Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients?

American Headache Society white paper on treatment of post-traumatic headache from concussion in youth

OBJECTIVE

To provide healthcare professionals guidance on youth at risk for prolonged recovery and post-traumatic headache (PTH), and on pharmacologic and non-pharmacologic management of PTH due to concussion and mild traumatic brain injury.

BACKGROUND

Headache is the most common persistent post-concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines.

METHODS

This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society.

RESULTS

Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair-to-poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro-modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective.

CONCLUSIONS

This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth.

Unsatisfactory response to acute medications does not affect the medication overuse headache development in pediatric chronic migraine

BACKGROUND

Chronic migraine (CM) negatively impacts the quality of life of 2 to 4% of pediatric patients. In adults, CM is frequently linked to medication overuse headache (MOH), but there is a much lower prevalence of MOH in children. A suboptimal response to acute therapies may lead to their reduced use, thus preventing MOH development in children and adolescents. The frequency of patients with CM who do not respond to acute therapies was examined in the present study. We investigated whether the prevalence of MOH was different between responders and non-responders. We also examined whether patients receiving prophylactic therapy had an improved response to acute therapy. Finally, we investigated if there was a difference in the frequency of psychiatric comorbidities between responders and non-responders.

METHODS

We retrospectively analysed clinical data of all chronic pediatric migraineurs under the age of 18 referred to the Headache Centre at Bambino Gesù Children Hospital in June 2021 and February 2023. ICHD3 criteria were used to diagnose CM and MOH. We collected demographic data, including the age at onset of migraine and the age of the CM course. At baseline and after 3 months of preventive treatment, we evaluated the response to acute medications. Neuropsychiatric comorbidities were referred by the children's parents during the first attendance evaluation.

RESULTS

Seventy patients with CM were assessed during the chosen period. Paracetamol was tried by 41 patients (58.5%), NSAIDs by 56 patients (80.0%), and triptans by 1 patient (1.4%). Fifty-one participants (73%) were non-responder to the abortive treatment. The presence of MOH was detected in 27.1% of the whole populations. Regarding our primary aim, MOH was diagnosed in 29% of non-responder patients and 22% of responders (p > 0.05). All patients received preventative treatment. After 3 months of preventive pharmacological therapy, 65.4% of patients who did not respond to acute medications achieved a response, while 34.6% of patients who were non-responder remain non-responder (p < 0.05). Prophylactic therapy was also effective in 69% of patients who responded to acute medication (p < 0.05). Psychiatric comorbidities were detected in 68.6% of patients, with no difference between responders and non-responders (72.2% vs. 67.3%; p = 0.05).

CONCLUSIONS

Despite the high prevalence of unresponsiveness to acute therapies in pediatric CM, it does not act as a protective factor for MOH. Moreover, responsiveness to acute drugs is improved by pharmacological preventive treatment and it is not affected by concomitant psychiatric comorbidities.

Opioids and Youth Athletes

CONTEXT

The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion.

OBJECTIVE

This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed.

DATA SOURCES

A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present.

STUDY SELECTION

Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted.

RESULTS

Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse.

CONCLUSION

The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

Inflammation, brain connectivity, and neuromodulation in post-traumatic headache

Post-traumatic headache (PTH) is a debilitating condition that affects individuals with different levels of traumatic brain injury (TBI) severity. The difficulties in developing an effective treatment are related to a lack of understanding the complicated mechanisms and neurobiological changes in brain function after a brain injury. Preclinical studies have indicated that peripheral and central sensitization of the trigeminal nociceptive pathways contributes to PTH. While recent brain imaging studies have uncovered widespread changes in brain functional connectivity following trauma, understanding exactly how these networks contribute to PTH after injury remains unknown. Stimulation of peripheral (trigeminal or vagus) nerves show promising efficacies in PTH experimental animals, likely mediated by influencing TBI-induced pathological plasticity by decreasing neuroinflammation and neuronal apoptosis. Non-invasive brain stimulations, such as transcranial magnetic or direct current stimulations, show analgesia for multiple chronic pain conditions, including PTH. Better mechanistic understanding of analgesia achieved by neuromodulations can define peripheral and central mechanisms involved in the development, the resolution, and the management of PTH.

