Posttraumatic Migraine as a Predictor of Recovery and Cognitive
Impairment After Sport-related Concussion.
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.
Simensky S, Freund B, French J, Collins MW.
Am J Sports Med. 2013; 41
(7):1497-504.
https://www.ncbi.nlm.nih.gov/pubmed/23698389
(with associated podcast summary)
(with associated podcast summary)
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.
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.
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.
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?
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
DO and Marc I. Harwood, MD
Reviewed by: Jeffrey Driban
Related Posts:
Chronic Daily Headache in U.S. Soldiers After Concussion
Related Reading:
Mihalik JP et al., Recovery of Posttraumatic Migraine Characteristics in Patients After Mild Traumatic Brain Injury. American Journal of Sports Medicine (2013).
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
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.
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.