What is the recommended concussion protocol for a patient over 5 years of age, including the use of naproxen (nonsteroidal anti-inflammatory drug) for headache management?

Concussion Management Protocol for Patients Over 5 Years

For patients over 5 years with concussion, implement 24-48 hours of moderate physical and cognitive rest, then begin supervised sub-threshold aerobic exercise, and use acetaminophen only (not naproxen or other NSAIDs) for headache management as recommended by a physician. 1, 2

Initial Management (First 24-48 Hours)

• Remove immediately from activity if concussion is suspected—never allow same-day return to play even if symptoms resolve 1, 2
• Implement moderate physical and cognitive rest for the first 24-48 hours to allow initial recovery 1, 2
• Do not prescribe strict rest beyond 48-72 hours, as prolonged rest (>3 days) actually worsens outcomes and delays recovery 3, 2, 4
• Monitor for red flags requiring emergency evaluation: loss of consciousness, altered mental status, repeated vomiting, severe or worsening headache, seizures, visual changes, or focal neurological deficits 1, 2

Medication Management for Headache

Use acetaminophen only for headache management, and only as recommended by a physician—avoid naproxen and other NSAIDs. 1, 2

Critical Evidence on Analgesics:

• The American Academy of Pediatrics specifically recommends limiting medication use to acetaminophen only for concussion symptom management 1, 2
• Do not return to play while taking any medications for concussion symptoms 1, 2
• A 2022 prospective cohort study of 2,277 pediatric patients found that acute treatment with ibuprofen, acetaminophen, or both showed no association with headache resolution at 7 days post-concussion 5
• While naproxen is FDA-approved for use in pediatric patients over 2 years for pain management 6, it is not specifically recommended in concussion guidelines and falls under the general NSAID category that guidelines advise against 1, 2

Important Caveat:

Non-opioid analgesics may be prescribed for short-term headache relief, but clinicians must be cautious with long-term medication overuse in patients whose headache symptoms persist beyond 7 days 5

Gradual Return to Activity (After Initial 24-48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial rest period—this is the only intervention with strong evidence, particularly in adolescents. 3, 1, 2

Stepwise Progression Protocol:

Each step requires a minimum of 24 hours and must be symptom-free before advancing 1, 2:

1. Light aerobic exercise (walking, swimming, stationary cycling at <70% maximum heart rate) 1, 2
2. Sport-specific exercise (skating drills in hockey, running drills in soccer) 1, 2
3. Non-contact training drills (passing drills, resistance training) 1, 2
4. Full-contact practice (following medical clearance) 1, 2
5. Return to competition 1, 2

Key Principles:

• If symptoms recur during any step, return to the previous asymptomatic level and rest for 24 hours before attempting to progress again 1, 2
• Exercise should remain below the symptom-exacerbation threshold—stop if symptoms worsen 1, 7
• Avoid high-intensity physical activity during recovery as this can be detrimental 1, 7
• Early return to physical activity within 7 days is associated with lower risk of persistent post-concussive syndrome (24.6% vs. 43.5% in those with no activity) 8

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated 1, 2
• Implement temporary accommodations if symptoms interfere with academic performance: shortened school days, reduced workloads, extended time for assignments and tests 1, 2
• Customize return-to-school protocols based on symptom severity 7

Return to Full Activity Criteria

Allow return to full activity only when the patient:

• Has returned to premorbid performance level 1, 2, 7
• Remains completely symptom-free at rest 1, 2
• Shows no symptom recurrence with increasing physical exertion 1, 2, 7
• Has received medical clearance from a physician experienced in concussion management 2
• Is not taking any medications for concussion symptoms 1, 2

Management of Persistent Symptoms (>10 Days)

• Implement multidisciplinary management for symptoms persisting beyond 10 days 1, 2
• Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 1, 2
• Consider formal neuropsychological assessment for persistent cognitive symptoms 1, 2
• Multidisciplinary approach may include: graded physical exercise programs (primary intervention), vestibular rehabilitation for vestibular dysfunction, manual therapy for cervical spine/neck pain, and cognitive behavioral therapy 1

Age-Specific Considerations

Adolescents (Most Robust Evidence):

• Aerobic exercise has the strongest evidence as appropriate therapy specifically in adolescents with acute concussion 3, 2
• Two high-quality RCTs with low to moderate risk of bias support aerobic exercise in this age group 3
• Most adolescents recover within 7-10 days, though some may take weeks to months 2

Children and Adults:

• The evidence for exercise in children under 12 and adults over 18 is less robust, though the panel consensus supports similar management 3
• Younger athletes may require more conservative management with stricter return-to-play guidelines due to longer recovery times 1, 2

Common Pitfalls to Avoid

• Never allow same-day return to play, even if asymptomatic 1, 2
• Do not exceed 3 days of strict rest, as this worsens outcomes 2, 4
• Returning to activity too soon can worsen outcomes or prolong recovery 1
• Inadequate rest during the acute phase (first 24-48 hours) 1
• Excessive rest beyond the initial 24-48 hours is counterproductive 1, 4
• Relying solely on patient-reported symptoms without objective assessment 2
• Using NSAIDs like naproxen instead of acetaminophen for headache management 1, 2