The prevalence of persistent post-traumatic headache in adult civilian traumatic brain injury: a systematic review and meta-analysis on the past 14 years

ABSTRACT

The most recent prevalence estimate of post-traumatic headache (PTH) after traumatic brain injury (TBI) in veterans and civilians dates back to 2008. The prevalence was found to be 57.8%, with surprising higher rates (75.3%) in mild TBI when compared with those with moderate/severe TBI (32.1%). However, the revision of mild TBI diagnostic criteria and an historic peak of TBI in the elderly individuals attributed to the ageing population may lead to different results. Thus, we conducted a systematic review and meta-analysis to assess the updated prevalence of PTH during the past 14 years only in civilians. A literature search was conducted following PRISMA guidelines guided by a librarian. Screening, full-text assessment, data extraction, and risk of bias assessment were performed blindly by 2 raters. Meta-analysis of proportions using the Freeman and Tukey double arcsine method of transformation was conducted. Heterogeneity, sensitivity analysis, and meta-regressions were performed with the predictors: year of publication, mean age, sex, TBI severity, and study design. Sixteen studies were selected for the qualitative analysis and 10 for the meta-analysis. The overall prevalence estimate of PTH was 47.1%, (confidence interval = 34.6, 59.8, prediction intervals = 10.8, 85.4), being similar at different time points (3, 6, 12, and 36+ months). Heterogeneity was high, and none of the meta-regressions were significant. The overall prevalence of PTH after TBI over the past 14 years remains high even if assessed only in civilians. However, the prevalence rates attributed to mild and moderate/severe TBI were similar, differing significantly from previous reports. Efforts are needed to improve TBI outcomes.

Medication Overuse Headaches among Children-The Contribution of Migraine and TTH

Medication overuse headaches are a frequent phenomenon observed in individuals suffering from chronic headaches. It arises due to the excessive consumption of pain-relief medications, resulting in the escalation and continuous persistence of headache symptoms. Nevertheless, the prevalence and distinctive characteristics of medication overuse headaches in the pediatric population have not been comprehensively explored. The primary objective of this research is to delineate the features of medication overuse headaches in children, particularly emphasizing the investigation of its epidemiology and the diagnostic patterns for headaches. We conducted a retrospective study and analyzed the medical records of children and adolescents who were evaluated at the outpatient pediatric headache clinic at the Bnai Zion Medical Center for headaches during the period spanning 2007 to 2017. Our study encompassed a cohort of 1008 patients experiencing headaches. Among these participants, 268 individuals (26.6%) were diagnosed with migraine, 250 (24.8%) exhibited tension-type headaches (TTH), and 490 (48.6%) were classified as having undifferentiated headaches. Out of the whole group, 65 had chronic headaches: 35 (54%) with migraine, 20 (30%) with tension-type headaches (TTH), and 10 (15%) with the undifferentiated headache of childhood, with the majority (73%) being female. In summary, medication overuse headaches are a prevalent issue among children grappling with chronic headaches. Intriguingly, they appear to be more pronounced within the tension-type headache (TTH) group compared to migraine sufferers and exhibit a higher prevalence among females. This study underscores the significance of early detection and careful management of medication overuse headaches in pediatric cases, shedding light on its distinct characteristics in the realm of childhood headache disorders. Further research is warranted to elucidate the underlying factors contributing to the observed gender disparity and the distinct prevalence rates among different headache subtypes.

Current evidence for pharmacological management of pediatric concussion: a systematic review

PURPOSE

Mild traumatic brain injury (mTBI) is a global public health problem and its current management is limited to rest and symptom management. Despite frequent use of drugs for symptom control, there is a lack of consensus on the optimal pharmacological management of post-concussive symptoms. We reviewed the relevant literature to compile the evidence about the pharmaceutical management of pediatric mTBI.

METHODS

We performed a systematic review of the literature available in PubMed, Cochrane CENTRAL, and ClinicalTrials.Gov as well as through citation tracing. A modified PICO framework was used for the construction of search strategy and eligibility criteria. Risk of bias was assessed using RoB-2 tool for randomized and ROBINS-I for non-randomized studies.

RESULTS

A total of 6260 articles were screened for eligibility. After exclusions, a total of 88 articles received full text review. A total of 15 reports representing 13 studies (5 randomized clinical trials, 1 prospective randomized cohort study, 1 prospective cohort study, and 6 retrospective cohort studies) met the eligibility criteria and were included in the review. We identified 16 pharmacological interventions in a total of 931 pediatric patients with mTBI. Amytriptiline (n = 4), ondansetron (n = 3), melatonin (n = 3), metoclopramide (n = 2), magnesium (n = 2), and topiramate (n = 2) were investigated in multiple studies. All RCTs were relatively of small size (n ≤ 33/group).

CONCLUSION

The available evidence supporting pharmacological intervention in pediatric mild traumatic brain injury is scarce. We propose a framework to facilitate future collaborative research efforts to test and validate various pharmacological interventions for acute and persistent post-concussive symptoms in children.

