Concussion (mild traumatic brain injury)
Last reviewed: May 2026
Outline
Concussion is a clinical diagnosis defined by the acute onset of neurological symptoms—physical, cognitive, emotional, and sleep-related—following direct or indirect traumatic force to the head, resulting in transient shear stress to brain tissue. [1-2] Headache is the most common symptom. Most patients recover within 2–4 weeks, though approximately one-third of untreated adolescents may have symptoms persisting beyond 4 weeks. [3-4]
1. History
- Mechanism of injury: Direct blow vs. indirect force (whiplash, blast); determine intensity (fall height, collision speed, ejection from vehicle) [5]
- Temporal relationship: Symptom onset immediately or within minutes to hours of injury; symptoms may evolve over days [2][5]
- Symptom characterization: Headache (most common), pressure in head, dizziness, nausea, light/noise sensitivity, feeling "foggy," difficulty concentrating, fatigue, visual disturbance, emotional lability [5-6]
- Loss of consciousness (LOC): Duration (brief vs. >30 seconds); LOC is not required for diagnosis [1][7]
- Amnesia: Retrograde (events before injury) and anterograde (events after); duration matters for CT decision rules [7-8]
- Important negatives: Seizure activity, neck pain, vomiting, worsening headache, anticoagulant use, prior concussions, pre-existing migraine or psychiatric history [9-10]
2. Alarm Features
- GCS <15 at 2 hours post-injury [7][11]
- Suspected open or depressed skull fracture [7]
- Signs of basilar skull fracture: raccoon eyes, Battle sign, hemotympanum, CSF otorrhea/rhinorrhea [7-8]
- Repeated vomiting (≥2 episodes) [7-8]
- Seizure post-injury [12]
- Focal neurological deficit [11]
- Deteriorating level of consciousness [12]
- Severe or worsening headache [12]
- LOC >30 seconds [12]
- Coagulopathy or anticoagulant use [11][13]
- Dangerous mechanism (pedestrian struck, ejection from vehicle, fall >3 ft or >5 stairs) [13]
3. Medications
Acute symptom management (no concussion-specific medications exist): [12]
- Headache: Acetaminophen and NSAIDs (ibuprofen, naproxen) as first-line abortive therapy; limit use to <10 days/month to avoid medication-overuse headache [9][14]
- Migraine-like headache: Triptans (sumatriptan, rizatriptan) if OTC analgesics fail [9][14]
- Nausea: Ondansetron commonly used in the ED [12]
- Sleep disturbance: Melatonin is commonly recommended though evidence is limited; sleep hygiene counseling is first-line [8][15]
- Prophylactic headache therapy (if >10 headache days/month): Amitriptyline, propranolol, candesartan, topiramate, or venlafaxine [9][14][16]
Medications to avoid: Opioids, barbiturates, oral ergot alkaloids. [14] Chronic NSAID/acetaminophen use is discouraged due to rebound headache risk. [9][12]
4. Diet
- Hydration: Maintain adequate fluid intake; dehydration may exacerbate headache and cognitive symptoms [9]
- Regular meals: No skipped or delayed meals; irregular eating may worsen headache [9]
- Alcohol avoidance: Recommended during recovery; alcohol may impair neurological recovery and exacerbate symptoms [9][17]
- Omega-3 fatty acids (DHA/EPA): Strongest emerging evidence supports potential neuroprotective benefit, particularly prophylactically in athletes exposed to repetitive head impacts; however, no definitive human clinical trial evidence yet supports routine use for treatment [18-20]
- Whole food diet: Rich in antioxidants, micronutrients, and fiber is generally recommended for brain health during recovery [17]
- Caffeine: Use cautiously; may contribute to medication-overuse headache patterns [9]
5. Review of Systems
- Neurological: Headache, dizziness, visual changes, photophobia, phonophobia, tinnitus, numbness/tingling
- Cognitive: Difficulty concentrating, memory problems, mental fog, slowed processing [5]
- Emotional/Behavioral: Irritability, sadness, anxiety, emotional lability [1][3]
- Sleep: Insomnia, hypersomnia, difficulty falling asleep, fatigue [1-2]
- Vestibular: Vertigo, motion sensitivity, balance problems [5][21]
