Mild traumatic brain injury

Last updated: July 19, 2023

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Summarytoggle arrow icon

Mild traumatic brain injury (mTBI) is a trauma-induced disruption of brain function on the lowest end of the TBI severity spectrum, typically due to a fall, motor vehicle accident, or sports injury. Characteristic manifestations include a GCS ≥ 13–15, transient loss of consciousness, altered mental status at the time of injury, posttraumatic amnesia, and minor neurological abnormalities that do not require surgical intervention. Concussion, a term often used synonymously with mTBI, is difficult to define but typically refers to a heterogeneous subset of TBI with variable constellations of physical, cognitive, and neuropsychiatric features and variable recovery times. mTBI is primarily a clinical diagnosis. Neuroimaging is not routinely indicated, as it is frequently normal or reveals only minor findings that do not alter management. Clinical decision rules for neuroimaging should be used to identify patients at risk of intracranial lesions that require surgical intervention. Most patients with a reassuring clinical presentation can be treated as outpatients after a period of observation, while some benefit from hospital admission and monitoring. If at any point during the observation period the GCS deteriorates to < 13, the patient should be reclassified as moderate TBI or severe TBI and managed accordingly. The mainstay of treatment of mTBI is physical and cognitive rest until patients are completely asymptomatic, followed by a gradual return to activity. Most patients recover completely within 1–2 weeks and better outcomes are associated with early diagnosis and treatment adherence. Postconcussion syndrome is the most common complication, causing symptoms lasting for weeks to months that usually require multidisciplinary care and follow-up.

Athletes with a possible sports-related concussion should be immediately removed from play and assessed by a healthcare professional trained in evaluating these injuries. Sports-specific assessment tools such as the Sport Concussion Assessment Tool (SCAT) may be used. Patients should not be permitted to return to play on the day of injury.

See also “Traumatic brain injury” for information on moderate and severe TBI.

Definitiontoggle arrow icon


  • There is a lack of consensus on the ideal terminology used to describe this entity.
  • “Mild traumatic brain injury” (mTBI) is the preferred term of most specialists and guideline working groups , however, its precise definition remains debated. [2][3][4]
  • Significant controversy surrounds the use of the terms “concussion” and “minor head injury”, as they are even more elusive to define and lack specificity. [5]
    • Several authorities have proposed to retire these terms in favor of “mTBI”. [4][6]
    • Nevertheless, “concussion” remains widely used in the literature [5][7][8][9]
    • Many authors and institutions use “concussion” interchangeably with “mTBI” despite ambiguities and variability in their definitions. [10][11]


The working definitions provided here are based on the best available evidence and may change as this is an evolving area of research. [2][3][12][13]

  • Mild traumatic brain injury consists of a trauma-induced disruption of brain function associated with: [4]
  • Concussion: A heterogeneous subset of mTBI associated with complex pathophysiology, and variable clinical features and natural history [5][9]
    • Symptoms should not be better explained by other injuries , toxic exposures , or comorbidities . [9]
    • Typically associated with no visible abnormalities on standard neuroimaging (i.e., CT, MRI) [6][10]
    • Can be categorized into the following concussion subtypes: [8]
    • Can be associated with sleep disturbance and/or cervical strain [8]

Epidemiologytoggle arrow icon

  • Incidence: mTBI accounts for approx. 75–90% of the estimated 1.7–2.5 million annual TBI cases. [12][14][15][16]
  • Sex: > [16][17][18]
  • Age: more common in children 0–4 years, teenagers and young adults 15–24 years, and adults > 65 years [19]
  • Occupation: more common in athletes and military populations. [17][20]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

The pathophysiology of mTBI is complex and poorly understood. It is most likely an interplay of the following mechanisms of brain injury: [23]

Clinical featurestoggle arrow icon

  • Prerequisite: GCS ≥ 13–15
  • Variable onset, severity, and duration. [25][26]
  • Most common symptoms: confusion and amnesia
  • Can be associated with features of whiplash injury
Clinical features of mTBI
Domain Signs and symptoms
Behavioral (emotional)

Symptoms of mTBI may be transient or subtle and should be explicitly asked about to avoid missing the diagnosis. [24]

Loss of consciousness at the time of injury is not required for the diagnosis, and its absence does not rule out mTBI. [24]

Red flagstoggle arrow icon

The following features suggest a more serious brain injury (i.e., moderate or severe TBI) or associated complications (e.g., intracranial hemorrhage, elevated ICP) that require further evaluation (e.g., neuroimaging, laboratory studies). [28][29][30]

Initial management approachtoggle arrow icon

All patients with suspected mTBI with or without loss of consciousness should be evaluated as early as possible by a trained clinician. Patients with an initially high GCS score can deteriorate rapidly if there is a significant intracranial lesion. Initial management of mTBI should be performed with the same urgency as patients with moderate TBI or severe TBI until the patient is stable and shows neurological improvement. [10][24]

Primary survey

In stable patients with suspected mTBI and no obvious significant additional injuries, there typically is little need for intervention during the primary survey.