Medication overuse headache

Medication overuse headache (MOH) is a secondary headache disorder attributed to overuse of acute headache medications by a person with an underlying headache disorder, usually migraine or tension-type headache. MOH is common among individuals with 15 or more headache days per month. Although MOH is associated with substantial disability and reductions in quality of life, this condition is often under-recognized. As MOH is both preventable and treatable, it warrants greater attention and awareness. The diagnosis of MOH is based on the history and an unremarkable neurological examination, and is made according to the diagnostic criteria of the International Classification of Headache Disorders third edition (ICHD-3). Pathophysiological mechanisms of MOH include altered descending pain modulation, central sensitization and biobehavioural factors. Treatment of MOH includes the use of headache preventive therapies, but essential to success is eliminating the cause, by reducing the frequency of use of acute headache medication, and perhaps withdrawing the overused medication altogether. Appropriate treatment is usually highly effective, leading to reduced headache burden and acute medication consumption.

Early analgesic administration and headache presence 7 days post-concussion in children

OBJECTIVE

This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth.

METHODS

A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models.

RESULTS

2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)].

CONCLUSIONS

Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

Efficacy of outpatient infusion therapy in pediatric patients with postconcussive headaches

PURPOSE

To determine the relative efficacy of intravenous therapy for postconcussive headaches in a pediatric population, as compared to oral therapy.

METHODS

Pediatric patients treated for postconcussive headaches at an outpatient infusion clinic from 2016 to 2018 were selected for inclusion in the study. Of the 95 patients who were treated in clinic, 53 patients were selected for a retrospective chart review. Clinic visits before and after infusions were reviewed to determine changes in headache score (HA), symptom severity score (SSS), and self-reported symptom relief. An age-matched and SSS-matched group served as a control. The control group received only oral therapy for their headaches. The infusion consisted of parenteral ketorolac, compazine, diphenhydramine, and a normal saline bolus (20 mg/kg).

RESULTS

Following infusion therapy, overall mean HA and SSS scores were both reduced (p < 0.0001). Oral therapy demonstrated a similar mean overall reduction in HA and SS scores (p < 0.0001). While both groups achieved a reduction in HA and SS scores, there was not a statistically significant difference in reduction of symptoms scores between the oral and infusion groups.

CONCLUSION

Infusion therapy is as effective at reducing HA and SSS as established oral therapies. Infusion therapy may have a shorter time to headache abortion than oral therapy based on pharmacokinetics. Further, some physicians are unwilling to allow an athlete to return to play while taking suppressive medication. Future studies may show that an infusion could allow a more rapid return to play and resolution of symptoms.

Acute and chronic management of posttraumatic headache in children: A systematic review

OBJECTIVES

The goal of this paper is to provide a compilation of the evidence for the treatment of posttraumatic headache (PTH) in the pediatric population. Headache features and timing of therapy were considered.

BACKGROUND

Headache is the most common symptom following mild traumatic brain injury (mTBI), affecting more than 80% of children and adolescents. It is unclear whether treatment for PTH should be tailored based on headache characteristics, particularly the presence of migraine features, and/or chronicity of the headache.

METHODS

Systematic literature searches of PubMed, Embase, Scopus, and Cochrane databases (1985-2021, limited to English) were performed, and key characteristics of included studies were entered into RedCAP^® (Prospero ID CRD42020198703). Articles and conference abstracts that described randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series were included. Participants included youth under 18 years of age with acute (<3 months) and persistent (≥3 months) PTH. Studies that commented on headache improvement in response to therapy were included.

RESULTS

Twenty-seven unique studies met criteria for inclusion describing abortive pharmacologic therapies (9), preventative pharmacotherapies (5), neuromodulation (1), procedures (5), physical therapy and exercise (6), and behavioral therapy (2). Five RCTs were identified. Studies that focused on abortive pharmacotherapies were completed in the first 2 weeks post-mTBI, whereas other treatment modalities focused on outcomes 1 month to over 1-year post-injury. Few studies reported on migrainous features (7), personal history of migraine (7), or family history of migraine (3).

CONCLUSIONS

There is limited evidence on the timing and types of therapies that are effective for treating PTH in the pediatric population. Prospective studies that account for headache characteristics and thoughtfully address the timing of therapies and outcome measurement are needed.

