Post-Concussion Syndrome¶

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Draft - Pending Review

DIAGNOSIS: Post-Concussion Syndrome (Persistent Post-Concussive Symptoms)

ICD-10: F07.81 (Postconcussional syndrome), S06.0X0A (Concussion without loss of consciousness, initial encounter), S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter), S06.0X9A (Concussion with loss of consciousness of unspecified duration, initial encounter), F07.89 (Other personality and behavioral disorders due to known physiological condition), G44.309 (Post-traumatic headache, unspecified, not intractable), G44.319 (Post-traumatic headache, unspecified, intractable), R41.3 (Other amnesia), R42 (Dizziness and giddiness), R53.83 (Other fatigue)

CPT CODES: 99213-99215 (Office visit), 96116 (Neurobehavioral status exam), 96132-96133 (Neuropsychological testing evaluation), 96136-96139 (Neuropsychological testing administration), 97110 (Therapeutic exercises - vestibular rehab), 97112 (Neuromuscular reeducation), 97530 (Therapeutic activities - cognitive rehab), 70551 (MRI brain without contrast), 70553 (MRI brain with and without contrast), 95816 (EEG routine), 95819 (EEG with sleep)

SYNONYMS: Post-concussion syndrome, PCS, postconcussional syndrome, persistent post-concussive symptoms, PPCS, post-concussive disorder, post-concussion disorder, postconcussion syndrome, chronic concussion symptoms, persistent concussion symptoms, prolonged concussion recovery, post-traumatic syndrome, mild TBI sequelae, chronic post-traumatic headache, post-traumatic cognitive impairment, concussion with persistent symptoms, post-concussional disorder, postconcussive syndrome, complicated concussion, post-mild TBI syndrome, post-head injury syndrome, post-head trauma syndrome, chronic concussion, lingering concussion symptoms, slow concussion recovery

SCOPE: Evaluation and management of persistent symptoms following mild traumatic brain injury (mTBI) or concussion in adults, defined as symptom persistence beyond 3 months from injury. Covers symptom-specific pharmacologic management (headache, dizziness, cognitive dysfunction, sleep disturbance, mood changes), vestibular rehabilitation, cognitive rehabilitation, graded return-to-activity protocols, neuropsychological testing, and mental health screening/treatment. Applicable primarily in outpatient setting with ED and inpatient considerations for acute re-evaluation. Excludes acute concussion management (first 0-4 weeks), moderate-severe TBI, pediatric concussion, and sports-specific return-to-play protocols.

DEFINITIONS: - Concussion / Mild TBI: Traumatically induced transient disturbance of brain function; GCS 13-15, LOC <30 minutes, PTA <24 hours - Post-Concussion Syndrome (PCS): Persistence of 3 or more concussion symptoms (headache, dizziness, fatigue, irritability, insomnia, concentration/memory difficulty) for >3 months after mTBI - Post-Traumatic Headache (PTH): Headache developing within 7 days of head injury or regaining consciousness after injury; persistent if >3 months - Persistent Post-Concussive Symptoms (PPCS): Current preferred terminology for symptoms lasting beyond expected recovery window (>4 weeks to 3 months) - Post-Traumatic Vestibular Dysfunction: Dizziness and balance impairment following TBI, may include BPPV, vestibular hypofunction, or central vestibular dysfunction - Cognitive Fatigue: Disproportionate mental exhaustion with cognitive effort, common in PCS

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	STAT	ROUTINE	ROUTINE	-	Anemia can worsen fatigue, dizziness; baseline	Normal
CMP (CPT 80053)	STAT	ROUTINE	ROUTINE	-	Electrolyte abnormalities, renal/hepatic function for medication dosing	Normal
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Hypothyroidism mimics PCS symptoms (fatigue, cognitive slowing, mood)	Normal (0.4-4.0 mIU/L)
Vitamin D, 25-OH (CPT 82306)	-	ROUTINE	ROUTINE	-	Deficiency common after TBI; associated with fatigue, mood, cognitive impairment	>30 ng/mL
Ferritin (CPT 82728)	-	ROUTINE	ROUTINE	-	Iron deficiency causes fatigue, cognitive impairment; especially in women	>50 ng/mL
Vitamin B12 (CPT 82607)	-	ROUTINE	ROUTINE	-	Deficiency causes cognitive impairment, fatigue, neuropathy	>300 pg/mL

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Inflammatory markers if autoimmune or inflammatory etiology suspected	Normal
Folate (CPT 82746)	-	ROUTINE	ROUTINE	-	Deficiency contributes to fatigue, cognitive dysfunction	Normal
Magnesium (CPT 83735)	-	ROUTINE	ROUTINE	-	Low levels worsen headache and fatigue	>1.8 mg/dL
HbA1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Diabetes/prediabetes contributes to cognitive impairment, neuropathy	<5.7%
Free T4 (CPT 84439)	-	ROUTINE	ROUTINE	-	If TSH abnormal; pituitary dysfunction post-TBI	Normal
Morning cortisol (CPT 82533)	-	-	ROUTINE	-	Post-traumatic hypopituitarism (fatigue, hypotension, cognitive decline)	>10 mcg/dL (AM)
IGF-1 (CPT 84305)	-	-	ROUTINE	-	Growth hormone deficiency post-TBI (fatigue, body composition, cognition)	Age-adjusted normal
Prolactin (CPT 84146)	-	-	ROUTINE	-	Pituitary dysfunction screening post-TBI	Normal
Testosterone (males) (CPT 84403)	-	-	ROUTINE	-	Post-traumatic hypogonadism (fatigue, mood, cognition)	Normal for age

