Concussion And Migraine.

In the old days, like 1971, when I was neurology resident at the Mayo Clinic, concussion was pretty simple as it was explained to me then.

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.

Concussion used to be a “head injury associated with brief loss of consciousness.”  Loss of consciousness usually meant being out cold for 3 or 4 minutes; a longer period of time being unconscious could be something more serious like a cerebral contusion, which means bruise of the brain, a skull fracture, or development of a blood clot in the head like a subdural or epidural hematoma.

For work up a skull x-ray and EEG were performed early on but later in the mid-seventies CAT scan use in emergency rooms spread all across America, evaluating persons from either a motor vehicle accident or sports related injury causing brief loss of consciousness from concussion.

Read my Mini Book on Migraine Here.

Later MRI scan was developed and that shows more precise interior brain damage and anatomy than CT but the chief question for the emergency room physician when he sees a head injury in the ER is “does this patient have blood in the head?”, and CT shows blood in the head better than MRI scan and does it quickly and reliably.  CAT scan analysis for head injury is now standard in American ER departments, but some patients who get follow up MRI scans will show microbleeds and linear brain lesions.

Migraine is a genetically inherited, common medical problem involving the release of inflammatory chemicals in the brain that inflame the trigeminal nerve, cerebral arteries, and the thalamus.  Trauma from concussion can aggravate migraine headache intensity and frequency.

Concussion and migraine are clinical diagnoses and medical testing is usually normal.

Concussion occurring in persons with migraine is a common neurologic problem.  A concussion may also be called a minor traumatic brain injury (TBI). A person with Migraine who suffers a concussion is a special injury because the brain of someone with Migraine is sensitive to stress, light, sound, odors, fasting, falling estrogen levels, insomnia, and stress. The head trauma stirs up the inflammatory neurochemicals of the Migraine patient’s brain to activate severe headache.

General considerations

A concussion occurring in a patient with migraine often results in a more severe headache than in a person without Migraine. A concussion could be referred to as “slight, mild, or a severe.”  These adjectives are subjective and relate to the perceived severity of the blow and the duration of time the patient is unconscious.

Concussion usually refers to brain trauma associated with brief, 3-4 minutes, of unconsciousness and short-termed neurologic dysfunction that resolves spontaneously in 7-14 days.  A small percentage of patients with concussion have symptoms that can be longer lasting and disabling, called post-concussion syndrome.

Sometimes a concussion is considered to occur with no loss of consciousness.  This is called a “blackout.” An example would be a football quarterback who received a head injury, but can still carry on with normal function, such as receiving the ball or passing it ok, but on sideline interview with the trainer is found to be confused and to not know the date or the name of the opposing team.

This would be like a “light concussion” while the player who has sustained a severe tackle and hits the ground with his head, may be completely out cold and unconscious on the ground for several minutes and have to be removed from the field on a stretcher.

The concussion blow to the sensitive brain of a migraine patient releases inherent brain neurochemicals which can result in severe migraine headache which can be short term such as the day of the head injury, or longer lasting such as migraine headaches that last weeks to a month.

Many post-concussed migraine patients overtreat with pain killers, caffeine, triptans, opioids, or butalbital.  Taking these drugs frequently can cause daily, severe migraine type headaches along with nausea, vomiting, sensitivity to light, and sound.

According to data compiled by the National Hospital Ambulatory Medical Care Survey the incidence in the United States of minor head injury was 503 per 100,000 population or 1,367,101 visits per year to hospital Emergency Departments.

The number of patients who sustain minor head injury and do not present for medical care is unknown; a situation limiting an accurate count of the number or person with head injury.

Read my article, “What is Migraine?” on my website, www.doctormigraine.com.

Persistent headache attributed to traumatic injury to the head.

The International Classification of Headache lists a type of headache called: Persistent headache attributed to traumatic injury to the head.

Description:

Headache of more than 3 months’ duration caused by traumatic injury to the head.

Diagnostic criteria:

Traumatic injury to the head has occurred.

Headache is reported to have developed within 7 days after one of the following:

the injury to the head.

regaining of consciousness following the injury to the head.

discontinuation of medication(s) impairing ability to sense or report headache following the injury to the head.

