How can I differentiate between a concussion and more serious head injuries in a primary care setting?

In a primary care setting, differentiating between a concussion and more serious head injuries primarily involves identifying specific risk factors that necessitate immediate referral to a hospital emergency department ¹,². If any of the following risk factors are present, the person should be referred to a hospital emergency department, using the ambulance service if necessary:

• Glasgow Coma Scale (GCS) score of less than 15 on initial assessment ¹,².
• Any loss of consciousness due to the injury ¹,².
• Any focal neurological deficit since the injury ¹,².
• Any suspicion of a complex skull fracture or penetrating head injury ¹,².
• Amnesia for events before or after the injury (note: assessing amnesia may not be possible in preverbal children or those under 5) ¹,².
• A persistent headache since the injury ¹,².
• Any vomiting episodes since the injury (clinical judgement is used for children 12 years or under regarding the cause of vomiting and need for referral) ¹,².
• Any seizure since the injury ¹.
• Any previous brain surgery ¹,².
• A high-energy head injury (e.g., fall from >1m or 5 stairs, high-speed motor vehicle collision, diving accident) ¹,².
• Any history of bleeding or clotting disorders ¹,².
• Current anticoagulant or antiplatelet treatment (except aspirin monotherapy) ¹,².
• Current drug or alcohol intoxication ¹,².
• Any safeguarding concerns (e.g., possible non-accidental injury or a vulnerable person is affected) ¹,².
• Irritability or altered behaviour, particularly in babies and children under 5 ¹,².
• Continuing concern by the professional about the diagnosis ¹,².
• Signs of a suspected basal skull fracture, such as clear fluid leaking from the ear(s) or nose, periorbital haematoma(s) without associated eye damage, bleeding from one or both ears, blood behind the eardrum (haemotympanum), new deafness, or Battle's sign (bruising behind the ear) ².
• Suspected cervical spine injury, indicated by neck pain or tenderness, or an inability to rotate the neck 45 degrees to the left and right ².

If none of these risk factors are present, the person is considered at low risk of an intracranial complication or cervical spine injury ². In such cases, advise that a responsible adult should stay with the person for the first 24 hours after the injury and remain alert for worrying signs and symptoms that indicate the need for urgent medical review ². Symptoms such as headache, dizziness, nausea, and cognitive difficulties (often described as 'brain fog') can be part of 'post-concussion syndrome', which can occur even with mild head injuries ¹.