REVIEW ARTICLE

C O N T I NU U M A UD I O
I NT E R V I E W A V AI L A B L E
ONLINE
CITE AS:
CONTINUUM (MINNEAP MINN)
2018;24(1, CHILD NEUROLOGY):300–311.
Address correspondence to
Dr Meeryo Choe, UCLA Mattel
Children’s Hospital, Department
of Pediatrics, Division of Pediatric
Neurology, 22–474 MDCC, 10833
LeConte Ave, Los Angeles, CA
90095–1752, mchoe@mednet.
ucla.edu.
RELATIONSHIP DISCLOSURE:
T
Dr Choe receives research/grant
support from the National
Institutes of Health/Small
Business Innovation Research for
Neural Analytics (R44NS09209)
and the University of California,
Los Angeles Steve Tisch
BrainSPORT Program and has
provided expert legal testimony
regarding concussion. Dr Barlow
receives research/grant support
from the Alberta Children’s
Hospital Research Institute and
the Canadian Institutes of Health
Research (293375).
UNLABELED USE OF
PRODUCTS/INVESTIGATIONAL
USE DISCLOSURE:
Drs Choe and Barlow report
no disclosure.
© 2018 American Academy
of Neurology.
300
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Pediatric Traumatic Brain
Injury and Concussion
By Meeryo Choe, MD; Karen M. Barlow, MD
ABSTRACT
PURPOSE OF REVIEW: This article summarizes the impact and complications
of mild traumatic brain injury and concussion in children and outlines the
recent evidence for its assessment and early management. Useful
evidence-based management strategies are provided for children who
have a typical recovery following concussion as well as for those who
have persistent postconcussion syndrome. Cases are used to demonstrate
the commonly encountered pathologies of headache, cognitive issues,
and mood disturbances following injury.
A clinical risk score using risk factors for poor recovery
RECENT FINDINGS:
(eg, female sex, adolescence, previous migraine, and a high degree of
acute symptoms) can be used to help the clinician plan follow-up in the
community. Prolonged periods of physical and cognitive rest should be
avoided. Multidisciplinary treatment plans are often required in the
management of persistent postconcussion syndrome.
SUMMARY: A paucity of research exists for the treatment of postconcussion
syndrome. Current treatments target individual symptoms.
INTRODUCTION
raumatic brain injury is a major public health issue causing significant
morbidity and mortality in the pediatric population and with increasing
awareness among the lay population and considerable attention in
the media. This article focuses on mild traumatic brain injury (TBI),
or concussion, which makes up the majority of injuries. While most
mild TBIs improve quickly, some result in more long-lasting sequelae. This
article provides recommendations for evidence-based management strategies for
treatment in the acute period. Risk factors that may predispose certain children
to persistent postconcussion symptoms and approaches for management of these
symptoms are also presented.
DEFINITIONS
Efforts to define TBI have been widespread over the past several years. The
International and Interagency Initiative Toward Common Data Elements for
Research on Traumatic Brain Injury and Psychological Health defines TBI as “an
alteration in brain function, or other evidence of brain pathology, caused by an
external force.”1 Alteration in brain function is defined as one of the following
clinical signs:
FEBRUARY 2018
u Any period of loss of consciousness or decreased level of consciousness KEY POINTS