Pediatric Medication-overuse Headache and Global Headache Research. A Systematic Review

Medication-overuse headache (MOH) is a relevant topic of interest but pediatric studies are scarce. Some authors have expressed their opinion regarding geographical differences in the perceived importance of adult MOH between European and North American research. To determine if there is a geographic difference in the research efforts on pediatric MOH; and to study pediatric MOH prevalence of published studies. An analysis of the Global Burden of Disease database focusing on Headache disorders prevalence per region was correlated with the region where research was conducted via PubMed search on pediatric MOH from 2006-2021. Analysis of databases from PubMed, HINARI, and ScienceDirect found 13 studies that fulfilled inclusion criteria to evaluate pediatric MOH prevalence. 6 regions were analyzed North America, Latin America, Europe, Asia, Africa, Oceania. Regions with higher prevalence of headache disorders were North America (28.45%) and Europe (28.54%).  Most pediatric MOH publications were from North America (44.2%) and Europe (37.2%). The prevalence found of pediatric MOH among pediatric headache patients is 4-11%. Prevalence increases to 20-70% among patients having a diagnosis of chronic headache. Higher prevalence was found in patients suffering post traumatic headaches. The perceived importance for pediatric MOH is similar between North America and Europe based on the research published. The prevalence varies greatly between published studies. Relationship between Post-traumatic headache and pediatric MOH prevalence should be further studied.

Treatment of Post-traumatic Headaches in Children: A Systematic Review

Post-traumatic headache is a secondary headache disorder beginning within 7 days of head injury. We conducted a systematic review of the evidence for treatment of post-traumatic headache in children. Of 2169 unique articles screened, 12 were included. Most studies pertained to headaches after concussion. The authors of seven studies examined the effect of medications, 4 studied nonpharmacological therapies, and 1 studied the reduction of medication usage. Much of the evidence came from retrospective chart reviews, had low level of evidence, and had fair risk of bias. High-quality randomized controlled treatment trials are needed to guide the clinical management of this condition.

Nonsteroidal anti-inflammatory drug use and concussions in adolescent athletes: incidence, severity, and recovery

OBJECTIVE

Given concerns about the potential long-term effects of concussion in young athletes, concussion prevention has become a major focus for amateur sports leagues. Athletes have been known to frequently use anti-inflammatory medications to manage injuries, expedite return to play, and treat concussion symptoms. However, the effects of baseline nonsteroidal anti-inflammatory drug (NSAID) use on the susceptibility to head injury and concussion remain unclear. This study aims to assess the effects of preinjury NSAID use on concussion incidence, severity, and recovery in young athletes.

METHODS

Data from 25,815 ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) tests were obtained through a research agreement with ImPACT Applications Inc. Subjects ranged in age from 12 to 22 years old. Those who reported NSAID use at baseline were assigned to one (anti-inflammatory [AI]) cohort, whereas all others were assigned to the control (CT) cohort. Differences in head trauma and concussion incidence, severity, and recovery were assessed using chi-square tests, unpaired t-tests, and Kaplan-Meier plots.

RESULTS

The CT cohort comprised a higher percentage (p < 0.0001) of males (66.30%) than the AI cohort (44.16%) and had a significantly greater portion of athletes who played football (p = 0.004). However, no statistically significant differences were found between the two cohorts in terms of the incidence of head trauma (CT = 0.489, AI = 0.500, p = 0.9219), concussion incidence (CT = 0.175, AI = 0.169, p = 0.7201), injury severity, or median concussion recovery time (CT = 8, AI = 8, p = 0.6416). In a multivariable analysis controlling for baseline differences between the cohorts, no association was found between NSAID use and concussion incidence or severity.

CONCLUSIONS

In this analysis, the authors found no evidence that preinjury use of NSAIDs affects concussion risk in adolescent athletes. They also found no indication that preinjury NSAID use affects the severity of initial injury presentation or concussion recovery.

Evaluation and Management of Pediatric Concussion in the Acute Setting

ABSTRACT

Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.

Post-traumatic cephalalgia

After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.

Persistent post-traumatic headache: a migrainous loop or not? The clinical evidence

BACKGROUND

Headache is a common complication of traumatic brain injury. The International Headache Society defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following trauma. Acute post-traumatic headache resolves after 3 months, but persistent post-traumatic headache usually lasts much longer and accounts for 4% of all secondary headache disorders.

MAIN BODY

The clinical features of post-traumatic headache after traumatic brain injury resemble various types of primary headaches and the most frequent are migraine-like or tension-type-like phenotypes. The neuroimaging studies that have compared persistent post-traumatic headache and migraine found different structural and functional brain changes, although migraine and post-traumatic headache may be clinically similar. Therapy of various clinical phenotypes of post-traumatic headache almost entirely mirrors the therapy of the corresponding primary headache and are currently based on expert opinion rather than scientific evidence. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, especially impaired sleep and post-traumatic disorder. There are also effective options for non-pharmacologic therapy of post-traumatic headache, including cognitive-behavioral approaches, onabotulinum toxin injections, life-style considerations, etc. CONCLUSION: Notwithstanding some phenotypic similarities, persistent post-traumatic headache after traumatic brain injury, is considered a separate phenomenon from migraine but available data is inconclusive. High-quality studies are further required to investigate the pathophysiological mechanisms of this secondary headache, in order to identify new targets for treatment and to prevent disability.

