Head Injury & Concussion

Sports-medicine approach to head injury classification/imaging and concussion recovery. For spinal-column injury, see Back: Acute Spinal Injuries; for facial/rib/sternal fracture management, see head, spine & chest fractures.

Classification and imaging

Classification — many qualifiers exist (primary/secondary, blunt/penetrating, focal/diffuse), but GCS is more clinically useful than focal-vs-diffuse: mild 13–15, moderate 9–12, severe 3–8. Structural vs non-structural is another useful split. Myoclonic seizures after head injury do not correlate with long-term epilepsy risk or injury severity.

Mild traumatic brain injury (mTBI)/concussion is defined by the first Australian and Aotearoa New Zealand Clinical Practice Guideline (2025) as an acute injury from an external mechanical force to the head causing one or more of confusion/disorientation or another neurological symptom, loss of consciousness ≤30 minutes, GCS 13–15, or post-traumatic amnesia <24 hours (neuroimaging evidence of TBI also now suffices). It’s common — “mild traumatic brain injury (mTBI), often referred to as a concussion, affects over 220,000 people in Australia and Aotearoa New Zealand (ANZ) annually, with 25–30% of people experiencing persisting symptoms for months or longer. “Traditional severity measures (LOC duration, GCS, amnesia duration) are not reliable predictors of recovery trajectory. Symptoms considered “persisting” (PPCS) once present beyond 4 weeks occur in 30–40% of children and 20–50% of adults. Risk factors for PPCS include past/current psychological distress, substance abuse, concurrent physical injury, chronic pain, unemployment, litigation and (independently) female sex.

Who to image — Canadian CT Head Rule

GCS <15 at 2 hours post-injury; suspected skull fracture; haemotympanum, periorbital/mastoid haematoma, CSF oto-/rhinorrhoea; ≥2 episodes of vomiting; age >65; amnesia of the minutes before impact; a dangerous mechanism. If any apply — image. CT is standard; MRI has little acute-trauma utility (except ICU) but no radiation. Incidental findings occur in 40–80% of scans (~1 in 50 have an incidental aneurysm) — counsel accordingly.

Persistent symptoms days/weeks later: low threshold to image — the value of a normal scan (to both patient and doctor) is real.

Specific conditions

• Traumatic SAH — generally recovers well, similar trajectory to a normal CT. If there’s no history of trauma, consider venous sinus thrombosis instead of assuming aneurysmal SAH.
• Skull fractures — convexity fractures are almost always non-operative; depressed fractures may need elevation. Skull-base fractures (petrous temporal bone extending into occiput/sphenoid/convexity) need assessment of CN VII, CSF leak and audiometry. CSF leak from the ears is rare even with base-of-skull fractures; send fluid for beta-2 transferrin if uncertain.
• Acute subdural haematoma — crescentic, hyperdense on CT; the classic neurosurgical emergency, but does not always need surgery — if the patient is sitting up talking to you, it likely doesn’t need evacuation. Chronic subdurals are a good reason to image chronic symptoms; fixed with burr holes.
• Extradural haematoma — classic “lucid interval”: seems fine for 10–15 minutes, then deteriorates.
• Return to play — individualised for haemorrhagic conditions; generally a minimum of 3 months if managed non-operatively, 6 months if operative — though most people who needed surgery choose not to return.

Concussion recovery and post-concussion management

• Exercise: early graduated return to non-contact exercise (within tolerance, rather than strict rest) both aids recovery and helps gauge how well the patient is progressing. Include some high-intensity bursts, not just light aerobic activity — an exercise physiologist can help guide the return-to-exercise program.
• Sleep: important — no daytime naps, good sleep hygiene.
• Vestibular/oculomotor symptoms are common and can benefit from behavioural optometry.
• Mood disorders post-concussion can benefit from amitriptyline.