When should a patient with a history of previous concussions or pre-existing medical conditions seek medical care if their concussion symptoms are not resolving?

When to Seek Medical Care for Non-Resolving Concussion Symptoms

Patients with previous concussions or pre-existing medical conditions should seek medical evaluation if concussion symptoms persist beyond 1-6 weeks, or immediately if any red flag symptoms develop. 1, 2

Immediate Emergency Evaluation Required

Seek emergency medical services (call 911) immediately if any of the following red flag symptoms develop 3, 1, 4:

• Loss of consciousness (even brief) 3, 4
• Worsening headache that progressively intensifies rather than improves 3, 1, 4
• Repeated vomiting (not just single episode of nausea) 3, 1, 4
• Altered mental status including confusion, disorientation, or decreased responsiveness 3, 4
• Seizures or convulsions 3, 4
• Visual changes including blurred vision, double vision, or visual field defects 3, 4
• Visible scalp swelling or deformities suggesting skull fracture 3, 4
• Severe memory problems or inability to recognize people/places 4

These symptoms indicate potential life-threatening complications including epidural hematoma, subdural hematoma, brain edema, or increased intracranial pressure requiring urgent hospital treatment. 3, 1, 4

Non-Emergency Medical Evaluation Timeline

For Patients with Previous Concussions or Pre-existing Conditions

Seek specialist evaluation if symptoms persist beyond 1-6 weeks, as this population is at higher risk for prolonged recovery. 2, 5 The specific timeframe depends on:

• Children and adolescents: Refer to concussion specialist if symptoms last longer than expected recovery period (typically 1-6 weeks) 2
• Adults: Seek evaluation if symptoms persist beyond 4 weeks, as persistent postconcussion symptoms (PPCS) are defined as lasting more than 4 weeks after injury 3
• Multiple previous concussions: Immediate referral to specialist if this is the 3rd concussion in a season or if postconcussive symptoms have lasted more than 3 months 2

High-Risk Populations Requiring Earlier Evaluation

Patients with pre-existing conditions should have lower threshold for seeking care 6, 7:

• Mood disorders, learning disorders, ADD/ADHD, or migraine headaches complicate diagnosis and management 6
• History of multiple prior concussions increases risk of prolonged recovery 6, 7
• Pediatric and adolescent patients generally require longer recovery (7-10 days or more) compared to adults 3, 2

Expected Recovery Timeline

Understanding normal recovery helps identify when symptoms are not resolving appropriately:

• Most concussions: Symptoms resolve within 7-10 days 2
• Pediatric/adolescent athletes: Often require 7-10 days or longer for full cognitive recovery 3
• Persistent symptoms: 15-20% of patients develop symptoms lasting beyond 3 months 1
• Chronic concussion: Symptoms persisting beyond the expected recovery period warrant specialist evaluation 3

Appropriate Specialists for Referral

When symptoms are not resolving, referral should be made to 2, 7:

• Healthcare provider with specific training in concussion management for symptoms lasting 1-6 weeks 2
• Pediatric neurosurgeon if structural brain abnormality is suspected or neuroimaging shows abnormalities 2
• Comprehensive neuropsychological evaluation for persistent symptoms or complicated courses 6

Critical Management Principles While Awaiting Evaluation

Complete cognitive and physical rest is required until symptoms resolve 3, 1, 2:

• Never return to activity while symptomatic at rest or with exertion 3, 2
• Cognitive rest includes reduced workload and extended time for tests in students 6
• Physical rest means no sports, exercise, or activities that worsen symptoms 3, 2

Common Pitfalls to Avoid

• Do not wait to see if symptoms improve on their own if red flag symptoms are present—seek emergency care immediately 1
• Do not rely on loss of consciousness as indicator of severity, as it occurs in less than 10% of concussions 4, 6
• Do not allow premature return to cognitive or physical activities, which can exacerbate symptoms and prolong recovery 2, 6
• Do not underestimate recovery time in pediatric/adolescent patients or those with previous concussions 3, 2

Special Considerations for High-Risk Patients

Patients with previous concussions or pre-existing conditions require more conservative management 3, 6:

• Greater number, severity, and duration of symptoms predict prolonged recovery 6
• Disproportionate impact and symptom severity may indicate progressively increasing vulnerability to injury 3
• Pre-existing mood disorders, learning disorders, or migraines complicate both diagnosis and management, warranting earlier specialist involvement 6