Post-traumatic headache attributed to traumatic brain injury: classification, clinical characteristics, and treatment.

Post-traumatic headache is a common sequela of traumatic brain injury and is classified as a secondary headache disorder. In the past 10 years, considerable progress has been made to better understand the clinical features of this disorder, generating momentum to identify effective therapies. Post-traumatic headache is increasingly being recognised as a heterogeneous headache disorder, with patients often classified into subphenotypes that might be more responsive to specific therapies. Such considerations are not accounted for in three iterations of diagnostic criteria published by the International Headache Society. The scarcity of evidence-based approaches has left clinicians to choose therapies on the basis of the primary headache phenotype (eg, migraine and tension-type headache) and that are most compatible with the clinical picture. A concerted effort is needed to address these shortcomings and should include large prospective cohort studies as well as randomised controlled trials. This approach, in turn, will result in better disease characterisation and availability of evidence-based treatment options.

Acute Effects of Concussion in Youth With Pre-existing Migraines.

OBJECTIVE: To examine associations between pre-existing migraines and postconcussion symptoms and cognitive performance acutely (within 72 hours) after a suspected concussion. DESIGN: Nested case-control study. SETTING: High schools in Maine, USA. PARTICIPANTS: From a sample of 39 161 adolescent athletes who underwent baseline preseason testing, 633 were assessed within 3 days of a suspected concussion. Of these, 59 reported a history of treatment for migraines at baseline (9.3%). These athletes were individually matched to 2 athletes who had a suspected concussion but denied preinjury migraines (total N = 177; age: M = 15.8, SD = 1.3). ASSESSMENT OF RISK FACTORS: Self-reported history of treatment for migraines by a physician. MAIN OUTCOME MEASURES: Post-Concussion Symptom Scale total score, ImPACT composite scores, and individual symptom endorsement. RESULTS: Individuals with a pre-existing migraine disorder endorsed greater symptom severity (M = 8.4, SD = 9.9) compared with controls (M = 4.5, SD = 6.5; Cohen's d = 0.47) at preinjury baseline and acutely after suspected injury (migraine: M = 26.0, SD = 25.5; controls: M = 16.7, SD = 15.4; d = 0.44). Acutely after a suspected concussion, greater proportions of athletes with migraine disorders reported mental fogginess (49.2% vs 33.9%) and memory problems (39.0% vs 24.6%; P < 0.05). Baseline ImPACT composite scores were similar between migraine and control groups (d = 0.04-0.13). Adolescents with pre-existing migraine disorders performed worse after a suspected concussion compared with the control participants on verbal memory (F = 4.32, P = 0.041) and visual memory (F = 3.95, P = 0.049). CONCLUSIONS: Individuals with pre-existing migraine disorders may be at higher risk for worse outcomes, including greater overall burden of symptoms and worse cognitive functioning in the memory domain, in the first 72 hours after concussion.

Concussion occurrence and recognition in professional boxing and MMA matches: toward a concussion protocol in combat sports.

Objectives: Determine, through video reviews, how often concussions occur in combat sport matches, what influence they have on the outcome, and how well non-physician personnel can be trained to recognize concussions.Methods: This is a retrospective video analysis by an 8-person panel of 60 professional fights (30 boxing and 30 mixed martial arts). Through video review, physician and non-physician personnel recorded details about each probable concussion and determined if and when they would have stopped the fight compared to the official stoppage time.Results: A concussion was recorded in 47/60 fights. The mean number of concussions per minute of fight time was 0.061 (0.047 for boxers and 0.085 for MMA). When stratifying by outcome of the bout, the mean number of concussions per minute for the winner was 0.010 compared to the loser at 0.111 concussions per minute. The fighter that sustained the first concussion ultimately lost 98% of the time. The physician and non-physician raters had high agreement regarding the number of concussions that occurred to each fighter per match. The physician raters judged that 24 of the 60 fights (11 boxing [37%]; 13 MMA [43%]) should have been stopped sooner than what occurred.Conclusion: Recognizing that the concussions often occur in combat sport matches, that the losing fighter almost always is concussed first and tends to sustain more concussions during the fight, along with the demonstration that non-physician personnel can be taught to recognize concussion, may guide policy changes that improve brain health in combat sports.

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.

Testosterone levels in men with chronic migraine.

Chronic migraine is a frequent and debilitating condition affecting 14% of the general population. This prospective observational pilot study investigated whether men with chronic migraine have lower than expected total serum testosterone levels. We identified 14 men ages 26-51 at our Institution who fulfilled the ICHD-3b criteria for chronic migraine and obtained serum total testosterone levels. The mean total testosterone level in our 14 patients was 322 ng/dL (range: 120-542 ng/dL) which is in the lower 5% of the reference range for our laboratory (300-1080 ng/dL). Men with chronic migraine had lower total testosterone levels compared to published agematched normative median values by a median difference of 62 ng/dL (P=0.0494). This finding suggests that hypothalamic regulation is altered in patients with chronic migraine. Further studies are warranted to determine whether testosterone supplementation in men with chronic migraine reduces the number of headaches or the associated symptoms of hypogonadism.

