There is evidence that providing information about expected symptoms, their likely time course, and suggested coping strategies minimises stress and anxiety and optimizes early management among adults and children who experience mTBI/concussion.27, 98
EBR (strong) 27. Ponsford J, Willmott C, Rothwell A, Cameron P, Ayton G, Nelms R, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108(6):1297-303. doi: 10.1542/peds.108.6.1297.
98. Ponsford J, Willmott C, Rothwell A, Cameron P, Kelly AM, Nelms R, et al. Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry. 2002;73(3):330-2. doi: 10.1136/jnnp.73.3.330Adapted6,29
EBR (strong)79 6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
79. NICE: National Institute for Health and Care Excellence. Head Injury: Assessment and early management (NICE Guideline CG176). 2019.Adapted6 EBR (strong)79 6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
79. NICE: National Institute for Health and Care Excellence. Head Injury: Assessment and early management (NICE Guideline CG176). 2019.Adapted6
Alcohol and recreational drugs may have a negative effect on mTBI/concussion recovery. Avoiding alcohol or drugs prevents people from self-medicating and resorting to drugs to relieve symptoms. Impaired judgement after a mTBI/concussion could lead to risky behaviour that causes further harm and may delay the identification of complications.
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adapted30 The Model Systems Knowledge Translation Center provides fact sheets on alcohol use after traumatic brain injury.
Pain management in the first 2 weeks after mTBI/concussion may involve paracetamol or ibuprofen. After 2 weeks, use of these should be limited to < 3/week or 15/month due to the risk of medication-associated headache. Non-steroidal anti-inflammatory medications (e.g. ibuprofen, naproxen) are not suitable for people taking anticoagulants or who have a bleeding disorder unless under the direction of their regular physician.
EBR (conditional)109,110 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
109. Hanalioglu D, Hanalioglu S, Arango Jorge I, Adelson PD. Current evidence for pharmacological management of pediatric concussion: a systematic review. Child’s Nervous System. 2023;39(7):1831-49. doi: https://dx.doi.org/10.1007/s00381-023-05960-x.
110. Feinberg C, Carr C, Zemek R, Yeates Keith O, Master C, Schneider K, et al. Association of pharmacological interventions with symptom burden reduction in patients with mild traumatic brain injury: a systematic review. JAMA Neurology. 2021.Adapted30
Receiving adequate sleep has been shown to facilitate health102 and, when not adequate, adversely affects medical conditions, including mTBI/concussion.103-105 Although there is limited evidence to recommend for sleep hygiene in children with mTBI/concussion, evidence in adults mTBI indicates benefits, suggesting that the maintenance of appropriate sleep and the management of disrupted sleep may be a critical target for treatment in both adults and children with mTBI/concussion.106-108 Following mTBI/concussion that has been assessed by an appropriately qualified health care professional, there is no need to keep person awake.
CBR 31. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853.
102. Stores G. Children’s sleep disorders: modern approaches, developmental effects, and children at special risk. Dev Med Child Neurol. 1999;41(8):568-73. doi: 10.1017/s001216229900119x.
103. Baumann CR, Werth E, Stocker R, Ludwig S, Bassetti CL. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain. 2007;130(Pt 7):1873-83. doi: 10.1093/brain/awm109.
104. Owens JA, Mindell JA. Pediatric insomnia. Pediatr Clin North Am. 2011;58(3):555-69. doi: 10.1016/j.pcl.2011.03.011.
105. Venter R. Role of sleep in performance and recovery of athletes: a review article. S Afr J Res Sport Phys Educ Recreation. 2012;34(1):167–84. doi:
106. Kemp S, Biswas R, Neumann V, Coughlan A. The value of melatonin for sleep disorders occurring post-head injury: a pilot RCT. Brain Inj. 2004;18(9):911-9. doi: 10.1080/02699050410001671892.
