Management of Mild Concussion

Initial Management

The American Academy of Pediatrics recommends brief physical and cognitive rest for the first 24-48 hours after concussion to allow for initial recovery during the acute neurometabolic cascade 1, 2
Monitor for warning signs requiring immediate medical attention, including repeated vomiting, worsening headache, confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, loss of consciousness, or seizures 2
The American Academy of Pediatrics advises against the use of NSAIDs and aspirin immediately after a suspected head injury due to theoretical risk of intracranial bleeding 3, 4
Acetaminophen may be used for symptom management, but there is no evidence demonstrating efficacy in alleviating symptoms or shortening the course of concussion 4

Implement "cognitive rest" to prevent exacerbation of symptoms and allow for continued recovery, which may include temporary leave of absence from school or shortened school day, reduction of workloads, and postponement of standardized testing 3, 4
Avoid activities requiring concentration and attention that may exacerbate symptoms, such as video games, computer use, television viewing, and exposure to loud music 3, 4
Consider sunglasses for significant photophobia and allow adequate time to make up assignments after reintegration into school 3

Begin gradual return to activity rather than prolonged complete rest after the initial 24-48 hour rest period, with a progressive schedule and close monitoring of symptom expression 1, 2
Each step in return-to-activity protocol should take a minimum of 24 hours, starting with light aerobic exercise, followed by sport-specific training, non-contact training drills, full contact practice, and return to normal activity/competition 1, 2
Exercise should be performed below symptom exacerbation threshold, and supervised, non-contact aerobic exercise is particularly beneficial for adolescents with acute concussion 1, 2

Allow return to full activity when the athlete has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 1, 3, 5
Athletes who are symptomatic at rest and after exertion for at least 20 minutes should be disqualified from returning to participation on the day of the injury, and those who experienced loss of consciousness or amnesia should be disqualified from further participation on the day of the injury 5

If symptoms persist beyond 3 weeks, referral to a specialist in traumatic brain injury is recommended, and implement graded physical exercise, vestibular rehabilitation, and manual therapy for the neck and spine when neck pain is present 2

Avoid high-intensity physical activity during recovery as this can be detrimental, and be more conservative in treating athletes with a history of concussion or younger athletes (<18 years) due to potential catastrophic effects on the maturing brain 1, 5, 6
Continued medication use to control concussion symptoms indicates incomplete recovery, and a team approach should be used in making return-to-play decisions, involving input from athletic trainers, physicians, the athlete, and any referral sources 3, 5