Patients who have a loss of consciousness > 30 minutes, posttraumatic amnesia > 24 hours, or evidence of intracranial hemorrhage on neuroimaging likely have a more severe brain injury (see ''Management of moderate or severe TBI'' for details).

Secondary survey

  • Detailed history
    • Obtain collateral information from witnesses.
    • Quantify mTBI symptom number and severity with a standardized assessment tool if appropriate.
      • Adults: Consider use of a tool (e.g., the Acute Concussion Evaluation). [38]
      • Children: Use of a tool is recommended (e.g., the Graded Symptom Checklist). [4][39]
    • Assess occupational risk (e.g., athletes, military personnel) of subsequent mTBI.
    • Identify lifestyle factors that may impact recovery (e.g., drug and alcohol consumption).
    • See also “Sport-related concussion.”
  • Physical examination
  • Monitoring
  • Further care and disposition: See "Treatment".

If at any point the GCS deteriorates below 13, reclassify the patient as moderate TBI (GCS 9–12) or severe TBI (GCS ≤ 8) and manage accordingly (see "Treatment of moderate or severe TBI" for details). [24]

Diagnosticstoggle arrow icon

Approach [10][24]

Indications for neuroimaging in mTBI

Various clinical decision rules (CDRs) have been developed to identify when neuroimaging is warranted in mTBI; the choice of CDR varies by institution and guidelines.


Although both of these CDRs have been validated for clinical use, the Canadian CT head rule is recommended. [41][42]

Adult clinical decision rules for neuroimaging in mTBI
CDR Criteria for neuroimaging: ≥ 1 of the following Inclusion criteria: all of the following

Canadian CT head rule (CCHR) [31][43]

New Orleans criteria [44]

The Canadian CT head rule is used for patients with an initial GCS of 13–15 with or without neurological deficits at presentation. The New Orleans criteria can only be used for patients with an initial GCS of 15 and no neurological deficits at presentation.

Alcohol and substance use alters the GCS score and neurological examination. Intoxication is considered a risk factor for traumatic intracranial lesion (according to the New Orleans Criteria). [24]

Children [45][46]

  • The Pediatric Emergency Care Applied Research Network (PECARN) blunt head-trauma prediction rule is typically the preferred pediatric CDR in US institutions. [45][47][48]
  • Inclusion criteria [45]
    • Children ≤ 24 hours after a nonpenetrating clinically relevant head trauma with a GCS ≥ 14
    • No known bleeding disorder or neurological disorder that would affect clinical assessment
Pediatric Emergency Care Applied Research Network (PECARN) blunt head-trauma prediction rule [45]
Criterion < 2 years 2–18 years
High-risk features Evidence of skull fracture
GCS = 14 or other signs of AMS
Intermediate-risk features Severe signs or symptoms
Severe mechanism of injury
  • Fall > 3 feet
  • Fall > 5 feet
  • Severe motor vehicle crash
  • Struck by a motor vehicle as a pedestrian
  • Head struck by high-impact object


  • Any high-risk feature: ∼ 4% risk of clinically important TBI; obtain CT head.
  • Any intermediate-risk feature: ∼ 1% risk of clinically important TBI; consider CT head or observation. [45][49]

Consider nonaccidental head trauma in children and infants. Perform a thorough history and examine for other signs of abuse. [50]

Neuroimaging modalities [24][51]

Laboratory studies [10][24]

Differential diagnosestoggle arrow icon

The following conditions may mimic mTBI (e.g., cause confusion and amnesia), but may also be the underlying precipitant of the injury that caused the mTBI. Careful clinical correlation and evaluation of the individual's pretest probability are recommended. [24]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Therapeutic measures for all patients [10][14][24][56][57]

After the initial management of mTBI, most patients only require rest and supportive therapy. See ''Special patient groups'' for additional considerations in patients on antithrombotic therapy.

