Is migraine a risk factor for the development of concussion?

Risk of Two Sport-Related Concussions in the Same Year: Is the Second Concussion Worse?

OBJECTIVES

1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion.

DESIGN

A retrospective, case-control study.

SETTING

Regional sports concussion center.

PATIENTS

Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020.

INDEPENDENT VARIABLES

Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions.

MAIN OUTCOME MEASURES

Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups.

RESULTS

Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion.

CONCLUSIONS

In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion.

Comparison of Clinical Outcomes Between Athletes With Immediate and Delayed Onset of Symptoms Following Sport-Related Concussion

OBJECTIVE

To compare characteristics and clinical outcomes of adolescent athletes with immediate and delayed onset of symptoms following sport-related concussion (SRC). A secondary objective was to describe the symptoms that are delayed and the timing of symptom onset.

DESIGN

Prospective, repeated measures study.

SETTING

Concussion Specialty Clinic.

PARTICIPANTS

One hundred fifty-two participants (63.3% men) aged 11 to 24 (15.78 ± 3.47) evaluated within 7 days (3.47 ± 1.66) of sustaining an SRC.

INDEPENDENT VARIABLE

Group classification of immediate (IMMEDIATE) or delayed onset of symptoms (DELAYED; >60 seconds following mechanism of injury) through structured clinical interview.

MAIN OUTCOME MEASURES

Group comparisons on demographic and medical history factors, concussion and clinical profile symptom scores, computerized neurocognitive test scores, vestibular/oculomotor screening scores, and days to medical clearance.

RESULTS

24.3% of athletes in the sample were DELAYED. The groups did not differ on demographics and medical history. The DELAYED group had increased likelihood of posttraumatic migraine (PTM) as a primary/secondary clinical profile ( P = 0.03). Groups did not differ on any other clinical profiles ( P > 0.05). Groups did not differ on recovery time ( P = 0.47), the IMMEDIATE group higher dizziness on vestibular/ocular motor screening ( P = 0.016) and increased likelihood of dizziness being the initial symptom experienced ( P < 0 .001).

CONCLUSIONS

The results indicated that delayed onset of symptoms in athletes were relatively common following SRC, supporting continued evaluation of athletes for several days following suspected injuries. Delayed onset of symptoms was associated with PTM, whereas immediate onset was associated with more pronounced vestibular dysfunction, suggesting that clinicians should consider the timing of symptom onset when assessing and treating athletes following SRC.

Risk Factors for Vestibular and Oculomotor Outcomes After Sport-Related Concussion

OBJECTIVE

To investigate the association between risk factors and vestibular-oculomotor outcomes after sport-related concussion (SRC).

STUDY DESIGN

Cross-sectional study of patients seen 5.7 ± 5.4 days (range 0-30 days) after injury.

SETTING

Specialty clinic.

PARTICIPANTS

Eighty-five athletes (50 male athletes and 35 female athletes) aged 14.1 ± 2.8 years (range 9-24 years) seeking clinical care for SRC.

INTERVENTIONS

Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocularmotor screening (VOMS). Chi-square tests with odds ratios and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes.

MAIN OUTCOME MEASURES

The VOMS.

RESULTS

Female sex (χ2 = 4.9, P = 0.03), on-field dizziness (χ2 = 7.1, P = 0.008), fogginess (χ2 = 10.3, P = 0.001), and post-traumatic migraine (PTM) symptoms including headache (χ2 = 16.7, P = 0.001), nausea (χ2 = 10.9, P = 0.001), light sensitivity (χ2 = 14.9, P = 0.001), and noise sensitivity (χ2 = 8.7, P = 0.003) were associated with presence of one or more postconcussion VOMS score above clinical cutoff. On-field dizziness (χ2 = 3.8, P = 0.05), fogginess (χ2 = 7.9, P = 0.005), and PTM-like symptoms including nausea (χ2 = 9.0, P = 0.003) and noise sensitivity (χ2 = 7.2, P = 0.007) were associated with obtaining a postconcussion near-point convergence (NPC) distance cutoff >5 cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively.

