Emergency Department Care

No specific care is required in the ED. Patients with the symptom constellation consistent with postconcussion syndrome (PCS) require thorough physical and neurological examinations. A CT scan should be obtained if significant concern about intracranial hemorrhage exists, although this injury is rare in the patient presenting late with nonfocal findings at examination.^[41]

Supportive care may include the use of nonnarcotic analgesics and antiemetics. However, there does not appear to be any medications at discharge that can prevent or hasten the resolution of PCS. Several drugs are under investigation, but none have proven to be clinically useful yet.
Several studies have shown that providing patients with an explanation of symptoms as well as expectations may decrease the severity and duration of postconcussive symptoms.
Although rare, patients may be admitted if symptoms are severe, the majority can be discharged. Several studies have revealed that patients admitted acutely after a minor head injury (MHI) may have a lower incidence of PCS and its attendant social and psychological morbidity. This finding, however, may be due to active interventions at follow-up.
Prompt follow-up care and reassurance may hasten resolution of symptoms. Patients should be referred to a primary care doctor, neurologist, or psychiatrist depending on their symptoms.
Follow-up and patient education on what to expect after minor head injuries is useful, as many patients will have symptoms for weeks after discharge.^[42]

Consultations

Rarely is consultation warranted in the ED once the diagnosis is made. Outpatient referral is the cornerstone of treatment. One study suggests that findings of early neuropsychological assessment may determine the prognosis; however, this assessment rarely is performed in the ED.

Medical Care

Outpatient care is the cornerstone of treatment of patients with postconcussion syndrome and involves multidisciplinary teams that provide testing and treatment, including cognitive rehabilitation, psychotherapy, stress management, vocational counseling, and symptomatic treatment with medications.

No treatments have been proven effective, though neurotherapy or quantitative EEG biofeedback is a modality that has been shown in recent studies to improve symptoms of PCS. More controlled studies are needed at this point.
A neurologist, physical medicine specialist, primary care physician, or psychologist specializing in these disorders usually coordinates treatment.

