When to go to the ER / call emergency services

These are “don’t debate it” signs. Get urgent medical care.

• Worsening headache that doesn’t go away
• Repeated vomiting
• Seizure / convulsions
• Increasing drowsiness, can’t wake up, or can’t stay awake
• Slurred speech, weakness, numbness, or decreased coordination
• Unusual confusion, agitation, or not recognizing people/places
• One pupil larger than the other or double vision
• Severe neck pain

Source: CDC “danger signs” list for concussion/mTBI. CDC Heads Up and CDC TBI symptoms/danger signs.

What do I do in the first 48 hours?

The old advice was basically: lie in a dark room until you become one with the dark room. The updated consensus is kinder (and more effective): relative rest for ~24–48 hours, then gradual activity. Amsterdam Consensus statement.

My practical version

• Protect your brain from a second hit. No sports, no risky activities, no “I’m fine” bravado.
• Keep stimulation low. Quiet environment, dim lights if light hurts, simple conversation, naps if needed.
• Screens: limit if they spike symptoms. Short checks are usually fine; doom‑scrolling is not your rehab plan.
• Hydrate + eat like a functional adult (even if your brain wants gummy bears). If nausea is an issue, small bland meals can help.
• Pain control: acetaminophen is commonly used early; discuss NSAIDs with a clinician if you’re unsure. Mayo Clinic
• Book follow‑up. If symptoms are not improving over the next few days, get reassessed.

Important: if you’re on blood thinners, have a bleeding disorder, had a high‑risk injury (car crash, fall from height), or have worsening symptoms, don’t “cheat sheet” your way through it—get evaluated.

Day 3 onward: what actually helps

1) Light aerobic exercise (sub‑symptom threshold)

Evidence has shifted hard: strict rest until symptoms resolve is not beneficial for many people. Early, controlled aerobic exercise tends to speed recovery.

• Adolescent RCT: aerobic exercise recovered faster than placebo‑like stretching (median 13 vs 17 days). PubMed
• Systematic review/meta‑analysis: early prescribed exercise/physical activity improved recovery by ~4.6 days on average. PubMed

Translation: start with a gentle walk or stationary bike. If symptoms ramp hard, back off. The goal is “a little challenge,” not “heroic suffering.”

2) Vestibular rehab (if dizziness/vertigo/balance issues)

Vestibular rehabilitation (a type of physio) can help with dizziness, balance problems, and vestibular/ocular symptoms. Evidence is supportive, though studies vary. Meta‑analysis.

3) Post‑traumatic headache / migraine pattern

Headache is the most common persistent symptom after concussion. If headaches are sticking around, ask about a structured plan. The American Headache Society has a clinical white paper on post‑traumatic headache in youth (useful even if you’re not a teen because it lays out the framework). PubMed.

• Medication options to discuss (not for DIY): migraine preventives (e.g., nortriptyline/amitriptyline), migraine abortives (triptans), newer agents (gepants like ubrogepant) depending on your situation.
• Non‑drug options to ask about: acupuncture, biofeedback, neuromodulation devices (e.g., Cefaly, gammaCore), etc. (These vary in evidence and availability.)

When can I return to work/school?

There’s a gray zone. You want to re‑engage your brain… without punishing it. The consensus approach is stepwise: short blocks of cognitive work + breaks + gradual screen ramp‑up. Amsterdam Consensus.

A workable template

• Start small: 15–30 minute blocks, then rest.
• Increase by tolerance: add time if symptoms stay mild and don’t spike later that day.
• Use accommodations: reduced hours, breaks, dimmer lighting, quiet workspace, speech‑to‑text, printed materials.
• If you crash the next day: that’s data—dial it back.

Supplements: what’s worth considering (and what to skip)

Here’s the honest framing: the supplement evidence for migraine prevention is stronger than for “speeding concussion recovery.” But post‑concussion headache often looks like migraine, and some supplements have limited concussion‑specific data.

Magnesium (400–600 mg/day)

• Migraine prevention evidence review (magnesium dicitrate 600 mg often cited). PubMed
• Acute concussion RCT in adolescents: oral magnesium improved symptom scores at 48 hours vs placebo. PubMed

Notes: magnesium can cause diarrhea (especially citrate/oxide). If you have kidney disease, talk to a clinician first.

Riboflavin (B2) (400 mg/day)

• Classic migraine RCT (400 mg/day vs placebo). PubMed
• Systematic review/meta‑analysis of riboflavin for migraine prophylaxis. PubMed
• Sport‑related concussion RCT: riboflavin 400 mg/day associated with shorter time to recovery (published; not as widely replicated yet). Contextual review citing trial

Melatonin (often 3 mg nightly; clinician‑directed)

• Migraine prevention RCT: melatonin 3 mg better than placebo and similar efficacy to amitriptyline 25 mg with better tolerability. PubMed
• Youth post‑concussion syndrome RCT (3 mg and 10 mg doses studied). Full text
• Neuroimaging correlates paper in pediatric PPCS. PubMed

Notes: can cause next‑day grogginess. If you’re driving early mornings, test on a weekend first.

CoQ10 (300 mg/day)

• Migraine RCT (100 mg three times daily) showed benefit vs placebo. Full text
• Systematic review/meta‑analysis on CoQ10 migraine prophylaxis. BMJ Open

Omega‑3s (EPA + DHA)

Omega‑3s are biologically plausible for brain inflammation/cell membrane support, but human concussion outcomes evidence is not settled. If you take them, do it with realistic expectations.

• Example clinical trial in concussion: ClinicalTrials.gov

Notes: if you’re on blood thinners or have bleeding issues, talk to your clinician first.

Choline / Citicoline (CDP‑choline)

This one is complicated. Smaller studies and some meta‑analyses suggest possible benefits, but large high‑quality trials in TBI have been mixed. If budget is tight, this is not my first spend.

• Citicoline systematic review & meta‑analysis (2017). PubMed

Butterbur (Petasites hybridus): not recommended anymore

Butterbur used to be recommended for migraine prevention (2012 AAN/AHS guideline), but the American Academy of Neurology stopped recommending it in 2015 due to serious liver toxicity concerns.

• NIH NCCIH summary (mentions AAN stopping recommendation in 2015). NCCIH
• American Headache Society: “Butterbur is no longer a recommended treatment for migraine.” AHS

Translation: even if it works for some people, the safety + product‑quality issues make it a hard pass for a public cheat sheet.

Supplement quality tip: choose third‑party tested brands when possible (USP/NSF/Informed Choice). Supplements can interact with meds—especially blood thinners, antidepressants, and seizure meds.

Evidence links (the short list)

• Amsterdam international concussion consensus statement (2023): BJSM | PubMed
• CDC concussion danger signs: CDC Heads Up
• Early exercise speeds recovery (adolescent RCT): PubMed
• Early exercise meta‑analysis (~4.6 days faster): PubMed
• Oral magnesium acute concussion trial: PubMed
• Vestibular rehab meta‑analysis: PubMed
• AHS white paper on post‑traumatic headache in youth: PubMed
• Butterbur safety: NCCIH

If any link breaks, search by the PubMed ID or article title—journals love moving URLs around.