CONCLUSIONS

Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment after SRC.

Predicting Risk of Sport-Related Concussion in Collegiate Athletes and Military Cadets: A Machine Learning Approach Using Baseline Data from the CARE Consortium Study

OBJECTIVE

To develop a predictive model for sport-related concussion in collegiate athletes and military service academy cadets using baseline data collecting during the pre-participation examination.

METHODS

Baseline assessments were performed in 15,682 participants from 21 US academic institutions and military service academies participating in the CARE Consortium Study during the 2015-2016 academic year. Participants were monitored for sport-related concussion during the subsequent season. 176 baseline covariates mapped to 957 binary features were used as input into a support vector machine model with the goal of learning to stratify participants according to their risk for sport-related concussion. Performance was evaluated in terms of area under the receiver operating characteristic curve (AUROC) on a held-out test set. Model inputs significantly associated with either increased or decreased risk were identified.

RESULTS

595 participants (3.79%) sustained a concussion during the study period. The predictive model achieved an AUROC of 0.73 (95% confidence interval 0.70-0.76), with variable performance across sports. Features with significant positive and negative associations with subsequent sport-related concussion were identified.

CONCLUSION(S)

This predictive model using only baseline data identified athletes and cadets who would go on to sustain sport-related concussion with comparable accuracy to many existing concussion assessment tools for identifying concussion. Furthermore, this study provides insight into potential concussion risk and protective factors.

Factors Associated With Self-Reported Concussion History in Middle School Athletes

OBJECTIVE

Identifying personal characteristics associated with sustaining a concussion is of great interest, yet only a few have examined this in children. The purpose of this study was to examine the association between sex, neurodevelopmental disorders, health history, and lifetime history of self-reported concussion in 12- and 13-year-old athletes.

DESIGN

Cross-sectional study.

SETTING

Middle schools.

PARTICIPANTS

Participants were 1744 twelve- and thirteen-year-old student athletes who completed preseason Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) testing, including a self-report questionnaire about previous concussions, developmental diagnoses, and previous medical treatment.

INDEPENDENT VARIABLES

Age, sex, attention-deficit/hyperactivity disorder (ADHD), learning disabilities (LDs), and previous treatment for migraine.

MAIN OUTCOME MEASURES

Self-reported history of concussion.

RESULTS

A minority of athletes (13.7%) reported previous concussions (1 concussion, n = 181; 2 concussions, n = 41; and 3+ concussions, n = 17). A small proportion reported a history of ADHD (4.4%), LD (2.8%) or migraine treatment (4.0%). Higher rates of self-reported previous concussions were associated with male sex [16.9% vs 9.1%; χ(1) = 21.47, P < 0.001] and previous migraine treatment [31.9% vs 13.0%; χ(1) = 20.08, P < 0.001]. There were no differences in self-reported concussion history between 12- and 13-year olds (P = 0.18) and those with/without ADHD (P = 0.41) or LDs (P = 0.06). The overall logistic regression model was statistically significant [χ(5) = 42.01, P < 0.001] but explained only 4.3% of the variance. Previous treatment for migraine [P < 0.001, Exp(B) = 3.30] and male sex [P < 0.001, Exp(B) = 2.06] were independently associated with a self-reported concussion history, whereas age, LD, and ADHD were not (P's > 0.05).

CONCLUSIONS

Male sex and previous migraine treatment were associated with higher rates of self-reported previous concussions in both independent and multivariate models in middle school athletes, whereas age, ADHD, and LDs were not.

Family History of Migraine Associated With Posttraumatic Migraine Symptoms Following Sport-Related Concussion

OBJECTIVE

To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes.

SETTING

Outpatient concussion clinic.

PARTICIPANTS

A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years).

DESIGN

Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury.

MAIN MEASURES

Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening.

