What is the best course of management for a 15-year-old adolescent with ongoing intermittent headaches worsened by movement 4 weeks after a head injury, without vomiting or loss of consciousness (LOC) at the time of incident?

Management of Persistent Post-Concussion Headache at 4 Weeks Post-Injury

This 15-year-old should begin an active rehabilitation program of progressive sub-symptom threshold aerobic exercise immediately, as prolonged rest beyond the first few days is contraindicated and may worsen symptoms. 1, 2

Immediate Active Rehabilitation Protocol

Begin graded aerobic exercise starting at 60-70% of maximum heart rate for 15-20 minutes daily, gradually increasing duration and intensity as tolerated without significantly exacerbating symptoms. 2 The CDC guidelines specifically recommend that after the first several days post-injury, patients with symptoms persisting beyond 4 weeks should receive an active rehabilitation program of progressive reintroduction of noncontact aerobic activity. 1

• Start with activities like stationary cycling, walking, or light jogging at sub-symptom threshold levels 2
• Monitor symptom expression closely—the goal is to increase activity without significantly worsening headache or other symptoms 1
• This approach is supported by evidence showing that physical exercise performed below symptom exacerbation reduces postconcussive symptoms in patients with prolonged symptoms beyond 4 weeks 1

Headache-Specific Management

For ongoing headache management, optimize acetaminophen dosing to 650-1000mg every 6 hours as needed (maximum 4000mg/24 hours), and consider adding an NSAID if acetaminophen alone is insufficient. 2

• Do not prescribe opioids or butalbital-containing medications, as these are contraindicated and may worsen outcomes through medication overuse headache. 2
• The headache pattern (intermittent, worsened by movement) is consistent with the headache/migraine subtype of concussion, which is the most common symptom following concussion 1
• Post-traumatic headaches often resemble migraine (29% of cases) or tension-type headache (37% of cases) 3, 4

Subtype Assessment and Targeted Interventions

Evaluate for specific concussion subtypes that may require targeted treatment, particularly vestibular dysfunction and cervical strain, given the movement-related headache exacerbation. 1

• Cervical strain should be assessed through examination for midline cervical tenderness, paraspinal muscle tenderness, limitation of cervical motion, and pain with cervical movement, as cervical pathology commonly coexists with concussion and can cause occipital/suboccipital headaches worsened by movement 1
• Vestibular dysfunction may present with movement-related symptoms and should be evaluated through balance testing and vestibular examination 1
• If vestibular dysfunction is identified, vestibular rehabilitation therapy is indicated 1

Activity Modifications and Return-to-School Protocol

Implement a gradual return-to-school protocol with customized academic accommodations based on symptom severity, increasing duration and intensity of academic activities without significantly exacerbating symptoms. 1

• Reduce screen time to 30-minute intervals with breaks 2
• Consider shortened school days with reduced workload initially 2
• School-based teams should assess educational needs and determine if additional supports under Section 504 or IDEA are required 1
• Monitor postconcussive symptoms and academic progress collaboratively between student, family, healthcare professionals, and school teams 1

Specialist Referral Criteria

Refer to a concussion specialist or sports medicine physician now, as symptoms persisting at 4 weeks warrant specialized evaluation. 2 The threshold for referral is symptoms persisting beyond 3 weeks, which this patient has exceeded. 2

• Specialist evaluation should include assessment for specific subtypes requiring targeted interventions (vestibular, ocular-motor, cervical, psychological) 1
• Interdisciplinary coordinated rehabilitative treatment may be beneficial for persistent symptoms 1

Red Flag Symptoms Requiring Immediate Evaluation

Instruct the patient and family to return immediately for repeated vomiting, worsening or severe headache, increasing confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, or seizures. 2

Prognosis and Expectations

Most patients (80-85%) recover completely within 3 months, but this patient is at higher risk for post-concussion syndrome given symptom persistence at 4 weeks. 2

• Symptoms persisting beyond 3 months occur in 15-20% of patients and constitute post-concussion syndrome 2
• Risk factors for prolonged recovery include female gender, high initial symptom burden, and prior concussion history 2

Critical Pitfalls to Avoid

Do not prescribe strict rest or complete activity restriction, as prolonged rest beyond 48-72 hours may actually prolong recovery and worsen symptoms. 1, 2 This represents a paradigm shift from historical management—the evidence clearly demonstrates that inactivity beyond the first few days is counterproductive. 1

• Do not use medications to mask symptoms to allow premature return to full activities 2
• Do not delay active rehabilitation—the evidence specifically supports exercise intervention for symptoms persisting beyond 4 weeks 1