Change in Headache Suffering and Predictors of Headache after Mild Traumatic Brain Injury: A Population-Based, Controlled, Longitudinal Study with Twelve-Month Follow-Up

Headache attributed to traumatic injury to the head (HAIH) is claimed to be the most common sequela following mild traumatic brain injury (MTBI), but epidemiological evidence is scarce. We explored whether patients with MTBI had an increase in headache suffering following injury compared with controls. We also studied predictors of headache.

The Trondheim MTBI follow-up study is a population-based, controlled, longitudinal study. We recruited patients exposed to MTBI and controls with minor orthopedic injuries from a trauma center and a municipal outpatient clinic, and community controls from the surrounding population. Information on headache was collected through questionnaires at baseline, and 3 and 12 months post-injury. We used a generalized linear mixed model to investigate the development of headache over time in the three groups, and logistic regression to identify predictors of headache.

We included 378 patients exposed to MTBI, 82 trauma controls, and 83 community controls. The MTBI-group had a larger increase in odds of headache from baseline to the first 3 months post-injury than the controls, but not from baseline to 3–12 months post-injury. Predictors for acute HAIH were female sex and pathological imaging findings on computed tomography (CT) or magnetic resonance imaging (MRI). Predictors for persistent HAIH were prior MTBI, being injured under the influence of alcohol, and acute HAIH. Patients who experience HAIH during the first 3 months post-injury have a good chance to improve before 12 months post-injury. Female sex, imaging findings on CT or MRI, prior MTBI, and being injured under the influence of alcohol may predict exacerbation of headache.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Low Usage of Analgesics for Pediatric Concussion-Related Pain in US Emergency Departments Between 2007 and 2015

OBJECTIVE

To estimate the proportion of pediatric patients with a concussion who received analgesia when presenting with pain to US emergency departments, and to describe the analgesics used.

STUDY DESIGN

This was a repeated cross-sectional analysis study using the National Hospital Ambulatory Medical Care Survey database of nationally representative emergency department visits from 2007 to 2015. We included children under 18 years old with isolated concussions. Survey weighting procedures were applied to generate population-level estimates and to perform multivariable logistic regression to identify factors associated with analgesic administration.

RESULTS

There were an estimated 1.54 million isolated concussion visits during the 9-year study period. Pain at presentation was reported frequently (78%), with the majority rated as moderate (36%) or severe (27%). Among all children reporting pain, 42% received no analgesics, including 40% with moderate-to-severe pain intensity. Multivariable analysis found younger age, male sex, and treatment in a nonacademic hospital were all negatively associated with analgesic administration. The medications most frequently administered were acetaminophen (54%), nonsteroidal anti-inflammatories (44%), and opioids (13%).

CONCLUSIONS

Analgesic medications seem to be underused in the treatment of pediatric concussion-related pain. Following acetaminophen and nonsteroidal anti-inflammatories, opioids, which are not recommended for this condition, were the most frequently prescribed analgesics. Further research should establish optimal, consistent, and responsible pain management strategies for pediatric concussions.

Diagnosis of Concussion in the Pediatric Emergency Department

Pediatric visits to the Emergency Department (ED) for concussion are common and increasing. ED clinicians evaluating children with concussion should first ensure the absence of more serious injuries requiring immediate intervention, such as intracranial hemorrhage or cervical spine injury. In the ED setting, signs and symptoms of concussion are sometime subtle and often overlooked. A thorough physical exam is warranted but may be normal. Imaging and laboratory studies have no role in concussion diagnosis and should be reserved for cases where an injury requiring immediate intervention is suspected. Symptom management may include avoiding symptom-triggers (such as bright lights triggering headaches) and/or specific treatments such as nonsteroidal anti-inflammatories or antiemetics. Discharge instructions should include a recommendation for a brief period of rest, followed by outpatient management for return-to-activity decisions in conjunction with a primary care provider.

Concussion part II: Rehabilitation - The need for a multifaceted approach

INTRODUCTION

While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

PURPOSE

The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

IMPLICATIONS

Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.

Treatment of Pediatric Concussion

Concussions have gained attention in medical literature, legal literature, and lay media over the past several years as a public health affecting children, particularly those who do not improve in the first few days after an injury. We discuss strategies for acute management immediately after a concussion and an introduction to medical and non-medical options for treatment of the complex symptoms that persist in some patients with concussions. We examine the role of rest and exercise during recovery. We briefly discuss the role of the multidisciplinary approach to concussion in a setting that engages multiple specialists. Finally, we address policy changes related to sport-concussions and their efficacy in improving long term outcomes.

