eMedicine Specialties > Sports Medicine > Neurological

Concussion: Treatment & Medication

Author: David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
Contributor Information and Disclosures

Updated: Aug 6, 2009

Treatment

Acute Phase

Medical Issues/Complications

Most of the complications listed below probably already existed when the athlete sustained the initial head injury; in other words, they are not caused by an MTBI. These conditions may be associated with what was thought of as an MTBI. Therefore, the reader should not think of these conditions as a complication of an MTBI but must consider these other conditions when evaluating an athlete with a head injury.

  • A subdural hematoma is a rare injury in the athlete who presents with a presumed concussion. The classic presentation of a subdural hematoma is an acute and persistent LOC associated with the initial injury.
  • No association between epidural hematoma and brain injury exists. This condition classically presents with a brief period of unconsciousness, followed by a lucid period, and then a subsequent deterioration over 15-30 minutes. Tearing of the middle meningeal artery secondary to an associated temporal skull fracture is the usual cause of an epidural hematoma.
  • Subarachnoid bleeding may also occur with a head injury of any type. Worsening headache and other signs of increasing intracranial pressure will gradually grow after the initial event.
  • Second impact syndrome has been described in many review articles. In this condition, fatal brain swelling occurs after minor head trauma in individuals who still have symptoms from a previous minor head trauma. Thus far, all cases of second impact syndrome have been described in relatively young patients (age < 20 y). Significant controversy exists over the etiology of this condition, although it is thought to be secondary to loss of autoregulation of cerebral blood flow in an already injured brain.
    • Authors have questioned the validity of second impact syndrome due to problems with the documentation of the (1) initial event, (2) persistent symptoms, and (3) severity of the second impact. Despite these problems, practitioners should be aware of this possible complication, especially when treating the relatively immature brain of a young athlete. Treatment of second impact syndrome requires immediate recognition and immediate treatment with hyperventilation and osmotic agents. Surgical treatment for this condition is ineffective. The overall prognosis is usually grim.
  • Postconcussive syndrome consists of prolonged symptoms that are related to the initial head injury. Unfortunately, the severity of the concussion does not necessarily predict who will experience prolonged symptoms. Similarly, the number of concussions is not necessarily predictive of future problems. Symptoms usually consist of persistent recurrent headaches, dizziness, memory impairment, loss of libido, ataxia, sensitivity to light and noise, concentration and attention problems, depression, and anxiety.
  • Most patients with MTBI recover in 48-72 hours, even with detailed neuropsychologic testing, and are headache free within 2-4 weeks of the injury. Obtain a more detailed history of emotional, concentration, and associated symptoms for patients who have persistent symptoms that last longer than 1 week. 
    • A study of retired professional football players (average age 53.8 +/– 13.4 y) by Guskiewicz et al reported significant memory changes in those players with a history of recurrent concussions.8  Another report by the same authors of these retired football players suggested a link between recurrent sports-related concussions and an increased risk of clinical depression.18

Consultations

Consultation with a neurologist or primary care sports medicine physician is indicated for patients who have prolonged symptoms. Neuropsychologic consultation may also be considered to document any deficits that may interfere with the athlete's return to sport, school, or work.

Medication

Overall, no medical therapy is usually prescribed for patients after an acute brain injury. Pain control is usually achieved with over-the-counter medications, such as acetaminophen. Avoid narcotics so that clouding of the patient's mental status or neurologic examination does not occur.

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or those who have sustained injuries.


Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin and/or NSAIDs; patients diagnosed with upper GI disease or who are on oral anticoagulants.

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d

>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity can occur, in chronic alcoholics, with various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate a serious illness.

More on Concussion

Overview: Concussion
Differential Diagnoses & Workup: Concussion
Treatment & Medication: Concussion
Follow-up: Concussion
References
[ CLOSE WINDOW ]

References

  1. Slobounov S, Cao C, Sebastianelli W, Slobounov E, Newell K. Residual deficits from concussion as revealed by virtual time-to-contact measures of postural stability. Clin Neurophysiol. Dec 6 2007;epub ahead of print. [Medline].