Medication

Butler IJ. Postconcussion Syndrome After Mild Traumatic Brain Injury in Children and Adolescents Requires Further Detailed Study. JAMA Neurol. 2013 Mar 25. 1-2. [QxMD MEDLINE Link].
Sullivan KA, Edmed SL, Cunningham LC. A comparison of new and existing mild traumatic brain injury vignettes: recommendations for research into post-concussion syndrome. Brain Inj. 2013. 27(1):19-30. [QxMD MEDLINE Link].
Barlow KM. Postconcussion Syndrome: A Review. J Child Neurol. 2016 Jan. 31 (1):57-67. [QxMD MEDLINE Link].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association; 2013.
Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016 Mar 8. 315 (10):1014-25. [QxMD MEDLINE Link].
Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J. 2014 Jan. 31 (1):72-7. [QxMD MEDLINE Link].
Heitger MH, Jones RD, Macleod AD, Snell DL, Frampton CM, Anderson TJ. Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability. Brain. 2009 Oct. 132:2850-70. [QxMD MEDLINE Link].
Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma. 2009 Feb. 66(2):289-96; discussion 296-7. [QxMD MEDLINE Link].
Sheedy J, Harvey E, Faux S, Geffen G, Shores EA. Emergency department assessment of mild traumatic brain injury and the prediction of postconcussive symptoms: a 3-month prospective study. J Head Trauma Rehabil. 2009 Sep-Oct. 24(5):333-43. [QxMD MEDLINE Link].
Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998--2000. Brain Inj. 2005 Feb. 19(2):85-91. [QxMD MEDLINE Link].
Barlow KM. Postconcussion Syndrome: A Review. J Child Neurol. 2014 Oct 20. [QxMD MEDLINE Link].
Dillard C, Ditchman N, Nersessova K, Foster N, Wehman P, West M, et al. Post-concussion symptoms in mild traumatic brain injury: findings from a paediatric outpatient clinic. Disabil Rehabil. 2017 Mar. 39 (6):544-550. [QxMD MEDLINE Link].
Kolias AG, Guilfoyle MR, Helmy A, Allanson J, Hutchinson PJ. Traumatic brain injury in adults. Pract Neurol. 2013 Mar 13. [QxMD MEDLINE Link].
Barry Kosofsky, M.D., Zuhal Ergonul, M.D., Ph.D.; Kenneth Perrine, Ph.D.; Jeffrey Greenfield, et al. Children and Concussions. Weill Cornell Medicine. Available at https://concussion.weillcornell.org/about-concussions/kids-and-concussions. Accessed: September 24, 2018.
University of Pittsburgh Medical Center. Concussion. Neurological Surgery. Available at http://www.neurosurgery.pitt.edu/centers-excellence/brain-and-spine-injury/concussions. 2018; Accessed: September 24, 2018.
Concussion. American Association of Neurological Surgeons. Available at https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Concussion.. Accessed: September 24, 2018.
Rees RJ, Bellon ML. Post concussion syndrome ebb and flow: longitudinal effects and management. NeuroRehabilitation. 2007. 22(3):229-42. [QxMD MEDLINE Link].
Meares S, Shores EA, Batchelor J, et al. The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury. J Int Neuropsychol Soc. 2006 Nov. 12(6):792-801. [QxMD MEDLINE Link].
Yang CC, Tu YK, Hua MS, Huang SJ. The association between the postconcussion symptoms and clinical outcomes for patients with mild traumatic brain injury. J Trauma. 2007 Mar. 62(3):657-63. [QxMD MEDLINE Link].
Tator CH, Davis HS, Dufort PA, Tartaglia MC, Davis KD, Ebraheem A, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016 Feb 26. 1-11. [QxMD MEDLINE Link].
Hiploylee C, Dufort PA, Davis HS, Wennberg RA, Tartaglia MC, Mikulis D, et al. Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers. J Neurotrauma. 2017 Apr 15. 34 (8):1511-1523. [QxMD MEDLINE Link].
Faux S, Sheedy J. A prospective controlled study in the prevalence of posttraumatic headache following mild traumatic brain injury. Pain Med. 2008 Nov. 9(8):1001-11. [QxMD MEDLINE Link].
Tator CH, Davis H. The postconcussion syndrome in sports and recreation: clinical features and demography in 138 athletes. Neurosurgery. 2014 Oct. 75 Suppl 4:S106-12. [QxMD MEDLINE Link].
Dawson KS, Batchelor J, Meares S, Chapman J, Marosszeky JE. Applicability of neural reserve theory in mild traumatic brain injury. Brain Inj. 2007 Aug. 21(9):943-9. [QxMD MEDLINE Link].
Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. 2007 Jun. 78(6):644-6. [QxMD MEDLINE Link].
Ma M, Lindsell CJ, Rosenberry CM, Shaw GJ, Zemlan FP. Serum cleaved tau does not predict postconcussion syndrome after mild traumatic brain injury. Am J Emerg Med. 2008 Sep. 26(7):763-8. [QxMD MEDLINE Link].
Lima DP, Simao Filho C, Abib Sde C, de Figueiredo LF. Quality of life and neuropsychological changes in mild head trauma. Late analysis and correlation with S100B protein and cranial CT scan performed at hospital admission. Injury. 2008 May. 39(5):604-11. [QxMD MEDLINE Link].