RESULTS

Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P <.001) and (2) Vestibular/Ocular Motor Screening (VOMS) (F = 8.52, P < .001). There was no main effect for family history of migraine on ImPACT/PCSS (P = .22) and VOMS (P = .83) or interaction between family history of migraine and PTM on ImPACT/PCSS (P = .84) and VOMS (P = .52).

CONCLUSION

Family history of migraine is associated with PTM symptoms following sport-related concussion, suggesting a genetic predisposition for migraine may serve as a catalyst or trigger for onset of PTM. However, only presence of PTM, rather than family history of migraine, was related to worse neurocognitive and vestibular/oculomotor outcomes.

Migraine and traumatic brain injury: a cohort study in Taiwan

OBJECTIVE

Traumatic brain injury is now a major contributor to the global healthcare burden. Migraine is another debilitating disease with a global health impact. While most researchers agree that traumatic brain injury is a risk factor for migraine, whether migraine is a risk factor for traumatic brain injury still remains under debate. We therefore aimed to investigate whether migraine was a risk factor for developing traumatic brain injury.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING

Data for people who had been diagnosed with migraine were retrieved from Taiwan's National Health Insurance Research Database.

PARTICIPANTS

We identified 7267 patients with newly diagnosed migraine during 1996-2010. The migraineurs to non-migraineurs ratio was set at 1:4 to enhance the power of statistical tests.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multivariate Cox proportional hazard regression models to assess the effects of migraines on the risk of traumatic brain injury after adjusting for potential confounders.

RESULTS

The overall traumatic brain injury risk was 1.78 times greater in the migraine group compared with the non-migraine group after controlling for covariates. Additionally, patients with previous diagnoses of alcohol-attributed disease, mental disorders and diabetes mellitus had a significantly higher traumatic brain injury risk compared with those with no history of these diagnoses.

CONCLUSIONS

This study of a population-based database indicated that migraine is a traumatic brain injury risk factor. Greater attention to migraine-targeted treatment modalities may reduce traumatic brain injury-related morbidity and mortality.

Sport-Related Concussions: Symptom Recurrence After Return to Exercise

Background:

Current guidelines dictate a gradual exercise progression after a concussion; however, it is unclear what proportion of athletes experience a recurrence of symptoms once they are symptom free at rest. Estimating the proportion of athletes and predictors of symptom recurrence would help shape return-to-play protocols.

Purpose:

To determine the proportion and associated risk factors of athletes who have a recurrence of concussion symptoms with exercise after being symptom free at rest.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Between October 1, 2009 and July 31, 2011, we studied patients from a sport concussion clinic located within a tertiary care regional children’s hospital. Patients were queried at every visit using a standardized questionnaire. Our main outcome variable was recurrence of symptoms with exercise after being symptom free at rest at some point in their recovery. Cofactors included age, sex, loss of consciousness with injury, prior concussion (diagnosed and undiagnosed), Post-Concussion Symptom Scale (PCSS) score, time until clinical presentation, and duration of symptoms.

Results:

Of the 217 patients included, 25 (12%) experienced a return of symptoms. Losing consciousness at the time of injury and a longer duration between injury and clinical presentation were associated with a decreased risk of symptoms recurring with exercise. Conversely, athletes who had sustained previously undiagnosed concussions and had suffered a longer duration of symptoms at rest were at an increased risk of symptom recurrence with exercise.

Conclusion:

Relatively few athletes who are symptom free at rest after a concussion will have a recurrence of symptoms when they resume exercise. The risk of symptoms recurring with exercise may be greater among those athletes who sustained previously undiagnosed concussions and had a longer period of symptoms at rest. The early identification of athletes who may be at risk of symptom recurrence will help mold treatment guidelines and exercise progression protocols.