1C. Rare/Specialized¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Comprehensive pituitary panel	-	-	EXT	-	If clinical suspicion for hypopituitarism (fatigue, weight gain, hyponatremia)	Normal
ACTH stimulation test (CPT 80400)	-	-	EXT	-	Adrenal insufficiency post-TBI if low morning cortisol	Normal cortisol response
GH stimulation test	-	-	EXT	-	Growth hormone deficiency if low IGF-1 and clinical suspicion	Normal GH peak
Autoimmune panel (ANA, anti-TPO)	-	-	EXT	-	Autoimmune thyroiditis, SLE if clinical suspicion	Negative
Heavy metals (lead, mercury)	-	-	EXT	-	Environmental exposure contributing to cognitive symptoms	Normal
Sleep study referral (polysomnography) (CPT 95810)	-	-	EXT	-	Post-traumatic sleep apnea or narcolepsy if excessive daytime sleepiness	Normal AHI; normal sleep architecture

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	-	-	-	If acute re-presentation with new/worsening symptoms, worst headache, focal deficits	Rule out hemorrhage, mass, hydrocephalus	Pregnancy (relative)
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	Within 2-4 weeks of persistent symptoms; or earlier if red flags	Rule out structural lesion, contusion, DAI, subdural hematoma	Pacemaker, metal implants
Videonystagmography (VNG) / vestibular testing (CPT 92540-92547)	-	-	ROUTINE	-	If persistent dizziness/balance impairment >4 weeks	Identify peripheral vs central vestibular dysfunction	None significant

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with and without contrast (CPT 70553)	-	ROUTINE	ROUTINE	-	If progressive symptoms, new focal deficits, or concern for mass/inflammation	Rule out mass, inflammation, enhancement	Contrast allergy, renal disease
MRI cervical spine (CPT 72141)	-	ROUTINE	ROUTINE	-	If persistent neck pain, cervicogenic headache, radiculopathy	Rule out disc herniation, ligamentous injury	Pacemaker, metal implants
CT angiography head/neck (CPT 70496/70498)	URGENT	URGENT	-	-	If new neurologic deficit, concern for dissection	Rule out vascular dissection, stenosis	Contrast allergy, renal insufficiency
EEG routine (CPT 95816)	-	ROUTINE	ROUTINE	-	If post-traumatic seizures suspected, episodic symptoms	Rule out epileptiform activity	None significant
Audiogram (CPT 92557)	-	-	ROUTINE	-	If hearing loss, tinnitus	Quantify hearing loss; identify type	None
VEMP testing (CPT 92517)	-	-	ROUTINE	-	If persistent vestibular symptoms; otolith dysfunction	Otolith function assessment	None significant
Dix-Hallpike maneuver (clinical test)	URGENT	ROUTINE	ROUTINE	-	If positional dizziness	Positive for BPPV (nystagmus pattern)	Cervical spine injury, severe positional vertigo

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
fMRI (functional MRI)	-	-	EXT	-	Research/specialized centers for refractory cases	Altered connectivity patterns	Standard MRI contraindications
DTI (diffusion tensor imaging)	-	-	EXT	-	Research; suspected diffuse axonal injury	White matter tract disruption	Standard MRI contraindications
PET-CT brain	-	-	EXT	-	Refractory cases; research settings	Regional metabolic abnormalities	Pregnancy, uncontrolled diabetes
Neuropsychological testing (CPT 96132-96133)	-	-	ROUTINE	-	3+ months post-injury if cognitive complaints persist	Objective cognitive deficits; identify pattern	Patient cooperation; acute distress
Oculomotor/saccade testing	-	-	ROUTINE	-	If persistent visual/reading difficulties	Saccadic dysfunction, convergence insufficiency	None
Computerized neurocognitive testing (ImPACT, etc.)	-	-	ROUTINE	-	Baseline comparison if available; track recovery	Return to baseline	Patient cooperation