Headache persists for >3 months after its onset.

Traumatic injury to the head is defined as a structural or functional injury resulting from the action of external forces upon the head. These include impact between the head and an object, penetration of the head by a foreign body, forces generated from blasts or explosions, and other forces yet to be defined.

When headache following head injury becomes persistent, THE POSSIBILITY OF MEDICATION OVERUSE HEADACHE NEEDS TO BE CONSIDERED.

Read my article, “What is Medication Overuse Headache?” on my website, www.doctormigraine.com.

 Related items

 Second impact syndrome

 If there’s a second head injury within 24 hours to 10 days after the initial concussion, there is an increased risk of having “second impact syndrome.”  This may cause massive brain edema with brainstem herniation and death or severe disability.  It’s fear of this syndrome that limits return of an athlete to active playing after certain periods of time.

Traumatic brain injury and chronic traumatic encephalopathy

Recently it has been discovered that repeated mild or severe concussions and worse head injury such as contusions may lead to the TBI, or traumatic brain injury. This is a situation where repeated traumatic cerebral events can lead to dementia and psychiatric mood changes called CTE, or Chronic Traumatic Encephalopathy, which has its own pathology and neurologic abnormalities.

Names and origin of the term Concussion

Concussion, in lay terms, can mean a bump, collision, crash, impact, impingement, jar, jolt, jounce, kick, shock, slam, smash, strike, or a wallop.  It comes from late Middle English: Latin concussio(n-), from the verb concutere ‘dash together, shake’, from con- ‘together’ + quatere ‘shake’.

Cerebral metabolism

The brain is precious, soft tissue, placed inside the skull into compartments for the frontal lobes, temporal lobes, and occipital and parietal lobes.  It’s sort of like pieces of chocolate that are placed in small paper slots in a box.  Then the brain is wrapped with the dura mater, which is a plastic-like material, like a steak wrapped in plastic at the grocery store.

Underneath the dura spinal fluid shields the brain and protects it from trauma.  When there is head trauma there is some movement of the brain within the skull so that there can be with frontal head injury a contrecoup injury to the back part of the brain as the mechanical gravitational forces from frontal head trauma press the brain against the opposite side of the skull, causing the contrecoup injury.

The brain has the consistency of gelatin. It's cushioned from injury by cerebrospinal fluid inside the skull.  A violent blow to the head and neck or upper body can cause the brain to move against the inner walls of the skull.  Sudden acceleration or deceleration of the head, caused by events such as a car crash or being violently shaken, also can cause brain injury.

These injuries affect brain function, usually for a brief period, resulting in signs and symptoms of concussion.  This type of brain injury may lead to bleeding in or around the brain, causing symptoms such as prolonged drowsiness and confusion. These symptoms may develop immediately or later.

The brain is made of billions of neurons carrying electrical and chemical information which with acute trauma shuts off suddenly like pulling the plug on Christmas tree lights.  After concussion the patient suddenly becomes unconscious and will stay so for several seconds or sometimes several minutes.

Pathology of concussion

The pathology of concussion is not certain.  There’s a disruption of cell membranes and channels for sodium, calcium, and potassium function leading to a loss of normal neuronal activity.  This can cause mitochondrial dysfunction resulting in failure and loss of energy and normal glucose metabolism.   

Duration of amnesia

Later, when the patient awakens, there may be no memory for the time the patient was unconscious, and awareness should return shortly after regaining consciousness.  However, some patients may have memory loss dating to before the time of the head injury and this is called retrograde amnesia.  It is that thought the severity of cerebral trauma may relate to the duration of time of retrograde amnesia. The longer the period of time of amnesia before impact, that is the longer the time of retrograde amnesia, the more severe the concussion. 

A loss of memory for a week before a head injury is more serious than someone who can remember everything up to the moment of impact.

Neurologic testing for concussion

Brain metabolic function is supplied by arteries which bring fresh oxygenated blood into the brain and veins which take metabolic products away from it.  A brain wave test, EEG, or electroencephalogram done during the time of a concussion is abnormal with slow brainwaves, but by definition CT or MRI scan should be normal immediately after impact.

