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Traumatic brain injury (TBI) is one of the most common injuries in the pediatric age group. It is estimated that as many as half a million children younger than 15 years sustain TBIs that require hospital-based care in the United States each year, with the majority of these injuries being mild in severity.1 A national cross-sectional study in the United States estimated that 1 of every 220 pediatric patients seen in emergency departments receive a diagnosis of mild traumatic brain injury (mTBI).2 Headaches are the most common symptom after mTBI or concussion and often occur with a constellation of physical, cognitive, emotional, and behavioral signs and symptoms. Headaches may affect a child’s ability to function and participate in school and extracurricular activities, which can cause disability and impair their quality of life.3


The Consensus Statement on Concussion in Sport from the 5th International Conference on Concussion in Sport held in Berlin in October 20164 defines concussion using the following criteria:

Sport-related concussion (SRC) is a TBI induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

  1. SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.

  2. SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.

  3. SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

  4. Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).


The initial evaluation of a suspected concussion involves a thorough history, including patient self-report and knowledge from others (eg, family, teacher, trainer), and a thorough exam.

The Centers for Disease Control and Prevention (CDC)5 has summarized recommendations in the initial evaluation of concussions. It is highly recommended the reader study the original document. Below are the recommendations used most consistently in our practice. The focus of evaluation and treatment often falls on addressing some combination of headache, dizziness, sleep issues, attentional issues, cognitive issues, mood/personality changes, or visual issues (eg, accommodative issues).

  1. Healthcare professionals should counsel patients and families that most (70%-80%) ...

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