3. TREATMENT¶

3A. Post-Traumatic Headache Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO	Mild-moderate post-traumatic headache	500-1000 mg :: PO :: q6h PRN :: 500-1000 mg PO q6h PRN; max 3000 mg/day	Hepatic disease, chronic alcohol use	LFTs if frequent use	ROUTINE	ROUTINE	ROUTINE	-
Ibuprofen	PO	Mild-moderate post-traumatic headache	400-600 mg :: PO :: q6-8h PRN :: 400-600 mg PO q6-8h PRN with food; max 2400 mg/day; limit to <15 days/month	Renal disease, GI bleeding, aspirin allergy	Renal function; risk of MOH	ROUTINE	ROUTINE	ROUTINE	-
Naproxen sodium	PO	Mild-moderate post-traumatic headache	250-500 mg :: PO :: BID PRN :: 250-500 mg PO BID PRN; max 1250 mg/day; limit to <15 days/month	Renal disease, GI bleeding	Renal function; risk of MOH	ROUTINE	ROUTINE	ROUTINE	-
Amitriptyline	PO	First-line preventive for post-traumatic headache	10 mg :: PO :: QHS :: Start 10 mg PO QHS; increase by 10 mg every 1-2 weeks; target 25-75 mg QHS; max 150 mg	Cardiac arrhythmia, glaucoma, urinary retention, recent MI	ECG at baseline; anticholinergic effects; weight gain; dry mouth	-	ROUTINE	ROUTINE	-
Nortriptyline	PO	Alternative TCA for post-traumatic headache (fewer anticholinergic effects)	10 mg :: PO :: QHS :: Start 10 mg PO QHS; increase by 10 mg every 1-2 weeks; target 25-75 mg QHS; max 150 mg	Cardiac arrhythmia, glaucoma, urinary retention, recent MI	ECG at baseline; anticholinergic effects (less than amitriptyline); weight gain	-	ROUTINE	ROUTINE	-
Topiramate	PO	Preventive for post-traumatic headache (second-line)	25 mg :: PO :: QHS :: Start 25 mg PO QHS; increase by 25 mg/week; target 50-100 mg BID; max 200 mg/day	Kidney stones, pregnancy, glaucoma	Bicarbonate; cognitive side effects (may worsen PCS cognition); weight loss; paresthesias	-	-	ROUTINE	-
Propranolol	PO	Preventive for post-traumatic headache	20-40 mg :: PO :: BID :: Start 20-40 mg PO BID; target 80-240 mg/day	Asthma, heart block, bradycardia, decompensated HF	HR, BP; fatigue may worsen PCS fatigue	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	Dual headache prevention and mood improvement	37.5 mg :: PO :: daily :: Start 37.5 mg PO daily; increase by 37.5 mg every 1-2 weeks; target 75-150 mg daily	Uncontrolled HTN, MAOI use, narrow-angle glaucoma	BP; serotonin syndrome risk; discontinuation syndrome	-	-	ROUTINE	-
Gabapentin	PO	Post-traumatic headache with neuropathic component	100-300 mg :: PO :: TID :: Start 100-300 mg PO TID; increase by 300 mg/day every 3-5 days; target 900-2400 mg/day divided TID	Renal impairment (adjust dose)	Sedation, dizziness; renal function	-	ROUTINE	ROUTINE	-
Sumatriptan	PO	Acute migraine-type post-traumatic headache	50-100 mg :: PO :: once :: 50-100 mg PO once; may repeat in 2h; max 200 mg/24h; limit <9 days/month	CAD, stroke/TIA, uncontrolled HTN, hemiplegic migraine	Chest tightness, BP; risk of MOH	URGENT	ROUTINE	ROUTINE	-
Occipital nerve block (CPT 64405)	INJ	Refractory post-traumatic headache; occipital neuralgia	Bupivacaine 0.25-0.5% :: INJ :: q4-12 weeks :: 2-3 mL per side with or without methylprednisolone 40 mg	Local anesthetic allergy, infection at site	Local reaction; transient dizziness	-	ROUTINE	ROUTINE	-
OnabotulinumtoxinA (Botox) (CPT J0585)	IM	Chronic post-traumatic headache (>15 days/month for >3 months)	155-195 units :: IM :: q12 weeks :: 155-195 units IM q12 weeks per PREEMPT protocol	Infection at injection sites, myasthenia gravis	Spread of toxin effect; neck weakness	-	-	ROUTINE	-

3B. Vestibular/Dizziness Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Canalith repositioning (Epley maneuver)	-	BPPV (post-traumatic)	Perform in clinic; may need 2-3 sessions	Cervical spine injury (relative)	Resolution of positional nystagmus	URGENT	ROUTINE	ROUTINE	-
Meclizine	PO	Acute vestibular symptoms (short-term only)	25 mg :: PO :: q8h PRN :: 25 mg PO q8h PRN; short-term only (<1-2 weeks); avoid chronic use	Glaucoma, urinary retention	Sedation; may impair vestibular compensation if used chronically	URGENT	ROUTINE	ROUTINE	-
Dimenhydrinate	PO	Acute vestibular symptoms (short-term only)	50 mg :: PO :: q6h PRN :: 50 mg PO q6h PRN; short-term only (<1-2 weeks)	Same as meclizine	Sedation; avoid chronic use	URGENT	ROUTINE	ROUTINE	-
Ondansetron	PO/IV	Nausea associated with vestibular dysfunction	4-8 mg :: PO :: q8h PRN :: 4-8 mg PO/IV q8h PRN	QT prolongation	QTc if risk factors	URGENT	ROUTINE	ROUTINE	-
Vestibular rehabilitation therapy (VRT) (CPT 97110, 97112)	-	Persistent dizziness, balance impairment, vestibular hypofunction	Specialized PT program; 1-2x/week for 6-12 weeks	Active vertigo crisis (defer until stable)	BESS score, DHI score, functional improvement	-	ROUTINE	ROUTINE	-
Betahistine	PO	Persistent vestibular symptoms (off-label in US)	16 mg :: PO :: TID :: 16 mg PO TID; not FDA-approved but used internationally	Peptic ulcer disease, pheochromocytoma	GI upset	-	-	EXT	-