Treatment of Acute Sports-Related Concussion

PURPOSE OF REVIEW

Here, we summarize the current scientific literature on the management of sports-related concussion (SRC) in the acute period (< 6 weeks post-injury) with a focus on rest, return to learn, return to play, and emerging treatments.

RECENT FINDINGS

While relative rest is recommended for the first 24-48 h following acute SRC, the most recent guidelines highlight the lack of evidence for complete rest and in fact show that prolonged cognitive and physical rest can be detrimental. Gradual return to learn and play is recommended. Return to sport should only occur once the patient is symptom free. While there are no FDA-approved medications for acute treatment of concussion, there is preclinical data for the benefit of omega 3 fatty acids. Evidence is limited around the benefits of treating sleep disorders, vestibular-ocular dysfunction, and neck pain in the acute period. After 24-48 h of rest, SRC patients may gradually resume cognitive and physical activity. More research is needed to determine if any supplements, medications, and/or physical therapy are indicated in the management in acute SRC.

Nurse practitioners' recommendations for pharmacotherapy in the management of adolescent concussion

BACKGROUND AND PURPOSE

Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion.

METHODS

This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described.

CONCLUSIONS

In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality.

IMPLICATIONS FOR PRACTICE

Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.

Review of the Management of Pediatric Post-Concussion Syndrome-a Multi-Disciplinary, Individualized Approach

PURPOSE OF REVIEW

Post-concussion syndrome (PCS), when the patient's concussion symptoms last longer than 4-6 weeks, affects 10-30% of concussion patients. PCS presents a significant source of morbidity to patients and a management challenge to providers. In this review, we present the current evidence and best management approaches for pediatric PCS.

RECENT FINDINGS

There is limited high-quality evidence in pediatric PCS. There is some evidence supporting pharmaceutical management of post-traumatic headaches, cognitive symptoms, and emotional symptoms. Vestibular-ocular dysfunction should be evaluated and managed appropriately. Neuropsychological recovery is expected, but requires appropriate attention to Return to Learn. Emotional symptoms are common in PCS and the evidence supports treatment with cognitive behavioral therapy. PCS presents a unique therapeutic challenge affecting multiple domains for patients-physical, sleep, cognitive, and emotional. Successful management of PCS requires a multi-disciplinary and individualized approach. There remains a significant need for further research, specifically looking into the outcomes and effective interventions in pediatric PCS.

The Clinical Implications of Youth Sports Concussion Laws: A Review

The recent passage of state youth sports concussion laws across the country introduces clinical implications for health care professionals caring for student-athletes. Although the laws were established to provide protections for student-athletes and prevent adverse outcomes, efforts aimed at implementation have uncovered various challenges in concussion diagnosis and management. Some of the most salient issues include medical evaluation, return to play, and return to learn. For this reason, health care professionals play a pivotal role in determining the critical next steps after a student is removed from play with a suspected concussion. Also, state laws may influence an influx of concussion patients to health care facilities and, thereby, present various unforeseen challenges that can be mitigated with adequate clinical preparation. This is key to helping student-athletes recover and resume regular activities in sports, recreation, and education. This review describes the various components of state youth sports concussion laws relevant to clinical practice and nuances that health care professionals should appreciate in this context. Additionally, concussion tools and strategies that can be used in clinical practice are discussed.

Narrative Review of the Pathophysiology of Headaches and Photosensitivity in Mild Traumatic Brain Injury and Concussion

The most common symptom of post-concussive syndrome (PCS) is post-traumatic headache (PTH) accompanied by photophobia. Post-traumatic headache is currently categorized as a secondary headache disorder with a clinical phenotype described by its main features and resembling one of the primary headache disorders: tension, migraine, migraine-like cluster. Although PTH is often treated with medication used for primary headache disorders, the underlying mechanism for PTH has yet to be elucidated. The goal of this narrative literature review is to determine the current level of knowledge of these PTHs and photophobia in mild traumatic brain injury (mTBI) in order to guide further research and attempt to discover the underlying mechanism to both symptoms. The ultimate purpose is to better understand the pathophysiology of these symptoms in order to provide better and more targeted care to afflicted patients. A review of the literature was conducted using the databases CINAHL, EMBASE, PubMed. All papers were screened for sections on pathophysiology of PTH or photophobia in mTBI patients. Our paper summarizes current hypotheses. Although the exact pathophysiology of PTH and photophobia in mTBI remains to be determined, we highlight several interesting findings and avenues for future research, including central and peripheral explanations for PTH, neuroinflammation, cortical spreading depolarization and the role of glutamate excitotoxicity. We discuss the possible neuroanatomical pathways for photophobia and hypothesize a possible common pathophysiological basis between PTH and photophobia.

