What is the appropriate management and treatment for a female patient with a history of playing soccer, who presents with headaches after falling and hitting the back of her head, and was diagnosed with a possible concussion at a hospital last week?

Management of Post-Concussion Headaches in a Female Soccer Player

This patient requires immediate medical clearance from a healthcare professional experienced in concussion management before any return to soccer, along with implementation of both physical and cognitive rest until all symptoms completely resolve. 1, 2

Immediate Assessment and Clearance Requirements

The patient must be evaluated by a physician with concussion management experience before any consideration of return to play. 1, 2 This evaluation should include:

• Structured symptom assessment using a standardized checklist (SCAT6) covering physical symptoms (headache, dizziness, nausea), cognitive symptoms (difficulty concentrating, memory problems), emotional symptoms (irritability, anxiety), and sleep disturbances 2, 3
• Cognitive evaluation including immediate memory tests, concentration tasks, and delayed recall 3
• Balance testing using Modified Balance Error Scoring System (mBESS) or Romberg test 2
• Neurological examination to rule out more serious intracranial injury, particularly since she is still symptomatic one week post-injury 1, 2

Critical Management: Physical and Cognitive Rest

Complete physical and cognitive rest is mandatory until symptoms resolve both at rest AND with exertion. 1, 2 This means:

Physical Rest

• No sports activities, exercise, or physical exertion until completely asymptomatic 1, 2
• Avoid activities that increase heart rate or blood pressure 1

Cognitive Rest

• Reduce or temporarily eliminate schoolwork depending on symptom severity 1
• Limit screen time (phones, computers, television) 1
• Avoid reading, even for leisure, if it worsens symptoms 1
• Request academic accommodations: shortened school days, reduced workload, extended time for assignments and tests, and postponement of standardized testing 1

A critical pitfall: Teachers and school officials often underestimate difficulties because the student "looks well" - proactive communication with school staff is essential 1

Red Flags Requiring Emergency Evaluation

The patient and family must be educated to seek immediate emergency care if she develops: 1, 2

• Loss of consciousness
• Severe or worsening headache
• Repeated vomiting
• Altered mental status or confusion
• Seizures
• Visual changes
• Neck pain or neurological deficits

Medication Considerations

There is no evidence-based medication treatment for concussion in pediatric/adolescent athletes. 1 Important points:

• NSAIDs and acetaminophen have not been proven effective for concussion symptoms 1
• NSAIDs should theoretically be avoided immediately post-injury due to potential (though unproven) risk of intracranial bleeding 1
• Any medication used to control symptoms indicates incomplete recovery - the patient must be symptom-free OFF all medications before return to play 1

Return-to-Play Protocol

The patient cannot return to soccer until she is completely asymptomatic at rest and with exertion, and only after medical clearance. 1, 2, 4 Once cleared, she must follow this stepwise progression with minimum 24 hours per step: 1, 2, 4

1. No activity - complete rest until asymptomatic
2. Light aerobic exercise - walking or stationary cycling at <70% maximum heart rate
3. Sport-specific exercise - running drills, no head impact
4. Non-contact training drills - progression to more complex training
5. Full-contact practice - after medical clearance
6. Return to game play

Critical rule: If ANY symptoms return at any stage, immediately stop and return to the previous asymptomatic level after 24 hours rest. 1, 4

Special Considerations for Young Female Athletes

• Female athletes have higher concussion rates and may have longer recovery times than male athletes in similar sports 5
• Adolescent athletes typically require 7-10 days or longer for recovery, which is more prolonged than college/professional athletes 1, 4
• She should NEVER return to play on the same day of injury, even if symptoms resolve 1, 3
• Since she is still symptomatic at one week post-injury, she is within the typical recovery window, but requires continued monitoring 1, 4

When to Consider Specialist Referral

Refer to a concussion specialist if: 2, 4

• Symptoms persist beyond 10-14 days 4
• Symptoms worsen rather than improve 2
• She has a history of multiple prior concussions 1
• Pre-existing conditions complicate recovery (migraines, ADHD, anxiety, depression) 5

Prognostic Information

• Most concussions resolve within 7-10 days 1, 4
• 80-90% of athletes recover within one month 4
• Approximately 10% remain symptomatic beyond 3 months (postconcussive syndrome) 1, 4
• Delayed evaluation (>30 days post-injury) is associated with more persistent symptoms at 3 months 6

Prevention of Future Injury

The patient should be counseled that: 1, 5

• History of concussion increases risk of future concussions
• Premature return to play significantly increases risk of repeat concussion with potentially prolonged recovery
• Rule enforcement and fair play are important preventive measures
• Helmets in soccer have not been proven to reduce concussion risk 1