First-Ever Pediatric Concussion Guidelines: Real-Life Cases

Debra Houry, MD, MPH


November 15, 2018

Editorial Collaboration

Medscape &

Management of Headache

The primary care provider recommended over-the-counter, nonopioid analgesics and gradually resuming activity as tolerated.

The guideline includes recommendations for caring for patients with posttraumatic headache. Early treatment for headache should focus on nonopioid analgesics, stating that "Healthcare professionals and caregivers should offer nonopioid analgesia (ie, ibuprofen or acetaminophen) to children with painful headache after acute mTBI but also provide counseling to the family regarding the risks of analgesic overuse, including rebound headache." Because chronic headaches may have multiple contributing factors, a multidisciplinary evaluation and treatment plan is recommended. If the patient experiences severe or worsening acute headache, this may prompt consideration of head CT.

Symptom Monitoring and When to Refer After mTBI

Five weeks after the injury, the patient was referred to a specialist because of persistent symptoms. During that visit, she reported mild headaches and head pressure with activity. She exhibited slight problems with memory and coordination, as well as moderate problems with balance. The specialist created a customized return-to-activity plan for her to complete at her own pace.

Six weeks post-injury, a repeated assessment by the specialist showed that the patient's memory and coordination were back to her baseline, with only some residual balance problems. The next week, the patient reported that she was no longer experiencing any symptoms at rest or with physical exertion (running). An assessment also showed that her balance had returned to her baseline.

If an mTBI is suspected, healthcare providers should use an age-appropriate, validated symptom rating scale as a component of evaluation. Examples of validated scales include, but are not limited to: Post-Concussion Symptom Scale; Health and Behavior Inventory; Post-Concussion Symptom Inventory; and Acute Concussion Evaluation. Computerized cognitive testing may also be used as a component of assessment for mTBI. However, computerized tools, as well as symptom scales, should not be used in isolation.

Healthcare providers should provide assurance and instructions to the family, including warning signs for more severe injury, symptom monitoring tips, the process for returning to activity (such as return to school and play), and when to follow up for additional care. Both verbal and written instructions are beneficial.

Following the first several days, healthcare providers should counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression (number, severity). Healthcare providers should refer patients whose symptoms do not resolve as expected with standard care after 4-6 weeks.