3C. Cognitive and Fatigue Management¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Methylphenidate	PO	Cognitive fatigue, processing speed deficits, attention impairment	5 mg :: PO :: BID :: Start 5 mg PO BID (morning and noon); increase by 5 mg/dose every 3-7 days; target 10-20 mg BID; max 60 mg/day; avoid afternoon dosing	Uncontrolled HTN, cardiac arrhythmia, glaucoma, anxiety disorder (relative), substance abuse history	HR, BP; appetite, weight, sleep; anxiety; potential for abuse	-	-	ROUTINE	-
Amantadine	PO	Cognitive fatigue, processing speed, motivation	100 mg :: PO :: BID :: Start 100 mg PO every morning; increase to 100 mg BID after 1 week; max 200 mg BID	Renal impairment (adjust dose), seizure history (relative)	Livedo reticularis, ankle edema, hallucinations, insomnia; renal function	-	-	ROUTINE	-
Modafinil	PO	Excessive daytime sleepiness, fatigue (off-label for TBI)	100 mg :: PO :: daily :: Start 100 mg PO every morning; may increase to 200 mg daily; max 400 mg/day	Cardiac arrhythmia, mitral valve prolapse, hepatic impairment	HR, BP; headache; Stevens-Johnson (rare); may reduce OCP efficacy	-	-	ROUTINE	-
Cognitive rehabilitation therapy (CPT 97530)	-	Attention, memory, executive function deficits	Specialized OT/SLP program; 1-2x/week for 8-16 weeks	None significant	Neuropsychological re-testing at 3-6 months	-	ROUTINE	ROUTINE	-
Speech-language pathology (cognitive-linguistic therapy)	-	Word-finding, processing speed, memory strategies	1-2x/week for 8-12 weeks	None significant	Functional cognitive improvement	-	ROUTINE	ROUTINE	-

3D. Sleep Disturbance Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Melatonin	PO	Insomnia, circadian rhythm disruption post-TBI	3-5 mg :: PO :: QHS :: 3-5 mg PO 30-60 minutes before bedtime; may increase to 10 mg	None significant	Well tolerated; vivid dreams	-	ROUTINE	ROUTINE	-
Trazodone	PO	Insomnia (non-habit forming)	25-50 mg :: PO :: QHS :: Start 25-50 mg PO QHS; may increase to 100-150 mg; max 200 mg QHS	Concurrent MAOIs	Orthostatic hypotension; priapism (rare); morning sedation	-	ROUTINE	ROUTINE	-
Hydroxyzine	PO	Insomnia with anxiety	25-50 mg :: PO :: QHS :: 25-50 mg PO QHS PRN	QT prolongation, elderly (fall risk)	Sedation; anticholinergic effects	-	ROUTINE	ROUTINE	-
Ramelteon	PO	Sleep onset insomnia (melatonin receptor agonist)	8 mg :: PO :: QHS :: 8 mg PO QHS 30 minutes before bedtime	Severe hepatic impairment, concurrent fluvoxamine	Well tolerated; no abuse potential	-	-	ROUTINE	-
Suvorexant	PO	Insomnia (orexin receptor antagonist)	10 mg :: PO :: QHS :: Start 10 mg PO QHS; may increase to 20 mg; take within 30 min of bedtime	Narcolepsy, severe hepatic impairment	Next-day somnolence; sleep paralysis (rare)	-	-	ROUTINE	-
Gabapentin (for sleep)	PO	Insomnia with comorbid headache or pain	100-300 mg :: PO :: QHS :: Start 100-300 mg PO QHS; may titrate to 600 mg QHS	Renal impairment (adjust dose)	Sedation, dizziness; may also help headache	-	ROUTINE	ROUTINE	-

