After receiving the prehospital provider's report, you note that the patient is complaining of headache, back pain and abdominal pain. He has no significant past medical history and takes no medications. Pertinent findings on exam include a slight tachycardia, an abrasion on his forehead, mild tenderness in his upper abdomen, and diffuse tenderness over his lumbar spine. He is alert and oriented but cannot remember any events since the accident. Otherwise, he has a normal neurologic exam.
Initial assessment of the mTBI patient in the ED is focused on identifying patients who may require medical or neurosurgical intervention for the treatment of increased intracranial pressure or an expanding mass lesion. Patients with “red flag” conditions such as altered mental status, papillary asymmetry, seizures, repeated vomiting, double vision, worsening headache, motor or sensory deficits, or ataxia should have an emergent non-contrast head CT scan performed. See for further imaging recommendations.
Patients with intra-cranial imaging abnormalities or declining mental status require immediate neurosurgical consultation. Worsening mental status is typically due to increasing intracranial pressure (ICP) leading to compromised cerebral blood flow and oxygen delivery. For these patients, airway management with endotracheal intubation to protect against aspiration as well as to control ventilation should be considered. Non-surgical management also includes mitigating ICP increases by raising the head of the bed to 30 degrees and treatment with hyperosmolar agents such as IV mannitol. Finally, brief periods of hyperventilation can also reduce dangerous ICP increases. Mechanistically, hyperventilation causes vasoconstriction and reduces intracranial pressure by decreasing cerebral blood flow. Overaggressive hyperventilation can result in ICP decreases at the expense of adequate tissue perfusion. Therefore, prolonged hyperventilation should be used only when other therapies have failed.
You obtain imaging studies, including computed tomography of head, neck, abdomen and pelvis which reveal no traumatic injuries. After returning from radiology, the patient does not recall meeting you. Although is head CT did not reveal a traumatic injury, he is admitted for observation overnight due to his persistent anterograde amnesia. He has an uneventful night and his amnesia resolves. He receives detailed discharge instructions that include a description of “red flag conditions”, common post-concussive symptoms, and reassurance that the vast majority of patients recover completely from concussion. He is advised to avoid activities that exacerbate his symptoms, to take acetaminophen as needed for headache, and to follow up with a local concussion clinic in one week if he is having any persistent discomfort from his concussion. He is accompanied home by his fiancée who will stay with him over the next 24 hours.
Acute Phase: Within One Week of Injury
After evaluating for “red flag” signs and symptoms (see ED Priorities
), a thorough history of symptoms including loss or alteration of consciousness, headache, irritability, unsteadiness, vertigo, photophobia, or phonophobia should be obtained. The physical exam includes a focused neurological exam including assessment of cranial nerves, postural instability, visual function, and mental status. Non-contrast head CT should be obtained when indicated (see ). Neurosurgical consultation is necessary for patients with imaging abnormalities. These patients are often admitted for 24 hours for ongoing mental status monitoring and repeat head CT prior to discharge. Patients in whom imaging was not indicated or with a normal head CT may be safely discharged 56-58
Discharge instructions for mTBI patients include two principle elements: symptoms requiring immediate re-evaluation (see ED Priorities
) and post-concussive symptom education. Post-concussive symptoms include headache, sleep disturbances, vertigo, nausea, fatigue, sensitivity to light or noise, attention and concentration problems, depression, and emotional lability. The vast majority of adults with post-concussive symptoms recover within 3-12 months 59
. Early patient education that includes likely post-concussive symptoms and reassurance about an expected positive recovery has been shown to speed recovery and decrease post-concussive symptoms 60-62
. Headache should be managed with acetaminophen. Non-steroidal anti-inflammatory drugs (NSAIDs) may be used in patients with negative neuroimaging but should be deferred until 48 hours after injury if imaging was not obtained. In addition, narcotics should be avoided in the treatment of post-traumatic headache.
