The triad of headache, nausea, and dizziness at initial ED presentation identifies high-risk patients: those with all three symptoms have a 50% chance of developing post-concussion syndrome at 6 months, while those with none have only a 28% chance. 1

Additional risk factors for prolonged recovery include:

• Female gender (strongest predictor) 3, 4
• Age over 40 years 4, 2
• Pre-existing mood disorders (depression, anxiety, PTSD) 1, 3
• High initial symptom burden at time of injury 1, 3
• History of prior concussion 4
• Lower educational level 4, 2

Immediate Management Protocol

Activity Recommendations

Begin sub-symptom threshold aerobic exercise immediately rather than strict rest, as complete rest beyond 2-3 days may delay recovery. 5

• Start light aerobic activity at 60-70% of maximum heart rate for 15-20 minutes daily, gradually increasing duration and intensity as tolerated 5, 3
• Implement partial cognitive rest with screen time limited to 30-minute intervals with breaks, reduced reading, and shortened work/school days 5
• Patients should refrain from strenuous mental or physical activity until symptom-free, typically requiring 2-3 days off work or school 1

Critical Pitfall to Avoid

Do not prescribe strict bed rest or complete activity restriction beyond 48-72 hours, as this prolongs recovery. 5 Home observation with frequent waking is not supported by evidence and is not recommended 1.

Red Flag Symptoms Requiring Immediate ED Return

Instruct patients to return immediately for:

• Repeated vomiting 1, 5
• Worsening or severe headache 1, 5
• Increasing confusion 1, 5
• Focal neurologic deficits 1, 5
• Abnormal behavior 1, 5
• Increased sleepiness or loss of consciousness 1, 5
• Seizures 1, 5

Prognosis and Timeline

Most adults with post-concussion symptoms recover within 3 to 12 months of injury, with 80-85% achieving complete resolution within 3 months. 1, 5, 3

However:

• 58% of patients have persistent symptoms at 1 month post-injury 1
• 28% continue to have symptoms at 6 months 1
• 15-20% develop persistent post-concussion syndrome beyond 3 months 1, 5, 3

At 1 month specifically, the most prevalent persistent symptoms are fatigue (17.2%) and forgetfulness (14.6%) 3.

Specialist Referral Criteria

Refer to a concussion specialist or sports medicine physician if symptoms persist beyond 3 weeks, significantly worsen despite conservative management, or if the patient plans to return to contact sports. 5, 3

Patient Education Requirements

Discharge instructions must be provided in both written and verbal form at a 6th-7th grade reading level to both patient and immediate caregiver. 1, 5

The written instructions should include:

• Complete list of post-concussion symptoms to monitor 1
• Red flag symptoms requiring immediate return 1, 5
• Activity recommendations and restrictions 1, 5
• Expected recovery timeline 1
• Information that providing systematic education about post-concussion symptoms can reduce long-term complaints 1

A critical omission in most discharge instructions is the lack of information about the possibility of developing post-concussion syndrome, which must be addressed. 1