Head Impact Density: A Model To Explain the Elusive Concussion Threshold

Concussion is a heterogeneous injury occurring throughout a range of impact magnitudes. Consequently, research focusing on a single or set of variables at the time of injury to understand concussive biomechanics has been thwarted by low injury prediction sensitivity. The current study examined the role of Impact Density in estimating concussive injury risk. Head impact data were collected across seven high school football seasons with the Head Impact Telemetry System (HIT System). Over the study period, 29 concussions were included for data analysis. The linear acceleration of the concussive impact was matched to a Control athlete, along with impacts in the 24 h before. Linear and rotational acceleration for the 19 impacts leading into the final event and the cumulative accelerations over time were evaluated. Analyses indicated no difference in impact counts within the final 24 h, or impact magnitudes for linear and rotational acceleration among the final 20 impacts (p > 0.05). A novel metric, Impact Density, was calculated from the final 20 impacts by summing the acceleration magnitude divided by time from the previous impact. Analyses indicated the Concussed athletes incurred a significantly higher linear (concussed: 255.4g/sec (standard error of the mean [SEM] = 40.1), controls:145.4g/sec (SEM = 23.8), p = 0.016), and rotational (Concussed:10311.3 rad/s/s/s (SEM = 1883.7), Controls: 6083.8 rad/s/s/s (SEM = 1115.9), p = 0.029) Impact Density than the Control athletes. Similar to other investigations, there was no difference in individual linear or rotational impact magnitude in the 20 impacts before and including the injury. The measure of Impact Density, however, revealed differences between the Concussed and Control athletes. These data suggest that the biomechanical threshold for concussion fluctuates downwardly with a greater impact magnitude and number with a return to pre-impact levels with time, suggesting physiological vulnerability to repeated head impacts. The current results highlight that time between impacts, not just impact magnitude, influences risk for concussion.

Head-Impact-Measurement Devices: A Systematic Review

CONTEXT

With an estimated 3.8 million sport- and recreation-related concussions occurring annually, targeted prevention and diagnostic methods are needed. Biomechanical analysis of head impacts may provide quantitative information that can inform both prevention and diagnostic strategies.

OBJECTIVE

To assess available head-impact devices and their clinical utility.

DATA SOURCES

We performed a systematic search of the electronic database PubMed for peer-reviewed publications, using the following phrases: accelerometer and concussion, head impact telemetry, head impacts and concussion and sensor, head impacts and sensor, impact sensor and concussion, linear acceleration and concussion, rotational acceleration and concussion, and xpatch concussion. In addition to the literature review, a Google search for head impact monitor and concussion monitor yielded 15 more devices.

STUDY SELECTION

Included studies were performed in vivo, used commercially available devices, and focused on sport-related concussion.

DATA EXTRACTION

One author reviewed the title and abstract of each study for inclusion and exclusion criteria and then reviewed each full-text article to confirm inclusion criteria. Controversial articles were reviewed by all authors to reach consensus.

DATA SYNTHESIS

In total, 61 peer-reviewed articles involving 4 head-impact devices were included. Participants in boxing, football, ice hockey, soccer, or snow sports ranged in age from 6 to 24 years; 18% (n = 11) of the studies included female athletes. The Head Impact Telemetry System was the most widely used device (n = 53). Fourteen additional commercially available devices were presented.

CONCLUSIONS

Measurements collected by impact monitors provided real-time data to estimate player exposure but did not have the requisite sensitivity to concussion. Proper interpretation of previously reported head-impact kinematics across age, sport, and position may inform future research and enable staff clinicians working on the sidelines to monitor athletes. However, head-impact-monitoring systems have limited clinical utility due to error rates, designs, and low specificity in predicting concussive injury.

Potential factors influencing recovery from concussion in collegiate student-athletes

Background

Factors including sex, previous diagnosis of migraines, previous diagnosis of Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder, and a history of concussion may influence the length of recovery from concussion in collegiate student-athletes.

Purpose

To better understand factors that may influence recovery from concussion in collegiate-student athletes.

Methods

A total of 91 student-athletes from a Division I NCAA University who sustained concussions from the fall of 2011 to the spring of 2015 were evaluated. They were considered recovered from their concussion when neurocognitive and symptom scores returned to baseline and they were cleared by their physician. Analyses of variance were conducted to determine if potential factors influenced concussion recovery ( p < .0125).