u Any loss of memory for events immediately before or after the injury ● Alteration in brain
(posttraumatic amnesia) function due to an external
force is the hallmark of
u Any neurologic deficits traumatic brain injury.
u Any alteration in mental state at the time of the injury (eg, confusion,
● The symptoms and signs
disorientation, slowed thinking)
of traumatic brain injury and
concussion should not be
To qualify as a TBI, alteration in brain function should not be more reasonably better explained by another
explained by other pathologic processes (eg, shock, substance use, metabolic medical or psychological
condition.
derangement), although these can co-occur with TBI. External forces may
include rotational acceleration-deceleration forces transmitted to the brain
without a direct blow to the head and forces due to blasts or explosions.
The definition of mild TBI poses particular problems, partly because of the
timing of the initial assessment and partly because of the overlap of neurologic
symptoms and signs from mild TBI with other medical and psychological
conditions (eg, posttraumatic stress disorder, depression, alcohol intoxication).2
The Glasgow Coma Scale score after TBI should be assessed at least 30 minutes
postinjury to allow for a brief period of loss of consciousness with rapid neurologic
improvement, which occurs in around 10% to 20% of cases of mild TBI. This,
however, is not always practical, leading to some patients with mild TBI being
incorrectly classified as having a moderate TBI when they are evaluated during
the initial period of loss of consciousness. Symptoms due to an emotional or
psychological response to the traumatic event may be incorrectly attributed to
confusion due to a brain injury. As many people with mild TBI present to medical
attention several days or weeks later, it is apparent that determining whether
their symptoms were due to a brain injury or other factors can be complicated.
Concussion is often viewed as being on the milder end of the spectrum of TBI,
and the term is often used interchangeably with mild TBI. The Zurich Consensus
(2012) states that a concussion is a brain injury that “is defined as a complex
pathophysiological process affecting the brain, induced by biomechanical
forces.” The injury can be sustained “either by a direct blow to the head…or
elsewhere on the body with an ‘impulsive’ force transmitted to the head.”3
Various physical symptoms can be caused by a concussion. The Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)4
lists these as physical fatigue, disordered sleep, headaches, and/or vertigo/
dizziness, and the International Classification of Diseases, Tenth Revision (ICD-10)5
expands these to include tinnitus/hyperacusis, photosensitivity, and reduced
tolerance to alcohol or medications. These symptoms should be present in the
first few days following the injury, but they should not be the sole basis
of the diagnosis. A plausible mechanism of injury or another brain injury
indicator should also exist, such as loss of consciousness, amnesia, or other
evidence of neurologic dysfunction.
The diagnosis of TBI and concussion relies on multimodal clinical assessments,
including a thorough history (eg, the mechanism of insult, presence of loss of
consciousness and amnesia, any acute symptoms) and examination (eg, presence
of coma, Glasgow Coma Scale score, focal neurologic signs), and may include
neuroimaging. The severity of TBI is determined following resuscitation (or
30 minutes postinjury) using clinical parameters. A Glasgow Coma Scale score of

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TRAUMATIC BRAIN INJURY AND CONCUSSION

8 or less is classified as a severe TBI, a score of 9 to 12 is classified as a moderate

TBI, and a score of 13 to 15 is classified as a mild TBI. The length of posttraumatic
amnesia is related to injury severity and predictive of outcome. Neuroimaging
(MRI or CT) is used acutely in moderate and severe injuries to determine the
severity and extent of the brain injury and to determine the need for neurosurgical
intervention. Little role exists for neuroimaging in mild TBI outside of research
unless the clinician suspects an intracranial hemorrhage. Several clinical decision
rules and guidelines exist to help the emergency physician determine the need for
neuroimaging.6,7 A 2015 review explored the use of ICD-10 codes across the
spectrum of TBI in children. Despite the wide range of codes used, many TBIs
may go uncoded, particularly when a patient has coincident injuries.8 It is clear
that better diagnostic methods to determine and categorize pediatric TBI are
needed to help with future research and outreach and prevention efforts. It is
important to note that while much research is being done to determine an objective
diagnostic tool for mild TBI and concussion (eg, blood or imaging biomarkers,
cognitive or reaction time testing, balance tests), no single measure can take the
place of a multimodal clinical assessment that includes a thorough history, physical
examination, and other validated diagnostic tools or adjunctive tests. Unfortunately,
few diagnostic tools have been validated in the pediatric population.

