What is the best management approach for a patient experiencing post-concussive symptoms after a traumatic brain injury?

Management of Post-Concussive Symptoms

Immediately initiate graded aerobic exercise at 60-70% maximum heart rate for 15-20 minutes daily, as complete rest beyond 2-3 days delays recovery, and provide systematic written education about expected symptoms and recovery timeline. 1, 2, 3

Initial Assessment and Risk Stratification

Systematically evaluate all patients using a standardized symptom checklist such as the Rivermead Post-Concussion Symptoms Questionnaire to document physical, cognitive, and emotional symptoms on a 0-4 severity scale. 1

Identify high-risk patients who require closer monitoring:

• Female gender (strongest predictor of persistent symptoms beyond 3 months) 4, 1
• Previous psychiatric history including depression, anxiety, or PTSD 4
• Presence of the symptom triad: headache, nausea, and dizziness at initial presentation (50% chance of post-concussion syndrome at 6 months) 4, 2
• GCS score <15 at initial presentation 4
• High initial symptom burden 2, 3
• Age over 40 years 2, 3

Active Treatment Protocol

Physical Activity Management:

• Start light aerobic exercise immediately at 60-70% maximum heart rate for 15-20 minutes daily 1, 2, 3
• Exercise below the symptom exacerbation threshold—do NOT prescribe complete rest beyond 48-72 hours 1, 3
• Gradually increase duration and intensity as tolerated over subsequent days 1, 2

Cognitive Activity Management:

• Implement partial cognitive rest with screen time limited to 30-minute intervals with breaks 2, 3
• Reduce reading duration and consider shortened work/school days with reduced workload 2, 3
• Gradually increase cognitive activity duration and intensity without significantly exacerbating symptoms 1

Domain-Specific Symptom Management

For Persistent Headache:

• First-line: Acetaminophen 650-1000mg every 6 hours as needed (maximum 4000mg/24 hours) 1, 3
• Add NSAIDs if acetaminophen alone is insufficient 1
• Do NOT use opioids or butalbital-containing medications—these are contraindicated and worsen outcomes 3
• Consider amantadine 100mg twice daily for 2 months if headaches persist despite conservative management (80% improvement rate even years after initial trauma) 5

For Neck Pain with Headache:

• Spinal manual therapy including mobilization or manipulation of the cervical spine 1

For Visual Symptoms:

• Oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 1

For Vestibular Symptoms (dizziness, balance problems):

• Vestibular rehabilitation with habituation exercises, adaptation exercises, and balance training 1
• Note: Dizziness adversely affects clinical outcomes at both early and late stages and requires aggressive management 6

Patient Education Requirements

Provide both written (at 6th-7th grade reading level) and verbal discharge instructions to patient AND immediate caregiver that include: 4, 2, 3

Expected Symptoms to Monitor:

• Chronic headaches, dizziness, balance problems 4
• Nausea, vision problems 4
• Increased sensitivity to noise and/or light 4
• Depression, mood swings, anxiety, irritability 4
• Memory problems, difficulty concentrating 4
• Sleep difficulties, persistent fatigue 4

Red Flag Symptoms Requiring Immediate ED Return:

• Repeated vomiting 4, 3
• Worsening or severe headache 4, 3
• Increasing confusion or problems remembering 4, 3
• Focal neurologic deficits 4, 3
• Abnormal behavior 4, 3
• Increased sleepiness or passing out 4, 3
• Seizures 4, 3

Recovery Timeline:

• Most patients (80-85%) recover completely within 3 months 1, 2, 3
• 15-20% develop persistent post-concussion syndrome requiring specialist care 1, 2, 3
• Symptoms may persist for at least 6 months and require continued medical care, social assistance (driving support, employment issues, financial assistance) 4, 1

Specialist Referral Criteria

Refer to concussion specialist or sports medicine physician if: 4, 1, 3

• Symptoms persist beyond 3 weeks from initial injury
• Symptoms significantly worsen despite conservative management
• Patient plans to return to contact sports
• Patient has not received information about brain injury from the ED (predictor of persistent symptoms) 4

Critical Pitfalls to Avoid

• Do NOT prescribe strict bed rest or complete activity restriction beyond 48-72 hours—this delays recovery 1, 3
• Do NOT use medications to mask symptoms for premature return to activities—any medication needed to control symptoms indicates incomplete recovery 3
• Do NOT discharge without written instructions at 6th-7th grade reading level given to both patient and caregiver 3
• Do NOT recommend home observation with frequent waking or pupil assessment—this is not supported by literature 4
• Do NOT overlook psychological factors (anxiety, depression, PTSD symptoms) which are the best predictors of persistent symptoms at 2 weeks post-discharge 4

Monitoring Physical and Psychosocial Symptoms

Physical symptoms (dizziness, headache) are most prominent at 1-2 weeks post-injury, while psychosocial symptoms (depression, irritability) become more significant at 4-8 weeks. 6 Monitor and address both domains throughout the recovery course, with particular attention to anxiety in patients with premorbid psychiatric history, as anxiety and age are better predictors of post-concussion syndrome at 3 months than initial injury characteristics. 4