The relationship of migraine and other headache disorders to concussion.

Concussion and migraine share many similar pathophysiologic mechanisms, including cortical spreading depression and failure in brain ion homeostasis. Migraine may predispose to concussion, and migraine and posttraumatic headache are common following concussion. This overlap may interfere with proper diagnosis following sport injury, thereby delaying either appropriate treatment or return-to-play. Posttraumatic headache is the most common symptom following concussion, and although symptoms are indistinguishable from migraine, persistent posttraumatic headache may be a unique entity that is more refractory to traditional headache management. There are few studies investigating the diagnosis and treatment of posttraumatic headache. This chapter provides a broad overview of migraine and other headache disorders in sport, with a specific focus on emerging treatment paradigms for posttraumatic headache.

Preinjury Migraine History as a Risk Factor for Prolonged Return to School and Sports following Concussion.

Having a preexisting migraine disorder might be a risk factor for a prolonged recovery following a sport-related concussion. We examined whether having a migraine history was associated with a prolonged return to academics and athletics following a concussion. High school and collegiate athletes (n = 1265; 42% female) who sustained a sport-related concussion were monitored by athletic trainers using a web-based surveillance system that collects information about concussion recovery. Nonparametric Kolmogorov-Smirnov tests (KS) were used to compare days to return to academics/athletics across groups due to non-normally distributed outcome variables and unequal distributions of scores between groups. Chi-squared tests were used to examine the proportion of players who had not returned to academics/athletics at 7, 14, and 21 days post-injury stratified by self-reported migraine history. There were 117 athletes (9.2%) who reported a preinjury migraine history. Athletes with a history of migraine took a median of 6 days to return to academics (mean [M] = 10.6, standard deviation [SD] = 14.2) and 15.5 days to return to athletics (M = 23.8, SD = 30.8), while those with no migraine history took a median of 5 days to return to academics (M = 7.5, SD = 10.9) and 14 days to return to athletics (M = 19.4, SD = 19.4). There were no statistically significant differences in days to return to school or athletics between the groups (KS p > 0.05). However, a lower percentage of athletes with a history of migraine had returned to school after 7 days (57% vs. 68%, χ2 = 5.53, p = 0.02), 14 days (75% vs. 88%, χ2 = 14.21, p < 0.001), and 21 days post-injury (89% vs. 94%, χ2 = 4.90, p = 0.03). Stratifying the analyses by sex showed that this effect was significant in girls and women with preexisting migraines, but not boys and men with preexisting migraines. There were no group differences in recovery rates when examining return to athletics. Athletes with a preinjury migraine history may be at an elevated risk for a protracted return to school after concussion, especially girls and women.

Neurologic Health in Combat Sports.

Neurologic injuries of both an acute and chronic nature have been reported in the literature for various combat sport styles; however, reports of the incidence and prevalence of these injury types vary greatly. Combat sports clinicians must continue to strive for the development, implementation, and enforcement of uniform minimum requirements for brain safety. These health care providers must also seize on the honor to provide this oft-underserved population with the health care advocacy they very much deserve, but often do not receive.

Comprehensive Headache Experience in Collegiate Student-Athletes: An Initial Report From the NCAA Headache Task Force.

BACKGROUND: The prevalence of primary headache disorders in the general population provides a unique challenge in the evaluation of headache occurring in the context of sport. Despite a wealth of studies exploring the epidemiology of headache in the layperson, little is known about the prevalence and nature of headaches in collegiate student-athletes. These scenarios are challenging in the return to play context, as it is often unclear whether an athlete has an exacerbation of a primary headache disorder, new onset headache unrelated to trauma, or has suffered a concussive injury. PURPOSE: To establish the prevalence and nature of headaches in collegiate student-athletes. STUDY DESIGN: Retrospective cross-sectional survey. METHODS: This cross-sectional survey evaluated the characteristics and prevalence of headache in 834 student-athletes from four NCAA Division-I institutions. Because headache occurrence may vary by sport (collision, contact, non-contact), by sex, and medical history, our sample included male and female athletes in a variety of sports, with differing degrees of contact exposure. The 20 question survey collected data on personal and family history of headache, as well as concussion history. RESULTS: A total of 23.7% (n = 198) of participants reported having a personal history of migraine, 25.2% (n = 210) history of sinus headache, and 12.3% (n = 103) history of tension type headache. Among athletes with a prior history of concussion, 46.3% (n = 25) of females reported a history of migraine, while only 32.2% of males reported history of migraine (χ2 = 3.421, P = .064). CONCLUSIONS: The etiology of increased prevalence of migraine in our study is unclear. Whether this is due to increased awareness of headache disorders, a consequence of contact exposure, or a predisposition for migraine development in this age group remains unclear. Further studies are indicated.