EPIDEMIOLOGY
TBI is the leading cause of death and disability among children and young adults
in the United States. These injuries may have persistent effects on a child’s
functioning throughout his/her development and into adulthood, even when
the initial insult is mild. As childhood is a critical stage of neurodevelopment,
a TBI during this period has the potential for causing serious long-term
consequences. Data from the Centers for Disease Control and Prevention (CDC)
show that the incidence of TBI in the United States is highest in children under
4 years of age and in those between 15 and 19 years of age.9
In Canada, the largest number of concussions is seen in the adolescent
population, which also saw the greatest increase in incidence between 2003 and
2013.10 The majority of TBIs at all ages are mild, and most heal after a short
recovery period, typically less than 4 weeks. The term concussion is frequently
used in place of mild TBI, particularly in the emergency department setting; this
is likely to play a role in clinical outcome, as parents may infer that there will be
no long-term consequences from a concussion versus a brain injury.11 However,
some children do go on to develop chronic issues and require carefully monitored
care. These complications may persist for months to years and include somatic,
cognitive, psychological, and sleep disturbances. Certain risk factors for these
complications can help to identify these children earlier in their recovery. It is
critical to identify these patients in the acute period so that early interventions
that may benefit them can be initiated, perhaps shortening recovery and
improving outcome.
Although falls are a common cause of mild TBI or concussion in children
presenting to the emergency department, mild TBI and concussion are often
sustained during sports participation. With more than 44 million youth participating
in sports each year, this is particularly important.12 A 2016 epidemiologic study
estimated that 1.1 to 1.9 million sports concussions occur each year among children
18 years of age or younger in the United States.13 However, only a fraction of these
patients seek medical care, with 630,000 estimated as presenting to emergency

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departments annually.9 Although an additional portion may also be seen in the KEY POINTS
outpatient clinic setting or by other nonphysician health care providers, the
● Traumatic brain injury is
number seeking some form of medical attention still falls short of the estimated the leading cause of death
total number of concussions. This suggests the need for further community and neurologic morbidity in
outreach to encourage presentation to health care providers to help guide the children.
recovery processes of injured youth.
● Mild traumatic brain
injury and concussion are
MANAGEMENT often sustained during
Despite guidelines endorsed by multiple provider associations, including the sports participation.
American Academy of Neurology, discharge management differs among health
● Removal from
care providers caring for children with TBI.14–16 Patients may not receive
sport-related activities
appropriate discharge instructions from the emergency department,17 which decreases early repeat
may delay the recovery process. As the majority of concussions in childhood injury and speeds recovery.
occur during sport or athletic activities, most of the guidelines have focused on
athletic-related concussions, although most of these can be reasonably ● After a short period of
rest following a concussion,
extrapolated to other etiologies. a graduated reentry into
While no specific treatment for TBI is known, many studies have shown that, normal activities is
for student athletes, removal from play after a concussion significantly improves encouraged.
the time course of recovery.18 Beginning with the state of Washington in 2009,
● Early involvement with a
states began passing concussion legislation for youth athletes. As of 2014, every
specialized concussion
state in the United States has enacted legislation regarding a mandated approach clinic should be considered
to concussion.19 Although the specific language sometimes differs, state in those children at risk of
legislation typically includes three components: education for the athletes and delayed recovery.
parents, removal from play, and return only after evaluation by a licensed health
● Management of
care provider trained in the evaluation and management of concussion. concussion is targeted to
Education for children and families should be emphasized, both for the problematic symptoms
prevention and during the postinjury period. Education of adolescents, while gradually increasing
families, and coaches should be emphasized and can take place even before participation in activities of
daily life.
injury to help prevent concussion and aid in early recognition of injury.
Unfortunately, current education tactics may not be sufficient for improving
self-report of injury by youth athletes despite increased knowledge,20–23 with
only half of respondents saying they would always or sometimes report a
concussion and 26% to 53% saying they may continue to play with an injury.
Clearly, education should focus on changing the attitudes of athletes and
coaches away from perceived negative consequences of reporting.