Pharmacologic treatment of other post-concussive symptoms is not recommended in the acute phase. Rather, patients with symptoms other than headache should be advised to rest and encouraged to return to normal activity as soon as possible. However, individuals whose normal activity includes a high risk for re-injury should have careful evaluation of their symptoms and exam findings with consideration of their specific activities that result in a high injury risk. Specific limitations on activity may be recommended for these patients to mitigate their individual risk. Patients reporting fatigue may be given a graded return to work or activity. For patients with normal activities involving significant physical activity, exertional testing may be performed. If this results in a return of symptoms, a monitored progressive return to these activities as tolerated should be recommended 1
Two weeks after the initial injury, the patient continues to suffer from frequent headaches that are only slightly relieved by acetaminophen. He also complains of increased irritability, sleepiness, and difficulty concentrating. During an initial follow up visit, a detailed history and physical examination fails to reveal comorbid psychiatric or physical problems including PTSD, depression, substance abuse, hypertension, cervical spine abnormalities, sinus infections, or visual acuity deficits. However, the patient indicates that he has not been sleeping well due to persistent headache. He is started on an NSAID for his headaches, and provided with education regarding good sleep hygiene and relaxation techniques. He is also advised to begin a regular exercise program. A follow up appointment is scheduled in 4 weeks.
Initial Management of Post-concussive Symptoms
This section provides an overview of treatment for the initial treatment of patients with mTBI and symptoms lasting more than one week after injury. Patients with a delayed initial presentation should also be treated according to these guidelines. Detailed recommendations for the evaluation and treatment of specific symptoms can be found in the VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI 1
Symptom classification and goals of therapy
Post-concussive symptoms generally fall into three categories: physical, cognitive, and behavioral or emotional. Typical physical symptoms include headache, nausea, vomiting, dizziness, fatigue, blurred vision, sleep disturbances, light or noise sensitivity, balance problems, and transient neurologic abnormalities. Cognitive symptoms may occur with attention, concentration, memory, processing speed, judgment, and executive functioning. Behavioral/emotional symptoms include depression, anxiety, agitation, irritability, and aggression.
Because there is an incomplete understanding of the etiology of symptoms after mTBI, the goal of intervention for post-concussive symptoms is to improve identified problems rather than affect a cure. It is believed that symptoms resulting from mTBI are inter-related and alleviation of one symptom often leads to improvement in others. Post-concussive symptoms are also common to many other psychiatric ailments including depression, anxiety disorders, post-traumatic stress disorder, and substance abuse disorders. Indeed, there is substantial evidence that affective disorders, post traumatic stress disorder (PTSD), and substance abuse disorders are often associated with mTBI 59, 63-64
. These disorders are also associated with higher rates of persistent post-concussive symptoms 65-66
. Consequently, aggressive treatment of any comorbid psychiatric illness may help to improve post-concussive symptoms.
Patient evaluation should include a thorough history, physical exam, and review of the medical record. A review of sleep habits is particularly important as poor sleep may contribute to symptoms including headache, fatigue, anxiety, irritability, depressive thoughts, poor concentration, memory difficulties, and poor decision making. TBI patients should also be screened for psychiatric conditions including PTSD, depression, and substance abuse disorders. Low yield diagnostic testing should be minimized. There is limited evidence to support the utility of comprehensive neuropsychological/cognitive testing within the first 30 days of mTBI and a focused clinical interview is sufficient to assess for cognitive difficulties 67
. Laboratory studies including electrolytes, a complete blood count, and thyroid function testing may be useful, particularly when evaluating behavioral and cognitive symptoms. Imaging studies are of limited use.
Physical symptoms should prompt a search for treatable causes. Screening patients with headaches for preexisting headache conditions, hypertension, cervical spine abnormalities, sinus infections, and visual acuity deficits may provide useful avenues of treatment. Symptoms related to dizziness including poor coordination, unsteadiness, vertigo, or loss of balance, may be due to medication effects, orthostatic hypotension, or peripheral vertigo. Nausea may be caused by medications or gastro-esophageal reflux disease. Nasal polyps, sinus infection, and traumatic injury to the lingual or olfactory nerves may cause appetite changes. Physical injuries to the eye including corneal abrasions, lens dislocation, retinal detachment, and optic nerve injury should be considered in the evaluation of post-concussive visual complaints. Ear abnormalities including infection, tympanic membrane rupture, and auditory nerve injury may lead to phonophobia.
