During a primary care assessment, differentiating concussion from more serious traumatic brain injuries (TBI) relies on careful clinical evaluation of symptoms, signs, and risk factors. Concussion is characterized by a Glasgow Coma Scale (GCS) score of 15, transient neurological symptoms such as headache, dizziness, nausea, amnesia (antegrade or retrograde), and cognitive difficulties without focal neurological deficits or structural brain injury on imaging NICE CKS. More serious TBI is suspected if any of the following are present: GCS less than 15 on initial assessment, persistent or worsening confusion, focal neurological signs, seizures, suspected penetrating injury, cerebrospinal fluid leak, or deterioration in neurological status NICE CKS,NICE NG232.
Key clinical features that warrant urgent hospital referral and imaging (usually CT head) include any loss of consciousness, amnesia lasting more than 5 minutes, persistent headache, vomiting, seizures, high-energy mechanism of injury, anticoagulant use, intoxication, or any suspicion of skull fracture or neurological deficit NICE CKS,NICE NG232. The presence of these features suggests a higher risk of intracranial complications beyond concussion and mandates urgent investigation NICE CKS,NICE NG232.
In contrast, concussion symptoms often include transient confusion, headache, dizziness, visual disturbances, and cognitive 'brain fog' but without focal neurological deficits or reduced consciousness beyond brief loss NICE CKS. The GCS remains 15, and neurological examination is normal. Post-concussion symptoms may persist but do not indicate structural brain injury NICE CKS.
Clinical decision rules embedded in UK guidelines emphasize the importance of GCS assessment, neurological examination, and identification of risk factors to triage patients appropriately NICE CKS,NICE NG232. CT imaging is the primary investigation for suspected clinically important TBI, whereas concussion is a clinical diagnosis without imaging abnormalities NICE NG232. MRI is not routinely used acutely but may provide additional prognostic information in selected cases NICE NG232.
Early education and reassurance about concussion symptoms and expected recovery are important, alongside advice on gradual return to normal activities and monitoring for any deterioration NICE CKS. Persistent or worsening symptoms beyond the acute phase may require specialist referral NICE CKS.
In summary, primary care differentiation hinges on GCS scoring, neurological examination, and identification of red flags for serious injury requiring urgent imaging and referral, while concussion is diagnosed clinically in the absence of these red flags NICE CKS,NICE NG232.