Posttraumatic headache in pediatrics: an update and review

PURPOSE OF REVIEW

Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers.

RECENT FINDINGS

The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA.

SUMMARY

PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa

Objective

Our aim was 1) to reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine.

Background

Modifiable risk factors for PTHA include stressful life event, sleep disturbances, and medication overuse. Cognitive-behavioral strategies, biofeedback, and relaxation therapy may have an important role in treatment and preventing progression to chronic post-traumatic headache (CPTHA). There is limited literature and a known practice gap for implementation of these techniques.

Design/methods

An IRB approved project focused on patients who were seen for PTHA and CPTHA. 1) Intervention consisted of lifestyle teaching, cognitive-behavioral therapy and biofeedback, supplemented by decreasing polypharmacy. 2) Patients were followed for 2 years and a retrospective review was conducted for 2 years prior to presentation. 3) Outcome measures included reduction in migraine intensity or frequency, improved quality of life, duty status, and decreased utilization of clinic visits.

Results

Over the course of one year, 221 patients were treated for migraines in the Naval Okinawa Neurology Clinic. Of these, 22 active duty service members and 3 Dependents suffered a mild TBI prior to onset. After intervention, there was a 36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared to the 2 years prior to intervention. Twenty-four percent had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year.

Conclusions

An implemented program geared towards reducing polypharmacy was shown to improve safety, quality of life and reduce hospitalizations from the burden of migraines. Our systematic approach resulted in quality of life improvements and decreased use of medical resources.

Trial registration

Authors received the approval of NAVMED West, Okinawa Naval Hospital Institutional Review Board on January 13th, 2016. QI.2016.0021.

Pharmacotherapy for Persistent Posttraumatic Headaches in Children and Adolescents: A Brief Review of the Literature

Concussion, now most often referred to as mild traumatic brain injury in recent literature, is common in pediatrics, and headache is often the most common complaint post-injury. Although most children and adolescents recover within 1-2 weeks, some develop frequent and debilitating headaches that can last for months or longer. Most clinicians would agree on the importance of managing both acute and persistent posttraumatic headaches appropriately to speed recovery, minimize disability, maximize function, and improve quality of life, but there are no well-established guidelines to instruct physicians in doing so. As this continues to be a developing field, there is much we still need to learn about concussion and the appropriate strategies to prevent and treat these injuries and their sequelae. This review is intended to help providers understand the current evidence, and sometimes the lack thereof, and ultimately to lead to improved care for children with headaches after mild traumatic brain injury.

Acute concussion: making the diagnosis and state of the art management

PURPOSE OF REVIEW

Concussion is an increasingly common injury in children. We aim to review the basic epidemiology and management of acute concussion and highlight recent studies that have contributed to our understanding of care for this injury.

RECENT FINDINGS

While concussion is considered a 'mild' form of traumatic brain injury, recent evidence suggests that as many as 30% of children are still symptomatic 1 month after injury. Although there is increasing interest in finding objective measures of injury and recovery, emerging imaging and serum biomarkers are not ready for routine clinical use. Identification of children at risk for prolonged symptoms is vital. Prolonged rest after injury may worsen outcomes.

SUMMARY

Concussion is a common injury in children. Objective measures of injury and recovery are needed, as are targeted therapies to mitigate the risk of prolonged recovery after injury.

Pediatric Traumatic Brain Injury and Concussion

PURPOSE OF REVIEW

This article summarizes the impact and complications of mild traumatic brain injury and concussion in children and outlines the recent evidence for its assessment and early management. Useful evidence-based management strategies are provided for children who have a typical recovery following concussion as well as for those who have persistent postconcussion syndrome. Cases are used to demonstrate the commonly encountered pathologies of headache, cognitive issues, and mood disturbances following injury.

RECENT FINDINGS

A clinical risk score using risk factors for poor recovery (eg, female sex, adolescence, previous migraine, and a high degree of acute symptoms) can be used to help the clinician plan follow-up in the community. Prolonged periods of physical and cognitive rest should be avoided. Multidisciplinary treatment plans are often required in the management of persistent postconcussion syndrome.

SUMMARY

A paucity of research exists for the treatment of postconcussion syndrome. Current treatments target individual symptoms.