107. Broglio SP, Macciocchi SN, Ferrara MS. Neurocognitive performance of concussed athletes when symptom free. J Athl Train. 2007;42(4):504-8. doi:
108. Mollayeva T, Pratt B, Mollayeva S, Shapiro CM, Cassidy JD, Colantonio A. The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion: insomnia and disability in chronic mild traumatic brain injury. Sleep Med. 2016;20:157–66. doi:Adapted31
Persisting amnesia (e.g. >24 hours) and/or abnormal neurological findings can indicate a moderate/severe TBI or alternative diagnosis and require different management. People should have a normal neurological examination before being discharged; this should include an examination for persisting amnesia, using a validated tool (e.g. the Abbreviated Westmead Post-traumatic Amnesia Scale), if possible, to ensure safe discharge. Normal mental status should be specifically assessed to ensure safe discharge.
Clinical factors such as persistent abnormal GCS, focal neurological deficit, vomiting/severe headache, presence of coagulopathy, persistent drug or alcohol intoxication, presence of multi-system injuries, presence of concurrent medical problems, or age (<2years; >65 years; or >50 years in Aboriginal or Torres Strait Islander peoples) may indicate clinical risk factors warranting continued hospital observation.39, 52, 70, 71 No age range has been specified as “elderly” among among Māori and Pasifika peoples.
EBR (conditional)39,52,70,71 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
39. Carney N, Ghajar J, Jagoda A, Bedrick S, Davis-O’Reilly C, du Coudray H, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery. 2014;75 Suppl 1:S3-15. doi: 10.1227/NEU.0000000000000433.
52. Hartwell JL, Spalding MC, Fletcher B, O’Mara M S, Karas C. You cannot go home: routine concussion evaluation is not enough. Am Surg. 2015;81(4):395-403.
70. Ayaz SI, Thomas C, Kulek A, Tolomello R, Mika V, Robinson D, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-6. doi: 10.1016/j.ajem.2014.11.015.
71. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.Adopted29
Follow-up provides the opportunity for healthcare professionals to identify persisting post-concussive symptoms, which occur in 30-40% of children,111 and are also prevalent in adults112 and elderly adults.113, 114
CT head is not indicated in people with mTBI/concussion presenting to the GP unless they have unexplained focal neurology, symptoms suggestive of raised intracranial pressure, or fulfills criteria for CT head (as indicated by the Canadian CT head injury/trauma rule, Nexus head CT instrument or PREDICT). If this is the case, refer to the emergency department.
EBR (conditional)99,100 6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
99. Eliyahu L, Kirkland S, Campbell S, Rowe BH. The effectiveness of early educational interventions in the emergency department to reduce incidence or severity of postconcussion syndrome following a concussion: A systematic review. Acad Emerg Med. 2016;23(5):531-42. doi: 10.1111/acem.12924.
100. Nygren-de Boussard C, Holm LW, Cancelliere C, Godbolt AK, Boyle E, Stalnacke BM, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-64. doi: 10.1016/j.apmr.2013.10.009.
111. Ewing-Cobbs L, Cox Charles S, Clark Amy E, Holubkov R, Keenan Heather T. Persistent postconcussion symptoms after injury. Pediatrics. 2018;142(5):4-15. doi: 10.1542/peds.2018-0939.
112. Permenter CM, Fernandez-de Thomas RJ, Sherman AL. Postconcussive syndrome. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Ricardo Fernandez-de Thomas declares no relevant financial relationships with ineligible companies. Disclosure: Andrew Sherman declares no relevant financial relationships with ineligible companies.2024.
113. Chung JW, Liu D, Wei L, Wen YT, Lin HY, Chen HC, et al. Postconcussion symptoms after an uncomplicated mild traumatic brain injury in older adults: frequency, risk factors, and impact on quality of life. J Head Trauma Rehabil. 2022;37(5):278-84. doi: 10.1097/HTR.0000000000000733.
