• The majority (80–90%) of concussions resolve in 7–10 days. However, recovery time may be longer in adolescents and children.
• Historically, patients were advised to rest (cognitively and physically) until symptoms resolved.
• Current guidelines indicate after 24–48 hours of physical and cognitive rest, patients should attempt light physical and cognitive activity as long as symptoms are stable or improving.

Return to activity

• Stage 1: Initial Rest
  • Physical and cognitive rest for 24–48 hours in a quiet environment with limited distractions (pending acute symptom resolution).
  • Complete physical and cognitive rest for over 48 hours is generally not recommended, as there is no evidence that this is beneficial.
• Stage 2: Gradual Increase in Activity Level as Tolerated
  • Perform simple tasks around the home, read, or do light physical activity (ie. walking or riding a stationary bike).
  • Symptoms usually get slightly worse with increased activity level, but these symptom changes tend to go away within a day. If symptoms are persistently worse with increased activity, return to the previous level of activity.
• Stage 3: Full Return to Activity
  • Gradually taper off extra rest breaks.
  • Do not return to risky activities where another concussion could occur, such as contact sports or dangerous job tasks, until symptoms have fully resolved.

• 30–80% of patients with mild to moderate TBI will experience at least one symptom of postconcussion syndrome (See Concussion Diagnosis).

Symptom management

• Treatment includes management of headache, sleep disturbances, and psychologic and cognitive complaints that can occur after concussion.

Headache management

• Headache is the most common symptom following a concussion.
• Acetaminophen and NSAIDs are reasonable adjuncts to cognitive and physical rest during the first few days after injury, but can be ineffective or cause medication-overuse headaches if used regularly after the initial stages of injury.
• Amitriptyline has been widely used for post-traumatic tension-type headaches, and for symptoms such as irritability, dizziness, depression, fatigue, and insomnia.
• An inpatient program of repetitive IV dihydroergotamine and metoclopramide may provide relief of refractory chronic post-traumatic headaches.

• Patients at risk for immediate complications from head injury, including patients with:
  • GCS <15
  • Abnormalities on head CT (eg, intracranial hemorrhage, ischemia, mass effect, midline shift)
  • Seizures
  • Bleeding diathesis or oral anticoagulation
  • Neurologic deficit
  • Recurrent vomiting.

• Outpatient observation may be permitted for the patient whose neurologic condition is unlikely to deteriorate.
• There is substantial evidence that patients with a GCS = 15, normal examination and head CT, and no predisposition to bleeding are unlikely to suffer subsequent neurologic deterioration.

1. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.

   
   

2. Youmans and Winn Neurological Surgery, 347, 2860-2867.e5 (Mild Traumatic Brain Injury in Adults and Concussion in Sports)

   
   

3. Rosen’s Emergency Medicine: Concepts and Clinical Practice, Chapter 34, 301-329. e5 (Head Trauma)

   
   

4. Evans RW, Christopher T Whitlow CT. (2019). Acute mild traumatic brain injury (concussion) in adults. UpToDate. Cited August 12, 2019.