  2. Pearce JM. Observations on concussion: a review. Eur Neurol. Nov 30 2007;59(3-4):113-9. [Medline].

  3. Lee LK. Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care. Aug 2007;23(8):580-3; quiz 584-6. [Medline].

  4. Kelly JP, Nichols JS, Filley CM, et al. Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA. Nov 27 1991;266(20):2867-9. [Medline].

  5. Ptito A, Chen JK, Johnston KM. Contributions of functional magnetic resonance imaging (fMRI) to sport concussion evaluation. NeuroRehabilitation. 2007;22(3):217-27. [Medline].

  6. Capruso DX, Levin HS. Cognitive impairment following closed head injury. Neurol Clin. Nov 1992;10(4):879-93. [Medline].

  7. Moser RS, Iverson GL, Echemendia RJ, et al. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol. Dec 2007;22(8):909-16. [Medline].

  8. Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. Oct 2005;57(4):719-26; discussion 719-26. [Medline].

  9. Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. JAMA. Sep 8 1999;282(10):958-63. [Medline]. [Full Text].

  10. Pieter W, Zemper ED. Head and neck injuries in young taekwondo athletes. J Sports Med Phys Fitness. Jun 1999;39(2):147-53. [Medline].

  11. Boden BP, Kirkendall DT, Garrett WE Jr. Concussion incidence in elite college soccer players. Am J Sports Med. Mar-Apr 1998;26(2):238-41. [Medline].

  12. Cantu RC. Second-impact syndrome. Clin Sports Med. Jan 1998;17(1):37-44. [Medline].

  13. Henninger N, Sicard KM, Li Z, et al. Differential recovery of behavioral status and brain function assessed with functional magnetic resonance imaging after mild traumatic brain injury in the rat. Crit Care Med. Nov 2007;35(11):2607-14. [Medline].

  14. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. Nov 19 2003;290(19):2556-63. [Medline]. [Full Text].

  15. Bigler ED. Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc. Jan 2008;14(1):1-22. [Medline].

  16. McCrea M, Kelly JP, Kluge J, Ackley B, Randolph C. Standardized assessment of concussion in football players. Neurology. Mar 1997;48(3):586-8. [Medline].

  17. De Beaumont L, Lassonde M, Leclerc S, Théoret H. Long-term and cumulative effects of sports concussion on motor cortex inhibition. Neurosurgery. Aug 2007;61(2):329-36; discussion 336-7. [Medline].

  18. Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc. Jun 2007;39(6):903-9. [Medline].

  19. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA. Nov 19 2003;290(19):2549-55. [Medline]. [Full Text].

  20. McCrory PR, Berkovic SF. Second impact syndrome. Neurology. Mar 1998;50(3):677-83. [Medline].

  21. McCrea M, Kelly JP, Randolph C, et al. Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete. J Head Trauma Rehabil. Apr 1998;13(2):27-35. [Medline].

  22. Young CC, Jacobs BA, Clavette K, Mark DH, Guse CE. Serial sevens: not the most effective test of mental status in high school athletes. Clin J Sport Med. Jul 1997;7(3):196-8. [Medline].

  23. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. Apr 2005;39(4):196-204. [Medline].

  24. Cantu RC. Second impact syndrome. Phys Sports Med. 1992;20(9):55-66.

  25. Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain. Dec 1974;97(4):633-54. [Medline].

  26. Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med. 1990;87:4.

  27. American Academy of Neurology. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology. Mar 1997;48(3):581-5. [Medline].

  28. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. CDC tool kit on concussion for high school coaches. February 2005;Accessed December 18, 2007. Available at http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm.

  29. Sullivan SJ, Schneiders AG, McCrory P, Gray AR. Physiotherapists' use of information in identifying a sports concussion: an extended Delphi approach. Br J Sports Med. Nov 29 2007;epub ahead of print. [Medline].

  30. Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon JC. Does loss of consciousness predict neuropsychological decrements after concussion?. Clin J Sport Med. Oct 1999;9(4):193-8. [Medline].

  31. Delaney JS, Al-Kashmiri A, Drummond R, Correa JA. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. Jul 5 2007;epub ahead of print. [Medline].

  32. McGuine T, Nass S. Football Helmet Fitting Errors in Wisconsin High School Players: Safety in American Football. West Conshohocken, Pa: American Society for Testing and Materials; 1997:83-8.