3E. Mood and Anxiety Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Sertraline	PO	Depression, anxiety, irritability post-TBI	25 mg :: PO :: daily :: Start 25 mg PO daily; increase by 25 mg every 1-2 weeks; target 50-150 mg daily; max 200 mg	Concurrent MAOIs, uncontrolled bipolar	Suicidality monitoring (weeks 1-4); GI upset; sexual dysfunction; serotonin syndrome	-	ROUTINE	ROUTINE	-
Escitalopram	PO	Depression, anxiety post-TBI	5 mg :: PO :: daily :: Start 5 mg PO daily; increase to 10 mg after 1 week; max 20 mg daily	Concurrent MAOIs, QT prolongation	Suicidality monitoring; QTc; sexual dysfunction	-	ROUTINE	ROUTINE	-
Duloxetine	PO	Depression with comorbid pain (headache, musculoskeletal)	20-30 mg :: PO :: daily :: Start 20-30 mg PO daily; increase to 60 mg daily after 1-2 weeks; max 120 mg	Concurrent MAOIs, hepatic impairment, uncontrolled glaucoma	LFTs; BP; nausea (transient); discontinuation syndrome	-	-	ROUTINE	-
Bupropion XL	PO	Depression with fatigue, low motivation; avoidance of sexual side effects	150 mg :: PO :: daily :: Start 150 mg PO daily; may increase to 300 mg daily after 1-2 weeks; max 450 mg/day	Seizure disorder (lowers threshold), bulimia/anorexia, concurrent MAOIs	Seizure risk (dose-dependent); insomnia; agitation; avoid in patients with seizure history	-	-	ROUTINE	-
Buspirone	PO	Anxiety (non-benzodiazepine)	5 mg :: PO :: TID :: Start 5 mg PO TID; increase by 5 mg every 2-3 days; target 15-30 mg/day divided BID-TID; max 60 mg/day	Concurrent MAOIs	Dizziness, headache; takes 2-4 weeks for full effect; no abuse potential	-	-	ROUTINE	-
Cognitive behavioral therapy (CBT)	-	Depression, anxiety, PTSD, adjustment disorder post-TBI	Weekly sessions for 12-16 weeks; evidence-based for PCS	None	Symptom questionnaires (PHQ-9, GAD-7); functional improvement	-	ROUTINE	ROUTINE	-
EMDR (Eye Movement Desensitization and Reprocessing)	-	Post-traumatic stress disorder comorbid with PCS	Per therapist protocol; evidence-based for PTSD	Active psychosis, acute suicidality	PTSD symptom scores (PCL-5)	-	-	ROUTINE	-

3F. Autonomic Dysfunction / Exertion Intolerance Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Graded aerobic exercise program (Buffalo Concussion Treadmill Test protocol)	-	Exercise intolerance, autonomic dysregulation post-concussion	Start at sub-symptom threshold HR; increase 5-10% per week; target 30 min moderate intensity	Uncontrolled cardiac disease; active vertigo	HR monitoring; symptom provocation tracking; stop if symptoms worsen >2 points	-	-	ROUTINE	-
Fludrocortisone	PO	Orthostatic intolerance, post-concussion autonomic dysfunction	0.1 mg :: PO :: daily :: Start 0.1 mg PO daily; max 0.2 mg daily	CHF, hypertension, renal failure	BP, potassium, edema; weight	-	-	EXT	-
Midodrine	PO	Orthostatic hypotension contributing to dizziness	2.5 mg :: PO :: TID :: Start 2.5 mg PO TID; increase to 5-10 mg TID; avoid evening dose	Supine HTN, urinary retention, pheochromocytoma	Supine BP; urinary symptoms	-	-	EXT	-
Compression stockings	-	Orthostatic intolerance	20-30 mmHg waist-high; wear during upright activity	Peripheral arterial disease	Comfort, compliance	-	-	ROUTINE	-
Salt supplementation	PO	Orthostatic intolerance (if no HTN)	1-2 g :: PO :: daily :: 1-2 g additional sodium daily via salt tablets or dietary increase	Hypertension, CHF, renal disease	BP, edema	-	-	ROUTINE	-

3G. Visual/Oculomotor Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Neuro-optometric rehabilitation	-	Convergence insufficiency, accommodative dysfunction, saccadic dysfunction	Specialized vision therapy; 1-2x/week for 8-12 weeks	None significant	Near point of convergence, symptom improvement	-	-	ROUTINE	-
Prism glasses (temporary)	-	Binocular vision dysfunction, diplopia	Prescribed by neuro-optometrist or ophthalmologist	None	Visual comfort, symptom relief	-	-	ROUTINE	-
FL-41 tinted lenses	-	Photophobia, light sensitivity	Worn as needed; indoor and outdoor versions	None	Subjective improvement	-	ROUTINE	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurology consult	URGENT	ROUTINE	ROUTINE	-	Persistent symptoms >4 weeks, post-traumatic headache management, new neurologic deficits
Neuropsychological testing	-	-	ROUTINE	-	Cognitive complaints persisting >3 months; objective assessment for rehab planning, disability documentation
Vestibular rehabilitation (PT)	-	ROUTINE	ROUTINE	-	Persistent dizziness, balance impairment, BPPV
Cognitive rehabilitation (OT/SLP)	-	ROUTINE	ROUTINE	-	Attention, memory, executive function deficits impacting function
Physical therapy (cervical/general)	-	ROUTINE	ROUTINE	-	Cervicogenic headache, neck pain, deconditioning
Psychiatry consult	-	ROUTINE	ROUTINE	-	Depression, anxiety, PTSD, irritability not responding to first-line treatment
Psychology/CBT referral	-	ROUTINE	ROUTINE	-	Psychological symptoms, adjustment difficulties, pain management
Neuro-ophthalmology / Neuro-optometry	-	-	ROUTINE	-	Persistent visual symptoms, convergence insufficiency, photophobia
Sleep medicine	-	-	ROUTINE	-	Refractory insomnia, excessive daytime sleepiness, suspected sleep apnea
ENT / Otolaryngology	-	-	ROUTINE	-	Persistent tinnitus, hearing loss, vestibular dysfunction
Sports medicine / Concussion specialist	-	-	ROUTINE	-	Graded return to activity guidance, exertion intolerance
Endocrinology	-	-	EXT	-	Suspected post-traumatic hypopituitarism
Occupational medicine	-	-	ROUTINE	-	Return to work planning, workplace accommodations
Social work	-	ROUTINE	ROUTINE	-	Insurance navigation, disability, vocational rehab, family support

