Version May 2024
INTRODUCTION — Concern over the effects of mild traumatic brain injury, or concussion, sustained during sport has grown substantially in recent decades. While the effects of sports-related concussions (SRCs) are usually benign and self-limited, severe long-term sequelae can occur, and careful evaluation is needed.
This topic reviews the management of older adolescents and adults who have sustained a concussion while participating in athletics and whose initial medical evaluation reveals no sign of other significant injury, such as intracranial hemorrhage, skull fracture, or cervical spine injury. The initial assessment and management of patients with significant head or other trauma is not discussed here. The clinic-based examination and assessment of older adolescents and adults with an SRC, and all other aspects of head trauma and brain injury, are reviewed separately:
●Clinic-based assessment of SRC (see "Clinic-based evaluation of sports-related concussion in adolescents and adults")
●Trauma assessment (see "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child")
●Traumatic brain injury in adults (see "Acute mild traumatic brain injury (concussion) in adults" and "Sequelae of mild traumatic brain injury" and "Management of acute moderate and severe traumatic brain injury")
●Children with concussion (see "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Concussion in children and adolescents: Management")
●Sports-related injury (see "Sideline evaluation of concussion" and "Evaluation of the collapsed adult athlete")
TREATMENT — Our approach to the management of patients who have sustained a sports-related concussion (SRC) is provided below. Assuming there are no complicating factors, this approach is the same for the patient with their first SRC and those who have sustained one or two prior injuries. However, a more comprehensive evaluation and more specialized treatment may be needed if an athlete has any of the following:
●Multiple concussions
●Concussions caused by progressively less severe trauma
●Increasingly severe symptoms or cognitive deficits
●Longer recovery times
In such cases, the clinician may deem it worthwhile to begin a conversation about continued participation in the offending sport or activity. (See 'Retirement from sport' below.)
Basic initial interventions and general approach — Early treatment common to nearly all cases of SRC includes the following:
●Relative cognitive and physical rest as indicated for 24 to 48 hours (see 'Return to learn, work, and driving' below)
●Minimizing visual and auditory stimuli (eg, stopping or limiting screen viewing and reading, avoiding crowds)
●Good sleep hygiene (see 'Sleep disturbances' below)
●Proper hydration and nutrition
●Analgesics for headache (see 'Headache' below)
After the initial 24 to 48 hours following injury, light cognitive and physical activity may be reintroduced gradually, provided they do not worsen symptoms. (See 'Exercise' below.)
Previously, therapeutic interventions beyond simple rest were reserved for patients whose concussion symptoms persisted longer than 10 to 14 days. Increasingly, interventions such as graduated aerobic exercise, physiotherapy, and vestibular rehabilitation have been initiated early to good effect [1,2]. Such interventions are based on a targeted assessment and determination of the clinical domains affected [3]. (See "Clinic-based evaluation of sports-related concussion in adolescents and adults".)
Exercise — Contrary to earlier protocols that advocated strict physical and cognitive rest until the patient was asymptomatic, exercise has become an important part of treatment for SRC. Consensus guidelines state that the athlete need not be symptom free to begin exercise but recommend that exercise not worsen symptoms either during activity or after [4,5].
Multiple studies support this approach [4,6,7]. In a randomized trial of 99 patients (ages 11 to 22), no clinically significant differences in symptom reduction, balance, or neurocognitive performance were found between those assigned to strict rest for five days and those permitted an early stepwise return to activity following one to two days of rest [6].
Before introducing exercise, the clinician should have performed a careful examination that excludes any contraindications, such as cardiac or respiratory disease, significant vestibular problems, and lower limb or cervical spine injury. (See "Clinic-based evaluation of sports-related concussion in adolescents and adults", section on 'Clinic evaluation'.)
We and others suggest a brief period of relative physical and cognitive rest for 24 to 48 hours immediately following injury, followed by an introduction and gradual increase in exercise. The initial types of exercise should be easy aerobic activities that do not worsen symptoms and do not entail any risk of falling or sustaining further head injury. Examples include riding a stationary bicycle and walking. Standardized exercise testing is a useful method for introducing a controlled physical stress and assessing patient response. Validated protocols that can be used to assess patients and introduce exercise include the Balke Treadmill Test [8], Buffalo Concussion Treadmill Test, and Buffalo Concussion Bike Test [9]. Heart rate, perceived exertion, and any symptoms should be recorded while the patient is at rest, during all grades of exercise, and during recovery.
