Management of Mild Traumatic Brain Injury

Initial Assessment and Triage

• The American College of Emergency Physicians recommends that patients with persistent headache after head trauma should be evaluated in an emergency department for assessment of possible mild traumatic brain injury (mTBI) and other injuries, as persistent headache 24 hours after a fall with possible head trauma requires medical evaluation to rule out intracranial pathology 1, 2
• The combination of a fall mechanism, possible head impact, and persistent headache meets criteria for evaluation of potential mild traumatic brain injury, and left arm pain should also be assessed for possible fracture or soft tissue injury 1, 2

Neurological Evaluation

• A thorough neurological examination should be performed to assess for signs of intracranial injury, including mental status and cognitive function, motor and sensory function, balance and coordination, and signs of basilar skull fracture 1, 2, 3

Neuroimaging

• A non-contrast head CT scan is indicated in patients with persistent headache after trauma, even without loss of consciousness, as recommended by the American College of Emergency Physicians guidelines 1, 2
• CT imaging of the left arm may also be necessary depending on physical examination findings 2

Management Plan

• If neuroimaging is negative, patients can be discharged home with appropriate instructions, including acetaminophen for pain management, and should be advised to return to the ED immediately if experiencing worsening symptoms 1, 4
• If neuroimaging shows abnormalities, management will depend on specific findings and may require neurosurgical consultation, including admission for observation, neurosurgical intervention, blood pressure control, and reversal of anticoagulation if applicable 1, 2, 5, 6, 7

Special Considerations

• Persistent headache after head trauma may indicate postconcussive syndrome if it continues beyond 3 weeks, and medication overuse headache should be considered if the patient has been using analgesics frequently 1, 4
• Referral to a headache specialist should be considered if symptoms persist beyond 3-4 weeks 1

Common Pitfalls to Avoid

• Failing to obtain neuroimaging in a patient with persistent headache after trauma, relying solely on the absence of loss of consciousness to rule out significant head injury, and prescribing opioids for headache management should be avoided 1, 2, 4