Results

No significant differences were found for sex (males = 7.4 ± 5.9; females = 8.3 ± 4.8 days; p = 0.417), previous diagnosis of migraines (diagnosis = 8.0 ± 5.7; no diagnosis = 7.8 ± 5.4 days; p = 0.926), or history of concussion (history = 8.3 ± 5.7; no history = 5.6 ± 3.4 days; p = 0.088). However, a significant difference in the length of recovery was found between those with a previous diagnosis of Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder and those without (diagnosis = 13.3 ± 7.3; no diagnosis = 7.3 ± 4.9 days; p = 0.002).

Conclusion

Student-athletes with Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder show significantly longer recovery from concussions than those without. Further investigation of this and other factors that influence recovery from concussion may help in concussion recovery and return-to-play guidelines that improve student-athlete well-being.

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.

Initial somatic symptoms are associated with prolonged symptom duration following concussion in adolescents

AIM

To determine which initial postinjury symptom domains are independently associated with symptoms lasting >28 days in youth athletes who sustained sport-related concussions.

METHODS

Patients who presented for care at a sport concussion clinic completed the postconcussion symptom scale. They were classified into two groups: those who reported symptom resolution within 28 days of injury and those who did not. Logistic regression models were constructed for children and adolescents to determine the independent association between symptom recovery and potential predictor variables: initial symptom scores in 5 postconcussion symptom scale domains (somatic, vestibular-ocular, cognitive, sleep and emotional), sex, loss of consciousness or amnesia at the time of injury, history of prior concussion, prior treatment for headaches or migraines, or family history of concussion.

RESULTS

Sixty-eight child (8-12 years of age) and 250 adolescent (13-18 years of age) athletes were included. For adolescents, initial somatic symptom severity was independently associated with prolonged symptom duration (adjusted odds ratio = 1.162; 95% CI: 1.060, 1.275) and no other predictor variables were. No potential predictor variables were independently associated with prolonged symptom duration for children.

CONCLUSION

Among adolescent athletes, a high initial somatic symptom burden (e.g. headache, nausea, vomiting, etc.) is associated with increased odds of symptoms beyond 28 days postinjury.

The Controversial Second Impact Syndrome: A Review of the Literature

BACKGROUND

Second impact syndrome is a devastating injury that primarily affects athletic children and young adults. It occurs when a second concussion occurs before symptoms from the first concussion have resolved. Diffuse and often catastrophic cerebral edema results. Reports of second impact syndrome are few, and some argue that second impact syndrome is simply diffuse cerebral swelling unrelated to the first concussion.

METHODS

Ovid and PubMed were searched from years 1946 to 2015 using the terms "second impact syndrome," "repeat concussion," and "catastrophic brain injury." In addition, review articles were found using a combination of the terms, "concussion," "second impact syndrome," and "repetitive head trauma."

RESULTS

Seventeen patients in seven publications met the criteria of having two witnessed hits and persistent symptoms from the first to the second concussion. Ten of the 17 (59%) included individuals were football players. All were male. Ages ranged from 13 to 23 years. All children with poor outcomes (death or permanent disability) were younger than 20 years, while four of the five players with good outcomes were older than 19 years. The lag time from first to second concussion ranged from one hour to four weeks, and in many cases, at least one of the two hits appeared minor.

CONCLUSIONS

American football, male gender, and young age appear to be associated with second impact syndrome. Controversies surrounding this syndrome are discussed. There is a need for prospective studies to clarify risk factors and outcomes of second impact syndrome to guide return-to-play recommendations for young athletes.

Initial symptom burden predicts duration of symptoms after concussion

OBJECTIVES

To determine which variables predict prolonged (>28 days) duration of symptoms after a concussion.

DESIGN

We conducted a prospective cohort study of adult (>18yo) patients cared for in a specialty concussion clinic.