Gradually, over days to weeks depending on the severity of symptoms, more demanding activity can be introduced based on clinical evaluation and progress (ie, improvement of symptoms). Exercise such as resistance training, intense anaerobic exercise (eg, sprinting, agility work), and controlled contact training should be undertaken only with close supervision and based on appropriate clinical progress. Symptoms should be monitored during and after each exposure [10]. A general approach to return to sport is provided (table 1).
Exercise, when introduced and performed properly, improves autonomic nervous system function, mood, sleep, and possibly other SRC-related symptoms. Conversely, uncontrolled, intense exercise performed prematurely can exacerbate the effects of SRC on the autonomic nervous system and worsen symptoms.
The exercise intolerance demonstrated by some athletes following a SRC may be related to abnormal regulation of cerebral blood flow. As aerobic exercise tolerance increases, autonomic nervous system function improves. Thus, exercise below the symptom threshold may be therapeutic for SRC, but further research is needed.
A systematic assessment of exercise tolerance using the Buffalo Concussion Treadmill Test has been safely employed to prescribe a progressive, individualized aerobic exercise program with activity below the symptom threshold that enables patients to return to sport and work [9,11,12]. Further study should determine the efficacy and optimal timing, dose, and duration of subthreshold aerobic exercise acutely after SRC.
Pharmacologic therapy for SRC — There are no medications or supplements that have been shown to speed recovery following concussion. Clinicians should make this clear to athletes, parents/guardians, coaches, and other concerned parties. Depending upon the patient's symptoms and comorbidities, medications may be used to treat specific conditions, such as migraine headache or anxiety.
Headache — Headache is the most common symptom associated with concussion [13-15]. Treatment is guided by the type of headache. The three most common types of postconcussive headache are migraine-like (approximately 50 percent), tension-type (approximately 32 to 37 percent), and cervicogenic (approximately 4 percent) headache [15]. Postconcussive headache is discussed in greater detail separately. (See "Concussion in children and adolescents: Management", section on 'Symptom management' and "Post-traumatic headache".)
In the immediate 24 to 48 hours after injury, acetaminophen is typically recommended for relief of headache, as it does not increase the risk for intracranial bleeding. When the presence of an intracranial bleed is deemed unlikely, most often because of improving symptoms when the patient is reassessed at 24 to 48 hours, patients may use other basic analgesics, such as ibuprofen, for acute post-traumatic headache. Patients with a prior history of migraine headache who develop symptoms typical of previous attacks can be treated with their usual abortive medications. If these interventions are ineffective, additional steps are taken, as outlined in the following discussion. We advise against using medications such as opioids that may affect the patient's sensorium or cognition, as such treatment may impede recovery and complicate assessments of clinical progress. (See "Post-traumatic headache", section on 'Treatment'.)
Headaches associated with an SRC may arise from or be exacerbated by other factors, including visual disturbances, photophobia, cervical injury, anxiety, stress, dehydration, nutritional deficits, and menstruation. In such cases, nonpharmacologic interventions such as physiotherapy, acupuncture, and massage may provide some relief in addition to standard treatments.
Free magnesium levels are often low in patients with migraine headaches, and magnesium may safely be used in post-traumatic headaches, although there remains insufficient evidence of efficacy [16,17]. Magnesium glycinate and magnesium citrate (400 to 600 mg daily) are more easily absorbed and have fewer gastrointestinal side effects.
Sleep disturbances — Good sleep hygiene is important for all patients recovering from a concussion and is an essential intervention for those whose recovery is complicated by insomnia or other forms of disturbed sleep (table 2 and table 3). Sleep hygiene includes [18]:
●Eliminating screen time in the evening before bedtime
●Avoiding caffeine and alcohol, particularly in the hours before bedtime
●Sleeping in a dark, cool, quiet room
●Minimizing/eliminating daytime napping
●Performing daily exercise (ideally not late in the evening)
Patients should try to maintain a regular sleep schedule consistent with normal circadian rhythms. Most importantly, patients should allow themselves sufficient time to sleep each day, as an increased need for sleep (pleiosomnia) is frequently observed after concussion and other traumatic brain injury. Individual time needs for sleep can be estimated based on whether the patient feels well rested after sleep and throughout the day or based on sleep times when no limits are set, such as during weekends and holidays. Ideally, sleep should not be curtailed by alarm clocks or other means.