Medications that can mask the symptoms of concussion (e.g., sedative-hypnotics) should be avoided. [25]

Disposition [10][11][24][57]

These criteria are not strict and clinical judgment and local resources should be considered for individual disposition decisions.

Outpatient treatmenttoggle arrow icon

Initial encounter [4][33][62]

Most patients with reassuring clinical features and either no neuroimaging (i.e., did not meet criteria for neuroimaging in mTBI) or normal neuroimaging can be managed safely as outpatients after an initial period of observation. [11]

Referrals [42][57]

  • Neurosurgical consultation is not routinely required.
  • Recommend follow-up with regular primary care provider within a few days.
  • Consider referral to a specialized multidisciplinary neurotrauma team for complex cases or patients with risk factors for postconcussion syndrome.

Patient counseling [4][33][62]

Provide written instructions regarding the following to the patient and caregivers.

  • Relative rest period: Limit physical and cognitive activities for a minimum of 24–48 hours. [33][62]
  • Resuming activity
    • Advise a stepwise and gradual return to regular physical and cognitive activity that is guided by symptoms.
    • Return to activity protocols may be used for certain patients (e.g., students, atheletes, military); for athletes, a full return to sports should take at least 1 week. [33][62][63]
  • Return precautions: Advise returning to seek care if any red flags for mTBI develop. [24]
  • Possible complications: Discuss the risk of complications such as postconcussion syndrome. [62]

Follow up [4][33][62]

  • Reassess regularly in the outpatient setting until symptoms resolve. [62]
  • Assess for ongoing symptoms; consider using symptom checklists.
  • Monitor progression through return to activity protocols, if relevant.
  • Consider additional workup if symptoms don't resolve within: [33]
    • 1–2 weeks for adults
    • 2–4 weeks for children
  • Persistent symptoms (typically, > 4 weeks): Consider referral to a specialized multidisciplinary neurotrauma team. [33][57][64]

Inpatient treatmenttoggle arrow icon

Short hospital admission is typically recommended for patients with disabling symptoms, high-risk injuries, or other patient and system factors that render outpatient management unsafe. [10]

  • Monitoring and referrals
  • Follow-up neuroimaging (e.g., in 8–24 hours) should be considered in the following situations: [65]
    • Any signs of neurological deterioration (or other red flags for mTBI) during observation period
    • Neurological findings unexplained by initial neuroimaging
    • Evidence of intracranial injury on initial neuroimaging [24][66][67]
  • Treatment of complications
    • Anticonvulsant therapy for posttraumatic seizures [24]
    • Management of traumatic intracranial lesions (see ''Treatment'' sections in “EDH”, “SDH”, “SAH”, “ICH”).

Follow-up neuroimaging is not routinely required for patients with normal findings on both neurological examination and initial neuroimaging.

Return to activity protocolstoggle arrow icon

General principles [58][62][64]

  • Return to activity protocols may be used for certain patients (e.g., students, athletes); see “Tips and Links” for the SCAT 6.
  • Protocols start with an initial period of relative rest.
  • If symptoms worsen with increased activity , slow the rate of progression through the protocol. [64]
  • Pediatric patients may proceed simultaneously through the different protocols but should fully return to school before fully returning to play.
  • See also “Tips and Links” for the SCAT6, which includes details on individualized protocols.

Return to school protocol [4][64][68]


  • If symptoms are exacerbated, reduce the pace of progression to the next step.
  • Accomodations to minimize symptoms may be needed, e.g.: [33][62]
    • Reduced workload
    • Extra time to complete tasks
    • Cognitive breaks
    • Supplemental written materials
    • Low-stimulatory environment

Order of steps

  1. Initial period of relative rest for 24–48 hours: daily cognitive activities as tolerated [64]
  2. School-specific activities at home
  3. Part-time return to school
  4. Full-time return to school

The return to play protocol can be followed at the same time as the return to school protocol, but individuals should have returned to school full-time before returning to sports full-time. [64]

Return to play protocol [64]

Full return to sports activities takes at least 1 week.


  • No more than one step should be completed per 24 hours.
  • Step 4 cannot be started until both of the following have occurred:
    • Complete resolution of all concussion-related signs and symptoms [7]
    • Medical clearance by a healthcare professional
  • If symptoms worsen
    • During steps 1–3: Stop activity until the next day.
    • During steps 4–6: Return to step 3.