METHODS

Symptoms were assessed using the Post-Concussion Symptom Scale (PCSS) developed at the 3rd International Conference on Concussion in Sports. Possible predictors including age, sex, loss of consciousness, amnesia, history of prior concussion, prior treatment for headaches, history of migraines, and family history of concussions, were measured by self-report. We recorded a PCSS score at each clinical visit and defined time to symptom resolution as the number of days between the date of injury and date of last symptoms.

RESULTS

Of 64 adult patients included in the study, 53.3% were male; 20.3% reported experiencing a loss of consciousness at the time of injury while 23.4% reported amnesia. Patients ranged in age from 18 to 27 years (mean 21±2 years). Most concussions (92.2%) occurred during sports. The mean initial PCSS score for those suffering symptoms for longer than 28 days was significantly higher than those who symptoms resolved within 28 days (42.5 vs. 19.2, p<0.01). Of all potential predictor variables, only the initial PCSS score was independently associated with the odds of symptoms lasting longer than 28 days (aOR 1.037; 95% CI 1.011, 1.063).

CONCLUSIONS

Among adult patients with concussions, those with a higher symptom burden after injury have an increased odds of suffering from prolonged symptoms. Other potential predictor variables are not associated with the risk of prolonged recovery.

Traumatic axonal injury and persistent emotional lability in an adolescent following moderate traumatic brain injury: A case study

A 15-year-old male was treated secondary to sustaining a moderate traumatic brain injury (moderate TBI). Symptom self-report, and computerized and paper-and-pencil-based neurocognitive, vestibular/ocular motor, and imaging data were used throughout to document impairment and recovery. The patient demonstrated persistent emotional lability concurrent with vestibular impairment. In addition to clinical evaluation and management, the patient also underwent susceptibility-weighted imaging, which revealed axonal shearing across the corpus callosum and areas innervating the prefrontal cortex. Paper-and-pencil neurocognitive measures revealed persisting deficits, despite normal-appearing computerized test results. Implications of this case underline the importance of an integrative evaluation process including clinical interview, neurocognitive and vestibular/ocular physical therapy, and advanced neuroimaging, especially in cases with atypical presentation.

Demographics and treatment of adolescent posttraumatic headache in a regional concussion clinic

OBJECTIVE

Mild traumatic brain injury affects over one million pediatric patients annually. Minimal data and no guidelines exist regarding treatment of posttraumatic headache (PTH). The current study investigated treatment and outcomes in patients with posttraumatic headache.

METHODS

Medical records of all patients (age 13-18 years of age) seen at a regional concussion program from 2006 to 2011 were reviewed. Statistical analysis using SAS 9.2 was conducted to determine the effectiveness of treatment as well as the association of gender, concussion history, and football participation on the duration of posttraumatic headache.

RESULTS

Four hundred subjects met the inclusion criteria. Females were more likely to report posttraumatic headache than males (90% vs. 79%, P = 0.004), more likely to be prescribed amitriptyline (24% vs. 13%, P = 0.004), and had a significantly longer recovery time (median, 80 days versus 34 days, P < 0.001). Seventeen percent of subjects were prescribed amitriptyline for treatment of posttraumatic headache, of which 82% reported a beneficial effect. There was no difference in the percentage of posttraumatic headache or recovery time in football players versus other male athletes from other sport mechanisms.

CONCLUSION

Females are more likely to report posttraumatic headache than males and also take longer to recover. Amitriptyline appears to be well-tolerated and an effective treatment strategy for patients with posttraumatic headache. Among pediatric patients evaluated in a concussion clinic, there is no difference in the proportion of football players reporting headaches compared with male players of other sports.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.

