Early Concussion
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Stage One
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Stage Two
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Stage Three
Stage One (Home or Hospital)
In the early or acute stages post-concussion, the main symptoms you need to manage are:
- Headaches
- Dizziness
- Nausea
These are best managed with regular food, water and symptom specific medication.
Good sleep at night is also important to aid recovery. You may need to sleep during the day as well, depending on your fatigue (but sleeping for too long or too late in the day may cause you to sleep poorly at night – the right amount varies between individuals).
You need supportive people around who can minimise pressures placed upon you and minimise decision making, to help reduce stress and anxiety.
Gentle movement within a safe / supported environment is important for dizziness.
You may have had other trauma in addition to the head knock/concussion and need to follow the medical management strategies for those alongside your concussion.
Resources
Headaches
Headaches are a very common symptom post-concussion following trauma to the head and neck. It can sometimes be quite difficult to determine if the headaches are a result of the head knock or trauma to the neck or both.
Following a concussion your brain is using its resources quicker and you can become dehydrated. Headaches can be ongoing, generally mild but intensify with fatigue.
Strategies to manage headaches
- Panadol can be used in the early days post-concussion to take the edge off the headaches. (Note: anti-inflammatories are not advised within the first 48 hours as they may mask an underlying bleed).
- Neurofen, Maxagesic and Panadeine Forte are all found to have use with managing significant persistent headaches post-concussion. You can discuss with your GP / pain specialist what is best for you, considering your symptom severity, other medical conditions and allergies.
- Medication needs to be taken regularly so that the impact of headaches on function is limited. Take medication prior to known challenging activities.
- Anti-inflammatories must be taken with food to protect the stomach lining.
- Increased water intake assists with hydration and reducing headaches.
- Some studies and individuals note significant relationships between headaches and the consumption of red meat, salad dressing, oil, dairy products, fruits, and vegetables. Diet may be discussed with your GP / dietician.
- Clients can find short term relief of pain with a travel foam neck pillow, but these clients will also need to follow a physical program to strengthen neck muscles.
- If you are also presenting with a stiff and sore neck you would benefit from review by a musculoskeletal physiotherapist to assist with headache management, where a specific set of exercises will be provided.
Vestibular (dizziness and balance) and visual problems
Dizziness, balance and visual problems are very common after a concussion. These problems can occur for several reasons including injury to the neck, vestibular and oculomotor systems. It is important to establish which system/s is impaired to ensure the best recovery and adequate treatment is provided.
Issues with persistent vertigo (a sense that you or your surroundings are spinning), reduced balance, dizziness and visual instability are often symptoms associated with vestibular impairment. The vestibular system helps us to keep our balance, maintain posture and stabilise our head and body during movement. This system is a complex network that includes the inner ear, brain, eyes and muscles. Vestibular issues are common after trauma to the head and can delay concussion recovery.
Depending on the type of vestibular impairment, different treatment interventions will be recommended. Your symptoms can be assessed by a health professional with further training in this area. Initial tests are often completed by a GP or physiotherapist, but may also require referral to other health professionals. Your health professional may look at your balance, coordination, vestibular system, vision and hearing.
Vestibular rehabilitation
Vestibular rehabilitation is typically provided by a physiotherapist with training in this area. It usually involves exercises to desensitize the vestibular system, coordinate eye and head movements and / or improve balance. Exercise programs vary depending on the specific issues that the person is experiencing. Your program will be developed specifically for you and the aim will be to gradually progress the exercises. The exercises usually cause a mild symptom increase during the exercise and, sometimes, for a short time afterwards. It is important to talk with your physiotherapist about how to progress your program as it gets easier and how to take a step back if it is increasing your symptoms too much. Being an active participant in your treatment is important for recovery.
Historically, medications have been used to reduce vestibular symptoms, including nausea, but current evidence does not support this approach in most cases.
A common vestibular issue after concussion is benign paroxysmal positional vertigo (BPPV). BPPV affects the inner ear and can cause short episodes of vertigo, abnormal eye movements (nystagmus), unsteadiness and nausea. Symptoms are associated with sudden changes in position (eg rolling over in bed, looking up). If this is suspected, your treating GP or physiotherapist will perform a test called the Dix-Hall pike manoeuvre or horizontal roll to assess if this is a cause of your vertigo. Treatment for BPPV is very effective and involves specific re-positioning manoeuvres once the effected canal is identified.