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD
Return to ED if: worst headache of life, new or worsening neurologic deficit, seizure, persistent vomiting, worsening confusion, loss of consciousness	ROUTINE	ROUTINE	ROUTINE
Post-concussion symptoms are real and expected to improve with appropriate management	ROUTINE	ROUTINE	ROUTINE
Gradual return to activity is key — avoid both complete rest and overexertion	-	ROUTINE	ROUTINE
Follow the "symptom threshold" approach: stay active but stop before symptoms worsen significantly	-	ROUTINE	ROUTINE
Track symptoms daily using a symptom diary or validated scale (RPQ, PCSS)	-	ROUTINE	ROUTINE
Avoid alcohol (worsens cognition, sleep, and balance; interacts with medications)	ROUTINE	ROUTINE	ROUTINE
Limit caffeine (<200 mg/day); maintain consistent intake	-	ROUTINE	ROUTINE
Do NOT use benzodiazepines chronically for anxiety/sleep (impairs recovery)	ROUTINE	ROUTINE	ROUTINE
Screen time management: take breaks every 20-30 minutes; reduce brightness; use blue-light filters	-	ROUTINE	ROUTINE
Follow up with neurology or concussion specialist within 2-4 weeks	ROUTINE	ROUTINE	-
Bring list of all medications and symptom diary to all appointments	-	ROUTINE	ROUTINE
Report new symptoms or worsening immediately (seizure, vision change, personality change)	ROUTINE	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Sleep hygiene: aim for 7-9 hours; consistent wake/bed times; dark, cool, quiet room	-	ROUTINE	ROUTINE
Graded aerobic exercise: start below symptom threshold; increase 10% per week	-	ROUTINE	ROUTINE
Stress management: mindfulness, meditation, deep breathing, progressive muscle relaxation	-	ROUTINE	ROUTINE
Cognitive pacing: alternate demanding and easy tasks; take scheduled breaks	-	ROUTINE	ROUTINE
Use compensatory strategies: calendars, lists, alarms, voice memos for memory	-	ROUTINE	ROUTINE
Maintain social connections; avoid prolonged isolation	-	ROUTINE	ROUTINE
Limit multitasking; focus on one task at a time in quiet environment initially	-	ROUTINE	ROUTINE
Wear sunglasses or FL-41 tinted lenses for photophobia	-	ROUTINE	ROUTINE
Use earplugs or noise-canceling headphones for phonophobia in noisy environments	-	ROUTINE	ROUTINE
Healthy diet: anti-inflammatory, Mediterranean-style; regular meals; stay hydrated	-	ROUTINE	ROUTINE
Prevent re-injury: no contact sports until fully recovered and cleared by specialist	ROUTINE	ROUTINE	ROUTINE
Second impact syndrome education: rare but catastrophic if re-injured before recovery	ROUTINE	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Chronic migraine	Pre-existing headache history before injury; meets ICHD-3 chronic migraine criteria independent of trauma	Headache diary, pre-injury history
Cervicogenic headache	Neck pain predominant, headache triggered by neck movement/posture, limited cervical ROM	Cervical exam, diagnostic block, cervical MRI
Subdural hematoma (chronic)	Progressive headache, cognitive decline, focal deficits; risk with anticoagulation, elderly, falls	CT head, MRI brain
Depression / Anxiety disorder	Mood symptoms predate injury or disproportionate to injury severity; lack of cognitive deficits on testing	PHQ-9, GAD-7, neuropsychological testing
PTSD (Post-traumatic stress disorder)	Re-experiencing trauma, avoidance, hyperarousal; nightmares; may overlap significantly with PCS	PCL-5, psychiatric evaluation
Post-traumatic hypopituitarism	Fatigue, weight changes, hyponatremia, sexual dysfunction; can present months after TBI	Pituitary hormones (cortisol, TSH, IGF-1, testosterone)
Sleep apnea (new or worsened post-TBI)	Excessive daytime sleepiness, snoring, witnessed apneas, morning headache	Polysomnography
Benign paroxysmal positional vertigo (BPPV)	Positional vertigo (brief episodes), positive Dix-Hallpike	Dix-Hallpike maneuver, VNG
Medication side effects	Symptoms correlate with medication initiation/dose changes	Medication review, trial discontinuation
Functional neurological disorder (FND)	Inconsistent exam findings, distractibility signs, Hoover sign	Clinical exam, neuropsychological testing
Whiplash-associated disorder	Neck pain predominant, limited ROM, no LOC at injury	Cervical imaging, clinical exam
Idiopathic intracranial hypertension	Headache with papilledema, visual obscurations, pulsatile tinnitus	Fundoscopy, LP with opening pressure, MRV
CNS infection	Fever, meningismus, progressive course	CBC, LP, MRI with contrast
Malingering / Symptom exaggeration	Medicolegal context, inconsistent performance, effort testing failure	Neuropsychological testing with embedded/stand-alone effort measures
Normal aging / Pre-existing cognitive impairment	Cognitive symptoms predate injury; stable rather than post-injury onset	Pre-injury cognitive testing, collateral history