Ramos-Zuniga R, Gonzalez-de la Torre M, Jimenez-Maldonado M, Villasenor-Cabrera T, Banuelos-Acosta R, Aguirre-Portillo L, et al. Postconcussion Syndrome and Mild Head Injury: The Role of Early Diagnosis Using Neuropsychological Tests and Functional Magnetic Resonance/Spectroscopy. World Neurosurg. 2013 Sep 18. [QxMD MEDLINE Link].
Groswasser Z, Reider-Groswasser I, Soroker N, Machtey Y. Magnetic resonance imaging in head injured patients with normal late computed tomography scans. Surg Neurol. 1987 Apr. 27(4):331-7. [QxMD MEDLINE Link].
Lewine JD, Davis JT, Bigler ED, et al. Objective documentation of traumatic brain injury subsequent to mild head trauma: multimodal brain imaging with MEG, SPECT, and MRI. J Head Trauma Rehabil. 2007 May-Jun. 22(3):141-55. [QxMD MEDLINE Link].
van der Naalt J, Hew JM, van Zomeren AH, Sluiter WJ, Minderhoud JM. Computed tomography and magnetic resonance imaging in mild to moderate head injury: early and late imaging related to outcome. Ann Neurol. 1999 Jul. 46(1):70-8. [QxMD MEDLINE Link].
Ghodadra A, Alhilali L, Fakhran S. Principal Component Analysis of Diffusion Tensor Images to Determine White Matter Injury Patterns Underlying Postconcussive Headache. AJNR Am J Neuroradiol. 2016 Feb. 37 (2):274-8. [QxMD MEDLINE Link].
Mutch WA, Ellis MJ, Ryner LN, Ruth Graham M, Dufault B, Gregson B, et al. Brain magnetic resonance imaging CO2 stress testing in adolescent postconcussion syndrome. J Neurosurg. 2016 Sep. 125 (3):648-60. [QxMD MEDLINE Link].
Barlow KM, Marcil LD, Dewey D, Carlson HL, MacMaster FP, Brooks BL, et al. Cerebral Perfusion Changes in Post-Concussion Syndrome: A Prospective Controlled Cohort Study. J Neurotrauma. 2017 Mar 1. 34 (5):996-1004. [QxMD MEDLINE Link].
Joyce AS, Labella CR, Carl RL, Lai JS, Zelko FA. The Postconcussion Symptom Scale: utility of a three-factor structure. Med Sci Sports Exerc. 2015 Jun. 47 (6):1119-23. [QxMD MEDLINE Link].
Begasse de Dhaem O, Barr WB, Balcer LJ, Galetta SL, Minen MT. Post-traumatic headache: the use of the sport concussion assessment tool (SCAT-3) as a predictor of post-concussion recovery. J Headache Pain. 2017 Dec. 18 (1):60. [QxMD MEDLINE Link].
Bin Zahid A, Hubbard ME, Dammavalam VM, Balser DY, Pierre G, Kim A, et al. Assessment of acute head injury in an emergency department population using sport concussion assessment tool - 3rd edition. Appl Neuropsychol Adult. 2016 Nov 17. 1-10. [QxMD MEDLINE Link].
Khazaei S, Hanis SM, Mansori K, Begasse de Dhaem O, Barr WB, Balcer LJ, et al. Correspondence regarding: Post-traumatic headache: the use of the sport concussion assessment tool (SCAT-3) as a predictor of post-concussion recovery. J Headache Pain. 2017 Aug 31. 18 (1):92. [QxMD MEDLINE Link].
Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale. Br J Sports Med. 2017 Jun. 51 (11):859-861. [QxMD MEDLINE Link].
Yengo-Kahn AM, Hale AT, Zalneraitis BH, Zuckerman SL, Sills AK, Solomon GS. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016 Apr. 40 (4):E6. [QxMD MEDLINE Link].
Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J. 2013 Mar 6. [QxMD MEDLINE Link].
Cunningham J, Brison RJ, Pickett W. Concussive symptoms in emergency department patients diagnosed with minor head injury. J Emerg Med. 2011 Mar. 40(3):262-6. [QxMD MEDLINE Link].
Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995. 45 (7):1253-60. [QxMD MEDLINE Link].
Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M. Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj. 1999 Mar. 13(3):173-89. [QxMD MEDLINE Link].
Bigler ED. Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc. 2008 Jan. 14(1):1-22. [QxMD MEDLINE Link].
Boake C, McCauley SR, Levin HS, et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2005 Summer. 17(3):350-6. [QxMD MEDLINE Link].
Bohnen N, Twijnstra A, Wijnen G. Tolerance for light and sound of patients with persistent post-concussional symptoms 6 months after mild head injury. J Neurol. 1991 Dec. 238(8):443-6. [QxMD MEDLINE Link].
Chan RC. How severe should symptoms be before someone is said to be suffering from post-concussion syndrome? An exploratory study with self-reported checklist using Rasch analysis. Brain Inj. 2005 Dec. 19(13):1117-24. [QxMD MEDLINE Link].
Chen JK, Johnston KM, Collie A, McCrory P, Ptito A. A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. J Neurol Neurosurg Psychiatry. 2007 Nov. 78(11):1231-8. [QxMD MEDLINE Link].
Collie A, Makdissi M, Maruff P, Bennell K, McCrory P. Cognition in the days following concussion: comparison of symptomatic versus asymptomatic athletes. J Neurol Neurosurg Psychiatry. 2006 Feb. 77(2):241-5. [QxMD MEDLINE Link].