114. King NS. A systematic review of age and gender factors in prolonged post-concussion symptoms after mild head injury. Brain Inj. 2014;28(13-14):1639-45. doi: 10.3109/02699052.2014.954271.Adapted6,29,30
Practice point for children and adults:
N/A New
EBR (conditional)115 115. Zemek R, Barrowman N, Freedman Stephen B, Gravel J, Gagnon I, McGahern C, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014-25. doi: 10.1001/jama.2016.1203. Adapted6
The symptoms experienced by most people with mTBI/concussion resolve within 1 to 3 months of the injury116 but some people experience persisting symptoms and delayed recovery. People with mTBI/concussion who are at high risk for persisting symptoms or delayed recovery are more likely to require intervention than those at low risk.31 Early identification of these factors and their treatment may facilitate recovery.
A range of factors affect the severity and duration of persisting post-concussive symptoms.114 These include concurrent factors such as pain, anxiety, depression, post-traumatic stress and ligation.114 Pre-injury variables, including psychopathology, substance misuse, and other forms of acquired brain injury, can also affect recovery.114 Repetitive head trauma and greater severity of symptoms at initial presentation have been associated with symptoms persisting for more than one month, although the vast majority of these patients recover by three months.117
6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
43. Cnossen MC, Winkler EA, Yue JK, Okonkwo DO, Valadka AB, Steyerberg EW, et al. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma. 2017;34(16):2396-409. doi: 10.1089/neu.2016.4819.
56. Madhok DY, Yue JK, Sun X, Suen CG, Coss NA, Jain S, et al. Clinical predictors of 3- and 6-month outcome for mild traumatic brain injury patients with a negative head CT scan in the emergency department: A TRACK-TBI pilot study. Brain Sci. 2020;10(5). doi: 10.3390/brainsci10050269.
57. Nelson LD, Furger RE, Ranson J, Tarima S, Hammeke TA, Randolph C, et al. Acute clinical predictors of symptom recovery in emergency department patients with uncomplicated mild traumatic brain injury or non-traumatic brain injuries. J Neurotrauma. 2018;35(2):249-59. doi: 10.1089/neu.2017.4988.
58. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-13. doi: 10.1037/a0027888.
59. Schmidt BR, Moos RM, Konu-Leblebicioglu D, Bischoff-Ferrari HA, Simmen HP, Pape HC, et al. Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury. Eur J Trauma Emerg Surg. 2019;45(2):191-8. doi: 10.1007/s00068-018-1029-1.
60. Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-26. doi: 10.1089/neu.2014.3600.
61. Sutton M, Chan V, Escobar M, Mollayeva T, Hu Z, Colantonio A. Neck Injury comorbidity in concussion-related emergency department visits: a population-based study of sex differences across the life span. J Womens Health (Larchmt). 2019;28(4):473-82. doi: 10.1089/jwh.2018.7282.
62. Yue JK, Cnossen MC, Winkler EA, Deng H, Phelps RRL, Coss NA, et al. Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol. 2019;10:343. doi: 10.3389/fneur.2019.00343.
63. Coffeng SM, Jacobs B, de Koning ME, Hageman G, Roks G, van der Naalt J. Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum: a prospective multicentre cohort study. BMC Neurol. 2020;20(1):315. doi: 10.1186/s12883-020-01887-x.
64. Cnossen MC, van der Naalt J, Spikman JM, Nieboer D, Yue JK, Winkler EA, et al. Prediction of persistent post-concussion symptoms after mild traumatic brain injury. J Neurotrauma. 2018;35(22):2691-8. doi: 10.1089/neu.2017.5486.
65. Roy D, Peters ME, Everett AD, Leoutsakos JS, Yan H, Rao V, et al. Loss of consciousness and altered mental state as predictors of functional recovery within 6 months following mild traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2020;32(2):132-8. doi: 10.1176/appi.neuropsych.18120379.
114. King NS. A systematic review of age and gender factors in prolonged post-concussion symptoms after mild head injury. Brain Inj. 2014;28(13-14):1639-45. doi: 10.3109/02699052.2014.954271.
