Welcome again to this weeks Concussion Blog. During this blog series we’re aiming to develop a better understanding of the pathologies and structures involved following concussion and how best to approach management.
The 5th International Consensus Conference on Concussion in Sport was held in Berlin in October 2016. The statement is now thought to be written but not yet published however it’s understood that the definition of concussion has been refined to include brain injury only. This means all of the other systems that are affected following head trauma such as the vestibular and oculomotor system, the cervical spine and somatosensory system, although no less important in our management following mild traumatic brain injury, don’t fall under the definition of concussion.
With that in mind, this week we’re going to review an article by Anderson and colleagues who looked at post-traumatic migraines and how to differentiate between migraines and concussive symptoms.
Anderson K, Tinawi S, Lamoureux J, Feyz M, de Guise E. Detecting Migraine in Patients with Mild Traumatic Brain Injury Using Three Different Headache Measures. Behav Neurol. 2015;2015:693925.
Post traumatic headaches are present in up to 92% of patients following concussion(5) and can lead to persistent symptoms following initial injury with 18% to 22% of sufferers still experiencing symptoms after one year. Classification of headache is important in determining treatment options. Post traumatic headache is classified as a secondary headache, however, there are few effective ways of differentiating them with primary headaches (a headache due to the headache condition itself and not due to another cause) other than their onset following trauma.
Several headache classification tools exist that measure specific characteristics of headaches and their associated disability. A large number of post-traumatic headaches fall in to the migraine category when using the International Classification of Headache Disorders. Anderson and her team defined migraine headaches using the Primary headache criteria as ‘a moderate to severe headaches that may be accompanied by systemic problems such as nausea and vomiting, pain worsening with activity, and photosensitivity. Migraines can also disturb cognitive function, vestibular function, emotional state, and social interactions’ – Sound familiar? What this is basically telling us, is that it is very difficult to distinguish between a post-traumatic migraine and a concussion. This is in no way to say that we can pass off our concussed athletes as migraine sufferers but it does suggest that there is an undefined number of post traumatic migraines that we may be misdiagnosing as concussions. Many clinicians working in sport will have encountered first hand or heard of athletes who suffer a concussion every time they return to play and take contact. These athletes are often considered to have high susceptibility to concussion following an initial insult and in some cases forced retirement through injury is considered.
The lifetime prevalence of migraine has been found to be as high as 18%; 12% in males and 24% in females(4). The other interesting point when considering this diagnosis is that migraine with aura is only present in 20% of migraines suffered(1) so if you are expecting an aura to classify a headache as a migraine then think again.
So, how do we start classifying these headaches and can we differentiate them with concussive symptoms?
Anderson and her team assessed Forty-three patients who sustained head trauma and were diagnosed with mild TBI by a physician who used WHO Task Force Criteria for assessment. Their goal was to examine the effectiveness of the self-administered Nine-Item Screener (Nine-Item Screener-SA), the Headache Impact Test- 6 (HIT‑6), the 3‑Item Migraine Screener, and the Rivermead Post-Concussion Questionnaire (RPQ) at discriminating between mild TBI patients with and without migraines.
Headache assessment tools
Headache Disorders, 2nd Edition (ICHD-II)
This clinician administered questionnaire is based on the International Headache Society criteria and consists of nine yes or no questions that s identify and categorise headaches into a hierarchical system. The questions clarify pain, aura, nausea, light and sound sensitivity, and functional impairment. Positive answers are calculated to obtain a total score.
The Headache Impact Test (HIT‑6)
This self-report questionnaire measures changes in headache impact. It consists of six questions that are designed to measure the impact that headaches have on the patient’s normal function in social, work, home, and school situations. Items are on a rating scale of 1 – 5 that includes never, rarely, sometimes, very often, and always. Scores of 50 or higher indicate that the patient requires medical attention.
Three-Item ID Migraine Screener
A self-reported questionnaire that consists of three yes or no items that can be used as a screening tool to identify headaches, nausea, light sensitivity, and functional impairment.
The Rivermead Post-Concussion Symptoms Questionnaire
This self-reported questionnaire measures the severity of cognitive, emotional and somatic symptoms in TBI patients. It consists of 16 questions on a rating scale including 0 (not experienced at all), 1 (no more of a problem), 2 (a mild problem) 3 (a moderate problem) and 4 (a severe problem). If three or more symptoms are present at three months, the patient is considered to have Post-Concussion Syndrome.
Twenty of the forty-three mild TBI patients suffered from migraine. There was no significant difference between groups in number or severity of previous injuries.
The Nine-Item Screener demonstrated significant differences between migraine patients with and without migraine on nearly every question. Sensitivity: 0.95 and specificity: 0.65 (95% CI, 0.64 – 0.90). The HIT‑6 showed significant differences between migraine and non-migraine patients on disability and pain severity, with disability having a sensitivity of 0.70 and specificity of 0.75 (95% CI, 0.54 – 0.83). Only Question 3 of the 3‑Item ID Migraine Screener (photosensitivity) showed significant differences between migraine and no-migraine patients, sensitivity: 0.84 and specificity: 0.55 (CI, 0.52 – 0.82). The RPQ did not reveal greater symptoms in migraine patients compared with those without.
An accurate diagnosis of post-traumatic migraine is critical to the delivery of both effective migraine treatment and onward concussion management. The two pathologies are separate entities with very different management approaches but deceptively similar presentations. Diagnosis of post-traumatic migraine can lead to fast and often highly effective treatment with a variety of medications found to be effective migraine prevention, including beta-adrenergic blockers, antidepressants, anticonvulsants, calcium-channel blockers, serotonin antagonists and NSAIDs(2)
At present a large number of mild TBI patients are not receiving an accurate diagnosis for their symptoms due to the assumption in part, that all headaches are of the same etiology. The headache assessment tools reviewed above by Anderson and colleagues demonstrate clear methods to delineate between concussion symptoms (a secondary headache) and post-traumatic migraine (a primary headache). Results show that migraine sufferers report greater pain severity, disability, and photosensitivity with the most effective tool at distinguishing between migraine and concussion to be the 9‑item screener with a sensitivity of 0.95 and specificity: 0.65 (95% CI, 0.64 – 0.90).
Categorising post traumatic headaches is an easy win and can lead to a more effective treatment strategy that will at the least speed recovery and in some cases maybe even save a career.
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