General Treatment Guidelines
Treatment of physical symptoms includes treating the underlying causative or contributory conditions. Interventions targeting specific patient complaints such as sleep hygiene education, physical therapy, relaxation, and modification of the environment should be used. Moreover, medications may be used to relieve pain, enable sleep, and reduce stress 1
. Cognitive deficits are often measurable within 30 days of mTBI but generally return to normal within the same period 68-70
. Unfortunately, many patients continue to have subjective cognitive complaints 9, 71-75
. Educational and cognitive-behavioral interventions consistently improve subjective cognitive complaints 61, 76-79
. Behavioral symptoms may improve with psychotherapeutic and pharmacological interventions. Treatment should be based upon severity and nature of the symptom presentation. Patients with atypical symptoms or with significant suspected or confirmed comorbid illnesses may benefit from specialty referral or consultation. Finally, “red flag” conditions indicating an acute neurologic condition requiring urgent neurologic or neurosurgical intervention should prompt emergent transfer to a medical facility with an appropriate level of care.
The primary goal of pharmacological therapies for mTBI is symptomatic improvement. Currently, disease altering therapies are not available. Drug therapy for mTBI symptoms should follow several general principles. Medications that lower the seizure threshold such as buproprion and some anti-psychotic medicines should be avoided. Similarly, medications such as lithium, anti-cholinergic agents, benzodiazepines and others can cause altered mental status and should also be avoided. Starting doses should be as low as possible and titrated to effect under close monitoring. Conversely, maximal tolerated dosing should be trialed before switching to a new agent to avoid under treatment. Patients should be advised to avoid alcohol, caffeine, and herbal supplements. Limited doses of medications with significant toxicity in intentional overdoses such as tri-cyclic antidepressants should also be considered because suicide risk is high in brain injured patients. Finally, patients should be monitored closely for medication interactions and toxicity.
Medication therapy for patients in the first week after injury should be reserved for the treatment of headache only. Acetaminophen is the agent of choice. NSAIDs should not be used until 48 hours after injury unless there is normal neuroimaging data for the patient. Other immediate post-concussive symptoms should not be treated as they typically resolve spontaneously within the first week of injury.
Headache is the most common symptom after mTBI affecting over 90% of patients. Post-traumatic headaches commonly fall into one of three categories: tension, migraine, or a combination of the two. The evaluation of post-traumatic headache should include assessment for neurologic findings suggestive of serious intra-cranial abnormalities. Focal neurologic deficits should prompt additional urgent investigation with appropriate neuroimaging. A medication review for patients with symptoms lasting more than two weeks is also important as rebound headaches are common in with daily acetaminophen or NSAID use. Similarly, withdrawal from caffeine or nicotine may also result in headache. Patients who state that their headache improves only with opiates should be referred to a pain or headache specialist. Headache symptoms often improve after treatment of comorbid conditions such as sleep disturbances, anxiety, and depression.
Pharmacologic treatment should be selected based on the type of headache suspected. Similar to the opiate dependent patients above, those with symptoms that do not improve within 3 months of initiating therapy should be referred to a headache or pain specialist. Episodic tension type headaches may be treated with aspirin, acetaminophen, or NSAIDs. These medications typically work best when combined with other treatment modalities such as a regular exercise program, relaxation techniques, or biofeedback. Combination medications that include caffeine or a sedative may be more effective but also have a greater likelihood of rebound headache.
Migraine treatment is divided into the prevention and management of acute episodes. Awareness and avoidance of precipitating events should be encouraged. Abortive medications for acute episodes include sumatriptan and zolmatriptan. These medications are most effective when used early in the course of the episode. Some patients with established migraines may require rescue medications to break their headache. Examples of effective rescue medications include ketorolac, butorphanol, opiods, prochlorparazine, and promethazine. Patients with migraine headaches that occur more than once a month should be placed on prophylaxis. First line agents for prophylaxis include metroprolol and toprimate. Prophylactic agents may take as long as three months to become maximally effective. Finally, mixed headache types may require separate agents for treatment of the tension and migraine components.