Expert consensus document: Mind the gaps—advancing research into short-term and long-term neuropsychological outcomes of youth sports-related concussions

Sports-related concussions and repetitive subconcussive exposure are increasingly recognized as potential dangers to paediatric populations, but much remains unknown about the short-term and long-term consequences of these events, including potential cognitive impairment and risk of later-life dementia. This Expert Consensus Document is the result of a 1-day meeting convened by Safe Kids Worldwide, the Alzheimer's Drug Discovery Foundation, and the Andrews Institute for Orthopaedics and Sports Medicine. The goal is to highlight knowledge gaps and areas of critically needed research in the areas of concussion science, dementia, genetics, diagnostic and prognostic biomarkers, neuroimaging, sports injury surveillance, and information sharing. For each of these areas, we propose clear and achievable paths to improve the understanding, treatment and prevention of youth sports-related concussions.

Factors Influencing Risk and Recovery from Sport-Related Concussion: Reviewing the Evidence

Identifying factors that influence the risk and recovery from sport-related concussion (SRC) has become an important part of the clinical management of the injury. Consensus statements and clinical anecdotes have suggested several factors (i.e., history of migraine headaches) that may increase risk or lead to a protracted recovery from SRC. In the current paper, we will present evidence supporting primary and secondary risk factors listed in current consensus statements and relevant literature on emerging factors proposed to influence SRC risk and recovery.

Early symptom burden predicts recovery after sport-related concussion

OBJECTIVE

To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion.

METHODS

We conducted a prospective cohort study of patients in a sports concussion clinic. Participants completed questionnaires that included the Post-Concussion Symptom Scale (PCSS). Participants were asked to record the date on which they last experienced symptoms. Potential predictor variables included age, sex, score on symptom inventories, history of prior concussions, performance on computerized neurocognitive assessments, loss of consciousness and amnesia at the time of injury, history of prior medical treatment for headaches, history of migraines, and family history of concussion. We used recursive partitioning analysis to develop a multivariate prediction model for identifying athletes at risk for a prolonged recovery from concussion.

RESULTS

A total of 531 patients ranged in age from 7 to 26 years (mean 14.6 ± 2.9 years). The mean PCSS score at the initial visit was 26 ± 26; mean time to presentation was 12 ± 5 days. Only total score on symptom inventory was independently associated with symptoms lasting longer than 28 days (adjusted odds ratio 1.044; 95% confidence interval [CI] 1.034, 1.054 for PCSS). No other potential predictor variables were independently associated with symptom duration or useful in developing the optimal regression decision tree. Most participants (86%; 95% CI 80%, 90%) with an initial PCSS score of <13 had resolution of their symptoms within 28 days of injury.

CONCLUSIONS

The only independent predictor of prolonged symptoms after sport-related concussion is overall symptom burden.

Risk modifiers for concussion and prolonged recovery

Context:

Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may affect concussion risk and the likelihood of prolonged recovery can be of value to providers who manage concussion.

Evidence Acquisition:

Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and risk or risk factor. Targeted searches for specific risk factors were conducted with additional keywords, such as gender and migraine. Manual review of reference lists was also performed to identify pertinent literature.

Results:

For risk factors of concussion, history of prior concussion and female sex have the most supporting evidence. Sports with consistently high risk for sustaining a concussion include football, men’s ice hockey, and women’s soccer. Younger athletes appear to be more susceptible to concussion, but data are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though it protects against other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms appear to be associated with prolonged recovery. Younger age may also increase the risk of prolonged concussion.

Conclusion:

High-quality evidence for risk modifiers in concussion remains sparse. Prior concussion, collision sports, female sex, and women’s soccer are the strongest known risk factors. Evidence for most other factors is inconclusive.

Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not

OBJECTIVE

To identify predictors of prolonged symptoms in athletes who sustain concussions.

STUDY DESIGN

This was a multicenter prospective cohort study of patients in 2 sport concussion clinics. Possible predictors of prolonged symptoms from concussion were compared in 2 groups, those whose symptoms resolved within 28 days and those whose symptoms persisted beyond 28 days. Candidate predictor variables were entered into a logistic regression model that was used to generate aORs.