With a concussion after the patient regains consciousness, there may be short duration of confusion, but nothing severe, and usually after several minutes the patient will be oriented normally again.

More severe head injuries may be associated with a longer period of time of non-arousal, like a patient in coma. These longer duration post impact times may be due to cerebral contusion (bruising of the brain) or subdural or epidural hematoma.

Neurologic symptoms following concussion:

Immediate symptoms

Headache or a feeling of pressure in the head.

Temporary loss of consciousness.

Confusion or feeling as if in a fog.

Amnesia surrounding the traumatic event.

Dizziness or "seeing stars."

Ringing in the ears.

Nausea.

Vomiting.

Slurred speech.

Delayed response to questions.

Appearing dazed.

Fatigue.

Post-concussion vertigo.

Epileptic seizure.

Post-Concussion syndrome with delayed symptoms hours or days after injury:

Concentration and memory complaints.

Irritability and other personality changes.

Sensitivity to light and noise.

Sleep disturbances.

Psychological adjustment problems and depression.

Disorders of taste and smell.

Vertigo or dizziness.

Symptoms in children

Head trauma is very common in young children. But concussions can be difficult to recognize in infants and toddlers because they can't describe how they feel. Concussion clues may include:

Appearing dazed.

Listlessness and tiring easily.

Irritability and crankiness.

Loss of balance and unsteady walking.

Crying excessively.

Change in eating or sleeping patterns.

Lack of interest in favorite toys.

Vomiting.

Incidence of concussion

A study from Columbia University of 1203 athletes found 23 % of women and 17 % of men had a least one concussion during their college days.  The American Medical Society (AMS) for Sports Medicine has estimated that 1-1.8 million sports related concussions occur per year in patients younger than 18 years old.  This organization defined concussion as “a traumatically induced transient disturbance of brain function.”

The American Academy of Neurology states that “each year, 1.6 to 3.8 million concussions result from sports/recreation injuries in the United States.  Almost 9% of all US high school sports injuries involve concussions.  Most concussions result in full recovery.  However, some can lead to more severe injuries if not recognized early and treated properly.”

Risk factors

Activities and factors that may increase the risk of a concussion include:

Falling, especially in young children and older adults

Concussions can occur in many sports.  Concussions are common in high-speed contact sports.  Football, rugby, hockey, boxing, and soccer have the greatest risks.  Baseball, softball, volleyball, and gymnastics involve the least risk gender varies from sport to sport but there some evidence that concussion risk and soccer and basketball is greater than in females than in males.

Specific risk factors:

Participating in high-risk sports without proper safety equipment and supervision

Being involved in a motor vehicle collision.

Being involved in a pedestrian or bicycle accident.

Being a soldier involved in combat.

Being a victim of physical abuse.

Having had a previous concussion.

Having migraine.

Having the APOE 4 gene.

Medical advice regarding return of activity:

American Medical Society consensus guidelines endorse 24-48 hrs. of symptom limited cognitive and physical rest followed by gradual increase in activity.  They stated that the large majority, that is 80 to 90% of concussed older adolescents and adults, return to pre-injury levels of function within two weeks but in younger athletes clinical recovery may take up to four weeks.

Good sleep hygiene is also important to help the athlete recover.  It stated that a return to sports activities should follow successful return to classroom activities.

A stepwise increase in physical demands or activity without symptoms is important before the patient is able to participate in full contact play.  It’s no longer recommended the patient have long periods of time of lack of cognitive or sports involvement such as weeks or months.

The patient should never return to play or vigorous activity while signs or symptoms of a concussion are present.  An athlete with a suspected concussion should not return to play until he or she has been medically evaluated and cleared to play by a health care professional such as a neurologist, headache doctor, or general doctor who is trained in evaluating and managing concussions.

 Consider this rule:  IF IN DOUBT.  SIT IT OUT.

 Complications of concussion include:

 Headache after head trauma may occur lasting a week or a few months.

If the patient has migraine, then post traumatic migraine headaches may occur, complicating recovery.

The migraine patient with traumatic head injury and concussion may be overtreated with NSAIDS, opioid narcotics, barbiturates, or caffeine which can cause medication overuse headache which prolongs the suffering of the post traumatic head injury patient.