The areas of the brain that help control eye movement are also vulnerable to injury following trauma to the head, often resulting in oculomotor dysfunction. Symptoms of oculomotor dysfunction include:
- Blurry or double vison
- Headache and eye strain that is typically made worse by reading, focusing or time in complex visual environments (eg supermarket)
- Difficulty with reading or other visual work (eg using a tablet, smartphone or computer)
- Difficulty tracking objects.
Depending on the findings of your assessment, as you may be given specific exercises to assist in retraining these systems.
Stage Two (Home)
As your post-concussion symptoms improve, you will need to:
- Attempt short amounts of activity around the home
- Slowly increase exercise to gradually get your heart rate up
- Take regular breaks to refresh yourself
- Continue regular food, water, sleep and symptom specific medication (if still needed.)
- Keep stress levels and demands low
- Gradually desensitize your intolerances to noise, light and movement.
If your symptoms of headache, nausea or dizziness worsen after activity, then you need to rest. Then reduce your activity and expectations of what you can achieve by about 20%.
Some people describe this as the FOG stage. Brain fog includes trouble concentrating, slowness in thinking or difficulty remembering and learning new information.
Resources
Noise and light sensitivity
After concussion, it can be quite common to:
- Want to hide away from the world in your darkened bedroom, with no demands
- Find loud, high-pitched or abrasive noises overwhelming
- Find sunlight and bright technology screens overwhelming.
This noise or light sensitivity can also make other symptoms such as headaches, nausea and dizziness worse.
Avoidance of noise or light can only help with coping in the early stages of a concussion. If you continue to avoid all challenging situations, you cannot improve and move forward. The symptom and it’s impact on your function will increase, not improve with time without gradually challenging what is difficult.
Things to consider in the early stages and how to gradually desensitize to these intolerances / symptoms:
- Avoid TV, phone and computers initially if light / noise sensitive
- Isolate yourself in quiet area if overwhelmed by too much stimulation or distracted by competing stimuli (lights or noises)
- Set boundaries of only one person talking at a time
- Check settings for display and brightness on iPhone / computer / tablet as you can alter brightness as well as colour tone/temperature (eg manually enable night shift)
- Consider changes to your environment and / or specific equipment / accessories for noise / light sensitivity (ie blinds down during the day, sunglasses / hat outside during the day, eye masks overnight, earmuffs / plugs, noise-cancelling headphones)
- Good quality noise-cancelling headphones use noise cancelling technology to block out background noise so you can keep focus on music even in busy community settings
- Turn volume down on TV / computer
- Certain sound frequencies can hurt your ears, so it can be useful to understand what the brain is not tolerating
- Go out into the sun with sunglasses and brimmed hat initially, then remove the hat and glasses for short periods. In winter or in colder climates people could trial a “blue light” to gradually desensitize to bright light.
- If symptom(s) persist, trial “full spectrum light bulbs” in your home so that you can control the strength of light
- Glasses can be fitted with an anti-reflective lens, to aid in light sensitivity to screens and when driving at night
- Safely challenge these symptoms / intolerances when you have more time and flexibility within your day.
This information is based on client experience and expertise of health care practitioners. There is currently limited literature in this area.
Eating habits
Eating habits are not included in any formal assessments post-concussion, but interestingly some individuals with persistent symptoms have independently reported altered eating habits.
They forget to eat, have lost interest in food and / or do not receive messages from their body that they are hungry. They also may not have the switch off button to tell them when they are full.
As the brain is using its resources quicker than usual, nausea can result from not eating enough. Try regular small snacks of plain food to settle the nausea.
It is important to establish a healthy balanced diet that provides enough fuel for the body. Some foods can help restore energy while others increase fatigue.
Strategies for establishing a healthy diet:
- Eat regular snacks throughout the day
- Timers / alarms on phone/watch help with prompting regular eating
- Consider making smaller meals more appropriate for some reduced activity
- Limit alcohol and coffee in the afternoon, as stimulants impact on sleep cycle as well as fatigue symptoms (eg. dizziness)
- Consider the impact of high sugar and caffeine food/drinks, as they can establish a more rollercoaster effect of highs and lows rather than establishing a more consistent pacing of the day
- GP and / or dietician may assist with establishing a more consistent diet.
This information is based on client experience and expertise of health care practitioners. There is currently limited literature in this area.