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Post-Concussion Symptom Scale (PCSS)	STAT	Daily	Each visit	-	Per encounter	Improving trend; score <10	Adjust treatment; consider additional referrals
Rivermead Post-Concussion Symptoms Questionnaire (RPQ)	-	-	Each visit	-	q4-6 weeks	Improving trend	Reassess treatment plan
PHQ-9 (depression screen)	-	ROUTINE	Each visit	-	q4-6 weeks	<5 (minimal)	Initiate/adjust antidepressant; psychiatry referral
GAD-7 (anxiety screen)	-	ROUTINE	Each visit	-	q4-6 weeks	<5 (minimal)	Initiate/adjust anxiolytic; therapy referral
PCL-5 (PTSD screen)	-	-	ROUTINE	-	q8-12 weeks	<33 (below threshold)	PTSD-focused therapy; psychiatry referral
Headache diary (frequency, severity)	-	Daily	Each visit	-	Ongoing	<4 headache days/month	Adjust preventive; consider specialist referral
Dizziness Handicap Inventory (DHI)	-	-	Each visit	-	q4-8 weeks	Improving; score <30	Vestibular rehab referral/adjust
Balance assessment (BESS, mBESS)	-	ROUTINE	Each visit	-	q4-8 weeks	Return to baseline	Vestibular rehab
Neurocognitive testing (ImPACT or equivalent)	-	-	q3-6 months	-	Per protocol	Return to baseline	Cognitive rehab adjustment
Sleep quality (PSQI or ISI)	-	-	Each visit	-	q4-6 weeks	PSQI <5 or ISI <8	Adjust sleep medications; sleep medicine referral
Vital signs	STAT	q shift	Each visit	-	Per encounter	Normal	Address abnormalities
Medication side effects	-	Daily	Each visit	-	Ongoing	No significant adverse effects	Dose adjustment or medication change

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge from ED	Stable neurologic exam, no red flags on imaging (if obtained), no acute intervention needed, outpatient follow-up arranged, safety precautions reviewed
Admit to hospital	New or worsening neurologic deficit, suspected delayed intracranial hemorrhage, acute psychiatric crisis (suicidality), severe vestibular dysfunction preventing safe ambulation, inability to maintain hydration/nutrition
Outpatient follow-up schedule	Initial: 2-4 weeks post-injury; then q4-6 weeks until symptom resolution; neuropsychological testing at 3+ months if cognitive symptoms persist
Return to work/school	Gradual return with accommodations; symptom-dependent; coordinate with occupational medicine; may need reduced schedule, extra break time, modified duties
Return to exercise	Per graded protocol (Buffalo Treadmill Test); stepwise progression: (1) light aerobic, (2) moderate aerobic, (3) sport-specific, (4) non-contact drills, (5) full activity
Return to driving	When able to tolerate visual stimulation, has adequate reaction time, no dizziness/cognitive impairment at highway speeds; per physician clearance
Specialty referral thresholds	If no improvement at 4-6 weeks: neurology; if no improvement at 3 months: neuropsychology, multidisciplinary concussion program

