Postconcussion Syndrome (PCS) / Mild Traumatic Brain Injury (mTBI)

BASICS

Definition: Constellation of physical, cognitive, and behavioral symptoms persisting after concussion (mTBI), lasting weeks to years.
Diagnosis: Based on history/clinical symptoms—no strict cutoff, but >10–14 days in adults and >4 weeks in children.
Symptoms:
Cognitive: Poor attention, memory, slowed response, diminished performance.
Physical: Headache, nausea, visual changes, photophobia/phonophobia, dizziness, sleep disturbance, fatigue.
Behavioral: Depression, anxiety, irritability, emotional lability, apathy, alcohol sensitivity.

Incidence: Wide range (5–80%) after concussion; 80–90% recover within 7–10 days (longer in kids).
Diagnosis of PCS: Persistent symptoms beyond acute recovery window.
Sex: Females slightly more likely to have prolonged symptoms.

Exact mechanism: Unclear; overlap with psychiatric conditions.
Not all with mTBI develop PCS.
Strongest predictor: Severity of initial concussion symptoms.
Behavioral/psychiatric factors and high initial symptom burden increase risk.

High initial symptom burden (amnesia, poor concentration, insomnia, loss of balance, sensory disturbance)
Preexisting psychiatric disorder (depression, anxiety, PTSD, personality disorder)
Preexisting expectation of poor outcome
Non-sport mTBI
Low socioeconomic status
Loss of consciousness is NOT a predictor.

Recent impact/closed head injury: mechanism, timing, previous history, symptom characterization.
Report by patient/family of neurologic/cognitive/behavioral symptoms.

Imaging/labs only if concern for bleed, coagulopathy, severe symptoms, or cervical spine injury.
Neuropsychological/CNP testing for management and academic/sports accommodations.
No single test diagnostic for PCS.

Return to activity: Graduated, evidence-based; restrict sports until asymptomatic and off masking meds.
School accommodations if cognitive symptoms persist.
Physical therapy for vestibular/cervical dysfunction.
CBT for mood/anxiety/PTSD symptoms.
Noncontact aerobic exercise may help recovery.

Headache/Neck pain: NSAIDs, avoid opioids. Consider occipital nerve block, propranolol/amitriptyline for prophylaxis.
Mood/Behavioral: SSRIs (e.g., sertraline), screen early and refer as needed.
Sleep: Sleep hygiene, melatonin, trazodone, amitriptyline.
Cognition: Neuropsych eval, consider neurostimulants (amantadine, methylphenidate, atomoxetine) if attention problems.
Referral: Neurology (refractory headache, seizure, vertigo, cognitive problems), psychiatry/psychology, OT/PT as indicated.

Regular follow-up for symptoms, medication efficacy, need for further evaluation
Serial neuropsychological testing as needed
Follow return-to-play and activity guidelines

Good: Most recover within 3 months.
Adolescents may recover more slowly.
Risk: Repeat injury before full recovery can worsen/prolong symptoms (second-impact syndrome: rare, but potentially fatal).

Imaging is rarely helpful for PCS.
Use a multidisciplinary approach for persistent symptoms.
Full return to sport/physical activity only after complete resolution of symptoms.
Gradual return to work, school, driving may require accommodations.