Return to Learn and Return to Play

Avoidance of a repeat injury within the hypothetical time period of increased
vulnerability (7 to 10 days postinjury) is the mainstay of acute management.24
Following an injury, a brief period of physical and cognitive rest should be
prescribed, usually 2 to 3 days or less. Current evidence suggests that children
can be encouraged to slowly return to their typical activities even while still
symptomatic. A prolonged period of rest has been associated with increased
recovery time, and so strict rest protocols are being revised, especially as
symptom exacerbations in the acute phase due to activity do not affect overall
recovery.25 Instead, earlier mobilization and a gradual return to modest levels of
physical activity within the first week after injury are encouraged as this may
decrease the risk of prolonged symptoms.26 Return to activities may be facilitated
by a provider trained in concussion management who can help devise an
individualized treatment plan for the eventual return to sport.27

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TRAUMATIC BRAIN INJURY AND CONCUSSION

The first priority after recovery should be returning to school (TABLE 15-128).
School not only provides an educational environment but is also crucial in social
development and mental well-being. DeMatteo and colleagues29 proposed a
protocol focusing on four main areas: timetable/attendance, curriculum,
environmental modifications, and activity modifications through a graduated
return, similar to return-to-play. To implement any protocol, it is critical to
create an interdisciplinary team and foster relationships with staff within the
school to facilitate an effective and successful return to the academic
environment. Multiple individuals within the school will be involved in the
return-to-learn plan, including a health care provider (nurse, athletic trainer),
teachers, and administration (counselors, dean, principal/assistant principal).
Forty-one percent of student athletes in the United States return to school
with academic accommodations, which necessitates good communication
between the health care provider, school, and the student and his/her family.30
However, ensuring good communication is a challenge. Schools often feel that
communication with the provider is inadequate, and education and training for
the school staff may be insufficient, including at the administrative level.31,32
In some secondary schools, the athletic trainer may be the contact point for
the student, family, school staff, and the health care provider who has made
the recommendations. Athletic trainers, however, may not be familiar with
the various academic accommodations that may be suggested (such as 504 plans
and individualized education programs [IEPs]) and so will need to be supported
by school staff and health care providers.30
After the child has returned to school without restrictions, the return-to-play
protocol can be implemented (TABLE 15-2). The Acute Concussion Evaluation
(ACE), endorsed by the CDC, proposes a return-to-play protocol that slowly
returns the student athlete to his or her sport in a stepwise progressive process.3,33,34
Although originally designed for contact sports, modifications can be made to

TABLE 15-1 Graduated Return-to-School Strategya

Stage Aim Activity Goal of Each Step

1 Daily activities at home that do
not give the child symptoms
Typical activities of the child during Gradual return to typical activities
the day as long as they do not increase
symptoms (eg, reading, texting, screen
time); start with 5–15 minutes at a time
and gradually build up

2 School activities Homework, reading, or other cognitive Increase tolerance to cognitive work
activities outside of the classroom

3 Return to school part-time Gradual introduction of schoolwork; Increase academic activities

may need to start with a partial school
day or with increased breaks during
the day

4 Return to school full-time Gradually progress school activities Return to full academic activities and
until a full day can be tolerated catch up on missed work

a 28
Reprinted with permission from McCrory P, et al, Br J Sports Med. © 2017 BMJ Publishing Group Ltd and British Association of Sport and Exercise
Medicine.