- Cervical: Neck pain, stiffness (cervical injury frequently coexists) [3][12]
- Constitutional: Fatigue, drowsiness [5]
6. Collateral History and Family History
- Bystander report: Witnessed LOC, confusion, blank stare, stumbling gait, lying motionless, seizure activity [5]
- Prior concussion history: Number, timing, and recovery duration of previous concussions; history of prolonged recovery [1][9]
- Pre-existing conditions: Migraine, ADHD, learning disabilities, anxiety/depression, sleep disorders [9-10]
- Family history: Migraine, psychiatric disorders, sudden cardiac events (if ECG abnormalities noted) [22]
- Social context: Sport type and level, academic demands, psychosocial stressors, substance use [3][9]
7. Risk Factors
For concussion
- Contact/collision sports (football, hockey, rugby, soccer) [1]
- Prior concussion history (strongest risk factor for future concussion) [1]
- Female sex (higher symptom reporting) [9]
- Youth and adolescent age [12]
For persisting symptoms (>4 weeks)
- High initial symptom burden (strongest predictor) [3][9]
- Pre-existing psychiatric history (anxiety, depression) [9-10]
- Prior concussions/TBIs [9]
- Female sex [9-10]
- Migraine history [9-10]
- Neck pain at presentation [10]
- Pre-existing sleep problems [10]
- Pessimistic recovery expectations, fearful avoidance of activity [9]
8. Differential Diagnosis
- Intracranial hemorrhage (epidural, subdural, subarachnoid, intraparenchymal): Cannot-miss; <10% of mTBI have CT abnormalities, ~1% require neurosurgery [8]
- Skull fracture (open, depressed, basilar) [7]
- Cervical spine injury: Frequently coexists; produces overlapping symptoms (dizziness, headache) [3][12]
- Vestibular injury (BPPV, labyrinthine concussion) [21]
- Migraine (with or without aura): May be triggered by or mimic concussion [3]
- Syncope/cardiac arrhythmia: Consider if LOC preceded the fall [7]
- Seizure disorder: Primary seizure vs. post-traumatic seizure [7]
- Malingering/symptom exaggeration: Particularly in medicolegal or sport contexts
- Anxiety/panic disorder: Symptoms overlap significantly with post-concussive symptoms [3]
- Cervicogenic headache: From concomitant whiplash injury [3][12]
9. Past Medical History
- Previous concussions (number, timing, recovery duration) [1][9]
- Migraine or chronic headache history [9-10]
- Psychiatric history: anxiety, depression, PTSD [9-10]
- Learning disabilities, ADHD [9]
- Sleep disorders [10]
- Anticoagulant/antiplatelet use [11][13]
- Prior neurosurgery or intracranial pathology
- Chronic medical conditions affecting recovery (e.g., chronic pain syndromes)
10. Physical Exam
Vital signs: Heart rate, blood pressure (autonomic dysfunction may cause transient elevations) [23]
Focused exam
- Neurological: GCS, cranial nerves, pupillary response, motor/sensory exam, coordination (finger-to-nose), gait assessment [5]
- Cervical spine: Palpation for tenderness, range of motion, spurling test [3]
- Balance: Modified Balance Error Scoring System (mBESS)—tandem stance, single-leg stance with eyes closed for 20 seconds [5]
- Vestibular-oculomotor: Smooth pursuits, saccades, near-point convergence, vestibulo-ocular reflex (VOR); abnormalities suggest vestibular-oculomotor dysfunction [5]
- Cognitive screening: Orientation, immediate memory (word list recall), concentration (digits backward, months in reverse), delayed recall (SAC) [5][24]
- Scalp/skull: Palpation for hematoma, lacerations, step-off deformity, signs of basilar fracture [7]
Observable signs of concussion: Lying motionless after injury, stumbling gait, blank/vacant stare, disorientation, confusion [5]
11. Lab Studies
- Routine labs are generally not indicated for uncomplicated concussion [3]
- Coagulation studies (INR, platelet count): If on anticoagulants/antiplatelets or suspected coagulopathy [11][13]
- Blood glucose: Rule out hypoglycemia as contributor to altered mental status
- Blood alcohol level/toxicology screen: If intoxication suspected (affects clinical assessment) [8]
