PITTSBURGH, June 21 -- High school and college athletes with migraine headache characteristics after a concussion may have increased neurocognitive impairment, suggests a University of Pittsburgh Sports Medicine Concussion Program study published in the May issue of the Journal of Neurosurgery. The study results speak to the need for extreme caution in clinical evaluation and return-to-play decisions, say the authors.
In the study, athletes who had characteristics of post-traumatic migraine (PTM) headache following a concussion also showed increased neurocognitive function impairment and related symptoms compared to concussed athletes with no post-injury headache or non-migraine headache.
"The findings of our study strongly support the need for clinicians to exercise increased vigilance in making decisions about managing a concussed athlete with PTM and extreme caution as to when that athlete should be allowed to return to play," said the study's lead author, Jason Mihalik, CAT(C), A.T.C., who now is a doctoral student working in the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill.
"This research is important because headache is the most common reported symptom after a sports-related head injury. As many as 86 percent of these injuries are accompanied by some type of headache," commented study co-author Joseph Maroon, M.D., professor of neurological surgery at the University of Pittsburgh School of Medicine.
"We are concerned because even though headache may be noted as a symptom in the young athlete with a concussion, he or she may be allowed to return to play before the headache resolves and later may suffer from second-impact syndrome, which, although rare, may be catastrophic," Dr. Maroon stressed.
University of Pittsburgh researchers were the first to study the relevance of headache in the recovery of concussed high school athletes. That study, published in the March/April 2003 issue of the American Journal of Sports Medicine, concluded that headache, even one week after a concussion, islikely associated with incomplete brain recovery, indicating the need to keep the athlete out of the game until the headache and other symptoms are resolved.
"Our ongoing research with younger athletes has increasingly suggested that kids are particularly at risk for neurocognitive decline following concussion, and this group also appears to be particularly vulnerable to post-traumatic migraine," said study co-author Mark Lovell, Ph.D., a neuropsychologist and director of the University of Pittsburgh Sports Medicine Concussion Program.
"Although it is estimated that up to 300,000 athletes sustain a concussion each year, the injury is still not well understood, the symptoms are not always straightforward and there is not one standard concussion severity grading scale or return-to-play protocol that has been scientifically validated as the best one to use. In fact, there is notable variability in the several injury severity scales and return-to-play guidelines that are in use today," added study co-author Michael Collins, Ph.D., a neuropsychologist and assistant director of the University of Pittsburgh program.
Concussion is any change in mental status caused by a sudden violent rocking back and forth of the brain inside of the skull due to a blow to the head or upper body. Symptoms can include headache, amnesia, dizziness, confusion, lack of hand-eye coordination, and in some cases, loss of consciousness. Generally, an athlete can safely recover from an initial concussion as long as the brain has had time to heal. Returning an athlete to play before the brain has had time to heal places that athlete at risk for a second concussion and further, more serious injury. First-ever research involving high school athletes published by the University of Pittsburgh in recent years has shown that even seemingly mild concussions may be more serious than previously thought. These studies have suggested that currently used return-to-play guidelines relating to symptoms, including headache, may be too lenient, often allowing athletes to return-to-play too soon, placing them at risk for more serious injury, according to study authors.
"One statistic we have discovered is that for every one concussion that occurs in the National Football League, more than 5,200 occur in our youth in the United States alone," said Melvin Field, M.D., study co-author who now is co-director of the Florida Sports Concussion Program and a neurosurgeon at the Orlando Neurosurgery and Florida Hospital Neuroscience Institute.
"This is a particularly important focus of study because symptoms of post-traumatic migraine are a complication of sports-related concussion that is often misunderstood," Mihalik said. "A specific diagnosis is often not assigned and an optimal course of therapy is often not provided."
The International Headache Society defines migraine as an episodic disorder characterized by acute attacks of pain with associated symptoms that often result in disability. These symptoms include but are not limited to headache, nausea, photophobia and phonophobia (hypersensitivity to light and sound).
The current University of Pittsburgh study is the first to compare acute neurocognitive impairments after sports-related concussion in athletes who exhibited migraine characteristics, those who complained of headache, and those who did not complain of headache.
In the study, 261 high school and college athletes who sustained a concussion underwent post-injury neurocognitive testing as part of a clinical evaluation through the University of Pittsburgh Sports Medicine Concussion Program. The athletes were separated into three groups: 74 athletes who had PTM; 124 athletes with headache complaints; and the non-headache group of 63 athletes. Neurocognitive outcome summary scores for verbal and visual memory, visual motor speed, reaction time and total symptom scores were collected using ImPACT® (Immediate Post-Concussion Assessment and Cognitive Testing), a scientifically validated computer software program developed years ago by the University of Pittsburgh team and widely used today as an objective assessment tool to help determine neurocognitive effects of concussion and measure recovery.
Significant differences existed among the three groups for all outcome measures, Mihalik reported. The PTM group demonstrated significantly greater neurocognitive deficits when compared with the headache and non-headache groups. Specifically, the PTM group had significantly lower verbal and visual memory, motor speed and reaction time scores than the other two groups. The researchers also observed significantly higher self-reported symptom scores in the PTM and headache group compared to the non-headache group.
"Given the significantly greater neurocognitive impairments observed in the PTM group in our study, any athlete with a concussion accompanied by characteristics of PTM should be examined in a setting that includes symptom status and neurocognitive testing to address their recovery more fully," asserted the study's authors. "Clearly, sports-related concussion is related to increased cognitive impairments, regardless of the presence of headache. It is critical that any athlete sustaining a concussion be followed up to not only assess lingering symptoms, but also to evaluate cognitive impairments. Symptoms may resolve before their neurocognitive deficits do."
Another investigator in the study was Jamie Pardini, Ph.D., neuropsychology fellow at the University of Pittsburgh Sports Medicine Concussion Program.
The University of Pittsburgh Sports Medicine Concussion Program is an ongoing clinical service and research program focusing on the diagnosis, evaluation and management of sports-related concussion in athletes of all levels. The program's internationally known team of clinicians and researchers are world leaders in studying the neurocognitive effects of sports-related concussion and pioneering the development of better methods of post-injury evaluation to better determine when it is safe for concussed athletes to return to play. For more information, visit: http://newsbureau.upmc.com/MediaKits/ConcussionMain.htm.
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