Assessing Posttraumatic Headache With Migraine Phenotype Among Concussed Youth

Posttraumatic headache (PTH) with a migraine phenotype is associated with persistent symptoms following concussion, compared with nonmigraine PTH or no PTH, according to study results published in JAMA Network Open.

Although concussion symptoms usually resolve days to weeks after an injury, 10% to 30% of patients can present with symptoms for longer than 4 weeks, and a smaller proportion can have symptoms that last much longer, authors explained. As concussions and mild traumatic brain injuries (mTBI) are common among children and adolescents, evidence suggests these age groups are “at particularly high risk in terms of symptoms burden and time to recovery.”

PTH is the most common acute and persistent symptom of concussion and is defined as new or significantly worsened head pain attributed to a head injury. Concordant PTH and migraine features could also be an early indication of prolonged symptoms after concussion, researchers said.

Despite adolescents’ increased risk of sustaining concussions, little data regarding PTH recovery and treatment in youth have been reported. To determine whether PTH phenotype following pediatric concussion (mTBI) is associated with a longer time to resolution of postconcussion symptoms or with the risk of persistent PTH 3 and 6 months after the injury, investigators analyzed data collected from the Four Corners Youth Consortium (4CYC), a multi-institutional collaboration.

The 4CYC registry consists of the Safe Concussion Outcome, Recovery, and Education (SCORE) program at Children’s National Hospital; Seattle Children’s Hospital and University of Washington Medical Center; and the UCLA Steve Tisch BrainSPORT program at UCLA Mattel Children’s Hospital.

All study participants were between the ages of 5 and 18 and presented to a clinic with a referral diagnosis of mTBI or concussion within 8 weeks of injury. Demographic data and medical history were assessed, and individuals completed the Postconcussion Symptom Inventory (PCSI) to determine PTH. Investigators defined PTH with migraine phenotype as “moderate-severe headache that is new or significantly worse compared with baseline and associated with nausea and/or photophobia and phonophobia.”

A total of 281 participants with 286 concussions were included in the final cohort; the majority were female (58.7%) and White (75.6%). Of patients included, 238 were between ages 13 and 18. Outcomes were measured between December 2017 and June 2019, and data were analyzed between February 2019 and January 2021.

Analyses revealed:

• At the initial visit, 133 concussions (46.5%) were from patients experiencing PTH with a migraine phenotype, 57 (20%) were from patients experiencing PTH with a nonmigraine phenotype, and 96 (34%) were from patients with no PTH.
• Patients with any PTH after concussion were more likely to have prolonged recovery than those without PTH (median [interquartile range (IQR)], 89 [48-165] days vs 44 [26-96] days; log-rank P < .001).
• Patients with PTH and a migraine phenotype took significantly longer to recover than those with nonmigraine phenotype (median [IQR], 95 [54-195] days vs 70 [46-119] days; log-rank P = .01).
• Characteristics associated with PTH with a migraine phenotype included female sex, depression at baseline, history of migraine, public insurance, and family history of attention-deficit/hyperactivity disorder.
• Within each phenotype, there was no significant difference between sexes in recovery or PTH at 3 months.

In addition, “abortive medications were recommended for treatment of 62 concussions (47%) for patients in the PTH-Migraine group and 28 concussions (49%) for patients in the PTH-Nonmigraine group,” researchers wrote. These medications included acetaminophen, ibuprofen, naproxen, rizatriptan or sumatriptan.

Results indicate that although PTH is one of the most persistent and often challenging symptoms after a concussion, “headache itself does not appear to indicate a single trajectory; it is the headache phenotype that correlates with outcome,” authors said. By phenotyping PTH, providers may be able to glean important prognostic information, better guide treatment, and adjust protocols in clinical trials. By characterizing headache after concussion, researchers may also gain a better understanding of PTH.

Migraine phenotype could offer a target for early intervention in these patients and evidence-based treatments could improve and manage their headaches. “This may also suggest potential for objective biomarkers (eg, molecular, imaging) to help distinguish between different PTH phenotypes,” researchers said.

The underlying mechanisms of PTH and migraine are not well understood. However, it has been hypothesized the 2 conditions have similar roots, potentially explaining “why the majority of PTH have migraine qualities, and why a history of migraine has been associated with prolonged recovery after concussion.”

A lack of data on disability related to headache marks a limitation to the study. Data were also missing for some participants at 3 and 6 months. Furthermore, patients referred to specialty TBI clinics may have had higher symptom burdens and prolonged recovery, potentially decreasing findings’ generalizability to nonspecialty populations.

“Future large studies validating the classification of posttraumatic headache phenotypes in youth and studying outcomes are essential,” authors concluded. “PTH phenotyping will improve prognostication of concussion recovery and will enhance the treatment for PTH with more appropriate and targeted therapies to treat and prevent persistent and disabling headaches in youth with concussion.”

Reference

Kamins J, Richards R, Barney BJ, et al. Evaluation of posttraumatic headache phenotype and recovery time after youth concussion. JAMA Netw Open. Published online March 8, 2021. doi:10.1001/jamanetworkopen.2021.1312