What is the appropriate treatment for a teenager with a headache or possible concussion after a fight?

Treatment for a Teenager with Headache or Possible Concussion After a Fight

Remove the teenager from any physical activity immediately and do not allow return to sports, school, or physical exertion that day—this is non-negotiable regardless of how quickly symptoms resolve. 1

Immediate Assessment and Red Flags

Evaluate the teenager immediately for concussion using a symptom-based approach that includes: 2, 1

• Physical symptoms: Headache (most common), dizziness, nausea, balance problems, visual disturbances, light/noise sensitivity 2, 1
• Cognitive symptoms: Memory problems, confusion, difficulty concentrating, feeling "foggy" or "slow" 2, 1
• Emotional symptoms: Irritability, sadness, nervousness, increased emotionality 2
• Sleep disturbances: Trouble falling asleep, excessive sleep, drowsiness 2

Obtain emergency CT imaging if any of these danger signs are present: 1

• Glasgow Coma Scale score <15 at 2 hours post-injury
• Loss of consciousness (occurs in <10% of concussions but signals potential serious injury) 2
• Prolonged altered consciousness or worsening mental status
• Repeated vomiting
• Focal neurological deficits or seizure activity
• Suspected skull fracture
• Progressive or severe worsening headache 2, 1

Initial Management Protocol

Prescribe complete physical AND cognitive rest for the first 24-48 hours: 3, 1

• Keep the teenager home from school during this initial period 3, 1
• Avoid ALL physical exertion including sports, gym class, and strenuous household activities 3
• Limit screen time (phones, computers, television, video games) 1
• Restrict cognitively demanding activities like reading, homework, and standardized testing 1
• Avoid acetaminophen and NSAIDs initially to prevent medication-overuse headache, which occurs in 70% of adolescents with chronic post-traumatic headache 1, 4

Monitor closely for symptom progression over the first 24-48 hours and provide clear instructions to parents about when to return to the emergency department (worsening headache, vomiting, confusion, focal deficits). 2

Post-Acute Management (After 48 Hours)

After the initial 24-48 hour rest period, implement gradual symptom-guided return to activities—prolonged rest beyond 48 hours worsens outcomes and delays recovery. 3

School accommodations are essential: 1

• Shortened school days
• Reduced workload and extended time for assignments
• Avoid activities that worsen symptoms (reading, screen time, testing)
• These modifications continue until the teenager is asymptomatic at rest 1

For persistent headache management: 4

• If analgesics are needed, use them sparingly (no more than 2 days per week) to avoid medication-overuse headache 4
• 70% of adolescents with chronic post-traumatic headache who overuse simple analgesics will improve after discontinuing them 4

Return-to-Play Protocol

The teenager must complete a strict 6-step protocol with each stage lasting a minimum of 24 hours: 3, 1

1. No activity: Complete rest until asymptomatic at rest
2. Light aerobic activity: Walking, swimming, stationary cycling at <70% maximum heart rate
3. Sport-specific exercise: Running drills, no head impact activities
4. Noncontact training drills: Progression to more complex training
5. Full-contact practice: Normal training activities after medical clearance
6. Return to play: Normal game participation 3, 1

If ANY symptoms return at any stage, stop activity immediately. Once asymptomatic for 24 hours, return to the previous asymptomatic stage. 1

Special Considerations for Adolescents

Adolescents require 7-10 days or longer for recovery—significantly longer than adults—because the developing brain is more vulnerable to concussive injury and at risk for second-impact syndrome (catastrophic brain swelling). 1

Apply stricter guidelines if the teenager has: 3, 1

• Three or more previous concussions (significantly increased risk of subsequent injuries, slowed recovery, prolonged cognitive dysfunction) 3
• History of prolonged recovery (>4 weeks) from prior concussions
• Progressively worsening symptoms with each injury 3

Consider temporary or permanent disqualification from contact sports in these high-risk cases. 3, 1

Common Pitfalls to Avoid

Never minimize the significance of concussion or allow premature return to activities—this increases risk of prolonged dysfunction, recurrent concussion, and potential catastrophic injury. 3

Never rely on loss of consciousness to diagnose concussion—it occurs in less than 10% of cases. 2, 1

Never allow same-day return to play even if symptoms resolve quickly—this is absolutely contraindicated in pediatric and adolescent athletes. 1

Beware of analgesic overuse—excessive use of even simple analgesics like acetaminophen or ibuprofen postconcussion contributes to chronic post-traumatic headache in 70% of adolescents. 4

Follow-Up and Monitoring

Most adolescents recover within 7-10 days, but 15-20% develop persistent post-concussion symptoms lasting beyond 4 weeks, with 10% remaining symptomatic beyond 3 months. 3

Establish regular follow-up to monitor for delayed or progressive symptoms, particularly in teenagers with multiple prior concussions. 3

Educate the teenager, family, and coaches about the cumulative risks of multiple concussions and the critical importance of reporting symptoms immediately. 3