Post-concussion vertigo can be severe and associated with headache,  especially with migraine patients and can last for weeks to months, aggravating recovery.

Post-concussion syndrome with symptoms as listed above.

Patients with repeated concussions may develop traumatic brain injury, TBI, and set themselves up for later developing, after further head injuries, chronic traumatic encephalopathy.

Tips to help prevention or minimize risk of head injury include:

Wearing protective gear during sports and other recreational activities. Make sure the equipment fits properly, is well-maintained and worn correctly. Follow the rules of the game and practice good sportsmanship.

When bicycling, motorcycling, snowboarding or engaging in any recreational activity that may result in head injury, wear protective headgear.

Buckling your seat belt. Wearing a seat belt may prevent serious injury, including head injury, during a traffic accident.

Making your home safe. Keep your home well-lit and your floors free of anything that might cause you to trip and fall. Falls around the home are a leading cause of head injury.

Protecting your children. To help lessen the risk of head injuries to your children, block off stairways and install window guards.

Exercising regularly. Exercise regularly to strengthen your leg muscles and improve your balance.

Educating others about concussions. Educating coaches, athletes, parents and others about concussions can help spread awareness. Coaches and parents can also help encourage good sportsmanship.

Migraine

Chronic migraine

The most painful conditions known are childbirth, a kidney stone, and migraine headache.  A single episode of migraine may last 4-72 hours.

Chronic migraine is defined as at least 15 headache days per month, 8 of which have migraine features.  Chronic migraine is usually due to overtreatment with pain killers, caffeine, triptans, opioid narcotics, or butalbital.

Persons with migraine who take triptans, opioid narcotics or butalbital for headache more than ten days per month or over the counter painkillers, like Advil, Tylenol, Aleve, or caffeine more than fifteen days per month may get chronic migraine due to medication overuse headache.

This group of patients may have continuous, all day, every day headache along with sensitivity to light and sound, irritability, anxiety, insomnia, nausea and vomiting, lasting for years, or as long as they overtreat. 

Read my article, “Intractable migraine,” on my website, www.doctormigraine.com.

Migraine symptoms with time

The migraine prodrome may come 24 hours before the attack occurs and may consist of fatigue, drowsiness, food cravings, depression, irritability, trouble concentrating, phonophobia, and increased urination or diarrhea.

 If these symptoms can be recognized by the patient as common and reliable recurrent symptoms before the attack occurs, then the patient should treat before headache occurs at prodrome with a triptan.

 The attack of a migraine which may last 4-72 hours and which may come as an early morning wake-up headache, during the night as a nocturnal headache, at a time of stress, or at the end of a time of stress such as the post-vacation migraine, or the Saturday morning or Sunday headache.  It may come three weeks into a woman’s menstrual cycle when estrogen levels drop.

 The migraine postdrome occurs the day after the severe headache and consists of fatigue, mild headache, lack of energy, and poor concentration.

 If a migraine with aura patient has a visual aura before the headache starts, then the patient should treat at the beginning of the aura with a triptan.  Migraine visual auras usually last 20-30 minutes but can be as long as an hour before headache follows.

 Treating at prodrome or aura means that treatment is early, and the drug use is more likely to succeed.  The problem is some patients have their aura at the same time their headache starts, and these persons should treat at the onset of their aura, which comes at the same time as the start of their headache.  Some patients have their aura near the end of the attack of headache, but they should have treated at the beginning of the headache.

To be sure that you know, read my article, “Migraine with Aura,” on my website, www.doctormigraine.com.

 Only migraine headache patients have the altered brain neurophysiology that leads to the headache, so that 94% of men and 75% of women who don’t have migraine, don’t have these physiologic changes, only migraine patients do this.

 The migraine process releases three different neuropeptides and these chemicals cause arterial dilatation and inflammation of the trigeminal nerve, the arteries and the thalamus.

 Triptans if taken early will stop this stage of the migraine process.  Over-the-counter drugs don’t do this.  That is why triptans, which came out in 1991 as injectable Imitrex subcutaneous 6 mg, have been so successful and important for treating migraine all over the world.