Longitudinal assessment of gray matter volumes and white matter integrity in patients with medication-overuse headache

Background Medication-overuse headache is a common clinical entity, but neuroimaging studies investigating volumetric and microstructural alterations of the brain in medication-overuse headache are rare. Therefore, in the current longitidunal study we evaluated gray matter volume and white matter integrity in patients with medication-overuse headache before and after drug withdrawal. Methods A prospective study evaluated 27 patients with medication-overuse headache and 27 age-, sex-, and education-matched healthy adults. High-resolution T1-weighted magnetic resonance imaging and diffusion tensor imaging were obtained from the control group and medication-overuse headache patients before and six months after drug withdrawal. Tract-based spatial statistics of multiple diffusivity indices and voxel-based morphometry were employed to investigate white and gray matter abnormalities. Results No correlation was found between age, gender, education and smoking status in both groups. The most commonly overused medications were simple analgesics (96.3%) and combined analgesics (3.7%). The mean duration of the history of medication overuse and headaches was 56.7 ± 63.5 months. White matter diffusional and gray matter morphological alterations including volume, fractional anisotropy, radial diffusivity, and axial diffusivity analyses showed no significant relationship in the patients before and six months after withdrawal of analgesics. Also no difference was observed between the patients versus controls. Conclusion Our data demonstrated no structural alterations within the brain in medication-overuse headache.

Posttraumatic Headache

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61-e68.].

Sports-Related Concussion: Acute Management and Chronic Postconcussive Issues

Sports-related concussion (SRC) is a common problem in youth sports. Concussion may occur after a forceful hit to the body or head, resulting in transient neuropathological changes that spontaneously resolve with relative rest and activity modification in most patients. Most SRCs are effectively managed by primary care physicians and sports medicine specialists. In some cases, symptoms may persist and the child and adolescent psychiatrist may be consulted. This article reviews important background information regarding SRC and highlights a variety of pharmacologic and nonpharmacologic treatment options that consultant psychiatrists should know.

Is Migraine Headache Associated With Concussion in Athletes? A Case-Control Study

OBJECTIVE

The purpose of this study was to investigate the association between migraine headache and concussion in athletes.

DESIGN

Case-control observational study.

SETTING

A university-associated combined sports neurology and orthopedic sports medicine clinic.

PARTICIPANTS

A total of 221 male (n = 140) and female (n = 81) athletes aged 12 to 24 years, including 115 concussion cases (52%) and 106 orthopedic controls (48%), were included in this study.

INTERVENTIONS

Participants completed a one-page questionnaire that recorded their age, sex, reason for visit (concussion vs any other injury), concussion history, and self/immediate family member migraine headache history.

MAIN OUTCOME MEASURES

The odds of having a previous history of migraine headache were compared in the concussion group versus orthopedic controls.

RESULTS

Controlling for between-group differences in age and sex, there was a significant positive association between concussion group status and history of migraine headache [adjusted odds ratio (OR), 1.90; 95% confidence interval (CI), 1.03-3.50. P = 0.039]. However, when including a previous concussion history in the statistical model, this relationship failed to reach significance [adjusted OR, 1.68; 95% CI, 0.89-3.16. P = 0.107].

CONCLUSIONS

These results suggest that there is an association between migraine headache and concussion in athletes, but the cause-effect nature of this relationship cannot be determined. Migraine headache should be considered a modifying factor when caring for concussed athletes.

Pediatric Headache: An Overview

Headache represents the most common neurologic disorder in the general population including children and is increasingly being recognized as a major source of morbidity in youth related to missed school days and activities. In this article, we take a holistic approach to the child presenting with headache with a focus on the detailed headache history, physical and neurologic examinations, and diagnostic evaluation of these patients. Clinical presentations and classification schema of multiple primary and secondary headache types in children are discussed using the International Headache Criteria (IHCD-3) as a guide, and a summary provided of the various treatment modalities employed for pediatric headache including lifestyle modifications, behavioral techniques, and abortive and preventive medications.

Concussion-Mild Traumatic Brain Injury: Recoverable Injury with Potential for Serious Sequelae

Concussion is increasingly recognized as a major public health issue. Most patients will return to baseline and experience full recovery, although a subset experiences persistent symptoms. Newer animal models and imaging studies are beginning to demonstrate that metabolic and neurovascular resolution may actually take longer than symptomatic recovery. Repeat traumatic brain injury within the metabolic window of dysfunction may result in worsened symptoms and prolonged recovery. The true risk for second impact syndrome appears to be small, and development of cerebral edema after a mild impact may be related to genetic risks rather than serial impacts.

Pharmacologic Therapies for Pediatric Concussions

Context:

Pediatric concussions are common, and emphasis on correct diagnosis and management is stressed in consensus guidelines. Medications may have a role in management of concussion, but no consensus exists regarding appropriate pharmacologic therapy.

Evidence Acquisition:

Nonsystematic review.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

There is limited evidence for hypertonic saline to improve posttraumatic headache in the emergency department setting. There is essentially no evidence for the use of any other medication in management of pediatric sport-related concussion.

Conclusion:

Further research is necessary to determine whether there is benefit to the use of any pharmacotherapy in the management of pediatric-aged athletes with concussions.