If possible, daytime naps are best avoided, unless this was part of an athlete's routine prior to their concussion and should be brief if taken. Naps should be avoided if night-time sleep has become interrupted. Daytime sun exposure combined with light exercise may help address circadian dysregulation. The management of insomnia and of other forms of disturbed sleep is reviewed separately. (See "Overview of the treatment of insomnia in adults" and "Behavioral sleep problems in children".)
In some cases, treatment with melatonin may be helpful. The best-established use is for patients with delayed circadian rhythms, who have difficulty falling asleep until late in the evening and then oversleep in the morning. For such patients, melatonin is typically given nightly, one to two hours before the desired bedtime. Timed dosing, in combination with behavioral modifications, aims to restore healthy circadian rhythms. Administration of melatonin and supporting evidence in this setting are reviewed separately. (See "Delayed sleep-wake phase disorder", section on 'Management'.)
Melatonin has also been studied as a treatment for disturbed sleep more generally in patients with traumatic brain injury, with mixed results [19]. Its effects are generally modest, and the main appeal is its relative safety and tolerability compared with other medications for insomnia. (See "Sleep-wake disorders in patients with traumatic brain injury", section on 'Insomnia'.)
The use of sedatives, including benzodiazepines and atypical gamma aminobutyric acid agonists, to treat disturbed sleep following SRC is discouraged because of the potential negative effects on cognition [20]. However, athletes previously prescribed sedatives or other medications for anxiety or depression diagnosed prior to any concussion should continue these therapies as indicated.
A variety of other sleep disorders may occur in the subacute to chronic phase of concussion recovery (figure 1). Excessive daytime sleepiness is common and may require a multifaceted approach. Evaluation and management are reviewed in more detail separately. (See "Sleep-wake disorders in patients with traumatic brain injury".)
Ocular or vestibular dysfunction — Limited evidence and the authors' clinical experience suggest that early initiation of a vestibular or ocular rehabilitation program (or both) may be helpful for patients with persistent symptoms [21,22]. This may involve referral to a physical therapist or other appropriately skilled clinician with an understanding of ocular and vestibular dysfunction. Specific management may include exercises for eye movement, accommodation, head movement, and balance. Where such specialist care is not available, a basic home exercise program may be used. (See "Sequelae of mild traumatic brain injury", section on 'Posttraumatic vertigo and dizziness'.)
Mood disorders and anxiety — While not as common as headache or cognitive findings, anxiety and mood-related symptoms are relatively common with SRC. The first step in addressing such problems involves educating the athlete about the injury, specifics of treatment, and the expectation that the vast majority of athletes experience timely improvement in symptoms and dysfunction and ultimately complete resolution. Such education is often effective.
Cognitive therapy and psychotherapy can play an important role in managing mood disorders that develop following an SRC. These should be implemented before medication is introduced. However, athletes previously prescribed sedatives or other medications for anxiety or depression diagnosed prior to any concussion should continue these therapies as indicated. Such patients should be evaluated by the clinician who treats their psychiatric illness in addition to the clinician managing their SRC. Specialist psychiatric consultation should be obtained if there is inadequate or no response to cognitive therapy.
Anxiety and mood-related symptoms are associated with delayed recovery and return to sport. (See 'Return to sport' below.)
Attention deficit — New-onset concentration deficits, which are common in the acute and subacute stages of SRC, should not be treated with stimulant medication initially. However, in patients already taking a stimulant medication for a previously diagnosed attention disorder, the medication should only be withheld during the initial 24 to 48 hours following injury. It should then be resumed. All other cognitive and exercise restrictions should be observed in such patients.
Adjunctive treatments — A number of supplements have been proposed as adjunct treatments for concussion, but research is scant and not specific to concussion [23]. As an example, a form of omega-3 fatty acid, docosahexaenoic acid (DHA), the predominant omega-r fatty acid found in the phospholipid membranes of neurons, at a dose of 2000 mg per day has been proposed to speed recovery in children [24].
