What is the appropriate workup for a mild traumatic brain injury (mTBI), also known as a concussion?

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Last updated: April 21, 2025View editorial policy

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From the Guidelines

The workup of a concussion involves a comprehensive assessment starting with a thorough history and physical examination, as recommended by the most recent guidelines from the Centers for Disease Control and Prevention 1.

Key Components of Concussion Workup

The evaluation should include:

  • A thorough history of the mechanism of injury and symptoms such as headache, dizziness, confusion, memory problems, or loss of consciousness
  • A neurological examination focusing on mental status, cranial nerves, coordination, and balance
  • The use of standardized assessment tools like the Sport Concussion Assessment Tool (SCAT5) or the Glasgow Coma Scale to quantify symptoms and cognitive function, as supported by recent guidelines 1
  • Consideration of neuroimaging such as CT or MRI if there are concerning features like prolonged loss of consciousness, worsening symptoms, focal neurological deficits, or signs of skull fracture, although this is not routinely needed for uncomplicated concussions 1
  • Cognitive testing to establish a baseline and track recovery
  • An assessment of risk factors for prolonged recovery and evaluation for associated injuries

Importance of Recent Guidelines

The most recent guidelines, such as those from 2021, emphasize the importance of a comprehensive approach to diagnosing and managing concussions, including the use of nonpharmacological treatments for persistent postconcussion symptoms 1.

Prioritizing Morbidity, Mortality, and Quality of Life

In the workup and management of concussion, it is crucial to prioritize morbidity, mortality, and quality of life outcomes. This means ensuring that the diagnosis is accurate, ruling out more serious brain injuries, and guiding appropriate management to prevent long-term sequelae and improve patient outcomes.

Recent Evidence

Recent evidence from high-quality studies, such as those published in 2021 and 2024, supports the use of a comprehensive and multidisciplinary approach to concussion management, including the use of standardized assessment tools and nonpharmacological treatments 1.

Clinical Decision Making

In clinical practice, the workup of a concussion should be guided by the most recent and highest-quality evidence, with a focus on prioritizing morbidity, mortality, and quality of life outcomes. This approach ensures that patients receive the best possible care and outcomes.

From the Research

Concussion Evaluation and Management

The process of working up a concussion involves several steps, including:

  • Evaluation of symptoms, such as headaches, dizziness, sleep disturbance, psychiatric symptoms, and cognitive issues 2
  • Use of standardized clinical tools for assessment of acute concussion across injury settings 3
  • Removal from play or activity to prevent further injury 4
  • Symptomatic treatment, such as management of headaches and sleep disturbances 2, 4

Return to Activity Recommendations

Research suggests that a gradual increase in activity may aid in returning to normal daily activity sooner than those who avoid both physical and cognitive activity during the acute stage of a traumatic brain injury 5, 6

  • Primary care providers can play a crucial role in the clinical management of concussion, including providing guidance on return to activity 6
  • Training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes 6
  • Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest 6

Best Practices for Concussion Management

Best practices for concussion management include:

  • Rapid removal from play or activity 4
  • Symptomatic treatment 2, 4
  • Gradual return to activity, with guidance from a primary care provider 5, 6
  • Use of standardized clinical tools for assessment and management of concussion 3

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Concussion: Evaluation and management.

Cleveland Clinic journal of medicine, 2017

Research

Diagnosis and Management of Acute Concussion.

Physical medicine and rehabilitation clinics of North America, 2017

Research

Concussion Evaluation and Management.

The Medical clinics of North America, 2019

Research

Concussions: Activity Avoidance and Rest Recommendation.

Seminars in speech and language, 2019

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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