RESULTS

A total of 182 patients met the inclusion criteria during the study period. The mean patient age was 15.2 ± 3.04 years. More than one-third of the patients (n = 65) underwent computerized neurocognitive testing on their initial visit. On univariate analyses, Post-Concussion Symptom Scale (PCSS) score and all composite scores on computerized neurocognitive testing were apparently associated with prolonged symptom duration. Sex, age, loss of consciousness at time of injury, and amnesia at time of injury were not associated with prolonged symptom duration. After adjusting for potential confounding, only total PCSS score was associated with the odds of suffering prolonged symptoms.

CONCLUSION

Further efforts to develop clinical tools for predicting which athletes will suffer prolonged recoveries after concussion should focus on initial symptom score.

Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion

BACKGROUND

Although previous research has demonstrated that patients with posttraumatic migraine (PTM) after concussion report more symptoms and cognitive deficits after injury than do those without PTM, it is not known whether these effects persist beyond the first week of injury or whether PTM predicts recovery time.

PURPOSE

To determine whether PTM during the first week after injury predicts (1) cognitive impairment and symptoms in the second week after injury and (2) overall recovery time.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Participants were 138 male high school football players with a mean age of 15.96 years (SD, 1.18 years; range, 13-19 years). They were classified into 3 groups: PTM (headache, nausea, and photosensitivity or phonosensitivity), headache (headache without the other PTM symptoms), or no headache (no headache or PTM symptoms). The Immediate Post-concussion Assessment and Cognitive Test (ImPACT) was used to assess cognitive performance and symptoms at baseline, postinjury days 1-7, and postinjury days 8-14. Recovery time data were collected from medical records.

RESULTS

The PTM group performed worse on verbal memory than did the headache group at 8-14 days after injury. The PTM group performed worse on visual memory, reaction time, and symptoms than did the other groups at 1-7 days and 8-14 days after injury. The PTM group was 7.3 times (95% confidence interval, 1.80-29.91) more likely to have protracted recovery (>20 days) than the no headache group and 2.6 times (95% confidence interval, 1.10-6.54) more likely than the headache group.

CONCLUSION

Results suggest that PTM is associated with cognitive impairments and protracted recovery and that headache alone is not a good predictor of recovery.

Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery

Little scientific attention has been aimed at the non-acute clinical care of pediatric mild TBI. We propose a clinical management model focused on both evaluation and intervention from the time of injury through recovery. Intervention strategies are outlined using a framework encompassing four relevant domains: the individual youth, family, school, and athletics. Clinical management has primary value in its potential to speed recovery, minimize distress during the recovery process, and reduce the number of individuals who subjectively experience longer lasting postconcussive problems. With proper management, most children and adolescents sustaining an uncomplicated mild TBI can be expected to recover fully.

Pediatric minor traumatic brain injury

The literature surrounding minor traumatic brain injury is complex, methodologically challenging, and controversial. Although we lack a consistent standardized definition, the annual rate is likely in excess of 200 per 100,000 children. The proportion of children with minor traumatic brain injury who will require neurosurgery is certainly <1%. Several studies are underway that have the potential to significantly advance our understanding of the specific risk factors for intracranial injury and more specifically neurosurgical injury. The mortality within children is very low, with estimates of 0% to 0.25%. Virtually all studies of the prognosis of minor brain injury in children have reported no long-term behavioral or cognitive sequelae as a specific result of the brain injury. Symptoms fall in 4 domains: somatic, cognitive, sleep/fatigue, and affective. Limited pediatric studies are available to assist clinicians in the prognosis or in optimizing recovery. Until further studies are available, a conservative approach is recommended. Children with suspected concussions should be removed from activity and observed. Children with symptomatic concussions must be limited to no physical activity. Adolescents and families need to self-monitor symptoms and limit environments or circumstances that exacerbate any symptoms. When symptoms resolve, a gradual progressive return to play is currently recommended. The recurrence risk for subsequent concussions is elevated, but there is limited documentation of the effectiveness of preventative efforts. Much remains to be learned.