Disequilibrium and Vertigo
Up to 30% of patients with mTBI complain of disturbed equilibrium or vertigo 87
. Despite this, symptoms do not correlate with objective evidence after the first week after injury 88
. A thorough medication review should be performed for all mTBI patients complaining of dizziness. Medications such as stimulants, benzodiazepines, tricyclics, monoamine oxidase inhibitors, tetracyclics, neuroleptics, selective serotonin reuptake inhibitors, beta blockers, and cholinesterase inhibitors may cause or exacerbate dizziness. Vestibular suppression may be useful in the acute phase but has not proven effective for persistent symptoms 89
. Vestibular suppressants should only be used if the symptoms significantly limit the patient's functional activities as they may result in delayed improvement 90-91
. Meclizine is the first agent recommended. Scopolamine and dimenhydrinate may be used if meclizine fails. Benzodiazepines should only be used after careful consideration of their sedating and habit-forming properties. Trials should be limited to two weeks duration.
Fatigue and Sleep Disturbances
Another common symptom after mTBI is fatigue, which may be due to central nervous system dysfunction, sleep disturbances or depression. Proper assessment of this symptom requires a thorough history of pre- and post-injury levels of activity. There are also several validated instruments to objectively measure fatigue 92-93
. Physical causes of fatigue may also be assessed with laboratory testing including metabolic panel, a complete blood count, and thyroid function testing. Review of the patient's medication history, alcohol, caffeine, and illicit drug use should also be performed as all of these may result in fatigue. Prior to initiating medications for fatigue conservative measures such as education of the patient, initiating an exercise program, as well as referring the patient for physical or cognitive behavioral therapy should be trialed. There is limited evidence for the efficacy of stimulant treatment for fatigue after mTBI. Commonly used agents include modafanil, methylphenidate, and amantadine. These medications should only be used if symptoms have lasted more than 4 weeks, the patient does not have substance abuse issues, and addressing other factors mentioned in this section have failed to improve symptoms. Trials of these medications should last at least 3 months.
Sleep disturbances are common after mTBI. The goal of therapy is to restore a regular, unbroken night-time sleep pattern and improve the perception of sleep quality. Any drug therapy for sleep disturbances should be accompanied by education regarding good sleep hygiene. Furthermore, concomitant primary sleep disorders such as obstructive sleep apnea, restless legs syndrome, and narcolepsy should be appropriately treated. In the acute phase, short term treatment with non-benzodiazepine sleep medications such as zolpidem may be helpful. Prazosin may be used in patients with nightmares or agitation during sleep.
The patient returns to the concussion clinic 4 weeks after his initial visit and 6 weeks after his accident. He reports that he instituted the sleep hygiene recommendations given to him on the prior visit and that his headaches, sleepiness, irritability, and concentration difficulties subsequently resolved. He has required NSAIDS with decreasing frequency and has not had a headache in the last two weeks. The patient is sent home with instructions to contact the clinic for a future appointment if symptoms return.
All patients require a follow up assessment within 4-6 weeks of initiation of therapy. Patients can be grouped into three categories at this second assessment: those with complete symptom resolution, those with partial resolution, and those with no improvement or worsened symptoms. Patients whose symptoms completely resolve should be given contact information to make a future appointment if symptoms return. Patients with a partial response may benefit from augmentation or adjustment of their current therapy. Those patients whose symptoms are refractory to initial treatment should be considered to have persistent post-concussive symptoms and treated according to the guidelines below (Management of Persistent Post-concussive Symptoms).
Management of Persistent Post-concussive Symptoms
This section is relevant for patients who have had an initial evaluation and failed a trial of treatment for mTBI related symptoms. Patients with delayed presentation for mTBI symptoms should first be treated according to the preceding section (Initial Management of Post-concussive Symptoms
) regardless of the interval since injury. The definitive reference is the VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI 1
Patients with persistent post-concussive symptoms often have concomitant behavioral health, psychosocial support, or compensation and litigation issues. Attention should be given to addressing these issues as this may help mitigate symptoms refractory to initial treatment. The evaluation of the patient with persistent post-concussive symptoms should include an assessment of available support systems, a mental health history including pre-morbid conditions, co-occurring symptoms such as chronic pain or personality disorders, substance abuse disorders, secondary gain issues, job status, and other financial or legal difficulties 1
. Finally, all patients presenting with persistent post-concussive symptoms should be assessed for any potential danger to themselves or others.
