Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – physical rest

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ACUTE
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all patients
1st line – 

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 on 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 level.[5] Clinicians should inform their patients that mild symptom exacerbation during physical activity, prescribed aerobic exercise treatment or during 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]

Plus – cognitive rest

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ACUTE
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all patients
Plus – 

cognitive rest

Treatment recommended for ALL patients in selected patient group

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]

Plus – return to play

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ACUTE
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all patients
Plus – 

return to play

Treatment recommended for ALL patients in selected patient group

Symptoms and signs of concussion 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]​ This light physical activity and prescribed sub-symptom threshold aerobic exercise treatment can be used therapeutically in a safe and supervised environment.[5][103] The athlete should also demonstrate psychological readiness for returning to play.[3]​​

Plus – education + return to school/activity/work plan

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ACUTE
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all patients
Plus – 

education + return to school/activity/work plan

Treatment recommended for ALL patients in selected patient group

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 modified school attendance, frequent rest breaks from cognitive/thinking/deskwork tasks throughout the day and/or limited screen time on electronic devices, a reduction in workload, extensions on assignments and projects, and delaying tests and/or permitting additional time to complete them.[5] 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]

Consider – analgesia

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ACUTE
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all patients
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

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 traumatic brain injury (TBI) is important to reduce anxiety which may exacerbate headache symptoms.[55] Patients who use pain medication should be cautioned that taking these medications 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]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 1200 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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