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Concussion Symptomatology

Original Editor - Ewa Jaraczewska based on the course by Megyn Robertson

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Concussion involves a direct or indirect trauma to the head that sets off a neurometabolic cascade.[1] Concussion can produce symptoms across five key domains, and these symptoms vary considerably between patients; two people with a similar mechanism of injury can present very differently.[1] Recognising which domains are involved, and to what degree, informs prognosis, referral, and treatment priorities.

Concussion Symptoms

Concussion symptoms can be grouped into five key domains:[2]

  • cognitive
  • emotional/mood
  • sleep and fatigue
  • physical (somatosensory)
  • autonomic (dysautonomia)

The number of domains involved tends to correlate with recovery time. A patient with symptoms across more domains generally has a longer recovery time.[2]

Domain 1: Cognitive Symptoms

Concussion can interfere with the brain's processing speed, executive function, and memory.[3] Managing cognitive symptoms is beyond the scope of physiotherapy, but physiotherapists can play a role in symptom recognition. For instance, the patient might report difficulty finding words, being easily distracted, poor memory, or struggling to shift attention between tasks. Physiotherapists should take note of these symptoms and refer on to a neuropsychologist or neuropsychiatrist where necessary.[2]

One aspect of cognitive function the physiotherapist can assess directly is reaction time.[4] Impaired reaction time is one of the most sensitive indicators of neurocognitive change in patients with concussion.[5] Research by Coenen et al. and Lau et al. indicates that reaction time has prognostic value in predicting recovery time.[6][7] Impaired reaction time often parallels the overall symptom burden. However, in some patients, reaction time can remain measurably impaired even after they report being symptom-free.[8] This has implications for return-to-activity decisions.

Domain 2: Emotional Symptoms

Following a concussion, patients may experience a range of emotional symptoms, including irritability, frustration, tearfulness, agitation, anxiety, or depression.[9] These changes have a possible neurobiological basis.

In relation to anxiety, concussion triggers stress-induced changes in the immune system that drive neuroinflammation. The resulting brain changes have been proposed as a neurobiological substrate for anxiety.[10]

In relation to depression, advanced neuroimaging after concussion shows alterations in the limbic-frontal circuitry that resemble those seen in major depression.[11] [12] At a neurochemical level, mood disorders and concussion share disruptions, such as serotonin imbalance and reduced dopamine in the prefrontal cortex and brainstem.[13]

Patients with pre-existing mental health conditions are more likely to experience mood and anxiety symptoms after concussion.[2]

While assessing and diagnosing these conditions is beyond the scope of physiotherapy, physiotherapists can screen for symptoms, using tools such as the Generalised Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9), and should refer on to a neuropsychologist or neuropsychiatrist where indicated.[14]

Domain 3: Sleep and Fatigue

Post-concussion sleep disturbance can present as insomnia, hypersomnia, obstructive sleep apnoea, or a disrupted sleep-wake cycle.[15] It is highly prevalent across all ages, with more than 50% of patients reporting sleep disturbance following concussion.[16][17] Sleep disturbances are associated with an increased recovery time and are predictive of a persistent symptom burden.[18] Both concussion and poor sleep each independently impair cognition, reaction time, balance, proprioception, autonomic function, and mood.[17][19] Clinicians should, therefore, routinely screen for sleep issues using validated tools like the Athlete Sleep Screening Questionnaire (ASSQ),[20][21] and provide practical sleep hygiene guidance early.[17][19]

Domain 4: Physical (Somatosensory) Symptoms

Physical symptoms of concussion are wide-ranging and include headache, dizziness, nausea, neck pain, and sensitivity to light and noise.[22][23] Many of these arise from the brain injury itself, though the cervical spine and vestibular system are important and often overlooked contributors that warrant assessment.[22][24]

Neck Involvement

Whiplash and concussion frequently coexist: the impact and acceleration–deceleration forces that cause a concussion commonly load the cervical spine as well.[25] Because the symptoms and mechanisms of these two conditions often overlap, and neither has a gold-standard diagnostic test, neck assessment should be routine even when the patient does not report neck pain. Physiotherapists should assess range of motion, midline positioning sense, strength, endurance, power and pain levels.[24][2]

Headache

Headache is a significant predictor of poorer attention and executive function, and a recognised risk factor for persistent post-concussion symptoms. The most common form is post-traumatic headache, which occurs in up to 95% of patients. Post-traumatic headache often has migraine-like features, such as light or sound sensitivity, throbbing pain, and nausea. The development and persistence of post-traumatic headache are thought to relate more to neuroinflammation and trigeminal system activation than to the concussion mechanism itself.[26] Other headache types can occur after concussion, including cervicogenic headache, where the neck is the direct source, or tension-type headache, where the neck aggravates rather than causes the pain.[2]

Tinnitus

Tinnitus (ringing or buzzing in the ears) is a common auditory symptom after brain injury, including concussion.[27][28][29] It may stem from inner ear damage, nerve damage, or disrupted auditory processing in the brain, and often appears alongside dizziness and sound sensitivity.[2]