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individualize the protocol for each athlete’s specific needs. Appropriate
individualization can help the athlete to return to physical activity sooner.35

POSTCONCUSSION SYNDROME
The ICD-10 coding system deems that organic disturbances (eg, headache,
dizziness, sleep problems) and psychogenic disturbances (eg, irritability,
emotional issues, affect changes) after closed head injuries that are chronic,
permanent, or late emerging may be termed postconcussion syndrome. Although
most children with mild TBIs recover within the first few weeks after injury,
one-third of children may go on to have prolonged postconcussion symptoms.
Demographic/premorbid factors, injury characteristics, and initial
symptomatology all may contribute to delayed resolution after injury.36 The
Predicting and Preventing Postconcussive Problems in Pediatrics study (5P
Study) developed a clinical risk score to identify those children who may go on to
have persistent postconcussion symptoms after presentation to an emergency
department within the first 48 hours after injury. Within this population,
presenting with early signs of headache, answering questions slowly, poor
balance, and phonophobia were associated with persistent postconcussion
symptoms. Additionally, female sex, age older than 13 years, a history of
migraine, and previous concussion with prolonged recovery also correlated with
prolonged recovery.37 Other studies have shown that vestibuloocular (visual
symptoms plus evidence of a visuomotor or vestibuloocular reflex abnormality)
and cognitive deficits acutely may also predict longer symptom duration.38,39

Role of Exercise in Recovery From Persistent Postconcussion Symptoms

Based on recent evidence that too much rest may in fact be detrimental to
recovery, a trend toward recommending stepwise return to physical aerobic

Graduated Return-to-Sport Strategya,b TABLE 15-2

Stage Aim Activity Goal of Each Step

1 Symptom-limited activity Daily activities that do not provoke symptoms Gradual reintroduction of work/school
activities
2 Light aerobic exercise Walking or stationary cycling at slow to medium Increase heart rate
pace; no resistance training

3 Sport-specific exercise Running or skating drills; no head impact Add movement

activities

4 Noncontact training drills Harder training drills, eg, passing drills; may Exercise, coordination, and increased
start progressive resistance training thinking

5 Full contact practice Following medical clearance, participate in Restore confidence and assess functional
normal training activities skills by coaching staff
6 Return to sport Normal game play

a 28
Reprinted with permission from McCrory P, et al, Br J Sports Med. © 2017 BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine.
b
An initial period of 24 to 48 hours of both relative physical rest and cognitive rest is recommended before beginning the return-to-play progression.
There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back
to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (eg, more
than 10 to 14 days in adults or more than 1 month in children), the athlete should be referred to a health care professional who is an expert in the
management of concussion.

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TRAUMATIC BRAIN INJURY AND CONCUSSION

activity even while some symptoms remain is growing.40 Individualized

subthreshold exercise may be prescribed during the recovery to help those who
experience persistent postconcussion symptoms. Studies have shown that
exertion testing in youth does not prolong symptom recovery and may in
fact help to direct activity in children with postconcussion symptoms.29 In a
retrospective review of children who had experienced sport-related concussion,
106 patients underwent graded aerobic treadmill testing to assess recovery and
tolerance of activity, helping to individualize the plan for the specific needs of
the patient.41 Recent studies have shown that this type of rehabilitation program
can lead to symptom resolution and improve mood.42

THE INFLUENCE OF PREINJURY LEARNING DIFFICULTIES ON RECOVERY

Cognitive factors antecedent to the injury may also play a role in a recovery.
Children who sustain a mild TBI and have a premorbid history of attention deficit
hyperactivity disorder (ADHD) tend to have more severe concussion symptoms
than those without ADHD (CASE 15-1).45 The theory of brain reserve suggests that
children with preexisting difficulties with learning may have less capacity to
compensate for a brain injury.46,47 Many parents may consider difficulties that were

CASE 15-1 A 9-year-old boy with a history of untreated attention deficit

hyperactivity disorder (ADHD) fell in class. He was initially dazed and
slightly confused. He was picked up from school by his mother, who took
him to the emergency department.
On arrival to the emergency department 2 hours after the fall, he
looked well but had a mild headache. His neurologic examination,
including his balance, was normal, and his family was reassured about
the likelihood of a good outcome. He was discharged home, told to
rest for the next 1 to 2 days, given some information by the emergency
department physician about returning to school and play, and advised to
follow up with his family doctor in the next few days. He did very well
initially and was back to normal activities by 2 weeks.
Several weeks later, his teacher raised some concerns about his school
performance, particularly his attention and concentration. He was
assessed by his school psychologist, who found no evidence
of change. After behavioral management strategies for ADHD were
incorporated for several weeks, medication for ADHD was initiated
3 months postinjury.