RETURN TO SPORT — The goal of return-to-sport protocols is to enable athletes to return safely to sport when they are neurologically and physically able. Return-to-sport planning begins at the time of initial evaluation and requires coordination among clinicians, athletic trainers, coaches, parents/guardians, and the athlete. Only limited evidence is available, and return-to-sport plans are guided primarily by expert opinion. Protocols typically involve a stepwise progression beginning with activities of daily living and advancing through subsequent stages that introduce activities posing greater cognitive and physical demands, culminating in sport-specific activities. The time required for resolution of symptoms and return to full sport is discussed below. (See 'Prognosis' below.)
The evaluating clinician relies on the athlete and athletic trainer to inform them of the athlete's progress. The clinician needs assurance that the athlete has no unresolved concussion symptoms or functional deficits, and that each stage has been completed without provoking symptoms, before allowing the athlete to return to full competition. The widely used Concussion in Sport Group return-to-sport protocol provides a sound approach and is provided here (table 1). The approach does not differ based on the type of sport to which the athlete is returning, be it collision (eg, rugby, American football, ice hockey), combat (eg, judo, wrestling), contact (eg, basketball, football [soccer]), or non-contact (eg, tennis, volleyball).
Before an athlete begins a return-to-sport protocol, all concussion-related symptoms should be resolved (or, at a minimum, stable and not severe). The content of each stage or phase may be individualized based on the sport, age, level of play, and degree of supervision [25]. As a general rule, each stage should last a minimum of 24 hours, and performance of all tasks at a given stage must not provoke symptoms before the athlete is permitted to move to the next stage. If symptoms do develop, the athlete should return to the previous stage. The time course for advancement may be modified based on individual factors such as a history of prior SRCs, previous recovery patterns, or specifics of the current injury.
The athlete must achieve the following to meet the minimum requirements for a full return to sport:
●Complete resolution of symptoms; return to preinjury state
●Neurocognitive function at preinjury baseline measures if available or at expected level based on population norms
●No symptoms provoked by full physical exertion
●No symptoms provoked by cognitive exertion or visual stress
●Return-to-sport protocol or equivalent is completed
●Athlete must express a desire to return to sport
●Athlete must show they understand the possible long-term risks of re-injury (clinicians should provide clear explanations in language the athlete understands [26])
More severe symptoms initially and prominent anxiety or mood-related symptoms are associated with delayed recovery and return to sport. In a study of over 2000 high-level collegiate athletes in the United States, the reporting of affective symptoms (ie, more emotional, irritability, sadness, and/or nervousness or anxiety) was associated with significant delays in full return to play [27].
The athlete and others (eg, parents/guardians of adolescents) should be made aware of the possible long-term risks associated with their return to contact or collision sports. It should be made clear that our understanding of the long-term risks from repetitive head trauma is incomplete and evolving [26]
Return to sport typically occurs in parallel with a return to academics ("return to learn"), work, or service [25]. In school-age athletes, return to sport should not occur ahead of a return to learning. Information on returning to school and work is provided below.
RETURN TO LEARN, WORK, AND DRIVING — Patients recovering from an SRC should return to school and work after a brief period of rest as their symptoms permit. The return to school for children and younger adolescents is discussed separately. (See "Concussion in children and adolescents: Management", section on 'Return to learn'.)
The rate at which patients can resume learning, reading, and using a computer will vary based on symptoms. In a systematic review of 278 studies notable for a large degree of heterogeneity, the average time for a concussed athlete to resume learning without restrictions was 8.3 days (95% CI 5.6-11.1), with 93 percent of athletes achieving this milestone by 10 days [28]. In a multisite, prospective study of over 1700 college athletes in the United States with an SRC, the median time until return to full academics was six days [29]. Students who resumed full coursework prior to the resolution of symptoms were significantly more likely to experience a prolonged recovery (21.5 percent less likely to return to full sport within 14 days; 95% CI -27.4 to -15.5) and delayed return to full sport (19.1 percent more likely to return after 28 days; 95% CI 13.4-24.7).
