Head or Brain?

FAA Medical Traumatic Brain Injury – It is essential to distinguish between an injury to the surface of your head and an injury to the brain itself. While physical trauma or injury to the head can be painful and distracting, it will have less of an ongoing impact on your cognition than an actual brain injury will. Many people, medical professionals included, will sometimes aggregate everything together and refer to all types as a form of head injury or TBI. However, it is essential to make a distinction from an aviation perspective.

The FAA considers a head injury only to be:

• A superficial scalp injury or globe and musculoskeletal injuries that do not persist and do not rise to the level of even a mild concussion
• Has no neurological symptoms
• No “mild concussion symptoms” such as headache, dizziness, nausea, or non-focal neurological symptoms such as photo/phonophobia, tinnitus, irritability, mental fogginess, etc.
• No evidence of brain trauma on CT or MRI, if performed

Bonk your head hard enough to split the skin and need stitches but lack severe symptoms or injury? You shouldn’t have any issues. As long as you have been released from any limitations by your doctor, this should not impede your ability to get your medical certificate issued at your next exam. You do not need to report it to the FAA or an AME before resuming flying. 

What is a “brain” injury?

The brain is suspended in a fluid-filled pouch, creating a thin, squish barrier between itself and your skull bones. Your skull bones are pretty strong, considering what they were designed to protect. The brain tissue is not very strong; it is somewhat spongy. A brain injury is when the brain tissue inside your skull has suffered disruption from whatever occurred. This is typically from an impact or significant acceleration, like whiplash injuries. In these cases, your brain makes contact with the inside of your skull bones. 

If your brain hits hard enough, it will bounce off and impact the other side. Radiologists routinely look for that pattern when reviewing CT and MRI results. With enough force, the squishy sac your brain is in can rip, letting the cerebral spinal fluid (CSF) leak out. You can tear blood vessels, resulting in an intracranial hemorrhage. Even nerve tissue can be torn. Penetrating skull injuries can cause direct brain damage as pieces of bone or penetrating objects can cut right into the brain tissue. 

Brain injury specialists typically classify injuries based on clinical features and imaging results from studies. The FAA also has a rating system for TBIs, but it will not always match the terms you may have discussed with your treating doctors. Each category has its own set of requirements pilots need to meet before being able to obtain a new medical certificate. 

FAA Brain Injury Classification and Requirements

The following section outlines the FAA’s criteria for classifying brain injuries, the grounding periods, and the basic documentation requirements associated with each one. 

Concussion or mild TBI:

• A head injury involving less than one hour of loss of consciousness, alteration of consciousness, post-traumatic amnesia, and
• No seizure activity

Returning to flight after a concussion requires a minimum of 6 months of recovery time before completing a comprehensive neurological evaluation.

Moderate TBI: 

• A head injury involving loss of consciousness, alteration of consciousness, and post-traumatic amnesia that lasts between 1 hour and 24 hours or
• A non-depressed skull fracture, regardless of symptoms or

• Small parafalcine or tentorial subdural hematoma (resolved by MRI); or

• Small subarachnoid hemorrhage (resolved by MRI)

Returning to flight after a moderate brain injury requires a minimum of 12 months of recovery time before completing a comprehensive neurological evaluation. Still, additional imaging and cognitive testing are needed at this time. 

Severe TBI:

• A head injury where significant intracranial bleeding such as brain contusion, intracranial bleed, hematoma, epidural hematoma, subdural hematoma, or diffuse axonal injury occurs or
• An injury involving more than 24 hours of loss of consciousness, alteration of consciousness, and post-traumatic amnesia or

• Any depressed skull fracture, regardless of symptoms or 

• Any penetrating head injury, regardless of symptoms 

A severe head injury has a minimum five-year recovery time before being eligible for FAA medical certification. The documentation requirements are similar for those with a moderate head injury, but you must also provide certain historical medical records. 

Preparation and Presentation

Many pilots do not learn about FAA medical certification standards until they visit their AME for their certification exam. By then, it may be too late to avoid lengthy administrative delays or even denial of your medical certificate. That applies even if you have satisfied the mandatory waiting period required by your type of injury. 

The medical evaluations and documentation necessary to return to flight after a brain injury are specific and complicated. This sets up prime conditions for your FAA medical certification horror story. Even though you must observe the FAA’s mandated waiting times, if you have suffered a mild or moderate brain injury, you can save valuable time by starting your AME exam preparation shortly following your injury. After a severe brain injury, we recommend starting your preparation about four years after your injury or six to twelve months before you plan to apply for a medical certificate. 

For brain injuries especially, but really for any new medical condition, knowing the FAA medical certification standards and meeting them before you schedule your AME appointment can often reduce the application process by months or years. Get your questions answered before your AME appointment to ensure you are adequately prepared.

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