COMMENT This case is an example of a child with ADHD and concussion. Children
sustaining any kind of traumatic injury are more likely to have a premorbid
history of ADHD, perhaps because of increased risk-taking behaviors and
impulsivity.43 Unlike more severe forms of traumatic brain injury, concussion
itself is unlikely to cause secondary ADHD.44 Children with ADHD, however,
often have more short-term symptoms following a concussion.45
Appropriate treatments for primary ADHD should be administered even, or
especially in, the setting of a concussion.

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present in early school years (eg, attention problems, reading difficulties) to have KEY POINTS
resolved and so may deny any preexisting school difficulties. A careful history is
● Preexisting conditions
required to uncover these potential contributors to persistent problems. Children can exacerbate symptoms
with premorbid learning difficulties often require increased support at school for 1 and lead to delayed
to 3 months following a concussion. Educational, behavioral, and pharmaceutical recovery.
therapies targeting premorbid learning difficulties should be implemented or
● Preinjury and postinjury
continued in collaboration with the school psychologist and health care provider. psychological factors are
often present in those with
THE INFLUENCE OF PSYCHOSOCIAL FACTORS ON RECOVERY prolonged recovery times.
Psychological and social factors may also be associated with delayed recovery from Psychological support is a
key strategy in healthy
concussion, particularly as the time from the injury becomes more prolonged.36 recovery.
Stress in the child’s life and in the family system may be associated with greater
postconcussion symptoms. Psychological factors such as somatization and ● Avoid overuse of
resiliency have frequently been shown to play a role in the time course of analgesics in posttraumatic
headaches.
recovery.48,49 Further, the tendency exists after mild TBI to remember the past in
an unrealistic more favorable light (ie, a “good old days” bias).50 Cognitive
restructuring and symptom reattribution are an important part of the treatment
approach at any stage in the recovery process.51,52 Cognitive restructuring can
help the adolescent or parent identify and target maladaptive thoughts, known as
cognitive distortions. This includes all-or-nothing thinking, overgeneralization,
magnification, and emotional reasoning. The psychotherapist can help the child
or parent recognize these distortions and reframe cognitive reasoning and
thought processes to aid recovery. CASE 15-2 highlights the multiple comorbidities
that are often seen in cases of persistent postconcussion symptoms.

REPEAT INJURY, SECOND-IMPACT SYNDROME, AND CHRONIC

TRAUMATIC ENCEPHALOPATHY
Another potential sequela of TBI is second-impact syndrome, a potentially
devastating rapid accumulation of cerebral edema that is hypothesized to be due
to repeat injury occurring before recovery from the first concussion. This is a
catastrophic but extremely rare injury that appears to affect young student
athletes, with very few cases being described worldwide. Although malignant
cerebral edema secondary to increased cerebral blood flow can be seen more
commonly in children and adolescents with TBI, the role of second injury in this
phenomenon is debated. Nevertheless, concern for this phenomenon has driven
many of the stepwise return-to-play policies in sport.
A prominent focus also exists within the media and public on the effects of repeat
injury from both multiple concussions and exposure to repeated subconcussive
hits and their potential relationship to the development of long-term neurocognitive
and psychological disturbances. A subconcussive hit is a high-energy impact after
which the athlete has no overt symptoms or signs to suggest acutely altered brain
function; it is of particular concern in contact sports, such as American football, hockey,
and boxing. While chronic traumatic encephalopathy (CTE) remains a postmortem
pathologic entity diagnosed primarily in those who have played competitive sports,
concern for the development of CTE is growing among patients and families that
present to the neurologist’s office. Repetitive injuries may lead to chronic learning
deficits long after typical recovery59; in animal studies, they have been shown to
cause distinct pathologic patterns and specific functional deficits in adolescent
mice.60 However, currently no prospective studies have shown the long-term
effects of repeated injury that are sustained during childhood and adolescence.