Athletes who experience photophobia, headaches, and cognitive manifestations progress more slowly. Individualized accommodations at school, university, and work may be needed (table 4). Communication among the clinician, patient, family, teachers, school health personnel, and supervisors is important. Examples of accommodations that may be needed are provided (table 5).
While most SRC-related cognitive deficits resolve within a short period, some patients may experience persistent problems extending over weeks or months [30]. Such patients should be referred to a neuropsychologist or other clinical specialist in cognition if deficits persist for a month or longer. Earlier referral may be warranted depending upon the severity of the deficits and their effect on the patient’s ability to resume academics or work.
Following a SRC, symptomatic patients demonstrate impaired driving ability [31,32]. Clinicians should discuss with patients the potential dangers of resuming driving prematurely (ie, while patients remain symptomatic) [25].
PROGNOSIS — The prognosis and possible sequelae of traumatic brain injury, including chronic traumatic encephalopathy, are discussed in detail separately; early recovery from such injury as it relates to a return to participation in sport is reviewed below. (See "Sequelae of mild traumatic brain injury" and "Postconcussion syndrome" and "Concussion in children and adolescents: Management".)
Overall recovery — The overwhelming majority of athletes who sustain an SRC can expect to return to their preinjury baseline in terms of symptoms and function. An SRC is considered resolved when the following criteria are met:
●All concussion-related symptoms have resolved, both at rest and during full cognitive stress or full physical exertion
●All neurologic, neurocognitive, vestibular, ocular, and oculomotor functions have returned to baseline
Clinical symptoms of SRC resolve in 80 to 90 percent of older adolescents and adults within two weeks [33]. In younger athletes and adults over 40 years of age, this can take longer, with most returning to preinjury levels of function within four weeks [34]. In a systematic review of 278 studies notable for a large degree of heterogeneity, the average time for a concussed athlete to resume full sport was 19.8 days (95% CI 18.8-20.7) [28].
Relatively few athletes (2.9 percent) are medically disqualified for the remainder of their season or permanently [35,36]. However, it should be emphasized that the duration of recovery is variable and dependent upon a variety of factors, including intrinsic and injury-specific risk factors, treatment, athlete compliance, and motivation. Predicting the duration of symptoms is an inexact science. (See "Clinic-based evaluation of sports-related concussion in adolescents and adults", section on 'Risk factors for more severe concussion'.)
Predicting duration of symptoms — Our understanding of symptom resolution following SRC continues to evolve [37-40]. While definitive studies are lacking, we believe that normal recovery from an SRC is a process requiring up to one month [41].
Earlier studies reported that nearly all collegiate American football players experienced a resolution of symptoms by day seven [42], but subsequent research describes significant numbers of athletes with symptoms and clinical deficits lasting beyond seven days [25,33,41,43,44]. In a large observational study of collegiate athletes from multiple sports, the median time for return to play was 12.8 days, with 9 percent of athletes not fully recovered at 28 days [45]. Some have expressed concern that the resolution of symptoms and measurable neurocognitive deficits as determined by typical office-based assessments may not reflect true physiologic recovery [46].
Prognostication based on pre-existing conditions, history, symptoms, and physical examination findings is challenging, but some factors appear to be associated with longer recovery times. While this research is limited, some highlights include the following:
●History of neuropsychiatric disorder – A pre-existing mental health condition, particularly depression, is associated with an increased risk for prolonged symptoms [47]. Conversely, athletes with attention-deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at risk for prolonged recovery [47]. In a large observational study, patients with ADHD recovered faster than unaffected patients even after controlling for stimulant therapy [45].
●History of brain injury – Recovery has been reported to be prolonged in athletes with ≥3 previous concussions [45].
●Sex and age – The role of sex remains unclear. While some studies report that recovery is prolonged in female athletes [36,45,47], an analysis of over 1000 concussions in United States collegiate athletes reported no differences in recovery time between females and males [48].
Adolescents appear to have longer recovery than young adults [47]. Adolescent athletes whose symptoms are provoked at lower heart rates during a graded exercise test within a week of sustaining an SRC have a longer recovery time [49].