Dizziness

Dizziness is an umbrella term. Patients may describe spinning, unsteadiness, or lightheadedness, and these descriptions can point to different mechanisms. Vertigo, particularly benign paroxysmal positional vertigo (BPPV), is a common cause of dizziness. Dizziness can also have a cervicogenic, psychogenic, or central origin, or it can signal postural orthostatic tachycardia syndrome (POTS), a form of dysautonomia discussed in Domain 5.[2][30]

BPPV occurs in up to 30% of patients after concussion, and is frequently missed. The Dix-Hallpike test is used to evaluate for BPPV. A positive test is indicated by vertigo and nystagmus; if neither occurs, the test is negative. Bedside repositioning manoeuvres, such as the Epley manoeuvre, are commonly used to treat BPPV. Where BPPV is identified, it should generally be treated as a priority, since patients are unlikely to tolerate or integrate other rehabilitation (vestibular, cognitive, or exertional) until it is resolved.[2]

Domain 5: Dysautonomia

Dysautonomia, or a dysregulation of the autonomic nervous system, is present in an estimated 10–15% of patients post-concussion. It is hypothesised to be caused by a failure or overactivity of the sympathetic and parasympathetic nervous systems.[31]

Concussion or whiplash can shift the neurocardiac axis toward sympathetic dominance, producing an elevated heart rate and impaired blood pressure regulation. POTS is a recognised form of dysautonomia, characterised by an increase in heart rate of more than 30 beats per minute (bpm) in adults (or 40 bpm in adolescents) within 10 minutes of standing. New-onset POTS occurs in an estimated 7–11% of patients with concussion. Other signs of dysautonomia include exercise or exertion intolerance (exertional dysautonomia), abnormal heart rate variability, headache, mood changes, sleep disturbance, and cognitive impairment.[2] Because symptoms of dysautonomia overlap with other signs of concussion, careful, structured questioning is needed to identify it as the source.[2]

Physiotherapy Assessment and Referrals by Domain

When assessing a patient with concussion, the physiotherapist should work through the five domains systematically.

Physiotherapy Role and Referral by Domain
Domain Physiotherapy Role Need for Referral
Cognitive Identify signs of cognitive impairment; assess clinical reaction time Neuropsychology referral for cognitive symptoms not resolving in step with recovery (e.g. memory, word-finding, attention)
Emotional Screen with GAD-7/PHQ-9 Neuropsychology/neuropsychiatry referral for suspected mood or anxiety disorder
Sleep and fatigue Screen with ASSQ and give sleep hygiene guidance Sleep specialist referral for persistent or severe sleep disturbance
Physical Assess neck, headache pattern, dizziness type, tinnitus, etc ENT/audiology referral for BPPV, tinnitus, or unresolved vestibular concerns; medical review for persistent headache
Autonomic Monitor heart rate response to position/exertion Refer for medical work-up for suspected POTS/dysautonomia

Summary

Concussion can cause a range of cognitive, mood, sleep, physical and autonomic symptoms. Recognising which domains are involved, and to what degree, guides referral, prognosis, and the order in which problems are addressed in rehabilitation.