Less than 5% of patients have persistent symptoms one year or more after injury 11
. Patients typically have more physical complaints within 4 weeks of injury after which emotional complaints predominate 80
. Once a thorough assessment has been obtained, the principle goal is to identify appropriate referrals for management of the persistent symptoms. Patients with behavioral symptoms and possible co-morbid psychiatric conditions may benefit from referral to mental health professionals. Persistent physical symptoms should be evaluated by appropriate specialists. Persistent cognitive symptoms are rare and are frequently accompanied by comorbid conditions such as mood disorders, poor physical health, poor psychosocial support, or chronic pain. In addition to addressing these comorbid conditions, these patients should be referred for neuropsychiatric evaluation to determine appropriate treatment options. Cognitive rehabilitation may be helpful for patients with persistent difficulties in memory, executive function, or attention 81-83
. A social work referral is appropriate for patients with poor psychosocial support, legal difficulties, or financial problems. While there is consistent evidence of an association between mTBI related compensation or litigation and increased symptom reporting and poor outcome 59, 84-86
, there is no evidence to support a therapeutic benefit of attributing persistent symptoms to these secondary gain issues 1
. Consequently, clinicians should not allow symptom exaggeration by patients seeking compensation to alter their care plans.
Given the diverse group of health professionals involved in the treatment of persistent post-concussive symptoms, a multi-disciplinary, team approach with the referring provider as the coordinator of care is required. A designated case manager can be very helpful for coordinating care. Typical tasks benefiting from case management includes coordination of referrals, ensuring appropriate patient and family education, participation in short and long-term goal setting, ensuring that appropriate social service and mental health screening is performed, and coordination with the multi-disciplinary team. Ongoing follow up visits should occur regularly with goals of monitoring symptom severity, reviewing symptom impact on activities, and the effectiveness of treatments.
Return to Play after Sports Injury
Guidelines for returning to play in an athlete differ from general instructions for return to normal activities after mTBI in that they are designed to prevent a repeat mTBI while the patient is recovering from the initial injury. In general, the risks of suffering a second and third TBI are 3 fold and 8 to 9 fold greater than the risk of a first TBI, respectively 94
. Furthermore, case reports suggest that athletes are at increased risk for concussion in the period immediately after their initial injury 95
. Therefore, consideration of the concussion risk in a sports-specific manner is important 96
. Return to play guidelines are consensus rather than evidence based. The most commonly used guidelines include those by R.C. Cantu and the American Academy of Neurology (AAN) and of Dr. Cantu 97-98
. Both sets of guidelines use severity of the concussion and presence of post-concussive symptoms as the criteria for return to play decision making. The Cantu guidelines allow a player to return once he/she is asymptomatic for one week if post traumatic amnesia lasted less than 24 hours and the initial loss of unconsciousness was less than five minutes. Players with more severe symptoms at the time of their concussion should not play for one month and then can return after an additional one week without symptoms. In players with a history of multiple concussions, consideration should be given to sitting out for the remainder of the season.
While the consensus based back to play guidelines referenced in this section are clinically accepted as the standard of care they are not infallible. A recent example of a second injury despite scrupulous application of these guidelines is seen with Brian Westbrook, a professional football player in the National Football League (NFL). Mr. Westbrook suffered the first concussion of his 8 year NFL career on October 26th 2009, suffering a brief loss of consciousness with associated retrograde amnesia after being tackled in a game. He was held from play for three weeks due to lingering headache and then suffered a second concussion in his first game back from injury. While there was widespread speculation that he might not return that season or even that his football career was over, he did play the final two games of the season without further injury after being out for a total of 5 weeks. While no guideline can prevent all adverse events, it is possible that improved guidelines could result in fewer repeat injuries. Prospectively validated, evidence based return to play guidelines are needed.