●Symptom type and severity – Greater number and severity of acute and subacute symptoms suggest a longer recovery [28,36,45,47], with headache and depression in the subacute period after injury associated with symptoms persisting beyond one month [47]. Early work on the relationship of physical examination findings to recovery suggests that vestibular impairment is associated with delayed recovery [48]. In some cases, balance deficits identified during the performance of dual tasks persist even after a return to normal daily activities [50,51].
●Delayed diagnosis – Delayed recognition of an SRC leading to continued play or exertion (eg, practice), regardless of whether additional head trauma was sustained, is associated with a greater symptom burden and prolonged recovery by three to five days [28,52,53].
●Biomarkers and imaging – No clinically available blood or salivary biomarkers or imaging methods have been found to predict recovery times accurately [54]. Preliminary laboratory studies suggests that total tau and glial fibrillary acidic protein concentrations may correlate with time required to return to sport, but further study is needed [55].
●Heat, altitude, and other environmental factors – Although once thought to affect SRC presentation and recovery, altitude up to 2500 m and on-field heat index at the time of injury do not appear to exacerbate symptoms [56]. Commercial airplane travel early after a concussion does not affect symptom severity or recovery following an SRC [57].
Other sequelae — Of note, SRC is associated with an increased rate for lower extremity injury in the months following return to sport [58,59].
The sequelae of brain injury, including chronic traumatic encephalopathy, are discussed in detail separately. (See "Sequelae of mild traumatic brain injury" and "Postconcussion syndrome" and "Concussion in children and adolescents: Management".)
RETIREMENT FROM SPORT
General considerations — The decision to retire from sport because of the effects of an SRC can be difficult, and there is little high-quality evidence available to guide such decisions [60,61]. If symptoms recur frequently or are particularly severe, the decision may be clear. However, the issues around reinjury and long-term risk can be challenging.
We believe that the decision to retire from a contact or collision sport should be made by the athlete in close consultation with the primary clinician and other trusted members of the athlete's social network, possibly including parents/guardians, spouse or partner, siblings, friends, coaches, teammates, work colleagues, and members of their academic support team. The decision may be informed by input from medical specialists with expertise in those clinical domains most affected. (See "Clinic-based evaluation of sports-related concussion in adolescents and adults", section on 'Concussion symptom categories (clinical domains)'.)
The decision need not be made immediately. It is appropriate to consider the decision over weeks to months, during which time symptoms are monitored and feedback is provided. Below, we provide some guidance for approaching the question of retirement from sport following SRC.
The question "how many is too many?" has no definitive answer. However, there is evidence of increased neurodegeneration and mortality among some participants in contact and collision sports that must be considered. When concussions are recurrent, occur from less impact, or cause prolonged symptoms, clinicians should warn athletes of potential long-term sequelae. In these situations, it is reasonable to remove the athlete from contact sport for a prolonged period (three to six months). This rest period can be used to address any identified deficits or problems and then re-evaluate. (See "Sequelae of mild traumatic brain injury".)
Joint decision-making — In some cases, an athlete may decide to retire from a sport based upon their own interpretation of their symptoms and assessment of their future risk. However, when making this decision, athletes often rely upon input from many people, possibly including their family, spouse or partner, friends, coaches, teammates, work colleagues, academic support team, and medical team. The team doctor, family or personal physician, and neurologist may all act as a sounding board for the athlete. In addition, the athlete may seek input from specialists, possibly including neurosurgeons, otolaryngologists, physical or occupational therapists, psychiatrists, clinical or neuropsychologists, and ophthalmologists.
Clinical evaluation — As with early assessments following acute injury, the medical evaluation of a player who has suffered numerous concussions, is experiencing prolonged symptoms, or is seeking advice regarding a future in contact sport should be thorough and cover all relevant clinical domains. Those domains that appear to be particularly problematic should prompt referral to a specialist.
Serial assessments — Many specialist evaluations must be repeated to determine whether the athlete's condition is improving. The primary supervising clinician should receive feedback after any specialist consultation and discuss the latest findings with the athlete. Decisions not to participate in sport may be provisional (for weeks or months) pending the results of future reassessments. Conversations about participation and risk may take place at any time, especially when new information comes to light or it becomes clear that the athlete's condition is becoming chronic.