- Serum biomarkers (GFAP, UCH-L1): FDA-cleared to help determine need for CT in adults; however, guidelines currently recommend against routine clinical use for concussion diagnosis [2-3]
- hs-CRP: Limited evidence for predicting post-concussion syndrome; not recommended routinely [7]
12. Imaging
CT head (non-contrast) is the imaging modality of choice in the ED: [8]
- Not routinely indicated for concussion; <10% of mTBI patients have CT abnormalities [3][8]
- Use validated clinical decision rules to determine need:
- Canadian CT Head Rule (CCHR): High-risk criteria (GCS <15 at 2 hours, suspected skull fracture, basilar fracture signs, ≥2 vomiting episodes, age ≥65) and medium-risk criteria (retrograde amnesia ≥30 min, dangerous mechanism); 100% sensitivity for neurosurgical lesions with 76% specificity [7-8]
- New Orleans Criteria (NOC): Headache, vomiting, age >60, intoxication, short-term memory deficit, trauma above clavicles, seizure; 100% sensitivity but only 25% specificity [7-8]
- PECARN (pediatric): For children <18 years [12]
MRI: Not indicated acutely; consider if symptoms persist >2 weeks with risk factors for neurosurgical lesion, or for evaluation of repetitive concussions. [8] Can identify hemorrhagic axonal injury not seen on CT. [8]
When imaging is unnecessary: GCS 15, no high- or medium-risk features on validated decision rules, normal neurological exam [3][13]
13. Special Tests
- SCAT6 (ages ≥13) / Child SCAT6 (ages 8–12): Standardized multimodal sideline assessment tool; includes symptom checklist, SAC cognitive screen, mBESS balance testing, neurological screen; takes ≥10 minutes; most accurate within 72 hours of injury [5][25]
- SCOAT6 / Child SCOAT6: Office-based assessment tool for evaluations >72 hours post-injury; guides ongoing management [3][5]
- mSIT Plus (mini Symptom Index Tool + modified VOMS): 6-question symptom tool with vestibular-oculomotor screening; AUC 0.94, sensitivity 88%, specificity 92%; can be completed in 2–3 minutes [6]
- Vestibular/Ocular Motor Screening (VOMS): Assesses smooth pursuits, saccades, near-point convergence, VOR; abnormalities beyond 10 days warrant vestibular PT referral [3][6]
- King-Devick Test: Rapid number naming test assessing saccadic eye movements
- ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing): Computerized neurocognitive testing; most useful with baseline comparison
14. ECG
ECG is not part of routine concussion evaluation but may be relevant in specific scenarios:
- Concussion can cause transient cardiovascular autonomic dysfunction: elevated resting heart rate and blood pressure within 48 hours, typically resolving within 24–48 hours [23][26]
- QTc prolongation has been reported after mild head trauma in pediatric patients; self-limiting but warrants awareness [22]
- ECG changes in severe TBI include ST-segment changes, T-wave inversions, "cerebral" T waves, and QT prolongation [27-28]
- Consider ECG if: syncope preceded the fall (to evaluate for arrhythmia as cause), irregular heart rhythm on exam, or chest trauma coexists [22]
15. Assessment
Clinical summary: Concussion is a clinical diagnosis based on temporal relationship between an appropriate mechanism and symptom onset. No single symptom, sign, or test definitively rules in or excludes concussion. [1][5]
Severity stratification
- The strongest predictor of prolonged recovery is the initial symptom burden (number and severity) [3][9]
- Most patients recover within 2–4 weeks [2][4]
- ~10–20% of adults and ~33% of untreated adolescents develop persisting symptoms (>4 weeks) [3][29]
Typical vs. atypical presentations
- Typical: Headache, dizziness, cognitive fog, fatigue, light/noise sensitivity
- Atypical: Predominantly emotional symptoms, isolated sleep disturbance, delayed symptom onset (hours after injury)
- Symptoms may overlap with pre-existing conditions (migraine, anxiety) [3]
Complications: Persisting post-concussion symptoms, second impact syndrome (rare, catastrophic—primarily in adolescents), chronic traumatic encephalopathy (CTE, associated with repetitive head impacts over years) [1][3]
16. Treatment Plan
Initial management (first 24–48 hours)
