Sports Medicine Research: In the Lab & In the Field: Posttraumatic Migraine as a Predictor of Recovery and Cognitive Impairment After Sport-related Concussion (Sports Med Res)
Wednesday, August 14, 2013

Posttraumatic Migraine as a Predictor of Recovery and Cognitive Impairment After Sport-related Concussion

Posttraumatic Migraine as a Predictor of Recovery and Cognitive Impairment After Sport-related Concussion. 

Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, Collins MW.  Am J Sports Med.  2013; 41 (7):1497-504.

Take Home Message:  Headache with post-traumatic migraine symptoms (nausea, photosensitivity, phonosensitivity) may be clinical predictors for prolonged recovery among patients with sport-related concussion.

The spectrum of post-concussive signs and symptoms can include headache, phonosensitivity (sensitivity to sound), photosensitivity (sensitivity to light), altered concentration, visual changes, and amnesia.  The duration of these symptoms varies but most athletes recover cognitive function within a relatively short-time period – on average between 7 to 10 days.  It is difficult to predict which athletes will have a protracted recovery but the authors postulate that an athlete who experiences a post-traumatic migraine (PTM) within the first week may be more likely to suffer a prolonged recovery.   To test this hypothesis, the authors developed a five-year longitudinal, multi-site cohort study and recruited 138 male high school football players who had suffered a sport-related concussion.  The athletes were divided into three groups based on self-reported symptoms; PTM (headache, nausea, and photosensitivity or phonosensitivity), headache (headache without additional PTM symptoms), or no headache.  Each athlete completed the Immediate Post-concussion Assessment and Cognitive Test (ImPACT; a  computerized neurocognitive test), which assessed his cognitive performance, at three time intervals: baseline, 1 to 7 days, and 8 to 14 days post injury.  The authors determined the recovery time by subtracting the date of return to play from the date of injury.  At both follow-up tests, the athletes in the PTM group performed worse on the visual memory and reaction time domains of ImPACT than the other two groups.  In addition, those in the PTM group had greater persistent symptoms than the other groups at the same intervals.  With regards to verbal memory, the PTM group performed worse than the headache group at 8 to 14 days post injury – but interestingly, athletes in the headache group performed better than the athletes that reported no headache at the first follow-up test.  Perhaps the most important finding was that an athlete with PTM was 7.3 times more likely to have a protracted recovery (> 20 days) compared with an athlete with no headache and 2.6 times more likely than an athlete with a headache. 

The results of this study lend credence to the notion that certain symptom of concussion; whether they are cognitive, behavioral, or both; may help predict recovery time. The presence of migraine symptoms after suffering a sports-related concussion may be an indicator that the athlete has suffered a more severe injury.  Although, we cannot rule out that injuries could be similar and the individual’s clinical response, due to genetic or physiological variables, alters the clinical presentation.  For athletes with migraine symptoms after a concussion it might be beneficial for us to pursue more aggressive treatment strategies including frequent evaluation and/or the use of pharmaceutical adjuvants early in the clinical course. The results of this study may also aid in counseling an injured athlete – specifically with regard to questions about timing of return to play. For clinicians who do not use ImPACT or other computerized neurocognitive testing, this study is of particular interest because it was the presence or absence of subjective symptoms that seemed to predict a protracted recovery.

Questions for Discussion: How do you determine which athletes will require more aggressive therapies?  Is there a symptom or symptom constellation that you find most or least worrisome?

Written by: Andrew W. Albano, Jr. DO and Marc I. Harwood, MD
Reviewed by: Jeffrey Driban

Related Posts:
Chronic Daily Headache in U.S. Soldiers After Concussion

Related Reading:
Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, & Collins MW (2013). Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. The American Journal of Sports Medicine, 41 (7), 1497-504 PMID: 23698389

2 comments:

Lauren Miller said...

As someone who has seen this both personally and professionally, I feel more studies like this are needed in general. While technological advances are great, they are not always reliable or even available.

In terms of the question you asked, I would find the nausea most troubling. I have seen that particular symptom handled several ways, from close observation to immediate referral to the physician. I, personally and professionally, would rather lean to the later and it just turn out to be a migraine than to not act and it be something more serious.

As to the study's findings, it was interesting because I had PTM following both concussions and had a protracted recovery with both of them (granted the second one occurred within two of the absence of symptoms from the first, with the second recovery taking several months.

Andrew Albano Jr said...

Historically, the physical exam served as the cornerstone of medical evaluation. As advancements have been made, reliance on diagnostic studies has threatened the importance of the physical exam. It is important that we, as medical practitioners, utilize all available resources in diagnosing and treating those with acute brain injury. Sound medical evaluations including a thorough history should not be superseded by medical technology.

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