Concussion & Post-Traumatic Headache in the Female Athlete

Concussion & Post-Traumatic Headache in the Female Athlete American Headache Society 2012 Scottsdale Headache Symposium Migraine Co-morbidities in Women Heidi Blume, MD, MPH Div. Pediatric Neurology Seattle Children s Hospital & Research Institute Univ. of Washington Seattle, WA Nov. 15, 2012 Case: Sports Concussion - Soccer 14 yo girl with no history of headache Was asked to head balls shot out from a machine for photo op Machine set too high, after heading 10 balls, triggered severe headache, but she recovered in time for the tournament games. During a game, ball was kicked into the side of her head: immediate pain, dizziness, nausea, vomiting 10 days later she had recovered 3 weeks later, bonked heads with her sister Next day sister elbowed her head triggering severe headache & dizziness Case: Sports Concussion Young Goalie 11 yo girl, premiere soccer goalie 1 year ago sustained 1 st concussion Headache, balance & memory problems 6 weeks later, asymptomatic, back to play 2 nd Concussion 16 months later Severe headache, balance & memory problems Headache decreased, but increased again with stress Daily headache continues 4 months after injury 1

Case: Sports Concussion Basketball Sophomore on women s basketball team at Ivy League College Elbowed in head during a game no LOC, immediate headache 2 nd or 3 rd lifetime concussion Personal and family history of migraine High achiever MRI, neuropsych testing, and exam all normal Two years later: chronic daily headaches and mental fogginess affecting ability to work and affecting her career and academic choices Concussion A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. A concussion is a violent jarring or shaking that results in a disturbance of brain function Sports Concussion 1-3 million sports related concussions/yr Many do not seek treatment with a medical care provider 46 states have pending or active legislation regarding concussion / head trauma Require education of coaches, parents and players After concussion player must be evaluated by a trained provider 2

Sports Concussion 38 million youth participate in organized sports in the U.S. In high school > 3 million girls and 4 million boys participate in sports High school athletes take longer to recover from concussion than college athletes Risks for Concussion: Female Sex Prior Concussion Game > Practice Sport & position Daneshvar et al. Rates of High School Sports Concussion Sport Rate per 10,000 Game AEs Rate per 10,000 Total AEs Rank Total # Concussions Football 22.9 6.4 1 Girls Hockey 9.0 Boys Hockey 14.6 5.4 8 Boys Lacrosse 10.4 4.0 7 Girls Soccer 9.2 3.4 2 Girls Lacrosse 8.6 3.5 9 Girls Basketball 5.5 2.1 4 Boys Soccer 5.3 1.9 5 Boys Wrestling 4.8 2.2 3 Girls Field Hockey 4.1 2.2 11 Boys Basketball 3.9 1.6 6 Cheerleading 1.2 1.4 13 AE: Athlete-exposure Mara et al 2012 based on High School Database Why do girls & women have more concussions? 1. Decreased head-neck segment mass in females Could lead to greater angular acceleration after impact Females have a larger ball:head ratio in soccer 2. Lower neck strength and girth in females Although it is unclear if neck strengthening affects concussion risk 3. Estrogen: May be helpful or detrimental Few studies on estrogen and concussion 4. Females report more concussion symptoms Social macho pressures in male sports Females athletes are more concerned about future health than males 3

Post- Concussion Syndrome Somatic Symptoms: headache, nausea, photophobia, phonophobia, fatigue and balance deficits Emotional Disturbance: irritability, apathy, depression and anxiety Cognitive Symptoms: slow processing speed, attention deficits, impaired concentration, foggy thinking, and poor performance on neuropsychological testing Sleep Disturbance: insomnia, hypersomnia, too much or too little sleep Post- Concussion Syndrome Acute Headache is reported immediately after concussion by > 97% of all athletes Other very common acute symptoms include: dizziness & balance deficits, confusion, difficulty concentrating, nausea, photophobia More female athletes reported drowsiness and phonophobia More males reported confusion and amnesia Some studies find females report higher number of symptoms Frommer et al, Covassin 2011 Post- Concussion Syndrome Acute Time to return to play and resolution of symptoms is similar between males and females Age: Cognitive recovery is prolonged in high school vs. college athletes Sex related differences in cognitive recovery: Girls had higher risk of cognitive deficits after concussion than boys in similar sports Recovery of reaction time may be longer for females However, males and females have differences in strengths and weaknesses on baseline testing Frommer et al, 2011, Broshek 4