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Definition and diagnostic criteria for PCS	Consensus	ICD-10 F07.81; McCrory P et al. Br J Sports Med 2017 (Berlin Consensus Statement on Concussion in Sport)
Persistent symptoms defined as >3 months post-injury	Consensus	Silverberg ND, Iverson GL. J Head Trauma Rehabil 2013
Graded aerobic exercise improves recovery from PCS	Class I, Level A	Leddy JJ et al. Clin J Sport Med 2019 (Buffalo Concussion Treadmill Test)
Sub-threshold aerobic exercise safe and beneficial for PCS	Class I, Level A	Leddy JJ et al. J Head Trauma Rehabil 2010
Vestibular rehabilitation effective for post-traumatic dizziness	Class I, Level A	Alsalaheen BA et al. Am J Phys Med Rehabil 2010
Amitriptyline effective for chronic post-traumatic headache	Class II, Level B	Cushman DM et al. Headache 2019
Topiramate for post-traumatic headache prevention	Class II, Level B	Packard RC. Curr Pain Headache Rep 2000; VA/DoD Clinical Practice Guideline 2016
Cognitive rehabilitation improves attention and executive function post-TBI	Class I, Level A	Cicerone KD et al. Arch Phys Med Rehabil 2019 (systematic review)
Neuropsychological testing recommended for persistent cognitive complaints	Class II, Level B	Iverson GL et al. NeuroRehabilitation 2009
Methylphenidate improves cognitive fatigue and processing speed post-TBI	Class II, Level B	Willmott C, Ponsford J. Neurology 2009
Amantadine improves cognitive function after TBI	Class I, Level A	Giacino JT et al. NEJM 2012
Post-traumatic hypopituitarism occurs in up to 25% of TBI cases	Class II, Level B	Tanriverdi F et al. J Clin Endocrinol Metab 2015
CBT effective for PCS-related mood and anxiety symptoms	Class I, Level A	Potter S et al. Neuropsychol Rev 2016
Melatonin improves sleep quality post-TBI	Class II, Level B	Grima NA et al. J Neurotrauma 2018
BPPV is common following concussion and responds to repositioning	Class I, Level A	Fife TD et al. Neurology 2008 (AAN Practice Parameter)
Post-traumatic headache management follows migraine treatment paradigm	Consensus	Seifert T. Curr Pain Headache Rep 2011; AHS 2019
OnabotulinumtoxinA for chronic post-traumatic headache	Class II, Level B	Yerry JA et al. Headache 2015
Occipital nerve block effective for post-traumatic headache	Class II, Level B	Ashkenazi A, Levin M. Headache 2007
Modafinil for post-TBI fatigue and somnolence	Class II, Level B	Kaiser PR et al. J Clin Psychopharmacol 2010
Berlin Consensus Statement on Concussion in Sport, 5th International Conference	Consensus	McCrory P et al. Br J Sports Med 2017
Amsterdam Consensus Statement on Concussion in Sport, 6th International Conference	Consensus	Patricios JS et al. Br J Sports Med 2023
VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI	Class I	VA/DoD Evidence-Based Clinical Practice Guideline 2021
ACR Appropriateness Criteria for head trauma	Class II, Level B	ACR Appropriateness Criteria Panel 2020
Risk of chronic symptoms after mTBI: 15-30% at 3 months	Class I	Levin HS, Diaz-Arrastia RR. NEJM 2015

NOTES¶

Post-concussion syndrome is a clinical diagnosis; neuroimaging is often normal and does not rule out PCS
Most patients recover within 3 months; 15-30% develop persistent symptoms
Avoid prolonged cognitive and physical rest beyond 24-48 hours acutely — this may worsen outcomes
Graded aerobic exercise (sub-symptom threshold) is the strongest evidence-based intervention for PCS recovery
Post-traumatic headache is the most common symptom; treat with migraine prevention paradigm (amitriptyline first-line)
Avoid topiramate as first-line in PCS due to cognitive side effects that may worsen PCS-related cognitive impairment
Avoid chronic benzodiazepine use — impairs vestibular compensation and cognitive recovery
Screen all PCS patients for depression, anxiety, and PTSD at each visit (PHQ-9, GAD-7, PCL-5)
Post-traumatic hypopituitarism is underdiagnosed; screen with morning cortisol, TSH, IGF-1 if persistent fatigue
Vestibular symptoms (dizziness, balance problems) respond well to targeted vestibular rehabilitation
Cognitive symptoms correlate poorly with injury severity; neuropsychological testing provides objective measurement
Multidisciplinary approach (neurology, neuropsychology, PT, OT, SLP, psychology) yields best outcomes
Consider cervicogenic headache as co-contributor; whiplash and concussion frequently co-occur
Secondary gain and medicolegal context do not preclude genuine symptoms but should be noted
Effort testing during neuropsychological evaluation is standard to ensure valid results

CHANGE LOG¶

v1.1 (January 30, 2026) - Fixed nortriptyline cross-reference: replaced "Same as amitriptyline" with self-contained contraindications (C1/M1) - Standardized all 7 treatment table separator rows with proper column alignment syntax (M2/R2) - Added REVISED date to metadata header (R7) - Version bump to 1.1 per checker review (R8)

v1.0 (January 30, 2026) - Initial template creation - Comprehensive symptom-specific treatment sections (headache, vestibular, cognitive, sleep, mood, autonomic, visual) - Post-traumatic headache preventive and abortive options with structured dosing - Graded aerobic exercise protocol (Buffalo Concussion Treadmill Test) - Cognitive and vestibular rehabilitation therapy recommendations - Post-traumatic hypopituitarism screening included - Mental health screening tools (PHQ-9, GAD-7, PCL-5) integrated into monitoring - Autonomic dysfunction management with graded exercise and pharmacologic options - 24 evidence-based references without PubMed links (pending citation verification) - Setting coverage: ED, HOSP, OPD