Cognitive changes
You can have cognitive changes to your thinking and memory following a concussion. If you are not sleeping well and tired during the day, this will also affect your thinking and remembering.
Changes in cognitive function and ideas for managing
Delayed and slower information processing – you can see situations happening around but not react as usual.
- Give yourself longer to react / process the information
- Do not put yourself under time pressure to reduce stress and errors.
Forget or slower to access specific words / memories
- Take a breath, to give yourself more time and relax
- Talk around the point or describe, and the word may come to you or you can get your message across in another way
- Be honest, that you cannot remember it all.
Initiation / monitoring – you are no longer good at beginning or knowing when to end or change an activity.
- Use alarms and diaries to prompt you to start and move on
Information processing – you can only read for short periods as unable to process a lot of information at once, becoming overwhelmed with pages of reports to read or forms to fill in.
- limit what can be seen at a given moment, enlarging a window on the computer screen or covering sections on a page of writing
- practice processing information with movies with subtitles, so the image can reinforce the verbal / written message.
Short term memory– forgetting new people’s names, not remembering what has been asked of you.
- use strategies to reinforce the new information (ie verbalisation, repetition or self-talk, visualisation, reminder / alarms on phone)
- be consistent with reminders (ie diary, calendar, lists).
Planning – no longer keeping track of what needs to be done each day
- encourage routines
- break large tasks into smaller tasks and spread throughout day
- pre-plan the day’s tasks in a diary.
Multitasking - unable to do more than one task at a time, if distracted from a task forgetting to go back to complete it.
- Complete one task at a time, so to ensure accuracy of what is done and remembered
- Set boundaries when others can interrupt, so to improve efficiency and limit distractions.
Note: Errors can be made at any time and are not necessarily as a direct result of your concussion.
Formal cognitive assessment
Some people may require a more formal neuro psychological assessment (NPA) following their concussion, for medico legal purposes. A NPA is an educationally biased assessment that can be relevant to highlight cognitive inefficiencies for those returning to high pressure jobs with long hours, requiring a lot of multitasking. Please note that a thorough NPA takes at least three hours to complete. This is not something to take lightly as for many in the early days post-concussion what you will be assessing is the impact of fatigue / headaches / nausea / dizziness on cognitive processing.
As there is usually no assessment prior to the concussion, many subtle changes that you note in yourself may not be apparent on formal, structured assessment. Some brief, functionally based cognitive tasks or assessments performed by an experienced occupational therapist, can aid in identifying cognitive strengths and weaknesses in verbal/visual and rate of information processing.
Functionally, the important things to help are:
- Acknowledge changes
- Use appropriate strategies to perform at your best
- Use your cognitive strengths to help support your weaknesses
- Aim for a work life balance.
Exercise and activity post-concussion
The best way to assist the body to regulate itself again post-concussion is through a graded return to activity.
- After the initial 24 to 48 hours relative rest period, it is important to resume gentle activity and movement. This helps give gentle exposure to external environments (eg. lights, noise, movement) and can help with mood and mental health
Doing too little initially, or pushing too much too soon can delay recovery.
- Post-concussion the body’s autonomic nervous system regulation can be impacted. The autonomic nervous system is responsible for regulating key involuntary functions including heart rate, blood pressure, breathing, digestion and gland secretion.
- Too little: The body needs some regular activity to gently challenge these systems and promote normal regulation. Extended rest leads to deconditioning (losing fitness) which can mean easier irritation of symptoms and can prolong symptoms such as fatigue, sleep disturbance and irritability.
- Too much: If pushed too hard too early you may get irritation of your symptoms (eg headache, dizziness or fogginess) as the systems get over loaded and struggle to regulate themselves.
The aim is to find the sweet spot doing as much as you can with minimal symptoms.
- As a general activity guide, initially aim for 15 to 20 minutes of gentle walking or low-grade cardio daily and gradually build from there. If this is too much at once, break into smaller timeframes throughout the day and gradually work up.
- It can be useful to score your symptoms on a 0 to10 scale prior to activity and consider the +3 rule
- If your score increases by 3 or more during the activity, the intensity or duration should be temporarily lowered to a manageable level
- If your score increases by less than 3 or improves during activity, you can step up the intensity or duration the following day
- If your symptoms at base line are limiting you from participating in regular activity review by your GP / health care provider is recommended to provide further guidance and enable you to return to activity
If you continue to have ongoing symptoms and / or you are returning to sport or other high-level activities (eg sports, military duty, manual labour) it is recommended you see a physiotherapist experienced with concussion to assess your readiness to return to your chosen activity. Trained therapists can assess your response to exertion using tests such as the Buffalo Concussion Treadmill Test (BCTT) and, based on these results, prescribe a tailored exercise program for you.
