Do I need a CT scan after hitting my head?

Not routinely. The Canadian CT Head Rule identifies specific indications: GCS below 15 at two hours post-injury, suspected skull fracture or basal skull fracture signs, two or more vomiting episodes, age 65 or older, any anticoagulant use, dangerous mechanism (pedestrian struck, ejection from vehicle, fall over one metre or five stairs), or retrograde amnesia over 30 minutes. CT carries radiation and yields very little in uncomplicated concussion with none of these features. If any red flag is present, your GP will arrange emergency department transfer rather than ordering a scan in the clinic.

How long should I rest after a concussion?

For 24–48 hours only — after that, evidence supports gradual activity rather than extended rest. Prolonged time in a dark, quiet room delays recovery and can worsen mood and anxiety. Begin light walking and simple household tasks, staying below the point where symptoms significantly worsen. Reduce heavy cognitive load (work emails, intensive study, gaming) in the first day or two. From 48 hours, a graduated return-to-learn and return-to-sport protocol guides progressive re-engagement, ideally supervised by your GP or a sports medicine clinician.

When can I return to sport after a concussion?

Only after completing a six-stage graded return-to-sport protocol — each stage at least 24 hours — and after the minimum sport-specific stand-down period. In Australian community sport, AFL and rugby union require 12 days for adults and 21 days for under-19s; NRL requires 11 days for adults. Stage 5 (full-contact practice) requires written medical clearance. If symptoms return at any stage, drop back one step and reassess with your GP. Returning before clearing all stages risks a slower recovery or, in adolescents, the rare complication of second-impact syndrome.

What are persistent post-concussion symptoms and how are they treated?

Persistent post-concussion symptoms (PPCS) are concussion-related symptoms lasting more than four weeks, affecting roughly 10–30% of people. They cluster into recognisable phenotypes: vestibular or oculomotor (dizziness, visual tracking problems), post-traumatic headache (tension-type or migrainous), cervicogenic (neck-driven pain and dizziness), mood and sleep disturbance, and autonomic or exertion intolerance. Treatment targets each phenotype — vestibular physiotherapy, sub-symptom-threshold aerobic exercise, CBT, and headache-specific medication. Prolonged rest beyond 48 hours worsens rather than improves most phenotypes and is not recommended.

Can concussion cause long-term brain damage?

A single, well-managed concussion in a healthy adult does not typically cause permanent neurological damage. However, repeated concussions and cumulative subconcussive head impacts — common in contact sports such as AFL, NRL, and rugby union — are associated with chronic traumatic encephalopathy (CTE), a progressive tauopathy confirmed only at post-mortem. Australian neuropathological studies have identified CTE in retired Australian rules footballers and rugby league players. Individual risk is not currently quantifiable; the most protective measure is strict adherence to stand-down rules and prompt management of every concussion.

What medication helps with concussion?

No medication treats concussion itself — pharmacotherapy is symptom-targeted only. Paracetamol is first-line for headache in the first 48 hours; NSAIDs and aspirin are cautiously avoided initially due to theoretical haemorrhagic risk. For persistent post-traumatic migraine: triptans (PBS Authority Streamlined) or prophylaxis with amitriptyline, propranolol, or topiramate. For sleep disruption: melatonin (reasonable adjunct; PBS-listed for adults 55 and over). For mood or anxiety: SSRIs on standard PBS general benefit. For vestibular symptoms, vestibular physiotherapy produces far better outcomes than medication.

Concussion and mild traumatic brain injury

Concussion: graded return, red flags, and the Australian GP approach

By Dr HB Lo, FACRRM Reviewed 30 June 2026 12 min read

Concussion is a functional brain injury from direct or indirect head force — loss of consciousness occurs in fewer than 10% of cases and is not required for diagnosis. In general practice, the first step is screening for red flags needing CT and emergency department transfer.

Most people recover within 10–14 days with 24–48 hours of relative rest followed by graduated activity. Persistent post-concussion symptoms (PPCS) after four weeks affect 10–30% of people and respond best to active rehabilitation — aerobic exercise, vestibular physiotherapy, and sleep support — rather than prolonged rest.

What concussion is

Concussion is a trauma-induced disturbance of brain function — a clinical syndrome, not a structural or imaging diagnosis. The 2023 Amsterdam Consensus Statement on Concussion in Sport defines it as a traumatic brain injury caused by a direct or indirect force, resulting in transient neurological dysfunction. Loss of consciousness is not required for the diagnosis and occurs in fewer than 10% of cases.

