Return-to-Play After Concussion in a 16-Year-Old With a History of Migraine
A 16-year-old soccer player sustains a head-to-head collision during a header duel. She has no loss of consciousness, but she is slow to get up, has a headache, and is unsteady. She is removed from play and evaluated. On the sideline, her SCAT6 symptom score is 28 (baseline unknown), she has convergence insufficiency and impaired tandem gait. She has a history of migraine with aura and had a concussion 14 months ago with resolution in 3 weeks. She is a high-performing student with final exams in 5 days and is being recruited by colleges. She wants to play in a tournament in 10 days.
1. How do you manage the first 48–72 hours, and how does her migraine history change your approach?
Read the worked answer
First 48–72 hours:
- Remove from play for the day (no same-day return), and do not let her return even if symptoms resolve.
- Relative rest, not prolonged darkness. Current consensus favors 24–48 hours of reduced physical and cognitive activity, followed by gradual, sub-symptom-threshold aerobic activity (e.g., walking or stationary cycling at a heart rate that does not provoke symptoms). Strict prolonged rest and screen blackout are no longer recommended and can prolong recovery.
- Symptom-guided cognitive pacing - she has final exams in 5 days. Coordinate with the school for academic accommodations (extended time, reduced workload, rest breaks, postponement of high-stakes testing if needed).
- Sleep hygiene and hydration; avoid alcohol and unnecessary screens late at night.
- Do not use aspirin or NSAIDs for the first 24–48 hours given the theoretical bleeding risk; acetaminophen is preferred early. Limit analgesic use to avoid medication-overuse headache.
How migraine history changes things:
- Migraine is a risk factor for prolonged recovery and for post-traumatic migraine, and her symptoms may be amplified by her migraine biology. This argues for earlier involvement of a headache specialist and for treating a post-traumatic migraine phenotype (e.g., with a triptan or migraine-directed therapy) rather than assuming all symptoms are concussion.
- It does not mandate a longer mandatory exclusion, but it lowers the threshold for a slower, more individualized return-to-learn and return-to-sport progression.
- Her prior concussion resolved in 3 weeks, which is somewhat reassuring, but recurrent concussion and a migraine history both warrant closer follow-up.
2. She is symptom-free at rest by day 7. Walk through the return-to-learn and return-to-sport progression and address the 10-day tournament.
Read the worked answer
Return to learn before return to sport. She should be back to full academic function (or with accommodations) before full sport. A stepwise progression:
- Full days of school with accommodations as needed.
- If symptoms recur with cognitive load, back off a step and re-advance.
Return-to-sport progression (each step ~24 hours, only if asymptomatic):
- Light aerobic activity (walking/cycling) - symptom-free.
- Sport-specific drills without contact.
- Non-contact training with resistance.
- Full-contact practice after medical clearance.
- Full game play.
The 10-day tournament: She is symptom-free at rest on day 7, but she has not yet completed the graded exertion and contact steps. It is unlikely she can be cleared for full contact by day 10 - she would need to be asymptomatic through step 3 and cleared before step 4, and the tournament involves headers and collisions. The appropriate answer is that return is conditional on completing the progression without symptom recurrence, and she should be counseled that the timeline is not guaranteed. Do not promise a date.
Additional considerations:
- Recruitment pressure is not a medical indication - address it directly and document the discussion.
- Prevention: discuss header technique and rule limits on heading in youth soccer, and consider whether the collision was avoidable.
- Persistent symptoms beyond 4 weeks warrant a multidisciplinary evaluation (vestibular/ocular therapy, cervicogenic contributors, mood/sleep).
- Second-impact syndrome is rare but catastrophic; she must not return while symptomatic.