Post- Concussion Syndrome Chronic 3 months after mild TBI 11% of children remained symptomatic, only 0.5% were symptomatic after other injury 1 year after mild TBI 2.3% were symptomatic vs. 0.01% in control group Barlow et al Posttraumatic Headache Post Traumatic Headache Headache that develops within 7 days of head trauma or regaining consciousness Criteria are based on severity of injury, latency from injury and duration of the headache. BUT No description of headache localization, characterization or accompanying features are used Some question 7 day rule Adult Posttraumatic Headache Headache is one of the most common complaints following traumatic brain injury (TBI) > 90% report headache acutely after mild TBI/concussion Headaches may be more common following mild TBI than moderate or severe TBI. Women have higher risk of chronic headache after mild TBI than men OR: 4.45 (1.6-12.4) headache increased compared with baseline men vs. women 18-46% of those with TBI report headaches 1 year following the injury 5

Adult Posttraumatic Headache Headache after Moderate/Severe TBI Lucas et al. 2011 Baseline Acute 3 Months 6 Months 12 Months % with HA 18% 46% 48% 44% 46% Risk Factors for Chronic Headache Pre-Injury Headache: 48% vs. 23% Female Sex: Females were more likely to report any headaches over time (74% versus 63%) and Were more likely to report headache at all time points (37%) compared to males (18%) ~ 50% Classified as migraine Pediatric Posttraumatic Headaches Mild TBI in the ED (< 18 years old) 1 month after injury 32-58% report headache 1.3% had chronic headache 12 months after injury Sports Concussion - High School Database > 90% report headache after concussion Most (83%) had resolution of their symptoms in <1 week Only 1.5% had symptoms last longer than 1 month Field et al, Barlow et al, Blinman et al, Meehan et al Child Health After Injury Study Prospective Case Controlled Study of TBI Children Ages 5-17 with TBI or Arm injury evaluated in the ER and/or hospital Headache was more common after mild TBI than arm injury 3 months after injury 43% vs. 26%, RR 1.7 (1.2-2.3) This risk was most pronounced in teens and girls Teens: 46% vs. 25%, RR:1.8 (95% CI: 1.1-3.1) Girls: 59% vs. 24%, RR: 2.4 (95% CI: 1.4-4.2) Headache was not more common 3 mo after mod/severe TBI and at 12 mo after injury was not different between mtbi and control groups Blume et al 2012 6

Mild TBI & Headache: CHAI Study 60 50 Girls with > 5/10 HA 3 months After Injury mtbi Boys with > 5/10 HA 3 Months After Injury 40 Arm 30 % 30 25 20 mtbi 20 % 15 Arm 10 10 5 0 5-7 8-10 11-13 14-17 0 5-7 8-10 11-13 14-17 Age, years Age, years Teen Girls Report of Headache 12 mo Increased headache after mild TBI in teen girls 12 months after injury compared to arm injury 43% vs. 14% 5/10 headache 26% vs. 7 % bothered a lot by headache Trend for increased headache after mod/severe TBI in girls 33% vs. 14% 5/10 headache 41% vs. 7% bothered a lot by headache However, these differences were not significant in this study Risk Factors for Headache 3 Months After Mild TBI 7

