Recommendations

Key Recommendations

Rest alone accounts for the resolution of symptoms in the vast majority of cases. Confusion typically clears within 24 hours in cases of uncomplicated mild traumatic brain injury (TBI) (i.e., no brain lesions found on computed tomography [CT] scan) diagnosed in the emergency room.[97] Postconcussion symptoms, including somatic (e.g., headaches, dizziness), cognitive (e.g., poor attention and memory), and emotional (e.g., irritability, depression) symptoms, gradually resolve in most patients with mild TBI during the 12 weeks following injury.[97] However, a subset of patients may have ongoing symptoms. For further details, see  Prognosis.

Referral to individual medical specialists or to a specialized multidisciplinary mild TBI clinic is appropriate for patients with persistent symptoms (lasting more than 4-6 weeks) who do not respond to treatment in a primary care setting.​[69][93][98]

All patients with mild TBI should temporarily discontinue activities that present a risk of additional head injury and consequently second impact syndrome.[4] Specifically, to mitigate the risk of repeated mild TBI, patients should be counseled to not return to activities that involve a relatively high risk of head impact exposure (e.g., collision sports) until they are clinically recovered.[3]​​​[98][99]​​​

Referral to the hospital

If the patient presents in the community, consider whether referral to the emergency department is warranted, for assessment and consideration of the need for admission.

If a patient presents at the hospital, the presence of any one or more of the following risk factors is an indication to arrange imaging of the brain and consider the need for admission:

  • A Glasgow Coma Scale (GCS) score <15 (or after imaging, a GCS score that has not returned to 15 or their pre-injury baseline, regardless of the imaging results)

  • Post-traumatic seizure

  • Signs of skull fracture or penetrating injury

  • Loss of consciousness[66]

  • Severe headache

  • Persistent vomiting

  • Meningism

  • Cerebrospinal fluid leak

  • Suspicion of ongoing post-traumatic amnesia

  • A high-risk mechanism of injury (e.g., road traffic accident, significant fall)

  • Suspected nonaccidental injury

  • A coagulopathy

  • Receiving anticoagulant therapy[67]​​

  • Previous brain surgery

  • Current drug or alcohol intoxication

  • Shock

  • Focal neurologic deficit since the injury

Rest

Relative rest for the first 24-48 hours after a mild TBI is recommended.​[5][93][98]​​[100]​​​​ Complete rest, such as lying in a dark room and avoiding all sensory stimuli (e.g., reading, interaction with others, etc.) does not accelerate recovery and is therefore not advisable.[5][98][100][101]​​​

Physical rest

After an initial period of relative rest and symptom stabilization, patients should be encouraged to gradually resume normal daily activities as tolerated and in a stepwise fashion.[4][5][93][98]​​​​​​ Specific guidelines should be consulted for detailed guidance regarding return to school, sports, and military service.[5][98][102]​​​ Physical activity/exercise should be stopped if symptom exacerbation is more than mild and brief, and may be resumed once symptoms have returned to the prior levels.[5] Clinicians should inform their patients that mild symptom exacerbation during physical activity, prescribed aerobic exercise treatment, or cognitive activity is typically brief (under an hour) and does not delay recovery.[5] Patients can systematically advance their exercise intensity based on the degree of symptom exacerbation experienced during the prior bout of aerobic exercise.[5]

Cognitive rest

Cognitive rest includes school and work activities.[5]​ Patients should gradually return to daily activities (including screen time) as tolerated and in a stepwise fashion.[4][5][93][98]​​​​ Attentional capacities should be closely monitored, particularly among children. Cognitive exertion should be halted if symptom exacerbation is more than mild and brief, and may be resumed once symptoms have returned to pre-injury levels.[5]

Return to play

Symptoms and signs of mild TBI should be resolved before returning to sport (but absolute physical and cognitive rest after sport-related concussion should be avoided).[3]​ Return to play is an individualized, gradual, stepwise increase in physical demands and sport-specific activities without return of symptoms before the final introduction of exposure to contact.[3]

Light physical activity and prescribed sub-symptom threshold aerobic exercise treatment can be used therapeutically in a safe and supervised environment.[5][103] Athletes should also demonstrate psychological readiness for returning to play.​[3]

Education and return to school/activity/work plan

Explaining to patients the pathophysiology, typical sequelae, recovery timeline, and potential complications is effective in aiding recovery, and in preempting potential anxiety and depression. This should be accompanied by individualized goal-setting for return to, or increase in, activity or work. Patients should be advised on these aspects in the presence of family and care providers.[104][105][106]

Taking appropriately implemented rest breaks throughout the day may be appropriate. Further accommodations may include:[5]

  • Modified school attendance

  • Frequent rest breaks from cognitive/thinking/deskwork tasks throughout the day

  • Limited screen time on electronic devices

  • A reduced workload

  • Extensions on assignments and projects

  • Delaying tests and/or permitting additional time to complete them

Specific considerations for children

Every attempt should be made to keep children and adolescents in school, even if on a modified schedule. This may require close collaboration between physicians, school, and family, and an individualized approach to returning the child to full participation.[93] Children should never return to play the same day.[37][107]

Analgesia

Taking analgesics is acceptable, if patients feel it is necessary to help control their headaches. If a patient is able to manage the headache with rest and relaxation, this is always preferable. The management of headaches is along standard lines, but advising patients about the nature and prognosis of mild TBI is important to reduce anxiety, which may exacerbate headache symptoms.[55]

Patients who use analgesics should be cautioned that taking these drugs for extended periods of time (≥2 consecutive weeks or more than 15 days per month) is not advised because medication overuse may contribute to headache after mild TBI.[55][108]​​​

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