Concussion-Related Migraine May Be Common in Young Athletes

Migraine associated with concussion appears to be more prevalent among young athletes than is currently appreciated, two new studies suggest.

In a survey of 74 high school football players, a third each reported having a history of previous concussion and of migraine.

In the other study, an examination of 25 children and adolescents with sports-related concussion, over two thirds had symptoms consistent with migraine.

Taken together, the data suggest that “Clinicians must be aware of the various presentations of both primary headaches like migraine as well as postconcussive headaches so that a correct diagnosis can be made and effective treatment instituted,” the first paper’s author, Tad D. Seifert, MD, director of the Sports Concussion Program at Norton Healthcare and clinical assistant professor of neurology at the University of Kentucky, Louisville said.

Dr Seifert, who also heads the Headache Task Force of the National Collegiate Athletic Association, added, “a comprehensive preseason evaluation that reviews personal headache history, family history of headache, and documentation of previous head trauma is imperative [in order] to aid medical staff in the diagnosis and management of future headache complaints.”

Lead author of the second paper, Devon A. Cohen, student at University of Miami School of Medicine, Florida, said, “Pediatric athletes suffering from posttraumatic headache following concussion experience significant disability and must be treated appropriately. This involves early intervention with an optimized treatment plan tailored to the patient and headache phenotype, in order to prevent progression to a chronic headache disorder. Patient education and implementation of a graded return to play are integral to the management of these patients.”

Both studies were presented here at the American Headache Society (AHS) 57th Annual Scientific Meeting.

Migraine Common in Football Players

In their study, Dr Seifert and colleagues conducted a cross-sectional 20-question survey of 74 competitive football players aged 14 to 18 years from six Louisville-area high schools.

Among them, 25 (34%) reported having a history of migraine and 21 (28%) and reported a history of sinus headache. Of 72 who responded to a question about previous concussion, 27 (37.5%) reported having had at least one concussion in the past, while 8 (11%) reported multiple previous concussions.

Of the 27 with a previous concussion, 11 (41%) reported a personal history of migraine. (The survey didn’t ask about the onset of headache in relation to the concussion.)

The 34% migraine prevalence seen in this population is significantly higher than the 16% estimated prevalence of migraine/probable migraine in the population and brings the question of whether the increase is due to increased awareness of headache disorders, a consequence of physical contact, or a predisposition for migraine development after concussion, Dr Seifert noted.

“These scenarios are challenging with regard to determining when a young athlete can return to play, as it is often unclear whether an athlete has experienced an exacerbation of a preexisting headache disorder, new-onset headache unrelated to trauma, or has suffered a genuine concussive injury,” he said.

Francis X. Conidi, MD, director of the Florida Center for Headache and Sports Neurology in Port St. Lucie, and the principal investigator of Cohen’s study said that Dr Seifert’s results are “quite consistent with my experience, ie patients with a prior history of migraine tend to have a more prolonged course when they suffer a concussion.”

However, he questioned some of the prevalence figures. “I am surprised at the overprevalence of migraine history, as [the prevalence among] males in the general population would be expected to be around 8%. This raises the question as to whether or not migraine history places an athlete at risk for concussion. The data on prevalence of multiple concussions is higher than what I am seeing.”

Postconcussion Migraine Common in Sports

Cohen and Dr Conidi conducted a retrospective chart review of 25 randomly selected patients with sports-related concussion aged 12 to 19 years from a tertiary concussion clinic and a headache center. The concussions occurred during a variety of sports, including football, soccer, basketball, hockey, and gymnastics.

The mean time until patients were cleared to return to play was 27.3 days.

All 25 had experienced headaches at some point between the event and return to play, and 20 (80%) said that the headache worsened throughout the day. Migraine or probable migraine was present in 17 (68%), with an average visual analogue pain score of 6.3 out of 10.

Past history of headache was present in 7 patients (28%), past history of concussion in 6 patients (24%), and attention-deficit/hyperactivity disorder in 3 (12%). Individuals with those three conditions had longer delays in returning to play.

Signs and symptoms occurring in more than half the patients included neurocognitive problems, vestibular symptoms, photophobia, and visual changes. Nausea and phonophobia were also common.

Dr Seifert said that these findings align with what he’s seen. “Per my own clinical experience as well as published reports…migraine-type headaches seem to be the most common phenotype of headache following concussion.”

Dr Conidi said he has been treating athletes and other individuals with concussion for many years. “During that time I have found that headache was far and away the most prevalent symptom associated with concussion and also the most disabling. By definition migraine headaches are disabling — as opposed to tension headaches — so it would make sense that these patients would meet the criteria.”