Why do females have more headaches after concussions than males? 1. Neuroanatomical Differences Higher cerebral blood flow and basal rate of glucose metabolism may lead to more pronounced metabolic derangements after concussion Differences in neuronal structure 2. Higher rates of migraine at baseline in women and teens 3. Hormonal Differences Estrogen may be helpful or detrimental after TBI, still a matter of debate 4. Females report more concussion symptoms Social macho pressures in male sports Females athletes are more concerned about future health than males Post-Traumatic Headaches in the Female Athlete Summary Women and teenaged girls are more likely to have a concussion than males in similar sports Women and teenaged girls are more likely to have chronic headaches following the concussion than males There is concern that women and girls have a higher risk for cognitive dysfunction and prolonged recovery following concussion The reasons for these differences are likely multifactorial, and remain unclear Zurich 2009 Guidelines 8

Return To Play Guidelines 1. No Activity - Cognitive and physical rest 2. Light aerobic exercise walking, swimming keep HR < 70% of predicted for age 3. Sport-specific exercise running drills 4. Non-contact training drills, progress to more complex training drills 5. Full Contact Practice after medical clearance 6. Return to play in game Each step takes at least 24 hours - in the acute period the athlete should return to previous step with increase in symptoms due to exercise Acute Headache Management Rule out neurological emergency, intracranial hemorrhage, and other acute injury No NSAIDs until evident there is no bleed Rest, acetaminophen, cool packs to head, heat to neck, possibly triptans Avoid exacerbating factors Hydration Then NSAIDs, possibly triptans, hydration, rest Management of Headache No Data Manage headache based on the patients headache and other symptoms Sub-threshold exercise Physical Therapy/Massage Supplements: Magnesium, B2/Riboflavin, CoQ10, Omega-3s Medications Counseling Autonomic symptoms Acupuncture, biofeedback Avoid Medication overuse & opiates 9

Management of Headache Sleep Meals & hydration Activity manage appropriately Sub-threshold exercise Relaxation/rest Trigger avoidance Management of Headache Medications used for acute post-traumatic headaches Acetaminophen Ibuprofen Naproxen Sumatriptan Ketorolac IV Fluids Depakote IV Magnesium Avoid medication overuse Management of Headache Preventive medications used for chronic post-traumatic headaches: Amitriptyline Topiramate Propranolol Depakote Magnesium Omega-3 Fatty Acids Gabapentin SSRIs Steroids.. 10

Acute Headaches after Concussion Summary Evaluate to ensure there is no life threatening or progressive injury or other secondary cause of headache Manage with rest, hydration, acetaminophen or NSAIDs, and conservative measures if possible Severe headaches should be treated to try to prevent conversion to chronic headache and to minimize disability, consider triptans for acute migrainous headache Follow Return to Play guidelines Most headaches will resolve within 1-2 weeks Chronic Headaches after Pediatric TBI Summary Chronic headaches affect a minority of children and teens with TBI/concussion Risk factors may include: female sex, prior TBI/concussion, prior headaches, family history of migraine, age Optimal treatment is not clear, but may involve: Sub-threshold exercise Massage or Physical Therapy Supplements and/or Complementary therapies Sub-threshold exercise Preventive prescription medications in appropriate situations Counseling Thank You 11

CHAI Study Group Frederick Rivara, Principle investigator Jin Wang Nancy Tempkin Thomas Koepsell Monica Vavilala Ken Jaffe Daniel Durbin Andrea Dorsch Case: Sports Concussion - Soccer 14 yo female soccer player Seen in local ER Stopped soccer Headaches and other symptoms resolved after about 2-3 weeks 4 months later cleared for gymnastics OK for 3-4 practices Severe migrainous headache after one practice w/o obvious head trauma ER, headache resolved with IV meds No further headaches or symptoms at rest or with activity in gymnastics, exam normal Case: Sports Concussion - Soccer 14 yo female soccer player Emerging common migraine or migraine triggered by concussion? Maternal Aunt with migraine, but no one else Should she go back to soccer? Advised early treatment of any future migrainous headaches with ibuprofen (if no evidence of ICH), +/- caffeine, and/or sumatriptan 12