115. Zemek R, Barrowman N, Freedman Stephen B, Gravel J, Gagnon I, McGahern C, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014-25. doi: 10.1001/jama.2016.1203.
116. Cowley LE, Morris CB, Maguire SA, Farewell DM, Kemp AM. Validation of a prediction tool for abusive head trauma. Pediatrics. 2015;136(2):291-8. doi:
117. Meehan William P, Mannix R, Monuteaux Michael C, Stein Cynthia J, Bachur Richard G. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83(24):2204-10. doi: 10.1212/WNL.0000000000001073.
118. Babcock L, Kurowski BG, Zhang N, Dexheimer JW, Dyas J, Wade SL. Adolescents with mild traumatic brain injury get SMART: An analysis of a novel web-based intervention. Telemedicine and e-Health. 2017;23(7):600-7. doi:
119. Iverson GL, Gardner AJ, Terry DP, Ponsford JL, Sills AK, Broshek DK, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941-8. doi: 10.1136/bjsports-2017-097729.
120. Mortenson P, Singhal A, Hengel AR, Purtzki J. Impact of early follow-up intervention on parent-reported postconcussion pediatric symptoms: a feasibility study. J Head Trauma Rehabil. 2016;31(6):E23-E32. doi: 10.1097/HTR.0000000000000223.
121. Nowacki R, van Eldik N, Eikens M, Roijen R, Haga N, Schott D, et al. Evaluation of a follow-up program for mild traumatic brain injury in schoolchildren. Eur J Paediatric Neurology. 2017;21(2):382-7. doi: 10.1016/j.ejpn.2016.10.009.Adapted6,29,30
Refs43, 56-65, 115, 118-121Modifiers that may delay recovery Children Adults – Previous concussion/mTBI with delayed recovery
– High pre-injury symptom burden
– High symptom burden at initial presentation
– Clinical evidence of vestibular or oculomotor dysfunction
– Personal and family history of migraines
– History of learning or behavioural difficulties
– Personal and family history of poor mental health
– Low family socioeconomic status/education– High symptom burden at initial presentation
– Neck painHistory of migraine or headache
– Previous concussion/mTBI with delayed recovery
– Injury obtained during traumatic circumstances, e.g. assault/fatal car crash
– Previous mTBI/concussion
– Mental health problems, depression, and/or anxiety pre-injury
– Lower level of education
– Litigation
23. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374-e81.
27. Ponsford J, Willmott C, Rothwell A, Cameron P, Ayton G, Nelms R, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108(6):1297-303. doi: 10.1542/peds.108.6.1297.
31. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853.
122. Babikian T, Satz P, Zaucha K, Light R, Lewis RS, Asarnow RF. The UCLA longitudinal study of neurocognitive outcomes following mild pediatric traumatic brain injury. J Int Neuropsychol Soc. 2011;17(5):886-95. doi: 10.1017/S1355617711000907.
123. Yeates KO, Taylor HG, Rusin J, Bangert B, Dietrich A, Nuss K, et al. Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics. 2009;123(3):735-43. doi:
124. Zemek RL, Farion KJ, Sampson M, McGahern C. Prognosticators of persistent symptoms following pediatric concussion: a systematic review. JAMA Pediatr. 2013;167(3):259-65. doi: 10.1001/2013.jamapediatrics.216.
125. Centers for Disease Control and Prevention. HEADS UP Updated March 14, 2017 [February 16, 2018]. Available from: http://www.cdc.gov/headsup.
126. Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, et al. National Athletic Trainers’ Association position statement: management of sport concussion. J Athl Train. 2014;49(2):245-65. doi: 10.4085/1062-6050-49.1.07.
127. Adams RJ. Improving health outcomes with better patient understanding and education. Risk Manag Healthc Policy. 2010;3:61-72. doi: 10.2147/RMHP.S7500.Adapted31
Refs23, 27, 122-127
Tools for assessing the risk of symptoms persisting are available from 5P study: Predicting and Preventing Post-concussive Problems in Pediatrics and the AUT Traumatic Brain Injury Network.
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