  33. Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma. Neurosurgery. Jan 1993;32(1):9-15; discussion 15-6. [Medline].

  34. Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning. J Trauma. Jul 1992;33(1):11-3. [Medline].

  35. Kirov I, Fleysher L, Babb JS, et al. Characterizing 'mild' in traumatic brain injury with proton MR spectroscopy in the thalamus: Initial findings. Brain Inj. Oct 2007;21(11):1147-54. [Medline].

  36. Broglio SP, Puetz TW. The effect of sport concussion on neurocognitive function, self-report symptoms and postural control: a meta-analysis. Sports Med. 2008;38(1):53-67. [Medline].

  37. Covassin T, Schatz P, Swanik CB. Sex differences in neuropsychological function and post-concussion symptoms of concussed collegiate athletes. Neurosurgery. Aug 2007;61(2):345-50; discussion 350-1. [Medline].

  38. Fazio VC, Lovell MR, Pardini JE, Collins MW. The relation between post concussion symptoms and neurocognitive performance in concussed athletes. NeuroRehabilitation. 2007;22(3):207-16. [Medline].

  39. Heegaard W, Biros M. Traumatic brain injury. Emerg Med Clin North Am. Aug 2007;25(3):655-78, viii. [Medline].

  40. Kelly JP, Rosenberg JH. Diagnosis and management of concussion in sports. Neurology. Mar 1997;48(3):575-80. [Medline].

  41. Kennedy JE, Jaffee MS, Leskin GA, et al. Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. J Rehabil Res Dev. 2007;44(7):895-920. [Medline].

  42. Kiraly M, Kiraly SJ. Traumatic brain injury and delayed sequelae: a review--traumatic brain injury and mild traumatic brain injury (concussion) are precursors to later-onset brain disorders, including early-onset dementia. ScientificWorldJournal. 2007;7:1768-76. [Medline].

  43. Lew HL, Thomander D, Chew KT, Bleiberg J. Review of sports-related concussion: Potential for application in military settings. J Rehabil Res Dev. 2007;44(7):963-74. [Medline].

  44. Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery. Aug 2007;61(2):352-9; discussion 359-60. [Medline].

  45. Ono K, Wada K, Takahara T, Shirotani T. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo). Jul 2007;47(7):291-7; discussion 297-8. [Medline]. [Full Text].

  46. Simpson G, Tate R. Suicidality in people surviving a traumatic brain injury: prevalence, risk factors and implications for clinical management. Brain Inj. Dec 2007;21(13):1335-51. [Medline].

  47. Wojtys EM, Hovda D, Landry G, et al. Current concepts. Concussion in sports. Am J Sports Med. Sep-Oct 1999;27(5):676-87. [Medline].

  48. Zemper E. Relative risk of cerebral concussion in football [abstract]. Paper presented at: Annual Meeting of the American College of Sports Medicine; June 1-5, 1999; Seattle, Washington.

  49. Piebes SK, Gourley M, Valovich McLeod TC. Caring for student-athletes following a concussion. J Sch Nurs. Aug 2009;25(4):270-81. [Medline].

  50. Chaput G, Giguere JF, Chauny JM, Denis R, Lavigne G. Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep Med. Aug 2009;10(7):713-6. [Medline].

  51. Dave Singh G, Maher GJ, Padilla RR. Customized mandibular orthotics in the prevention of concussion/mild traumatic brain injury in football players: a preliminary study. Dent Traumatol. Jul 9 2009;epub ahead of print. [Medline].

  52. Catena RD, van Donkelaar P, Chou LS. Different gait tasks distinguish immediate vs. long-term effects of concussion on balance control. J Neuroeng Rehabil. Jul 7 2009;6:25. [Medline]. [Full Text].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

concussion, mild traumatic brain injury, MTBI, head injury, brain injury, traumatic neurologic dysfunction syndrome, second impact syndrome, postconcussion syndrome, post-concussion syndrome, postconcussive syndrome, post-concussive syndrome, repetitive head injury syndrome

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph P Garry, MD, FACSM, FAAFP,, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine
Joseph P Garry, MD, FACSM, FAAFP, is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and North American Primary Care Research Group
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.