In Australian general practice, concussion arrives by several routes: sport (AFL, NRL, rugby union, soccer, equestrian, cycling, combat sports, snow sports), motor vehicle collision, falls (especially in older adults and young children), and assault. Concussion in Sport Australia estimates more than 150,000 mild traumatic brain injuries occur in Australia annually; many never reach a clinician.

The underlying aetiology is a neurometabolic cascade — glutamate release, ionic flux across neuronal membranes, increased glycolysis with reduced oxidative metabolism, and mitochondrial dysfunction. This creates an energy crisis lasting hours to days, during which the brain is particularly vulnerable to a second injury. Standard CT and MRI are typically normal; diffusion tensor imaging reveals white-matter microstructural changes in research settings but has no current clinical role.

A. Core clinical — the AU general-practice framework

History

Structured history should cover: mechanism (direct or indirect blow, dangerous mechanism?); immediate symptoms (confusion, retrograde and post-traumatic amnesia duration, loss of consciousness duration, vomiting count, headache onset, balance, vision); current symptom domains (somatic, cognitive, emotional, sleep — see table below); prior concussion history (each prior event lowers the threshold for the next); comorbidities that modify recovery (pre-existing migraine, ADHD, mood disorder, sleep disorder, motion sickness); and functional impact (school, work, driving, sport participation).

Domain	Common symptoms
Somatic	Headache, nausea, dizziness, fatigue, photophobia, phonophobia, balance difficulty
Cognitive	Feeling “foggy”, slowed processing, poor concentration, confusion, amnesia
Emotional	Irritability, sadness, anxiety, emotional lability
Sleep	Insomnia, hypersomnia, drowsiness, vivid dreams

Red flags requiring urgent transfer

The Canadian CT Head Rule and NICE NG232, both endorsed by the Amsterdam Consensus, identify the following as indications for CT and emergency department assessment:

GCS below 15 at two hours post-injury
Suspected open or depressed skull fracture, or signs of basal skull fracture (haemotympanum, raccoon eyes, Battle’s sign, CSF rhinorrhoea or otorrhoea)
Two or more vomiting episodes
Age 65 or older
Any anticoagulant or antiplatelet use (single antiplatelet in older adults warrants a low threshold)
Dangerous mechanism: pedestrian struck by vehicle, ejection from vehicle, fall over one metre or five stairs
Retrograde amnesia lasting more than 30 minutes
Seizure post-injury
Focal neurological deficit or deteriorating conscious state
Suspected non-accidental injury in a child

When any of these is present, arrange emergency department transfer; do not organise CT in general practice and delay transfer.

Examination

A structured examination includes:

Neurological — Glasgow Coma Scale, cranial nerves, pronator drift, reflexes, sensation; serial GCS if any concern about deterioration
Balance — modified Balance Error Scoring System (mBESS) or tandem gait; these provide reproducible markers for serial monitoring
Oculomotor — smooth pursuit, saccades, near-point convergence; oculomotor dysfunction is a modifiable and treatable PPCS phenotype
Cervical spine — palpation, range of motion, symptom reproduction with cervical movement; cervicogenic contribution is common and underdiagnosed
Cognitive screen — orientation, immediate and delayed recall (the SCAT6 standardises this for athletes 13 and over; the Child SCAT6 covers 5–12 years)

Initial management — the 24–48 hour window

Relative rest for 24–48 hours — light activities, reduced cognitive load, adequate sleep. Strict “cocooning” in a dark, silent room is no longer recommended and delays recovery.
Analgesia: paracetamol first-line for headache. NSAIDs and aspirin are cautiously avoided in the first 48 hours — theoretical haemorrhagic risk, though increasingly debated in mild injury.
No alcohol, recreational drugs, or sedatives during the acute phase.
Driving: avoid for at least 24 hours and for longer while symptomatic — cognitive slowing, reaction time impairment, and fatigue all impair driving safety.
Written information — patients cannot reliably retain verbal advice following head injury. Brain Injury Australia and Concussion in Sport Australia both provide downloadable consumer fact sheets.
Follow-up in 24–72 hours: monitor for deterioration, evolving symptoms, or red-flag emergence. Delayed haemorrhage is rare but possible, particularly in anticoagulated older adults.

B. Evidence appraisal — graded return, not prolonged rest

Graded return-to-learn

Graduated cognitive re-exposure — not a binary return — is the consensus standard. Progress through each stage only when the previous stage is tolerated without significant symptom exacerbation:

Stage	Activity
1	Light activities at home; brief reading; screen breaks
2	School or work in short sessions with frequent rest
3	Half-days with modified workload
4	Full days with gradual load increase
5	Full school or work attendance plus extracurricular activity

Allow at least one day per stage. A GP letter describing the graduated return plan is typically needed for schools and employers, who may otherwise insist on full return or full exclusion.

