Factors Associated with Sport-Related Post-concussion Headache and Opportunities for Treatment

DOI: https://doi.org/10.1007/s11916- 018- 0724- 2

Abstract-Summary The purpose of this review is to (1) describe factors both pre- and post-injury that are associated with post-concussion headache, (2) describe the influence of post- concussion headache on recovery following concussion, and (3) provide potential post-concussion treatment options that may reduce the burden of headache, as well as other symptoms to facilitate recovery.

Various factors may be associated with post-concussion headache presentation. Complex interplay of factors, many treatment options may improve headache symptoms and recovery post-concussion including rehabilitation programs focus- ing on deficits such as visual-vestibular dysfunction, sub-symptom threshold exer- cise, and potential pharmacological interventions.

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Post-concussion Syndrome

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Understanding factors related to post-concussion headache presentation and the available options for treatment may improve patient care and outcomes post-concussion.

Introduction The mechanism of concussion as well as other pre- and post-injury factors may influence both clinical presentation and outcome following injury.

The most common acute post-concussion symptom is headache. Headache presence post-concussion can complicate assessment and decision- making, as it is difficult to distinguish if presenting dysfunction and many associ- ated symptoms are a result of the concussion or the headache-type [85].

It is important to understand factors closely associated with post-concussion headache and the potential influence post-concussion headache can have on the assessment and management process following concussive injury.

The symptoms associated with post-concussion headache are often treatable. The purpose of this review is to describe factors both pre- and post-injury that are associated with post-concussion headache, to describe the influence of post- concussion headache on recovery following concussion, and to provide potential treatment options post-concussion that may reduce headache burden, as well as other symptoms to facilitate recovery.

Pre-injury Factors Associated with Headache Post-concussion headache in particular is reported more often by females and at greater intensities [30].

Females report a higher prevalence of pre-existing headache and migraines both of which may influence the presence of post-concussion headache and recovery time [86].

Self-reported pre-existing headache is less examined in those with post- concussion headache where reported prevalence is similar to that of migraines, and varies between 16 and 45% [30, 62].

While the literature is mixed, premorbid depression and anxiety is associated with higher frequency and severity of immediate post-concussion and persistent symptoms, including headache [87].

Recent studies have shown that individuals with a prior concussion history tend to report more symptoms post injury and experience greater symptom severity [88, 89].

The presence of post-concussion headache, and headache severity in particular, is more commonly reported in athletes with a concussion history compared to those without [88, 90].

Post-concussion and Injury-Related Factors Associated with Headache Although few studies have looked at specific headache presentations post- concussion, previous studies have illustrated that individuals with migraine-like symptoms (headache along with photo- and/or phonophobia and dizziness) and those with more severe post-concussion headache exhibit greater initial symptom burden after injury [91, 92].

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Among service members, migraines are the most common type of headache pre- senting post-concussion [93]; however, no studies of this type have been done in athlete-specific populations.

Beyond clinical data, recent studies also support structural brain differences in individuals with post-traumatic headache following concussion compared to those without it.

Common concussion symptoms that could have a cervicogenic basis include

neck pain or stiffness, and headache.

More importantly though is the persistence of post-traumatic headache in a sub-

set of individuals following sport-related concussion.

Examination among individuals with persistent post-traumatic headache follow- ing concussion in athletes suggested decreased brain activation patterns [57] in those who presented with migraine-like symptoms as well as other symptoms.

Treatment Considerations Treatment of post-concussive headache must be tailored to the individual patient following a detailed evaluation.

While studies are lacking to demonstrate specific improvement in post- concussive headache with these interventions, there is some evidence to suggest overall address- ing these areas may be beneficial and including exercise as well as pharmacological intervention may be warranted in some patients.

For headache that may be the result of potential physiologic post-concussion

disorder, this type of sub-symptom-threshold exercise treatment may be effective.

Controlled studies of medications in post-concussive patients are lacking, and at

this time, all medication use is considered off-label [94].

The topiramate group had the lowest response, and another retrospective study evaluating topiramate in chronic post-concussive headache found that only 16% of patients had greater than 50% reduction in headache [95].

Many post-concussion patients have been using medications to treat headaches

since the time of their injury [96].

Conclusions Post-concussion headache can be from the interplay of various pre- and post-injury factors that may influence headache presentation, duration, and type.

There are no set diagnostic criteria to tease out headache vs. concussion effects,

specifically early in the post-concussion recovery process.

Recent research suggests reasonable options for potential treatment of post- concussion headache and the other sequelae that may result following sport-related concussion.

Acknowledgement A machine generated summary based on the work of Register-Mihalik, Johna K.; Vander Vegt, Christina B.; Cools, Michael; Carnerio, Kevin 2018 in Current Pain and Headache Reports.

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Utilizing the Biopsychosocial Model in Concussion Treatment: Post-Traumatic Headache and beyond