 It can be said that 80% of persons who treat their migraine at the onset of headache as outlined above, may be headache free in 2 hours. 

 Migraine and Tension Type Headache are both primary headaches without certain cause, which have a normal physical exam, and tests, and which compromise 99% of all headaches.

 Migraine definition

A. At least five attacks fulfilling B-D.

B. Attacks lasting 4-72 hours (untreated or unsuccessfully treated).

C. At least two of the following characteristics:

    1. Unilateral (one sided) location.

    2. Pulsating (throbbing) quality.

    3. Moderate or severe intensity (inhibits or prohibits daily activities).

    4. Aggravation by walking stairs or similar routine activity.

 D. At least one of the following:

     1. Nausea and/or vomiting.

     2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

 Tension Type Headache 

usually generalized

non-throbbing, feels like pressure or tight

not associated with nausea , vomiting, or sensitivity to light or sound

is usually mild to moderate (1-5)

patients stay in their life with these headaches, don’t leave work or miss social activities.

Better check out, “Migraine or Tension Type Headache,” on my website, www.doctormigraine.com.

Migraine aliases:  that is, names people call what is usually a migraine.  Usually these conditions should be treated at onset as if they were a migraine.

Sick Headache

Sinus Headache

Menstrual Headache

Allergy Headache

Hungry Headache

Nocturnal Headache

Wake up Headache

Let down, holiday, weekend Headache

Sun Headache

Medication overuse headache

The International Classification of Headache describes medication overuse headache (MOH) as a syndrome related to overtreating.

Chronic Daily Headache is a term that implies having headache over 15 days a month.  A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly.

MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans.

Patients typically rotate to different drugs and take many drugs at the same time that may cause MOH.

After a while the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem.  It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t.  When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going.  The patient develops a constant, daily headache problem often times with sensitivity to light, nausea, and irritability. Because serotonin levels in the brain drop, the patient may also develop anxiety, depression, poor concentration, and insomnia, which also are core symptoms.

Drugs that can cause this syndrome are:

Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Wigraine; Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Aleve), and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Demerol, MS OxyContin, Darvocet, Darvon, Tylenol with codeine; Drugs with the barbiturates butalbital-- Fiorinal, Fioricet, Phrenilin, Esgic.

The International Headache Society criteria for medication overuse headache are:

Triptans or Ergotamine intake >10 days/month

Non-opioid simple analgesics >15days/month

Opioids or Analgesics combined with barbiturates >10days/month

The only effective treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time.

Unless the patient was treated with “Bridge Medication” a terrific headache would come after stopping medication and then the headache would clear. The patient has to stay off any drug on the list above during this time.

Bridge medication is one or two weeks dose of oral steroids, as prednisone or Medrol Dosepak, for the chemical brain inflammation and Migranal nasal spray every 3 hours as needed for acute treatment of headache.

The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of medication abuse.  Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume.

The patient should limit painkillers to no more than 2 days/ week for the rest of their life.   Preventive medications such as CGRP blockers, or topiramate, amitriptyline, or beta-blockers may reduce the number of monthly migraines.  50% of patients with MOH have generalized anxiety disorder (GAD) which may need treatment and 50% of patients with MOH get it again.

Take home advice

Post-Concussion Syndrome has indistinct borders of limit of time patients may be affected.  Especially in the older literature, many of these patients had a simple concussion and were overtreated causing medication overuse headache.

Previous migraine patients and latent migraine patients have more severe headache after concussion.  These patients should limit analgesic use after head injury.

I use the  term “latent migraine” to refer to the commonly occurring new patient with daily headache following a previous mild concussion with normal workup and scanning who had no significant headache prior to the head injury, but may have subtle links to migraine in their history.

Some of these latent migraine post-concussed patients may have a close relative with migraine.  They may have motion sickness which has a 60% link to migraine, or previous mild, not very severe hungry headache, “sinus headache” treated with pseudoephedrine medication, or menstrual headaches.

Patients and doctors should be instructed to limit medication treatment for post-concussion patients.

Check out my Big Book on Migraine Here.

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All the best.

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Britt Talley Daniel MD