- For a general guide to return to sports and higher-level activity see return to sports protocol.
Stage Three (Home and Community)
Gradual step ups are required to get back to your best functional level (physical, cognitive / mental and emotional). However, it is important to be aware that you may increase symptoms when you first attempt that step up, but the next time you challenge yourself in the same way you should feel it is getting easier. When experimenting with these step ups only change one thing at a time, so that you are more likely to identify the triggers for your symptoms.
You can now start setting more realistic goals and time frames for return to driving, work, study or sport. You can increase your exercise, but also consider if you had additional trauma / injury from the initial incident, this may also affect your ability to safely return to activities. You need to consider ongoing sensitivities (eg light / noise) and/or changes in function (eg balance) where you may need a different approach to manage returning to your usual activities. You also need to continue with the basics of:
- Regular food, water, and medication (if still required)
- Good sleep and breaks during the day.
If it has taken only a few weeks to move through these three stages, you will likely return to a regular life balance with no major changes. However, if your recovery process has taken you months, the information in Stage 4 will be more important for you.
Resources
Driving
There are no legal requirements regarding returning to driving following a concussion or mild head injury, as the expectation is that the majority of people will return to all previous activities with little to no changes in performance within a week or a few weeks. If you have presented to ED or your GP, they may recommend a limited time of not driving based on the symptoms you present with.
These symptoms may include:
- Reduced concentration
- Reduced rate of thinking and responding
- Headaches and fatigue
- Dizziness
- Overstimulation from fast moving environment
- Poor visual tracking
- Intolerance to noise and light.
Some people post-concussion report a loss of confidence and capacity to manage driving safely at night, in busy / fast environments, when under time pressures, when reversing and when fatigued.
It is important to maintain safe driving practices such as:
- Choosing not to drive at night
- Practice skills in quieter environments initially
- Starting with short / local trips
- Initially returning to driving with someone else in the car
- Reduce any additional demands or distractions when driving (eg passengers don’t talk, music is off)
- No time pressures
- Plan ahead (ie Time it will take you at the time of day to get to your appointment and add on more time than necessary, visualize the route in your head or on your phone prior to the trip).
If you do present with persisting symptoms your doctor may recommend for you to have an on-road occupational therapy driving assessment prior to commencing driving.
Return to sport protocol
Allow 24 hours as a minimum between each stage, if symptom free. Go back one step if symptoms resume.
| Stage | Functional exercise | Objective |
| 1. No activity | Complete physical and cognitive rest. | Recovery |
| 2. Light aerobic exercise | Walking, swimming or stationary cycling for 10 - 15 minutes, keeping intensity <70% maximum permitted heart rate. Avoid resistance training and other heavy lifting. | Increase heart rate |
| 3. Sport specific exercise | Running and throwing drills. Avoid body contact, resistance training, heavy lifting and other jarring motions. | Add movement |
| 4. Non contact training drills | Progression to more complex training eg. passing / press drills. Start progressive resistance exercises but avoid impact activities. | Exercise, coordination and cognitive load |
| 5. Full contact practice | Following medical clearance, return to normal training activities. | Restore confidence and assess functional skills |
| 6. Return to play | Normal game play. | Full return to pre-concussion activities |
Return to study protocol
Allow 24 hours as a minimum between stages 1 to 3 and 1 to 2 weeks as a minimum between stages 4 to 6, if symptom free. Go back one step if symptoms resume.
| Stage | Functional exercise | Objective |
| 1. No activity | Complete cognitive rest | Recovery |
| 2. Minor cognitive activity at home | Short periods (5 to 15min) of cognitive activity (homework) | Gradual, closely monitored increase in sub symptom threshold activities |
| 3. Moderate cognitive activity at home | Longer periods (20 to 30mins) of cognitive activity (homework) | Increase cognitive stamina, self paced activity |
| 4. Partial school entry | Part day of school attendance, plus 1 to 2 cumulative hours of homework | Re-entry into school with accommodation to maintain cognitive load below symptom threshold |
| 5. Gradual reintegration to school | Gradual increase to full day of school attendance | Increase cognitive stamina, gradual decrease of accommodations |
| 6. Full cognitive workload resumed | Catch up on essential missed work, re-introduce testing and assessments | Full return to school, recommended to commence RTP protocol |
Return to work protocol
Allow 24 hours as a minimum between stages 1 to 3 and 1 to 2 weeks as a minimum between stages 4 to 6, if symptom free.
