Return to usual activities: When to say Yes, when to say No. You advise Max’s parents to keep him home from school and have him take a break from homework. Concentrating on schoolwork can aggravate concussive symptoms.12 Strenuous physical activity is out, too, and he shouldn’t be alone for more than short periods until all his symptoms subside.
Sports concussions have their own imperatives, based on the grade of the concussion. Patients with a grade 1 concussion can return to the playing field within 15 minutes, as long as their neurologic exam is normal and they have no symptoms. With a grade 2 concussion, the player should be asymptomatic for 1 week before going back to normal activities. A grade 3 concussion requires that the player stay off the field until he or she has been asymptomatic for 2 weeks.4 This recommendation would apply to Max, who had a grade 3 concussion.
TABLE 1
AAN concussion grading scale1
| GRADE 1 | GRADE 2 | GRADE 3 | |
|---|---|---|---|
| Loss of consciousness | No | No | Yes |
| Symptoms | Lasting <15 minutes | Lasting >15 minutes | Lasting >15 minutes |
When symptoms linger
Most concussion patients will recover fairly rapidly. Unfortunately, however, some 38% of patients who have experienced a concussion with loss of consciousness continue to be plagued with what is called post-concussive syndrome (PCS).16 The International Classification of Diseases (ICD-10, 2nd ed.) defines PCS as a combination of signs and symptoms that occur within 4 weeks of head trauma with loss of consciousness. These include headache, fatigue, depression, emotional lability, difficulty concentrating, insomnia, and a preoccupation with symptoms with a fear of brain damage. The incidence of PCS using criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is similar to that documented with the ICD-10, which suggests that either definition could be used to evaluate for PCS.17
By far the most common of these post-concussive symptoms is headache, reported by nearly 80% of patients with PCS and occurring most often in those who are headache-prone.18 That’s the case with Max, who has always had a problem with headaches and returns to your office a month after the accident complaining of persistent head pain.
Most post-concussive headaches resolve with rest and over-the-counter medications such as acetaminophen or ibuprofen. You may also consider prescribing antidepressants, particularly the selective serotonin reuptake inhibitor sertraline, which has been shown to decrease the vertigo, blurred vision, visual changes, and headache often associated with PCS.16,19,20 Start sertraline at a dosage of 25 mg/d, then titrate after a week to the recommended 50 mg/d.19 If symptoms persist, slowly titrate to the maximum dose of 200 mg/d while carefully monitoring for potential side effects.19
Patients with post-concussive status migrainosus, a headache lasting longer than 3 days that is unresponsive to conventional treatment, may benefit from a short course of corticosteroids.4 Additional treatment options include triptans, anticonvulsants, and β-blockers, although none of these options has been backed up by a large-scale, randomized controlled trial.16,20
Vigilance needed in cases of repeated trauma
Patients who experience repeated head trauma require particular attention. They are more likely to have detectable signs and symptoms and PCS.21 Also, they are more likely to incur second impact syndrome (SIS), a cascade of symptoms that can occur within 2 to 5 minutes of sustaining a second blow. SIS patients experience a rapid and diffuse cerebral edema, which can lead to brain herniation and death.3 SIS is a primary risk in sports like football, when players are allowed to return to the field too early. TABLE 2 sets out the special diagnostic criteria the AAN has formulated for managing patients who experience repeated concussions.
TABLE 2
Multiple concussions: When can your patient return to play?1
| SYMPTOM SEVERITY | SECOND CONCUSSION | THIRD CONCUSSION (OR MORE) |
|---|---|---|
| Concussive symptoms lasting <15 minutes | Return to play when asymptomatic for 1 week | Return to play when asymptomatic for 1 week |
| Post-traumatic amnesia <30 minutes, without loss of consciousness | Return to play when asymptomatic for 2 weeks | Return to play when asymptomatic for 1 month |
| Post-traumatic amnesia >30 minutes or loss of consciousness | Return to play when asymptomatic for 1 month | Discourage return to play indefinitely |
Help prevent concussion
In your role as educator, you can inform patients, school officials, and community leaders about the importance of protective equipment such as sports helmets, seat belts, and air bags in reducing the incidence of concussion.9,15 As a family physician, you have a special opportunity to teach parents, teachers, coaches, and players to recognize the signs and symptoms of concussion, understand the risks, and stop players from returning to sports activities prematurely.4