Rest and treatment/rehabilitation following sport-related concussion: a systematic review.

AIM OR OBJECTIVE: The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC). DESIGN: Systematic review. DATA SOURCES: MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded. RESULTS: Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care. SUMMARY/CONCLUSIONS: A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2016:CRD42016039570.

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.

Sports Neurology in Clinical Practice: Case Studies.

With regard to persistent posttraumatic headache, there is legitimate concern that duration of symptoms may have an impact on the efficacy of future treatment attempts. Without neuropathologic confirmation, a clinical diagnosis of chronic traumatic encephalopathy cannot be made with a high degree of confidence. Sport-related headaches are challenging in a return-to-play context, because it is often unclear whether an athlete has an exacerbation of a primary headache disorder, has new-onset headache unrelated to trauma, or is in the recovery phase after concussion. Regular physical exercise may prove beneficial to multiple neurologic disease states.

Post-Traumatic Headache Therapy in the Athlete.

Post-traumatic headache can occur after any traumatic brain injury, regardless of severity. Headache is consistently the most common symptom following concussion and occurs in over 90% of athletes with sports-related concussion. Despite this prevalence, the complaint of headache after a possible concussive injury is often dismissed. Even when sports-related concussion is accurately diagnosed, many athletes fall victim to mismanagement of this associated symptom by clinicians who are not well-versed in headache treatment. Furthermore, benign headaches may also occur incidentally in the context of head trauma. This complex, and often non-specific, nature of headaches provides a significant challenge in return to play decision-making. Post-traumatic headaches are generally categorized according to primary headache disorders in an attempt to guide treatment; however, there is minimal medical literature on headache management in the concussed athlete. There is clearly a continued need for prospective studies of existing treatments and new approaches.

Determining brain fitness to fight: Has the time come?

Professional boxing is associated with a risk of chronic neurological injury, with up to 20-50% of former boxers exhibiting symptoms of chronic brain injury. Chronic traumatic brain injury encompasses a spectrum of disorders that are associated with long-term consequences of brain injury and remains the most difficult safety challenge in modern-day boxing. Despite these concerns, traditional guidelines used for return to sport participation after concussion are inconsistently applied in boxing. Furthermore, few athletic commissions require either formal consultation with a neurological specialist (i.e. neurologist, neurosurgeon, or neuropsychologist) or formal neuropsychological testing prior to return to fight. In order to protect the health of boxers and maintain the long-term viability of a sport associated with exposure to repetitive head trauma, we propose a set of specific requirements for brain safety that all state athletic commissions would implement.

The Pathophysiology of Sports Concussion.

During concussion, the brain is exposed to rapid acceleration, deceleration, and rotational forces, resulting in the stretching and distortion of neural structures. This produces in an injury of transient neurological dysfunction, as evidenced by the clinical symptomatology. It is now evident that recurrent head trauma is also associated with the development of some chronic neurodegenerative disorders. Despite increased awareness of concussion over the past decade, large voids remain in our understanding of its pathophysiology. Prospective longitudinal studies are needed to better understand the underlying biological mechanism of acute concussive injury as it relates to chronic neuropathology.

Expert consensus document: Mind the gaps­advancing 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.

Exercise and neurologic disease.

PURPOSE OF REVIEW: This article provides a practical clinical approach for the role of exercise in the treatment and management of neurologic disorders. RECENT FINDINGS: A number of clinical studies have reported positive benefits from exercise in various neurologic disease states, suggesting that this mode of intervention should be considered as another option in clinical management. SUMMARY: Significant evidence-based data exists confirming the positive effects of exercise in otherwise healthy populations. Good evidence also exists that physical activity may benefit people with long-term neurologic conditions. Despite this evidence, exercise is often neglected in patients with normal aging or neurologic disease progression. Neurologists should counsel patients on this therapeutic adjunct and provide specific recommendations when possible.

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.

Sports concussion and associated post-traumatic headache.

Despite an incidence of approximately 3.8 million sports-related concussions per year, the pathophysiological basis of this injury remains poorly understood. Associated post-traumatic headache, both acute and chronic, can also provide a unique treatment challenge for medical personnel. The presence of new onset or persistent headache following injury often complicates return to play decisions. It is also now evident that recurrent head trauma may be associated with the development of some chronic neurodegenerative disorders. Although anecdotal reports and consensus guidelines are utilized in the management of sports concussion and associated post-traumatic headache, further evidence-based data are needed. Improved prevention and management of this injury will occur with ongoing educational and research efforts. As such advances are made, it is imperative the headache specialist have continued understanding of this evolving field.