Graded return-to-sport

The Amsterdam 2023 Consensus specifies six stages, each requiring a minimum of 24 hours and symptom-free progression before advancing:

Stage	Activity
1	Symptom-limited daily activity
2	Light aerobic exercise — walking, stationary cycling at ≤70% maximum heart rate
3	Sport-specific exercise without head-impact risk
4	Non-contact training drills
5	Full-contact practice after written medical clearance
6	Return to play

If symptoms recur at any stage, drop back one step and reassess. Returning to full-contact play before clearing stage 6 risks a prolonged recovery or, in adolescents particularly, the rare but serious second-impact syndrome — catastrophic cerebral oedema from sustaining a second concussion before the first has resolved.

Australian sport-specific minimum stand-down periods

These represent the minimum days before return to full contact — the graded protocol still applies on top of them:

Sport	Adults	Under-19s
AFL community	12 days	21 days
NRL community	11 days	21 days
Rugby Union (World Rugby protocol)	12 days	21 days
Soccer / Football Australia	Per Concussion in Sport Australia guidance	14 days minimum

Stand-down applies regardless of how quickly symptoms resolve. Written medical clearance is required before stage-5 full-contact practice.

Evidence for active rehabilitation

Leddy et al. (JAMA Paediatrics, 2019) demonstrated in an RCT that sub-symptom-threshold aerobic exercise — the Buffalo Concussion Treadmill Test (BCTT) protocol — accelerated recovery in adolescents with sport-related concussion compared with stretching placebo. This shifted practice firmly away from extended rest toward early, titrated aerobic activity for PPCS.

Sports Medicine Australia and the Amsterdam Consensus both endorse sub-symptom-threshold aerobic exercise as the main active treatment for PPCS, supported by RCT data and as a recovery-accelerating strategy in uncomplicated concussion beyond 48 hours. The threshold-based principle is key: the exercise should be below the intensity that triggers significant symptom flare.

C. Persistent post-concussion symptoms (PPCS)

PPCS is defined as concussion-related symptoms persisting beyond four weeks in adults (some guidelines use 10–14 days in adolescents). It affects approximately 10–30% of people after concussion. The framing of PPCS as having recognisable, treatable clinical phenotypes — rather than as a fixed, inevitable outcome — is the key contemporary advance.

Clinical phenotypes and targeted treatment

Phenotype	Features	Treatment
Vestibular / oculomotor	Dizziness, imbalance, convergence insufficiency, saccadic dysfunction	Vestibular and oculomotor physiotherapy
Post-traumatic headache	Tension-type or migrainous pattern; often cervicogenic component	Headache-specific pharmacotherapy; cervical physio
Cervicogenic	Neck pain, stiffness, dizziness reproduced by cervical movement	Cervical spine physiotherapy, manual therapy
Mood / anxiety / sleep	Irritability, depression, anxiety, insomnia	CBT, SSRIs, sleep restoration strategies
Autonomic / exertion intolerance	Symptom exacerbation with physical or cognitive load	Graded aerobic exercise (BCTT protocol)
Cognitive	Slowed processing, memory difficulty, fatigue with mental effort	Cognitive pacing, OT, gradual load increase

Risk factors for PPCS: prior concussion, pre-existing migraine, ADHD or learning difficulty, mood or anxiety disorder, female sex (particularly in adolescent sport cohorts), motion sickness history, high initial symptom burden, and slow early recovery.

When to refer for PPCS

Refer to a concussion clinic or sports medicine physician at four weeks without clear recovery (or two weeks in children and adolescents). The multidisciplinary PPCS team typically includes a sports physician or neurologist, vestibular physiotherapist, psychologist, occupational therapist (cognitive rehabilitation), and exercise physiologist.

D. Australian operations

MBS item numbers

All items verified via MBS Online:

GP consultations: standard attendance items 23, 36, 44.
Mental Health Treatment Plan (PPCS with mood or anxiety symptoms): item 2715 (preparation) and 2717 (review); enables referral to a psychologist for up to 10 subsidised sessions per year under the Better Access Initiative.
Chronic Disease Management plan (complex PPCS affecting multiple domains of function): items 721 (plan preparation) and 723 (review); allows referral to up to five allied health sessions annually — physiotherapy, OT, exercise physiology, psychology.
Health Assessment for adults 75 and over (item 705): applicable for older adults presenting after a fall with head injury.
Neurologist referral: item 110 (initial), 116 (subsequent).
CT brain (usually ED-initiated): items 56001/56007.
MRI brain (specialist-requested for persistent or atypical symptoms): item 63507.
Telehealth: most standard GP items have telehealth equivalents — useful for monitoring regional and remote patients during the graduated return.