References McCrory, P., et al., Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med, 2009. 43 Suppl 1: p. i76-90. Lucas, S., et al. Natural history of headache in the first year after traumatic brain injury. in Amereican Neurological Association. 2011. Honolulu, HI. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998--2000. Brain Inj. Feb 2005;19(2):85-91. Preiss-Farzanegan SJ, Chapman B, Wong TM, Wu J, Bazarian JJ. The relationship between gender and postconcussion symptoms after sport-related mild traumatic brain injury. Pm R. Mar 2009;1(3):245-253. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. Aug 2010;126(2):e374-381. Blinman TA, Houseknecht E, Snyder C, Wiebe DJ, Nance ML. Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury. J Pediatr Surg. Jun 2009;44(6):1223-1228. Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr. May 2003;142(5):546-553. Giza, C.C. and D.A. Hovda, The Neurometabolic Cascade of Concussion. J Athl Train, 2001. 36(3): p. 228-235. Giza, C.C., R.B. Mink, and A. Madikians, Pediatric traumatic brain injury: not just little adults. Curr Opin Crit Care, 2007. 13(2): p. 143-52. www.cdc.gov/concussion/sports/index.html Post Concussion Scale Directions: After reading each symptom, please circle the number that best describes the way you have been feeling today. A rating of 6 means you have experienced severe problems with this symptom today. Subjects check a box if they are "not experiencing the symptom." Symptom Minor Moderate Severe Headache 2 3 4 5 6 1 Nausea 1 2 3 4 5 6 Vomiting 1 2 3 4 5 6 Balance Problems 1 2 3 4 5 6 Dizziness 1 2 3 4 5 6 Fatigue 1 2 3 4 5 6 Trouble Falling Asleep 1 2 3 4 5 6 Sleeping More Than Usual 1 2 3 4 5 6 Sleeping Less Than Usual 1 2 3 4 5 6 Drowsiness 1 2 3 4 5 6 Sensitivity to Light 1 2 3 4 5 6 Sensitivity to Noise 1 2 3 4 5 6 Irritability 1 2 3 4 5 6 Sadness 1 2 3 4 5 6 Nervousness 1 2 3 4 5 6 Feeling More Emotional 1 2 3 4 5 6 Numbness or Tingling 1 2 3 4 5 6 Feeling Slowed Down 1 2 3 4 5 6 Feeling Mentally "Foggy" 1 2 3 4 5 6 Difficulty Concentrating 1 2 3 4 5 6 Difficulty Remembering 1 2 3 4 5 6 Visual Problems 1 2 3 4 5 6 Total Score: 13

Mild TBI & Headache: CHAI Study Headache 3 months after Injury mtbi is associated with headache overall compared to children with arm injury 43% vs. 26%, RR 1.7 (95% C.I:1.2-2.3) This effect is most notable in girls and teens Girls: 59% vs. 24%, RR: 2.4 (95% C.I:1.4-4.2) Teens: 46% vs. 25%, RR: 1.8 (95% C.I:1.1-3.1) Teen Girls w/ > 5/10 HA: 55% vs. 23%, RR: 2.5 (1.0-6.5) Risk of headache after mtbi appears to increase with age in girls but not boys Mild TBI & Headache: CHAI Study Headache 12 months after Injury Association between mtbi and headache 12 months after injury is suggested in girls but not boys Girls: 26% vs. 10% with > 5/10 headache RR: 2.2 (95% C.I.:0.9-5.6) Particularly in teenaged girls 44% vs. 14%, RR: 3.1 (0.8-11.9) Mod./Severe TBI & Headache: CHAI Study 12 months After Injury Headache not significantly associated with pediatric moderate/severe TBI BUT Trend for teen girls to report more headache at 12 months following moderate/severe TBI than girls with arm injury Teen Girls Bothered a lot by headache : 42% vs. 7%, RR: 5.8 (95% C.I.: 0.9-38.2) 14

CHAI Study Child Health After Injury Study Large, prospective, population-based CDC funded study of function of children and families after pediatric TBI compared to children with an arm injury Fred Rivara et al. at Harborview Injury Prevention & Research Center Children age 5 17 years at the time of injury: n=649 Mild TBI: n=441 Moderate/Severe TBI: n=71 Orthopedic Arm Injury: n=137 Analysis of data obtained at baseline, 3 and 12 months 15