Resources

References

  1. ↑ 1.0 1.1 Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014 Oct;75 Suppl 4(0 4):S24-33.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Robertson M. Concussion Symptomatology Course. Physiopedia Plus, 2026.
  3. ↑ Collins LK, Ofa SA, Miskimin C, Mulcahey M. Cognitive deficits following concussion: A systematic review. Journal of Orthopaedic Experience & Innovation. 2023 Jun 1;4(1).
  4. ↑ Barnes A, Smulligan K, Wingerson MJ, Little C, Lugade V, Wilson JC, Howell DR. A Multifaceted Approach to Interpreting Reaction Time Deficits After Adolescent Concussion. J Athl Train. 2024 Feb 1;59(2):145-152.
  5. ↑ Ray T, Fleming D, Le D, Faherty M, Killelea C, Bytomski J, Ray T, Lemak L, Martinez C, Bergeron MF, Sell T. Effect of concussion on reaction time and neurocognitive factors: implications for subsequent lower extremity injury. International journal of sports physical therapy. 2022 Aug 1;17(5):816.
  6. ↑ Coenen J, Henckert S, Lausberg H, Helmich I. Post-concussion symptoms and clinical reaction time performance of athletes with a history of concussion. J Sports Med Phys Fitness. 2022 Oct;62(10):1391-1396.
  7. ↑ Lau B, Lovell MR, Collins MW, Pardini J. Neurocognitive and symptom predictors of recovery in high school athletes. Clin J Sport Med. 2009 May;19(3):216-21.
  8. ↑ Lempke LB, Lynall RC, Hoffman NL, Devos H, Schmidt JD. Slowed driving-reaction time following concussion-symptom resolution. J Sport Health Sci. 2021 Mar;10(2):145-153.
  9. ↑ Riggio S, Jagoda A. Concussion and its neurobehavioural sequelae. International review of psychiatry. 2016 Nov 1;28(6):579-86.
  10. ↑ Won E, Kim YK. Neuroinflammation-associated alterations of the brain as potential neural biomarkers in anxiety disorders. International Journal of Molecular Sciences. 2020 Sep 7;21(18):6546.
  11. ↑ Mirza M, Ahmed Z. Role of task-based functional MRI in the assessment of sports-related concussion: a systematic review. Frontiers in Neurology. 2026 Mar 13;17:1720290.
  12. ↑ Chen JK, Johnston KM, Petrides M, Ptito A. Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion symptoms. Archives of general psychiatry. 2008 Jan 1;65(1):81-9.
  13. ↑ Sami S. Psychological Predictors of Sport-Related Concussion Symptoms-The Role of Emotion Regulation. Master's thesis, University of Windsor, Ontario, Canada. 2025
  14. ↑ Faro A, Tejada J, Al-Delaimy W. Severity Classification of Anxiety and Depression Using Generalised Anxiety Disorder Scale and Patient Health Questionnaire: National Cross-Sectional Study Applying Classification and Regression Tree Models. JMIR Public Health and Surveillance. 2025 Sep 30;11:e72591.
  15. ↑ Viola-Saltzman M, Musleh C. Traumatic brain injury-induced sleep disorders. Neuropsychiatr Dis Treat. 2016 Feb 15;12:339-48.
  16. ↑ Djukic S, Phillips NL, Lah S. Sleep outcomes in pediatric mild traumatic brain injury: a systematic review and meta-analysis of prevalence and contributing factors. Brain Injury. 2022 Dec 6;36(12-14):1289-322.
  17. ↑ 17.0 17.1 17.2 Australian and Aotearoa New Zealand Concussion Guidelines Development Group. Australian and Aotearoa New Zealand Clinical Practice Guideline for Mild Traumatic Brain Injury and Persisting Post-Concussion Symptoms. Brisbane: The University of Queensland, Centre for Children's Health Research; 2026. Sleep disturbance and fatigue. Available from: https://anzconcussionguidelines.com/[accessed 14 August 2026].
  18. ↑ Wilkes J, Fedonni D, Cottone J, Arbogast KB, Master CL. Sleep disturbance after pediatric and adolescent concussion. Front Sleep. 2025 Mar 20;4:1528458.
  19. ↑ 19.0 19.1 Smulligan KL, Wingerson MJ, Little CC, Wilson JC, Howell DR. Early physical activity after concussion is associated with sleep quality but not dizziness among adolescent athletes. J Sci Med Sport. 2023 Mar;26(3):183-188.
  20. ↑ Samuels C, James L, Lawson D, Meeuwisse W. The Athlete Sleep Screening Questionnaire: a new tool for assessing and managing sleep in elite athletes. Br J Sports Med. 2016 Apr;50(7):418-22.
  21. ↑ Bender AM, Lawson D, Werthner P, Samuels CH. The Clinical Validation of the Athlete Sleep Screening Questionnaire: an Instrument to Identify Athletes that Need Further Sleep Assessment. Sports Med Open. 2018 Jun 4;4(1):23.
  22. ↑ 22.0 22.1 Harmon KG, Clugston JR, Dec K, Hainline B, Herring S, Kane SF, et al. American Medical Society for Sports Medicine position statement on concussion in sport. British Journal of Sports Medicine 2019;53:213-225.
  23. ↑ Treleaven J. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. Journal of orthopaedic & sports physical therapy. 2017 Jul;47(7):492-502.
  24. ↑ 24.0 24.1 Kinney AET, Richmond SLK, Mizner RL. Cervical spine sensorimotor deficits persist in people post-concussion despite minimal symptoms. Ann Med. 2024 Dec;56(1):2422048.
  25. ↑ Rebbeck T, Evans K, Elliott JM. Concussion in combination with whiplash-associated disorder may be missed in primary care: key recommendations for assessment and management. journal of orthopaedic & sports physical therapy. 2019 Nov;49(11):819-28.
  26. ↑ Mavroudis I, Ciobica A, Luca AC, Balmus IM. Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies. J Clin Med. 2023 Jun 23;12(13):4233.
  27. ↑ Evers T, Tisch M. Tinnitus as an Indication of Head Injury. Dtsch Arztebl Int. 2024 Jul 12;121(14):482.
  28. ↑ Le M, Šarkić B, Anderson R. Prevalence of tinnitus following non-blast related traumatic brain injury: a systematic review of literature. Brain Inj. 2024 Sep 18;38(11):859-868.
  29. ↑ Konstantinides NA, Leung M, Grashow R, Pugh JA, Nolan E, Whittington AJ, Speizer FE, Taylor HA, Baggish AL, Zafonte RD, Weisskopf MG. Associations Between Football-Related Exposures, Head Injury, Tinnitus, and Neuropsychological Health Outcomes Among Professional American-Style Football Players. Sports Medicine-Open. 2026 Dec;12(1):75.
  30. ↑ Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci. 2021 Nov;235:102828.
  31. ↑ Pertab JL, Merkley TL, Cramond AJ, Cramond K, Paxton H, Wu T. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review. NeuroRehabilitation. 2018;42(4):397-427.
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