Order of steps

  1. Initial period of relative rest for 24–48 hours: daily physical activities as tolerated [33]
  2. Light to moderate aerobic exercise
  3. Sport-specific exercise individually, with no risk of head impact [64]
  4. Non-contact sports drills within the team
  5. Full contact practice
  6. Full return to sports activities

A health care professional should be consulted before individuals with a sports-related concussion resume any activities that include a risk of fall, contact, or collision. [64]

Premature return to competitive sport may increase the risk of second-impact syndrome. [58]

Special patient groupstoggle arrow icon

Patients on antithrombotic therapy [10][24][69][70]

Management of mTBI in patients on anticoagulant and/or antiplatelet medication is a challenge due to the risk of immediate and delayed intracranial hemorrhage (DICH) . There is a paucity of evidence on the optimal management of these patients.

Patients with bleeding disorders [75]

Patients with inherited bleeding disorders, e.g., hemophilia, should receive:

Prognosistoggle arrow icon

  • Most (80–90%) patients make a full recovery within 1–2 weeks. [24][25]
  • Outcomes are improved with early diagnosis and adherence to treatment. [57]

Complicationstoggle arrow icon

Immediate complications [10][24][40]

  • Posttraumatic seizures: uncommon [24]
  • Intracranial bleeding (e.g., ICH, SDH): uncommon
    • Abnormalities on initial CT are seen in approx. 5% of mTBI patients with GCS of 15 and 30% of mTBI patients with GCS of 13.
    • < 1% of mTBI patients require neurosurgical intervention.

Postconcussion syndrome (PCS) [7][15][32][76][77]

  • Epidemiology: most common consequence of mTBI
  • Definition: clinical features of mild TBI that persist longer than expected, typically at least > 4 weeks post-injury [33][64][78]
  • Risk factors for postconcussion syndrome include: [42][79]
    • Female sex
    • Injury-related factors: assault as cause, acute intoxication
    • mTBI symptoms: loss of consciousness, GCS score < 15
    • History of anxiety, depression, or psychiatric symptoms
  • Diagnostics [80]
    • Diagnosis is primarily clinical.
    • Consider neuroimaging. [33]
    • Evaluate for other causes for symptoms. [33]
  • Treatment [59]
  • Prognosis: Most patients recover within 6 months.

Other delayed complications [24]

  • Second-impact syndrome (SIS)
    • A very rare, but potentially devastating brain injury precipitated by a second injury that occurs prior to complete healing from an initial mTBI. [9][81][82]
    • Postulated pathomechanism: reinjury to susceptible brain cells with incomplete recovery→ rapid development of diffuse cerebral edema→ ↑ ICPbrain herniationdeath. [83]
  • Chronic traumatic encephalopathy [24]
    • A condition of cumulative neuropsychologic symptoms attributed to repeated TBI (e.g., from sports-related mTBI, military trauma).
    • Seen more commonly in professional athletes engaging in contact sports (e.g., boxing, football, hockey)
  • Other neurodegenerative diseases (e.g., Alzheimer disease, Parkinson disease): Patients with mTBI have an increased long-term risk of developing these conditions. [24]

We list the most important complications. The selection is not exhaustive.

Sports-related concussiontoggle arrow icon

Definition [64]

A direct physical impact to the head, neck, or body that both:

  • Transmits an impulsive force to the brain, resulting in a traumatic brain injury
  • Occurs during a sports-related or exercise-related activity


  • Sports-related concussions account for ∼ 10% of all TBIs in the US. [84]
  • Significant underreporting may occur. [58]

Risk factors [7][58]

  • Competition settings (versus practice settings)
  • Younger ages (i.e., middle school versus high school)
  • High-impact sports

Initial management [7][9][58][64]

Follow these steps for any individual with possible sports-related concussion based on the presence of clinical features of mTBI.

Concussion assessment tools such as the SCAT6 cannot rule out a concussion and do not replace a full neurological examination. [58]

Athletes often downplay or ignore symptoms to be allowed to keep playing. [58]

Athletes with a suspected sports-related concussion should be removed from play and not permitted to return to play on the day of injury. [58][64]

Subsequent management [7][9][58][64]

Prevention [58][64]

  • Educate school-based professionals, parents, and athletes about signs, symptoms, and risks of concussion.
  • Recommend sport-specific protective gear (e.g., mouthgards for ice hockey players). [64]

Acute management checklisttoggle arrow icon

References: [10][24][87][88]

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