- Relative rest (not strict "cocooning"): Reduced activities of daily living, limited screen time [9][25]
- Light-intensity physical activity (e.g., walking) is encouraged even within the first 24–48 hours, as tolerated, to a level that does not more than mildly exacerbate symptoms [9][25]
- Symptom-limited aerobic exercise early after injury reduces the incidence of persisting symptoms [3]
Symptom management
- Acetaminophen or ibuprofen for headache (avoid chronic use) [9][12]
- Sleep hygiene counseling; melatonin may be considered [8][15]
- Antiemetics for nausea as needed [12]
- Cervical physical therapy if cervicogenic component identified [3][12]
- Vestibular rehabilitation for persistent dizziness/balance problems [12][21]
Graduated return to activity: [12][25]
- Symptom-limited activity (24–48 hours post-injury)
- Light aerobic exercise (walking, stationary cycling)
- Sport-specific exercise (no contact)
- Non-contact training drills
- Full-contact practice (after medical clearance)
- Return to competition
Each step requires minimum 24 hours; advance only if symptoms do not worsen more than mildly (≤2-point increase on 0–10 scale, resolving within 1 hour). [9][25] Full return to school/learn should precede unrestricted return to sport. [4][30]
Persisting symptoms (>4 weeks): Referral to multidisciplinary concussion specialist; consider targeted therapies—vestibular PT, vision therapy, cognitive behavioral therapy, cognitive rehabilitation, pharmacologic headache prophylaxis [3][21][29]
The following figure summarizes the evidence for pharmacological interventions in mTBI, stratified by timing and age:
17. Disposition
Discharge criteria (majority of concussions)
- GCS 15 with improving or stable symptoms
- Normal neurological exam
- CT not indicated or CT negative
- Reliable companion available for home observation [8]
- Patient/family educated on return precautions
Admission/observation criteria
- GCS <15 or not improving to 15 within 2 hours [7]
- Abnormal CT findings (intracranial hemorrhage, fracture) [8]
- Persistent vomiting, worsening symptoms, or neurological deterioration [8]
- Anticoagulant use with positive CT or high-risk features [13]
- No reliable home observation available
- Intoxication precluding adequate assessment [8]
Specialist consultation triggers
- Symptoms persisting >4 weeks → concussion specialist/multidisciplinary team [3][9]
- Abnormal vestibular-oculomotor findings beyond 10 days → vestibular PT [3]
- Significant mood/anxiety symptoms → mental health referral [9]
- Abnormal CT → neurosurgery consultation [8]
18. Follow-Up / Return Precautions
Follow-up timing
- Early medical follow-up within 1 week of injury, then weekly, facilitates recovery [3]
- At-risk patients (high symptom burden, psychiatric comorbidity) may benefit from weekly visits over the first month [9]
Return precautions (provide written instructions): [8]
- Return immediately for: worsening headache, repeated vomiting, increasing confusion or drowsiness, seizure, weakness or numbness in extremities, slurred speech, unequal pupils, inability to recognize people/places, unusual behavior, loss of consciousness
- Companion should monitor for first 24 hours; wake patient every 2–4 hours overnight to check for deterioration [8]
Patient counseling
- Most concussions resolve within 2–4 weeks; reassurance and education improve outcomes [1][3]
- Avoid contact sports, high-risk activities, and driving until medically cleared [25]
- Avoid alcohol and recreational drugs during recovery [9]
- Prolonged strict rest is counterproductive; gradual return to activity is beneficial [3][9]
- Academic accommodations (extra time, reduced workload, breaks) may be needed; a provider letter facilitates this [3][9]
Expected recovery: Median symptom-free by ~14 days; return to school ~8 days; unrestricted return to sport typically within 1 month (~20 days average). [3][25]
The following table summarizes current guideline consensus on concussion management:
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