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TRAUMATIC BRAIN INJURY AND CONCUSSION

CONCLUSION
TBI, especially mild TBI, is a significant public health concern. The diagnosis
of mild TBI can be difficult because of confounders, such as intoxication,
stress, attribution bias, and delayed presentation to medical attention, and
warrants careful evaluation. Preinjury history of headache and environmental,
psychological, and cognitive difficulties influence outcome, especially in persistent
postconcussion syndrome. Prolonged periods of rest and social isolation
should be avoided. A collaborative approach with educators, athletic trainers,
and health professionals is needed to facilitate a smooth return to school
and activities. Treatments for prolonged recovery are targeted toward

CASE 15-2 A 16-year-old girl with persistent headaches, mood disturbance, sleep
difficulties, and a decrease in school performance was evaluated in the
concussion clinic 4 months after a concussion that occurred while in
cheerleading practice. She was taking ibuprofen or acetaminophen daily
for her headaches. She found it difficult to fall asleep because of
concerns about her schoolwork, then slept from 3:00 AM to 11:00 AM each
day and only attended school in the afternoon. She did not drink
caffeinated beverages. She had a previous history of migraine as well as
anxiety that had been managed with cognitive-behavioral therapy and a
family history of anxiety and mood disturbance. Her headaches were
constant and holocephalic. No evidence of psychosis or risk of self-harm
was noted, although she was worried she would “never get back to
normal” and stated she could no longer do “anything.” She was diagnosed
with a medication-overuse component to her headache disorder and an
anxiety disorder. Amitriptyline was started, and analgesics were stopped.
A psychiatric referral was made, and cognitive-behavioral therapy was
restarted. Her sleep and headaches improved over the next 3 months,
and her school performance increased as school attendance increased.

COMMENT This case demonstrates how premorbid difficulties, such as headaches and
mood disturbances, are exacerbated after a concussion. Although these
problems can occur de novo following a mild traumatic brain injury (TBI),
exacerbation of preexisting problems is probably more common. Currently,
no one therapy exists for persistent postconcussion symptoms. The
management of a patient with multiple comorbidities requires a
multifaceted and multidisciplinary approach, targeting the most
problematic areas, as demonstrated in this case. Medication overuse is
common in posttraumatic headaches,53 and amitriptyline can be helpful
when withdrawing analgesics.54 Short-term elevated anxiety levels and
new-onset anxiety disorders are 4 times more likely after a mild TBI than
after an orthopedic injury.55 Cognitive-behavioral therapy or similar
psychotherapies are effective treatments for anxiety in youth.56,57
Sleep problems are common after a mild TBI and are often comorbid with
psychiatric disorders.58 If treatment of psychiatric comorbidities does not
improve sleep, referral to a sleep specialist should be considered.

308 FEBRUARY 2018

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symptoms. An urgent need exists for more evidence-based management in
postconcussion syndrome.
USEFUL WEBSITES
AMERICAN ACADEMY OF NEUROLOGY, SPORT
CONCUSSION RESOURCES
The American Academy of Neurology provides
sports concussion resources to help physicians,
coaches, athletes, and parents better understand,
prevent, identify, diagnose, and treat
sports concussions.
aan.com/concussion
CENTERS FOR DISEASE CONTROL AND PREVENTION,
HEADS UP
The Centers for Disease Control and Prevention
helps parents, coaches, school professionals, and
health care providers know how to recognize,
respond to, and minimize the risk of concussion and
other brain injuries.
cdc.gov/headsup/
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