What is the appropriate evaluation and management of a patient with a suspected concussion, including red‑flag assessment, indications for non‑contrast head CT, return‑to‑play/return‑to‑learn protocol, and analgesic recommendations?

Concussion Evaluation and Management

Immediate Recognition and Removal from Activity

Any athlete with a single concussion symptom must be immediately removed from play and cannot return to activity that same day, regardless of whether symptoms improve. 1, 2 This "when in doubt, sit them out" principle is non-negotiable—even if the athlete feels better within minutes, same-day return to play is prohibited under all circumstances. 3, 4

Key Symptoms and Signs to Recognize

Physical symptoms that indicate concussion include: 3

• Headache (most common)
• Dizziness or balance problems
• Nausea or vomiting
• Visual changes, blurred vision, or seeing stars
• Sensitivity to light or noise
• Ringing in the ears

Cognitive symptoms include: 3, 1

• Memory problems (retrograde or anterograde amnesia)
• Confusion or disorientation
• Slowed reaction time
• Concentration difficulties
• Feeling "dinged," stunned, or dazed

Important caveat: Loss of consciousness occurs in less than 10% of concussions and should NOT be relied upon to diagnose concussion. 2 Athletes frequently minimize symptoms to return to play, particularly males, so self-report alone cannot be trusted. 1

Red Flags Requiring Emergency Evaluation and CT Imaging

Obtain non-contrast head CT immediately if any of the following are present: 1, 2

• Loss of consciousness (any duration)
• Worsening or severe headache
• Repeated vomiting
• Altered mental status or deteriorating neurological status
• Seizure activity
• Focal neurological deficits
• Signs of skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak)
• Glasgow Coma Scale score ≤14
• Prolonged disturbance of conscious state (>1 minute)

Routine imaging is NOT indicated for uncomplicated concussion with normal examination. 2 CT contributes little to concussion evaluation in most cases, but must be used when suspicion of structural lesion exists. 3 If CT is negative but symptoms persist or worsen, consider MRI due to superior sensitivity for subtle traumatic brain injuries. 2

Initial Assessment Protocol

Perform structured sideline evaluation including: 1, 2

• Cervical spine evaluation (to rule out associated neck injury) 3, 1
• Standardized symptom checklist (document baseline severity for comparison) 3, 1
• Cognitive screening: Orientation, immediate and delayed memory, new learning, concentration—use Standardized Assessment of Concussion (SAC) or similar validated tool 3, 2
• Balance testing: Balance Error Scoring System (BESS), though note this is specific but not sensitive 1, 4
• Neurological examination: Cranial nerves, gait, coordination 1, 2

Monitor vital signs and level of consciousness every 5 minutes until condition improves. 3, 1 Continue monitoring for several days to assess for delayed symptoms. 3, 1

Critical pitfall: Standard orientation questions (time, place, person) are unreliable in the sporting situation compared with memory assessment. 3 Focus on retrograde and anterograde amnesia evaluation instead. 1

Acute Management

Initial 24-48 hours: Complete physical and cognitive rest. 1, 2 This means:

• No physical exertion
• Limited screen time
• Reduced cognitive demands
• Avoid activities that worsen symptoms

Analgesic recommendations: Acetaminophen only as recommended by a physician. 2 Never prescribe medications to mask symptoms for return-to-activity purposes. 2 Avoid NSAIDs in the acute period due to theoretical bleeding risk.

Provide clear written instructions on warning signs requiring emergency evaluation: 2

• Severe or worsening headache
• Repeated vomiting
• Seizures
• Increasing confusion
• Weakness/numbness
• Slurred speech
• Inability to wake

Arrange follow-up within 24-48 hours with a healthcare professional trained in concussion management. 1

Return-to-Learn Protocol

Students require cognitive rest and academic accommodations while recovering. 4 This includes: 1, 2

• Reduced workload
• Extended time for tests
• Frequent breaks
• Delayed return to full academic schedule
• Gradual reintroduction of cognitive demands

Return-to-learn should be prioritized before return-to-play, especially in pediatric patients. 5

Return-to-Play Protocol

Begin return-to-play protocol ONLY after the athlete is completely asymptomatic at rest. 3, 2 The stepwise progression requires a minimum of 24 hours at each step: 3, 2, 4

1. Complete rest until asymptomatic
2. Light aerobic exercise (walking, stationary cycling—no resistance training)
3. Sport-specific training (skating in hockey, running in soccer—no contact)
4. Non-contact training drills (more complex drills, may start progressive resistance training)
5. Full contact practice (after medical clearance)
6. Return to game play

If ANY symptoms recur at any step, drop back to the previous asymptomatic level and wait 24 hours before attempting to progress again. 3, 2

Medical clearance is required from a licensed healthcare provider trained in concussion evaluation and management before returning to play. 1, 4 When standardized assessment tools are not used, a 7-day symptom-free waiting period before return-to-play is recommended. 2

Baseline comparison when available: Compare neurocognitive testing, postural stability testing, and symptom scores to pre-injury baseline. 1 However, most concussions can be managed appropriately without neuropsychological testing. 4

Special Populations Requiring Conservative Management

Pediatric patients (<18 years): 2, 6, 5

• Require longer recovery periods
• More susceptible to prolonged symptoms
• Higher risk of catastrophic second-impact syndrome
• Must emphasize return-to-learn as well as return-to-play
• More conservative return-to-play guidelines mandatory

Athletes with concussion history: 2, 4, 6

• Higher risk of sustaining another concussion
• Slowed recovery expected
• Prolonged cognitive dysfunction more likely
• Require more conservative management

Predictors of prolonged recovery (>3 weeks): 6, 2

• Greater number and severity of symptoms at presentation
• Neuropsychological deficits at initial assessment
• Acute pain or postural instability
• History of multiple prior concussions
• Pre-existing mood disorders, learning disorders, ADD/ADHD, or migraines

Management of Persistent Symptoms

For symptoms persisting beyond 3 weeks, implement targeted interventions based on subtype: 1, 2

• Vestibular subtype: Vestibular rehabilitation
• Ocular-motor subtype: Vision therapy
• Cognitive subtype: Graded cognitive exercise
• Anxiety/mood subtype: Psychological intervention
• Cervical strain: Manual therapy
• Sleep disturbance: Sleep hygiene and targeted treatment
• Headache/migraine: Appropriate headache management

Refer to specialists including neurology, sports medicine, neuropsychology, or physical therapy as indicated. 1, 2

Critical Pitfalls to Avoid

• Never allow same-day return to play, even if symptoms resolve completely 1, 2, 4
• Never discharge based solely on normal imaging—clinical assessment remains paramount 2
• Never trust athlete self-report alone—athletes frequently minimize symptoms 1
• Never use loss of consciousness as the primary diagnostic criterion—it occurs in <10% of cases 2
• Never use the term "ding" to describe concussion—it diminishes the seriousness of the injury 3
• Never prescribe medications to mask symptoms for return-to-activity purposes 2