PBS-listed pharmacotherapy

Per the Pharmaceutical Benefits Scheme and eTG:

Paracetamol — over-the-counter; PBS-listed in standard formulations for concession cardholders.
Triptans for post-traumatic migraine: PBS Authority Required (Streamlined) — sumatriptan, zolmitriptan, eletriptan.
Amitriptyline (tension-type headache prophylaxis / off-label sleep aid) — PBS general benefit.
Propranolol (migraine prophylaxis) — PBS general benefit.
Topiramate (migraine prophylaxis) — PBS Authority Required.
Prolonged-release melatonin (Circadin 2 mg) — PBS Authority for adults 55 and over, short-term insomnia; reasonable off-label use in younger adults with post-concussion sleep disruption (private prescription).
SSRIs (sertraline, escitalopram) for post-concussion mood disorder and anxiety — PBS general benefit.
Metoclopramide or prochlorperazine for acute nausea — PBS general benefit; avoid prolonged use.

Insurance, compensation, and medico-legal documentation

Workers compensation (state-based): applies to work-related head injury; return-to-work capacity certificates and functional reports.
Compulsory Third Party (CTP): motor vehicle injury; thorough functional documentation is important.
NDIS: persistent disability following moderate-to-severe TBI; functional capacity assessment required.
DVA: military concussion and TBI (use DVA Gold or White Card pathways).

Thorough contemporaneous documentation — mechanism, symptom severity, GCS, functional limitations, return-to-work timing, assessment findings — is essential in cases that may involve medico-legal review or compensation claims.

Driving (Austroads 2022)

Avoid driving for at least 24 hours post-concussion, and longer while symptomatic — cognitive slowing, reaction time impairment, fatigue, and visual disturbance all affect driving safety. Heavy-vehicle and commercial drivers have stricter requirements and may require an occupational therapy driving assessment following PPCS.

E. Special populations

Children and adolescents. Recovery is often slower than in adults. The Child SCAT6 applies for ages 5–12. The paediatric minimum stand-down is 21 days across major Australian codes. Schools require a written GP letter before the child returns to learning and contact sport. Pre-existing ADHD, learning difficulty, or anxiety substantially increases PPCS risk — proactive management from the outset supports better outcomes.

Older adults. Falls are the dominant mechanism in adults 65 and over. Age itself is a Canadian CT Head Rule criterion, so CT should be performed more readily. Anticoagulation (warfarin, direct oral anticoagulants) substantially increases haemorrhagic risk; the threshold for emergency department transfer should be low and a 48-hour reassessment is essential. Chronic subdural haematoma can develop over days to weeks and present subtly with confusion, persistent headache, or gait disturbance — a sustained index of suspicion is appropriate in any older adult with head trauma.

People on anticoagulants or antiplatelet therapy. Any head trauma in this group warrants a low imaging threshold. Discuss anticoagulant management with the prescriber if haemorrhage is confirmed or strongly suspected. Do not routinely withhold anticoagulants without specialist advice in patients with established indications such as atrial fibrillation.

Women and girls. Adolescent females show higher reported PPCS rates and longer recovery duration in sport cohort studies. Hormonal variation across the menstrual cycle is under active investigation as a recovery modifier. Current stand-down and graded return-to-play protocols are not differentiated by sex; awareness of this difference supports closer monitoring and earlier referral in female adolescent athletes.

Return-to-work in cognitively demanding roles. A staged cognitive-load return mirrors the sport graded protocol. A written GP plan describing the return schedule with specific restrictions (e.g., no client-facing work or deadline-driven tasks initially) is often required by employers and occupational health departments.

When to escalate

Refer or escalate when:

Any red flag is present at any time → emergency department transfer; do not delay for imaging in general practice.
LOC greater than 30 seconds, post-traumatic amnesia beyond 24 hours, or GCS persistently below 15 → moderate-to-severe TBI pathway; neurosurgical or emergency department assessment.
Post-traumatic seizure (distinct from brief LOC-related unresponsiveness) → neurology assessment.
Focal neurological deficit at any time point → CT and specialist review.
No meaningful improvement at two weeks in a child or adolescent, or four weeks in an adult → concussion clinic or sports medicine physician.
PPCS not improving despite targeted physiotherapy, CBT, and appropriate pharmacotherapy → multidisciplinary brain injury rehabilitation service.
Severe, worsening, or new neurological symptoms at any stage → re-evaluate; CT or MRI via specialist if no prior imaging.
Severe or deteriorating mood, or suicidal ideation → mental health crisis pathway; Lifeline 13 11 14, Beyond Blue 1300 22 4636, emergency department.
Suspected non-accidental injury in a child → mandatory notification, social work, and safeguarding pathway.

