What are the key symptoms and activities to watch out for in a patient post-concussion?

Post-Concussion Monitoring: Critical Symptoms and Activities to Avoid

Monitor closely for red flag symptoms requiring immediate emergency evaluation: repeated vomiting, worsening headache, loss of consciousness, seizures, confusion, focal neurologic deficits, abnormal behavior, or increased sleepiness. 1, 2

Dangerous Symptoms Requiring Immediate Medical Attention

• Severe or progressively worsening headache, especially when combined with vomiting or altered mental status, may indicate life-threatening intracranial complications and should never be dismissed as "just a concussion symptom" 3
• Repeated vomiting beyond the initial injury period suggests increased intracranial pressure 1, 2
• Loss of consciousness after the initial injury or increased sleepiness/difficulty arousing 1, 2
• Seizure activity of any kind 1, 2
• Focal neurologic deficits including weakness, numbness, vision changes, or double vision 4, 1
• Confusion or altered mental status that worsens or fails to improve 1, 2

Activities to Strictly Avoid During Recovery

Physical Activities to Watch Out For

• No return to sports or physical exertion on the day of injury under any circumstances - this is universally agreed upon across all major guidelines 2
• Avoid all physical activity until asymptomatic at rest during the first 24-48 hours, as the brain is in an acute energy crisis with increased vulnerability 4, 2
• High-intensity physical activity during recovery is detrimental and should be avoided even after the initial rest period 3
• Driving should be temporarily avoided due to slowed reaction times that persist after concussion 4

Cognitive Activities That Worsen Symptoms

• School attendance may need to be temporarily suspended or significantly modified, as cognitive activities commonly exacerbate symptoms 4
• Reading, even for leisure, commonly worsens symptoms and should be limited during acute recovery 4
• Video games, computer use, and television viewing should be discouraged as they require concentration and may exacerbate symptoms 4
• Standardized testing should be postponed, as lower-than-expected scores may occur that don't represent true ability 4
• Math, science, and foreign-language classes are particularly challenging and may require accommodations 4

Environmental Triggers to Avoid

• Loud music or headphone use should be avoided if phonophobia (sound sensitivity) is present 4
• Bright lights may require use of sunglasses if significant photophobia (light sensitivity) exists 4
• Noisy environments can trigger or worsen symptoms in patients with noise sensitivity 4

Medication Precautions

• Never allow return to activity while taking any medications for concussion symptoms - this applies to all symptom-management medications including pain relievers, anti-nausea medications, or sleep aids 2
• Avoid NSAIDs immediately after injury due to theoretical risk of intracranial bleeding; use acetaminophen only as recommended by a physician 1, 2
• Analgesic overuse is a critical pitfall: taking pain medication more than 2-3 days per week causes rebound headaches that worsen the overall condition 3

Common Pitfalls in Post-Concussion Management

The most common error is returning to activity too soon before symptoms have resolved, which can significantly worsen outcomes or prolong recovery 2. The phrase "When in doubt, sit them out!" is paramount 4

• Prolonged strict rest beyond 48 hours is counterproductive and may actually worsen outcomes and delay recovery 2, 3, 5
• Underestimating recovery time or relying solely on patient-reported symptoms without objective assessment leads to premature return to activity 1
• Teachers and school officials often underestimate difficulties because students physically look well, downplaying the need for cognitive rest 4

Timeline for Persistent Symptoms

• Most concussion symptoms resolve within 1-3 months, but 15-20% of patients develop persistent symptoms requiring specialized care 4, 1
• If symptoms persist beyond 3 weeks, referral to a specialist in traumatic brain injury is recommended 1
• Younger athletes generally require longer recovery times and more conservative management with stricter return-to-play guidelines 2

Long-Term Sequelae to Monitor

• Multiple concussions increase risk of long-term difficulties with memory, concentration, chronic fatigue, persistent headaches, depression, and other neurological sequelae 2
• Depression, anxiety, and posttraumatic stress disorder can develop months after concussion, representing persisting conditions 4
• Cognitive deficits may persist even after clinical symptoms have resolved in some patients 4