de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002 Aug. 73(2):167-72. [QxMD MEDLINE Link].
De Kruijk JR, Leffers P, Menheere PP, Meerhoff S, Rutten J, Twijnstra A. Prediction of post-traumatic complaints after mild traumatic brain injury: early symptoms and biochemical markers. J Neurol Neurosurg Psychiatry. 2002 Dec. 73(6):727-32. [QxMD MEDLINE Link].
de Kruijk JR, Leffers P, Menheere PP, Meerhoff S, Twijnstra A. S-100B and neuron-specific enolase in serum of mild traumatic brain injury patients. A comparison with health controls. Acta Neurol Scand. 2001 Mar. 103(3):175-9. [QxMD MEDLINE Link].
Duff J. The usefulness of quantitative EEG (QEEG) and neurotherapy in the assessment and treatment of post-concussion syndrome. Clin EEG Neurosci. 2004 Oct. 35(4):198-209. [QxMD MEDLINE Link].
Evans RW. Post-traumatic headaches. Neurol Clin. 2004 Feb. 22(1):237-49, viii. [QxMD MEDLINE Link].
Guerrero JL, Thurman DJ, Sniezek JE. Emergency department visits associated with traumatic brain injury: United States, 1995-1996. Brain Inj. 2000 Feb. 14(2):181-6. [QxMD MEDLINE Link].
Kraus J, Hsu P, Schaffer K, Vaca F, Ayers K, Kennedy F, et al. Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury. J Head Trauma Rehabil. 2009 Sep-Oct. 24(5):344-54. [QxMD MEDLINE Link].
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006 Sep-Oct. 21(5):375-8. [QxMD MEDLINE Link].
Larrabee GJ. Neuropsychological Outcome, Post Concussion Symptoms, and Forensic Considerations in Mild Closed Head Trauma. Semin Clin Neuropsychiatry. 1997 Jul. 2(3):196-206. [QxMD MEDLINE Link].
Lee LK. Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care. 2007 Aug. 23(8):580-3; quiz 584-6. [QxMD MEDLINE Link].
Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon JC. Does loss of consciousness predict neuropsychological decrements after concussion?. Clin J Sport Med. 1999 Oct. 9(4):193-8. [QxMD MEDLINE Link].
McCullagh S, Feinstein A. Outcome after mild traumatic brain injury: an examination of recruitment bias. J Neurol Neurosurg Psychiatry. 2003 Jan. 74(1):39-43. [QxMD MEDLINE Link].
Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Brain Inj. 2005 Nov. 19(12):975-87. [QxMD MEDLINE Link].
Olver J. Traumatic brain injury--the need for support and follow up. Aust Fam Physician. 2005 Apr. 34(4):269-71. [QxMD MEDLINE Link].
Potter S, Leigh E, Wade D, Fleminger S. The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis. J Neurol. 2006 Dec. 253(12):1603-14. [QxMD MEDLINE Link].
Preiss-Farzanegan SJ, Chapman B, Wong TM, Wu J, Bazarian JJ. The relationship between gender and postconcussion symptoms after sport-related mild traumatic brain injury. PM R. 2009 Mar. 1(3):245-53. [QxMD MEDLINE Link].
Savola O, Hillbom M. Early predictors of post-concussion symptoms in patients with mild head injury. Eur J Neurol. 2003 Mar. 10(2):175-81. [QxMD MEDLINE Link].
Stalnacke BM, Bjornstig U, Karlsson K, Sojka P. One-year follow-up of mild traumatic brain injury: post-concussion symptoms, disabilities and life satisfaction in relation to serum levels of S-100B and neurone-specific enolase in acute phase. J Rehabil Med. 2005 Sep. 37(5):300-5. [QxMD MEDLINE Link].
Stalnacke BM, Elgh E, Sojka P. One-year follow-up of mild traumatic brain injury: cognition, disability and life satisfaction of patients seeking consultation. J Rehabil Med. 2007 May. 39(5):405-11. [QxMD MEDLINE Link].
Stulemeijer M, van der Werf S, Borm GF, Vos PE. Early prediction of favourable recovery 6 months after mild traumatic brain injury. J Neurol Neurosurg Psychiatry. 2008 Aug. 79(8):936-42. [QxMD MEDLINE Link].
Voller B, Benke T, Benedetto K, Schnider P, Auff E, Aichner F. Neuropsychological, MRI and EEG findings after very mild traumatic brain injury. Brain Inj. 1999 Oct. 13(10):821-7. [QxMD MEDLINE Link].
Wood RL. Understanding the 'miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Brain Inj. 2004 Nov. 18(11):1135-53. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jon Mark Hirshon, MD, MPH, PhD, FACEP Professor, Department of Emergency Medicine, Professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine; Chief, Emergency Department, Baltimore VA Medical Center

Jon Mark Hirshon, MD, MPH, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Tina Wu, MD Staff Physician, Department of Emergency Medicine, New York University Medical Center, Bellevue Hospital Center

Tina Wu, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Rachel Alt, MD Staff Physician, Department of Emergency Medicine, New York University Bellevue Hospital

Disclosure: Nothing to disclose.