When Concussion Symptoms Persist

Persisting post-concussion symptoms are defined as symptoms continuing beyond four weeks after the injury. They are not rare: the ANZ guidelines put the figure at 30 to 40 per cent of children and as many as 20 to 50 per cent of adults.

That prevalence matters for how the situation is framed. A person still symptomatic at five weeks has not failed, and is not an unusual case requiring an unusual explanation. What they need is a structured reassessment rather than more of the same advice.

Factors associated with a slower course include previous medical conditions, pre-injury anxiety or mood disturbance, learning difficulties and attention deficit disorders, and the mechanism and setting of the original injury. Identifying these early changes what is offered and when.

The guidelines recommend reassessment at one to two weeks after injury, and again at four weeks where symptoms persist. That review is deliberately broad, because persisting symptoms are usually several problems layered together rather than one.

It covers headache and neck pain, including whether a migraine pattern has been triggered; mood, screening for depression, anxiety and post-traumatic stress; sleep disturbance; dizziness, balance and visual problems; cognitive symptoms of memory and attention; fatigue; and a review of medications and substances, including whether analgesia has itself become part of the problem.

Examination should include vital signs, a full neurological examination, assessment of the cervical spine and a mental state examination. The cervical spine deserves particular emphasis — the force that concusses a brain also loads a neck, and neck-driven headache and dizziness are readily mistaken for ongoing concussion and are treatable.

The guidelines are unusually direct on this point, and give it a strong evidence-based recommendation: the symptoms attributed to persisting concussion occur commonly in a range of other conditions, and attributing everything to the head knock delays treatment of the thing that is actually driving it.

The guidelines advise considering functional neurological disorder early where symptoms are progressive, atypical, or have failed to improve by around three months. This is a positive diagnosis made on characteristic features, not a label applied when tests are normal, and it matters because it responds to specific treatment that is entirely different from concussion management.

It is worth saying plainly to anyone who encounters this in their own care: it does not mean the symptoms are imagined or that the injury did not happen. It means the mechanism producing the symptoms has changed, and the treatment needs to change with it.

Management is coordinated rather than sequential — several things at once, because the symptoms drive each other. Poor sleep worsens headache, headache worsens mood, low mood reduces activity tolerance, and inactivity worsens all three.

The components are education about what recovery looks like, given in written as well as verbal form; activity modification with a graded reintroduction of daily activity beginning within days rather than weeks; non-pharmacological strategies including sleep hygiene, fatigue management, identifying and limiting triggers, and a graduated return to cognitive and physical load; and genuine reassurance, because most people do resolve with this approach.

Where symptoms span several domains, interdisciplinary care delivered in an integrated way — rather than as a series of unconnected appointments — is what the guidelines recommend.

Hyperbaric oxygen therapy is specifically not recommended for treating symptoms after concussion, and that carries a strong evidence-based recommendation rather than a cautious one. It is included here because it is actively marketed to people with persisting symptoms, and because a strong negative recommendation in a national guideline is worth knowing before spending money on it.

The guidelines recommend considering referral to an interdisciplinary concussion team or a subspecialist for people with persisting symptoms — a team meaning a physician experienced in concussion management working alongside allied health practitioners, rather than a single practitioner working alone.

Where progress is very slow or absent, referral should not wait. In rural and remote settings the guidelines accept GP monitoring combined with telehealth to organise assessment and coordinate services rather than treating distance as a reason to do less.