Exercise stress tests — In cases where symptoms have resolved at rest, an exercise program with a gradual increase in intensity can be used to determine whether symptoms are provoked by physical stress.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sports-related concussion" and "Society guideline links: Minor head trauma and concussion".)
SUMMARY AND RECOMMENDATIONS
●Basic initial interventions – Early treatment common to nearly all cases of sports-related concussion (SRC) includes the following (see 'Basic initial interventions and general approach' above):
•Relative cognitive and physical rest as indicated for 24 to 48 hours
•Minimizing visual and auditory stimuli (eg, stopping or limiting screen viewing and reading, avoiding crowds)
•Good sleep hygiene
•Proper hydration and nutrition
•Analgesics for headache
●Exercise – Following the initial 24 to 48 hours of relative rest, athletes need not be symptom free to begin light exercise. Exercise should begin with easy aerobic activities that do not worsen symptoms and do not entail any risk of falling or sustaining further head injury. Gradually, over days to weeks depending on the severity of symptoms, more demanding activity is introduced while monitoring closely for symptoms, particularly those in the domains predominately affected. (See 'Exercise' above.)
●Pharmacologic therapy – There are no medications or supplements that have been shown to speed recovery following concussion. Clinicians should make this clear to athletes, parents/guardians, coaches, and other concerned parties. (See 'Pharmacologic therapy for SRC' above.)
●Headache – In the immediate 24 to 48 hours after injury, acetaminophen is typically given for relief of headache. Once the presence of an intracranial bleed is deemed unlikely, most often because of improving symptoms, patients may use other basic analgesics, such as ibuprofen. Patients with a prior history of migraine headache who develop symptoms typical of previous attacks can be treated with their usual abortive medications. If these interventions are ineffective, additional steps may be needed. (See "Post-traumatic headache", section on 'Treatment'.)
●Sleep – All patients recovering from an SRC should allow themselves sufficient time to sleep and adhere to sound sleep hygiene (table 2 and table 3), including (see 'Sleep disturbances' above):
•Eliminating screen time in the evening before bedtime
•Avoiding caffeine and alcohol, particularly in the hours before bedtime
•Sleeping in a dark, cool, quiet room
•Minimizing/eliminating daytime napping
•Performing daily exercise (ideally not late in the evening)
●Ocular or vestibular dysfunction – For patients with persistent symptoms of vestibular or ocular dysfunction, focused rehabilitation programs may be helpful. These generally entail referral. (See 'Ocular or vestibular dysfunction' above.)
●Mood disorders and anxiety – Educating the athlete about SRC and the expectation that the vast majority of players experience timely improvement in symptoms and dysfunction, and ultimately complete resolution, is often helpful. Cognitive therapy and psychotherapy can play an important role in managing mood disorders. Athletes previously prescribed sedatives or other medications for anxiety or depression diagnosed prior to any concussion should continue these therapies as indicated under the supervision of the prescribing clinician. Anxiety and mood disorders are associated with delayed return to sport. (See 'Mood disorders and anxiety' above.)
●Attention deficits – New-onset concentration deficits, which are common in the acute and subacute stages of SRC, should not be treated with stimulant medication initially. In patients already taking a stimulant medication for a previously diagnosed attention disorder, the medication should only be withheld during the initial 24 to 48 hours following injury. (See 'Attention deficit' above.)
●Return to sport – We suggest that athletes meet minimum requirements before returning to full sport, including the following (Grade 2C) (see 'Return to sport' above):
•Complete resolution of symptoms; return to preinjury state
•Neurocognitive function at preinjury baseline measures if available or at expected level based on population norms
•No symptoms provoked by full physical exertion
•No symptoms provoked by cognitive exertion or visual stress
•Return-to-sport protocol or equivalent is completed
The return to school for children and adolescents is discussed separately. (See "Concussion in children and adolescents: Management", section on 'Return to learn'.)
●Prognosis – Clinical symptoms of SRC resolve in 80 to 90 percent of older adolescents and adults within two weeks. In younger athletes and adults over 40 years of age, this can take longer, but most return to preinjury levels of function within four weeks. Few athletes (2.9 percent) are medically disqualified for the remainder of their season or permanently. Guidance about possible retirement from sport is provided. (See 'Prognosis' above and 'Retirement from sport' above.)
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