| Stage | Functional exercise | Objective |
| 1. No activity | Complete cognitive rest (Maximum of 1 to 2 days). | Recovery |
| 2. Minor cognitive activity and light aerobic exercise in / around home | Short periods (5 to 15min) of cognitive activity (texting / computer) and going for walks up to 10 to 15 minutes, simple chores. | Gradual, closely monitored increase in sub symptom threshold activities |
| 3. Moderate cognitive/physical activity in / around home | Longer periods (20 to 30mins) of cognitive activity (social media / TV) or housekeeping tasks. | Increase cognitive / physical stamina, self paced activity |
| 4. Part time work | Part day in work environment, consider 3 mornings a week (ie Monday, Wednesday, Friday) for 3 to 4 hours. Ensure one task at a time. | Re-entry into work environment with accommodation to maintain cognitive load below symptom threshold, commence GRTWP |
| 5. Gradual reintegration to work | Gradual increase to full work days (ie Monday, Wednesday, Friday), then onto a full working week with reduced responsibilities, time pressures and restricted duties. | Increase cognitive stamina, gradual decrease of accommodations, progress GRTWP |
| 6. Full time work and duties | Catch up on essential missed work, and plan out priorities. | Full return to work |
Return to work considerations
Open return to work considerations page.
Mental Health
In the early stages following a concussion, your symptoms may prevent you from doing everything you usually do. Headaches, dizziness, nausea and confusion may all prevent you from safely and effectively caring for yourself, caring for others, working, studying and / or driving. Acknowledging this as part of your recovery is an important part of managing your early symptoms.
It may be helpful to consider who around you can support you at this time (your partner, family members or supportive friends), or ways that you can give yourself the time you need to recover from the symptoms.
Mental health problems, such as depression and anxiety, are common after a concussion and can impact a person’s wellness, ability to function in their everyday life, relationships with others and recovery. It can be hard to understand how a hit to the head, with no outward signs or any evidence on brain scans can continue to affect your function weeks or months later.
The autonomic nervous system controls emotional regulation and fight/flight responses. This can be affected after traumatic injuries like a concussion. You may feel:
- Distressed for no known reason
- Unable to control your emotions
- An exaggerated or slower response to a fright.
This can make you feel as if you are losing control of your thinking and emotions.
Mood symptoms can include irritability, anxiety, mood swings, depressed mood, changes in behaviour (like being more impulsive or increased aggression), and reduced motivation. Many concussion and mental health symptoms can be related to, and influence, each other. For instance, trauma to the brain and body may impact on sleep; then ongoing sleeping difficulties may cause a person to feel depressed; and depression may then further impact on sleep.
More information on depression and anxiety can be found on the Beyond Blue website (external site)
Talk to your GP if you notice any of the symptoms above, are feeling depressed, anxious, or if you are having sleep difficulties. Treating these problems early will help prevent them from worsening and interfering with your recovery. Also let your GP know if you have mental health problems that existed before your concussion.
Your GP may refer you to see a psychologist. A clinical psychologist is trained in the assessment of mental health issues, and may use a range of therapies as part of treatment. This may include talking therapy, but more often will include specific evidence-based techniques, such as cognitive behaviour therapy, and practical strategies designed to address your areas of concern.
Some things that may be helpful
Take a deep breath or breathe deeply in and out. Take additional time to process how you are feeling before responding or reacting.
It is important to be able to find some capacity to leave all your stressors behind for a few minutes to refresh your system. Try just sitting in a quiet area, closing your eyes and doing or thinking nothing for 30 to 60 seconds. If thoughts come, don’t fight them, just let them go. This refresh break can reset your visual processing and your brain.
Relaxation or stress management strategies that have worked for you in the past
- Progressive muscle relaxation (PDF)
- Coping with stress (PDF)
- Postpone your worry (PDF)
- Mindfulness and letting go (PDF)
Be kind to yourself
Contact us
Tel: (08) 6457 4488
Email: WAABIRS@health.wa.gov.au
Location: Ground Floor, E Block, Sir Charles Gairdner Hospital
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