What is the recommended management for mild traumatic brain injury (mTBI), also known as concussion?

From the Guidelines

The recommended management for concussions involves a gradual return to normal activities after an initial period of rest, with patients returning to full activity when they have remained symptom-free at rest and with increasing levels of physical exertion. This approach is supported by the most recent guidelines, including those from the Centers for Disease Control and Prevention 1 and the American Heart Association 1. The initial period of rest is crucial, typically lasting 24-48 hours, to allow the brain to begin healing. After this period, patients should slowly resume daily activities while staying below the threshold that triggers symptoms.

Some key points to consider in the management of concussions include:

• Removing the person from sports and other activities posing a risk of reinjury until they have fully recovered, as recommended by a broad consensus of health care organizations 1
• Monitoring for signs of increased risk of life-threatening brain injury, such as loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizure, neurological signs and symptoms, and skull fracture 1
• Using a step-wise protocol to reintroduce physical exertion, starting with light aerobic exercise, then sport-specific exercise, non-contact training drills, full-contact practice (if appropriate), and finally return to competition or full activity 1
• Managing symptoms with acetaminophen (500-1000mg every 6 hours as needed) for headaches, while avoiding NSAIDs like ibuprofen in the acute phase due to bleeding risk
• Prioritizing sleep hygiene, hydration, proper nutrition, and avoiding alcohol and recreational drugs to support recovery

It's essential to note that most concussions resolve within 7-10 days for adults and up to 4 weeks for children, though some patients experience prolonged symptoms requiring specialized care. This conservative approach allows the brain's metabolic imbalance caused by the injury to normalize while preventing secondary injury from occurring during the vulnerable recovery period. As stated in the guidelines, health care professionals should counsel patients to return to full activity when they return to premorbid performance if they have remained symptom-free at rest and with increasing levels of physical exertion 1.

From the Research

Recommended Management for Concussions

The management of concussions involves several key steps, including:

• Rapid removal from play to prevent further injury 2
• Symptomatic treatment to manage symptoms such as headaches, dizziness, and sleep disturbances 3
• Return to learn/play recommendations to ensure safe return to activity after acute concussion 2, 4
• Physical and cognitive rest alone may be sufficient for most sport-related concussions, which typically resolve within a short time frame 5
• For patients with prolonged recovery courses, persistent symptoms, and significant deficits in cognitive functioning, more involved therapy may be required, including:
  • Additional education and academic accommodations 5, 6
  • Physical therapy 5, 6
  • Cognitive rehabilitation 5
  • Medication to manage or minimize disruptive symptoms 6
  • Vestibular and ocular therapy 6
  • Psychological support 6
  • Graded noncontact exercise 6

Key Considerations

• Understanding the key features of diagnosis, postinjury assessment tools, symptomatic treatment, and management of concussion is essential for primary care providers 2
• Consensus guidelines provide guidance regarding injury management and approaches to ensure safe return to activity after acute concussion 4
• Medications and supplements remain a small part of the concussion treatment plan, and are typically used to help manage or minimize disruptive symptoms while recovery proceeds 6