What this article is and is not

This is general health information drawn from current Australian general practice and sports medicine sources — Therapeutic Guidelines (eTG), RACGP, Concussion in Sport Australia 2024 Position Statement, Sports Medicine Australia, and the 2023 Amsterdam Consensus Statement on Concussion in Sport. It is not personal medical advice and does not create a doctor–patient relationship. Sport-specific stand-down periods and return-to-play decisions involve individual clinical assessment by a registered practitioner; the protocol here is a framework, not a substitute for that assessment.

For consumer-friendly information: HealthDirect — Concussion, Better Health Channel, Brain Injury Australia, Concussion in Sport Australia.

For acute mental-health crisis: Lifeline 13 11 14.

Sources cited

Frequently asked questions

Do I need a CT scan after hitting my head?

Not routinely. The Canadian CT Head Rule identifies specific indications: GCS below 15 at two hours post-injury, suspected skull fracture or basal skull fracture signs, two or more vomiting episodes, age 65 or older, any anticoagulant use, dangerous mechanism (pedestrian struck, ejection from vehicle, fall over one metre or five stairs), or retrograde amnesia over 30 minutes. CT carries radiation and yields very little in uncomplicated concussion with none of these features. If any red flag is present, your GP will arrange emergency department transfer rather than ordering a scan in the clinic.
How long should I rest after a concussion?

For 24–48 hours only — after that, evidence supports gradual activity rather than extended rest. Prolonged time in a dark, quiet room delays recovery and can worsen mood and anxiety. Begin light walking and simple household tasks, staying below the point where symptoms significantly worsen. Reduce heavy cognitive load (work emails, intensive study, gaming) in the first day or two. From 48 hours, a graduated return-to-learn and return-to-sport protocol guides progressive re-engagement, ideally supervised by your GP or a sports medicine clinician.
When can I return to sport after a concussion?

Only after completing a six-stage graded return-to-sport protocol — each stage at least 24 hours — and after the minimum sport-specific stand-down period. In Australian community sport, AFL and rugby union require 12 days for adults and 21 days for under-19s; NRL requires 11 days for adults. Stage 5 (full-contact practice) requires written medical clearance. If symptoms return at any stage, drop back one step and reassess with your GP. Returning before clearing all stages risks a slower recovery or, in adolescents, the rare complication of second-impact syndrome.
What are persistent post-concussion symptoms and how are they treated?

Persistent post-concussion symptoms (PPCS) are concussion-related symptoms lasting more than four weeks, affecting roughly 10–30% of people. They cluster into recognisable phenotypes: vestibular or oculomotor (dizziness, visual tracking problems), post-traumatic headache (tension-type or migrainous), cervicogenic (neck-driven pain and dizziness), mood and sleep disturbance, and autonomic or exertion intolerance. Treatment targets each phenotype — vestibular physiotherapy, sub-symptom-threshold aerobic exercise, CBT, and headache-specific medication. Prolonged rest beyond 48 hours worsens rather than improves most phenotypes and is not recommended.
Can concussion cause long-term brain damage?

A single, well-managed concussion in a healthy adult does not typically cause permanent neurological damage. However, repeated concussions and cumulative subconcussive head impacts — common in contact sports such as AFL, NRL, and rugby union — are associated with chronic traumatic encephalopathy (CTE), a progressive tauopathy confirmed only at post-mortem. Australian neuropathological studies have identified CTE in retired Australian rules footballers and rugby league players. Individual risk is not currently quantifiable; the most protective measure is strict adherence to stand-down rules and prompt management of every concussion.
What medication helps with concussion?

No medication treats concussion itself — pharmacotherapy is symptom-targeted only. Paracetamol is first-line for headache in the first 48 hours; NSAIDs and aspirin are cautiously avoided initially due to theoretical haemorrhagic risk. For persistent post-traumatic migraine: triptans (PBS Authority Streamlined) or prophylaxis with amitriptyline, propranolol, or topiramate. For sleep disruption: melatonin (reasonable adjunct; PBS-listed for adults 55 and over). For mood or anxiety: SSRIs on standard PBS general benefit. For vestibular symptoms, vestibular physiotherapy produces far better outcomes than medication.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.